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A CLINICAL TEXT-BOOK
Surgical Diagnosis and Treatment
PRACTITIONERS AND STUDENTS OF
SURGERY AND. MEDICINE.
BY
J. W. MACDONALD, M.D.,
Graduate in Medicine of the Univeksity of Edinburgh; Licentiate of the Royal
College of Surgeons, Edinburgh ; Professor of the Practice of Surgery and
OF Clinical Surgery in Hamline University , Minneapolis, etc.
WITH 328 ILLUSTRATIONS.
PHILADELPHIA :
W. B. SAUNDERS,
925 Walnut Street.
1898.
Copyright, 1897,
By \fV. B. SAUNDERS,
ELECTROTYPED BY PRFcq nv
WESTCOTT 4 THOMSON, PHILADA. W. B. SAUNDERS PHILADA.
TO
JOSEPH BELL, Esq., F.R.C.S.,
FROM WHOSE LIPS I RECEIVED MY FIRST LESSONS IN SURGERY,
THIS WORK IS GRATEFULLY DEDICATED BY
THE AUTHOR.
PREFACE.
The rapid advances made in the art of surgery have caused the
literature of the science to grow apace. Systems of surgery in many
volumes, and text-books of large dimensions, are now deemed neces-
sary to cover the field. The practical part of the surgeon's work is,
however, almost limited to two questions which he must answer every
time his professional advice or help is sought. The first question is,
"What is the disease or injury?" The second question is, "What is
the proper treatment ? "
While I would not for a moment underestimate the importance of a
profound study of the principles of surgery, of surgical pathology, or
of bacteriology, the present work will be confined to a solution of the
two questions just mentioned with the view of putting into the hands
of students and practitioners a single volume containing the most
practical part of practical surgery.
The young practitioner is often embarrassed by not knowing how
to make a systematic examination in a case of injury, and he may be
placed at a disadvantage by the criticism of excited bystanders. The
man who goes about the examination of his patient in a systematic
manner, leaving nothing undone and guarding against all contingencies,
will not only command the approval of the patient and his friends, but
will protect himself against dangerous errors. In the following pages
care is taken to make the examination of each disease or injury sys-
tematic and comprehensive, and, when possible, directions are laid down
as to the methods of examination.
The surgery of the eye, the ear, and the skin is now so generally left
to the care of specialists in these respective fields that I have thought
it best to refer the reader to works exclusively devoted to these studies.
While the field of medical diagnosis has been well covered by such
excellent works as those of DaCosta, Musser, Vierordt, and others,
surgical diagnosis up to the present time is not dealt with in any work
that claims to represent the most recent surgical knowledge ; at the
same time the profession may almost be said to have stampeded to
surgery. This very popularity of surgery, especially among young
practitioners, is not free from a serious danger — viz. that in being
8 PREFACE.
absorbed with the thouf^ht of the operation that may be required the
mind of the surt:^eon dwells too lightly upon the diai^nosis of the dis-
ease. I send this work upon its mission with the hope that the reader
ma}' be led into the habit of making every examination systematic and
exhausti\e, that he may find help in the diagnosis of difficult cases,
and that his labors may be thereby lessened and his responsibilities
lightened.
I take this opportunity of expressing my deep obligations to Drs.
Hoegh, Bartlett, Hall, Ferro, and others for valuable suggestions ; to
Dr. Florence M. Baier, Dr. Findley, Dr. Mowat, and Dr. C. B. Roberts
for long-continued and patient labor in collecting and arranging mate-
rials ; and to the many friends who have contributed illustrations.
J. W. MACDONALD.
Minneapolis, November, 1S97.
CONTENTS.
CHAPTER I.
PAGE
General Examination of Patients 17
Introduction, 17. — Information obtained from the Patient or his Friends, i8. —
Influence of Age, Sex, Heredity, Habits, etc., 18. — History of Present Disease or
Injury, 19. — General Examination of the Patient, 19. — General Appearance, Posi-
tion, Surface Markings and Changes of Contour, Condition of the Sicin, etc., 20. —
Temperature, Local and General, 21.
CHAPTER II.
Examination of the Vascular System 22
I. The Heart and Pericardium, 22. — Overdistention of the Ventricles, 22. —
Effusion into the Pericardium, 23. — Injuries of the Heart, 24. — Wounds of the
Heart, 24.
II. Examination of the Veins, 24. — Wounds of Veins, 24. — Thrombosis,
25. — Varix, 25. — Nevus, 27.
III. Examination of the Arteries, 27. — Wounds, 27. — Rupture, 28. — Acute
Arteritis, 29. — Chronic Arteritis, 29.
IV. Aneurysm, 32. — Symptoms Common to Aneurysm in General, 32. — Treat-
ment of Aneurysm, 34.
V. Special Aneurysms, 35. — Aneurysm of the Arch of the Aorta, 35. — Aneu-
rysm of the Ascending Portion of the Arch, 36. — Aneurysm of the Transverse Por-
tion of the Arch, 37. — Aneurysm of the Descending Portion of the Arch, 38. —
Innominate Aneurysm, 39. — Treatment of Aortic Aneurysm, 39. — Aneurysm of the
Carotid, 41. — Vertebral Aneurysm, 41. — Orbital or Ophthalmic Aneurysm, 4I. —
Subclavian Aneurysm, 42. — Axillary Aneurysm, 42. — Aneurysm of the Abdominal
Aorta, 43. — Aneurysm of the Branches of the Abdominal Aorta, 44. — Iliac Aneu-
rysm, 44. — Femoral Aneurysm, 46. — Popliteal Aneurysm, 46. — Traumatic Aneu-
rysm, 47. — Varicose Aneurysm, 48.
CHAPTER III.
Injuries and Diseases of the Osseous System 49
I. Fractures, 49. — How to Deal with Accidents and Emergencies, 49. — Class-
ification of Fractures, 50. — Diagnosis of Fractures in General, 52. — Complications
of Fracture, 55. — Diagnosis and Treatment of Special Fractures, 58. — The Nasal
Bones, 58. — The Malar Bone, 59. — The Upper Jaw, 59. — The Lower Jaw, 60. —
The Clavicle, 60. — The Hyoid Bone, 62. — The Sternum. 63. — The Ribs, 63. —
The Scapula, 64. — The Humerus, 65. — The I'lna, 71. — Fracture of the Radius
and Ulna together, 72. — Fracture of the Radius alone, 73. — The Metacarpal Bones,
75. — The Phalanges, 75. —The Pelvis, 75.— The Femur, 77. — The Patella, 82. —
The Tibia, 84. — The Fibula, 86. — The External Malleolus, 87. — The Astragalus,
87. — Compound Fractures, 88. — Amputation after Injury, 88.
II. Diseases of Bone, 89. — Inflammation, 89. — Osteoperiostitis, 90. — Osteo-
myelitis, 91. — Sejitic Inflammation of Bone, 91. — Necrosis, 92. — Chronic Inflam-
mation of Bone, 93. — Tubercular Ostitis, 94. — Syphilitic Diseases of Bone, 95. —
Fragilitas Ossium, 96. — Rachitis, 96. — Osteomalacia, 97. — Actinomycosis, 97. —
Tumors of Bone, 98. — Malignant Tumors of Bone, loi. — Acromegaly, 105.
lO CONTENTS.
CHAPTER IV.
PAGB
Injuries and Diseases of Muscles, Tendons, and Burs^ .... 105
Strain, 105. — Rupture, 105. — Wounds, 106. — Myaljjia, 106. — Myositis, 106. —
Tenosynovitis, 107. — Ganglion, 109. — Diipuytren's Contraction, 109. — Diseases of
Bursa', no. — Bursitis, no.
CHAPTER V.
Injuries and Diseases of Joints m
I. Injuries of Joints, in. — Contusions, ni. — Sprains, in. — Wounds of Joints,
113. — Dislocations, I14. — Diagnosis of Special Dislocations, 118. — The Lower Jaw,
118. — Injuries about the Clavicle and Shoulder, 1 19. — The Clavicle, 120. — The
Sternum, 122. — The Shoulder, 123. — The Elbow, 127. — The Wrist -joint, 130.
The Ilip-joint, 131. — The Knee-joint, 139. — The Patella, 140. — The Fibula, 140.
— The Ankle. 140. — Subastragaloid Dislocations, 142. — Dislocation of the Astrag-
alus, 142. — Loose Bodies in Joints, 142. — Displacement of a Semilunar Cartilage,
144.
n. Diseases of Joints, 144. — Examination of Joints for Disease, 145. — Sim-
ple Acute Synovitis, 145.- Dry Synovitis, I47. — Chronic Synovitis, 147. — Arth-
ritis, 148. — Acute Arthritis w-nh Suppuration, 150. — Pyemic Arthritis, 150. — Tuber-
cular Arthritis, 152. — Tuberculosis of Special Joints, 153. — The Hip-joint, 153. —
The Sacro-iliac Joint, 158. — The Knee-joint, 161. — The Ankle-joint, 162.— The
Shoulder-joint, 163. — The Elbow-joint, 163. — The Wrist-joint, 164.— The Phalan-
geal Joints, 164. — Rheumatic Arthritis, 164. — Gonorrheal Arthritis, 1 64. — Neuro-
pathic Arthritis, or Charcot's Disease, 165. — Gouty Arthritis, 165.
CHAPTER VI.
Injuries and Diseases of the Digestive System 166
I. The Lips, Palate, Jaws and Gums, Tonsils, Pharynx, and Esoph-
agus, 166. — The Lips, 166. — Hare-lip, 166. — Macrostoma and Microstoma, 170.
— Nevi, 171. — Other Tumors of the Lips, 171. — Furuncle and Carbuncle, 172. —
Hypertrophy of the Lips, 172. — Wounds, 172. — Inflammation, 172. — Epithelioma,
173. — The Palate, 174. — Cleft-Palate, 174. — Tumors of the Palate, 179. — Syph-
ilis of the Palate, 179. — The Mouth, 179. — Salivary Calculus, 179. — Ranula,
180. — The Tongue, 180. — Malformations, 180. — Injuries, 181. — Diseases of the
Tongue, 181. — Tumors of the Tongue, 185. — The Jaws and Gums, 186. —
Deformities, 186. — Chronic Affections of the Jaw, 186. — Diseases of the Temporo-
maxillary Articulation, 192. — The Tonsils, 193. — Tonsillitis, 193. — Hypertrophy
of the Tonsils, 194. — Calcareous and Cheesy Concretions, 194. — Sarcoma and Car-
cinoma, 195. — The Pharynx, 195. — Retropharyngeal Abscess, 195. — Tumors,
196. — The Esophagus, 196. — Malformations, 196. — Pouches or Diverticula, 196.
— Stricture, 196.
n. Diseases and Injuries of the Abdomen, 201. — Examination of the
Abdomen, 201. — Abdominal Topography, 201. — Objective Symptoms, 203. —
Inspection, 203. — Palpation, 204. — Percussion, 205. — Auscultation, 205. — Explor-
atory Puncture and Incision, 206. — Injuries of the Abdomen, 207. — Contusions,
207. — Wounds of the Abdomen, 208.
HI. Examination of the Stomach, 215. — Inspection, Palpation, Percussion,
215. — Injuries and Diseases of the Stomach, 216. — Rupture, 217. — Foreign Bodies,
217. — Mechanical Fixation of the Stomach, 218. — Ulcer, 218. — Gastric Fistula,
219. — Cancer, 220. — Stricture of the Cardiac Orifice, 229. — Dilatation of the Stom-
ach, 231.
IV. Diseases and Injuries of the Intestines, 233. — Examination of the
Intestines, 233. — Carcinoma, 234. — Acute Intestinal Obstruction, 237. — Intussus-
ception, 246. — Volvulus, 253. — Strangulation by Bands, 253. — Chronic Intestinal
Obstruction, 253.
V. Hernia, 255. — Irreducible Hernia, 259. — Incarcerated Hernia, 260. — Strang-
ulated Hernia, 260. — The Radical Cure of Hernia, 263. — Championniere's Ope-
ration, 265. — Macewen's Operation, 267. — Bassini's Operation, 268. — Halsted's
Operation, 268. — The Radical Cure of Femoral Hernia, 270. — Palliative Treat-
ment of Hernia, 270. — Umbilical Hernia, 271. — Ventral Hernia, 272. — Lumbar
Hernia, 273. — Obturator, Perineal, and Diaphragmatic Hernias, 273.
CONTENTS. 1 1
PAGE
VI. Appendicitis, 273. — Causes, 274. — Symptoms, 275. — Diagnosis, 276. —
Classification, 277. — Prognosis, 279. — Treatment, 279.
VII. Diseases and Injuries of the Peritoneum, 281. — Functions of the
Peritoneum, 2S1. — Plastic Peritonitis, 282. — Septic Peritonitis, 283. — Suppurative
Peritonitis, 285. — Tubercular Peritonitis, 286.— Carcinoma of the Peritoneum, 288.
— Sarcoma of the Omentum, 289. — Benign Tumors of the Peritoneum, 289. — Rup-
ture of the Peritoneum, 289. — Wounds of the Peritoneum, 289.
VIII. Injuries and Diseases of the Liver, 290. — E.xamination of the Liver,
291. — Rupture of the Liver, 291. — Wounds of the Liver, 291.— Abscess of the
Liver, 292. — Hydatids of the Liver, 296. — Floating Liver, 298.
IX. Injuries and Diseases of the Gall-bladder, 298. — Gall-stones, 299. —
Pathological Changes produced by Gall-stones, 304. — Operations, 308-313. —
W^ounds of the Gall-bladder. 313. — Empyema of the Gall-bladder, 314.
X. Diseases and Injuries of the Pancreas, 314. — Functions of the Pan-
creas, 314. — Pancreatic Hemorrhage, 315. — Suppuration and Abscess of the Pan-
creas, 315. — Cysts of the Pancreas, 315. — Cancer of the Pancreas, 316.
XI. Injuries and Diseases of the Spleen, 31 7. ^Examination, 317. —
Wounds of the Spleen, 317. — Abscess, 319. — Rupture, 320. — Cysts, 320. — Carci-
noma and Sarcoma, 320.
XII. Diseases and Injuries of the Rectum and Anus, 320. — Examination,
320. — Inspection, 320. — Digital Examination, 320. — Examination with the Spec-
ulum, 321. — Manual Examination, 321. — Wounds and Other Injuries of the Rec-
tum, 322. — Foieign Bodies in the Rectum, 322. — Hemorrhoids, 323. — Prolapsus
Ani, 327. — Prolapsus Recti, 328. — Pruritus Ani, 329. — Inflammatory Diseases of
the Rectum, 330. — Proctitis, 330. — Ulceration, 330. — Periproctitis, 332. — Ischio-
rectal Abscess, 332. — Abscess above Levator Ani Muscle, TyT,T). — Fistula in ano,
333. — Fissure of the Anus, 337. — Spasm of the Sphincter, 339. — Tumors of the
Rectum, 339. — Papillomata, 340. — Condylomata, 341. — Fibromata, etc., 341. —
Stricture of the Rectum, 341. — Congenital Malformations of the Rectum and
Anus, 345.
CHAPTER VII.
The Genito-urinary System
347
I. Injuries and Diseases of the Kidneys, 347. — Surgical Anatomy, 347. —
Injuries of the Kidney, 349. — Contusion without Laceration of the External Tis-
sues, 349. — Wounds of the Kidney, 350. — Diseases of the Kidney, 351.— Exam-
ination, 351. — Movable Kidney, 352. — Renal Calculus, 354. — Nephro-lithotomy,
357. — Nephrectomy, 357. — Perinephritic and Nephritic Abscess, 360. — Surgical
Kidney, 361. — Hydronephrosis, 363. — Pyonephrosis, 364. — Tuberculosis of the
Kidney, 365. — Hydatid Cysts, 365. — Simple Cysts, 366. — Solid Tumors, 366.
II. Injuries and Diseases of the Ureter, 368. — Surgical Anatomy, 368. —
Palpating the Ureter, 369. — Rupture of the Ureter, 369. — Ureteral Calculus, 373. —
Longitudinal Ureterotomy, 373. — Other Operations, 373. — Ureteritis, 373. — Stric-
ture of the Ureter, 374.
HI. Injuries and Diseases of the Bladder, 37;. — Significance of Symp-
toms, 375. — Rupture of the Bladder, 378. — Retention of Urine, 380. — Atony of the
Bladder, 381. — Sacculation and Pouching of the Bladder, 382. — Cystitis, 383. —
Acute Cystitis, 383. — Chronic Cystitis, 384. — Stone in the Bladder, 386. — Symp-
toms indicating the Presence of Stone, 387. — Sounding the Bladder, 38S. — The
Cystoscope, 391. — Measuring the Calculus, 392. — Removal of Stone, 393. — Contra-
indications, 394. — Litholapaxy, 395. — Operation, 395. — Lithotomy, 399. — Lateral,
400. — Median, 401. — Perineal Lithotrity, 402. — Suprapubic Lithotomy, 403. —
Tumors of the Bladder, 404. — Deformities of the Bladder, 407. — Cystocele and
Hernia of the Bladder, 409.
IV. Injuries and Diseases of the Prostate, 409. — Surgical Anatomy, 409. —
General Symptoms of Prostatic Disease, 410. — Hypertrophy of the Prostate, 410. —
Operative Procedures, 415. — Double Castration, 415. — Prostatectomy, 415. — Inflam-
mation of the Prostate, 417. — Malignant Disease of the Prostate, 419. — Calculus of
the Prostate, 419. — Wounds and Injuries of the Prostate, 420.
V. Injuries and Diseases of the Male Urethra, 420. — Surgical Anatomy,
420. — Rupture of the Urethra, 421. — False Passages in the Urethra, 422. — Foreign
1 2 CONTENTS.
PAGE
Bodies in the Urethra, 423. — Urethritis, 425. — Gonorrhea, 425. — Chronic Urethritis,
432. — Chronic Gunorrliua, 433. — Stricture of the Urethra, 434. — Urinary Pouches,
442.
VI. Injuries and Diseases of the Male Generative Organs, 443. — Dis-
eases and Malformations of the I'enis, 443. — Hypospadias, 443. — tipispadias, 445. —
Phimosis, 445. — Paraphimosis, 445. — Carcinoma of liie Penis, 445. — Diseases of the
Scrotum, 447. — Edema and Inllammalion, 447. — Epithelioma, 447. — Elephantiasis,
447. — Swellings of the Scrotum, 447. — (hxhitis, 448. — Syphilitic Testicle, 448. —
Tubercular Orchitis, 449. — Gouty Orchitis, 449. — Malignant Disease of the Tes-
ticle, 449. — Sarcoma, 449. — Carcinoma, 450.- — IJenign Tumors, 451. — Abnormal-
ities of the Testicles, 451. — Hydrocele, 451. — Hematocele, 453. — Inflammation of
the Speiniatic Cord, 453. — Encysted Hydrocele, 454.
CHAPTER VIII.
Injuries and Diseases of the Head 455
I. Cerebral Topography, 455. — The Sensori-motor Area, 456. — The Area of
Speech, 459. — The Areas of Vision and Hearing, 460. — The Area of Sensations
of Smell and Taste, 460. — Methods of Determining the Position of the Fis-
sures, 460.
II. Injuries and Diseases of the Scalp, 462. — Contusions, 462. — Cephal-
hematoma, 402. — Wounds, 4O2. — Tumors, 463, — Horns and Warts, 464. — Pneu-
matocele, 464.
HI. Injuries of the Skull, 464. — Contusions, 464. — Osteomyelitis, 464. — Frac-
tures of the \'ault of the Skull, 465. — Fractures of the Base, 467.
IV. Injuries of the Brain and its Membranes, 469. — Concussion of the
Brain, 469. — Compression ot the Brain, 470. — Intra-cranial Hemorrhage, 472. —
Extra-dural Hemorrhage, 472. — Sulxlural, Subarachnoid, and Cerebral Hemor-
rhage, 473. — Treatment of Intra-cranial Hemorrhage, 473. — The Operation of
Trephining, 475. — Wounds of the Brain, 478.
V. Injuries of the Cranial Nerves, 479. — The Olfactory Nerve, 479. — The
Optic Nerve, 480. — The Third, Fourth, Pifth, Sixth, and Seventh Cranial Nerves,
481. — The Eighth and Ninth Cranial Nerves, 482.
VI. Gunshot Wounds of the Head, 482. — Wounds of Entrance and Exit,
482. — Finding the Bullet, 483. — The Telephone Probe, 483. — Lilienthars Probe,
484.
VII. Septic Inflammation within the Cranium, 485. — Portals of Entrance
of Septic Germs, 4S5. — Inflammation of the Brain and its Membranes, 486.
VIII. Abscess of the Brain, 487. — Causes, 487. — Symptoms, 488. — Differ-
ential Diagnosis, 492. — Treatment, 492. — Thromi)osis of the Lateral Sinus, 496.
IX. Cerebral Tumors, 496. — Varieties, 496. — Symptoms, 497. — General, 497.
— Focal, 499. — Diagnosis, 500. — Treatment, 503. — Tumors of the Cerebellum, 503.
X. Epilepsy, 504.
CHAPTER IX.
Injuries, Diseases, and Deformities of the Spine 506
Surgical Anatomy, 506. — Examination of the Spine, 507. — Injuries of the
Spine, 508. — Sprains, 508. — Railway Spine, 508. — Concussion of the Spinal Cord,
510. — Compiression of the Spinal Cord, 510. — Wounds of the Back, 51 1. — Fractures
of the Spine, 512. — Gunshot Wounds of the Spine, 520. — Dislocation of the Spine,
520. — Deformities of the Spine, 521. — Spina Bifida, 521. — Sacro-coccygeal Tumors,
525. — Curvature of the Spine, 525. — Tuberculosis of the Spine (Pott's Disease), 530.
CHAPTER X.
Diseases and Injuries of the Nerves 543
Neuritis, 543. — Neuralgia, 544. — Injuries of Nerves, 547. — Wounds of Nerves,
547. — Injuries of Special Nerves, 550. — Facial Nerve, 550. — Pneumogastric, 552. —
Posterior Thoracic, 553. — Musculo-spiral, Radial, Median, and Ulnar Nerves, 553.
—Sciatic, 555.
CONTENTS. 13
CHAPTER XI.
PAGE
Injuries and Diseases of the Respiratory System 556
I. The Nose, 556. — External Injuries, 556. — Elephantiasis, 556. — Rhinoscle-
roma, 556. — External Tumors. 556. — Internal Injuries, 557. — Parasites, 55S. —
Rhinoliths, 55S. — Polypi, 559. — Fibro-myomata and Fibromata, 561. — Papillomata,
Adenomata, Enchondromata, Osseous Growths, Angeiomata, 563. — Sarcomata, 563.
— Carcinomata, 564. — Epistaxis, 564. — Ulcers, 566. — Lupus, 567. — Epitheliomata,
567. — Syphilis, 56S. — Leprous Ulcers, 570. — Rhinitis, 570. — Atrophic Nasal
Catarrh,' 575. — Ozena, 576. — Diphtheritic and Membranous Rhinitis, 577. — Puru-
lent Rhinitis, 577. — Diseases and Injuries of the Septum, 577.— Deviations,
577. — Hematomata, 580. — Abscesses. 580. — Perforation of the Septum, 580. —
Deformities, Congenital Malformations, and Defects of the Nose, 580. —
Rhinoplasty, 5S2.— Rhinoscopy, 584.— Anterior Rhinoscopy, 585. — Posterior
Rhinoscopy, 585.
II. Diseases and Injuries of the Accessory Sinuses of the Nose, 588. —
The Antrum of Highmore, 5S8. — The Frontal Sinus, 591.— The Ethmoidal Sinuses,
594. — The Sphenoidal Sinuses, 594.
III. Neuroses of the Nasal Passages, 594.— Anosmia, 594. — Hyperosmia
or Hyperesthesia of the Olfactory Nerve, 596. — Reflex Neuroses, 596.
IV. The Larynx, 597. — Laryngoscopy, 597. — Injuries of the Larynx, 600.
— Internal Injuries, 600. — External Injuries, 602. — Foreign Bodies in the Air-pas-
sages, 605. — Diseases of the Larynx, 608. — Laryngitis, Catarrhal, 608. — Acute
Infantile Laryngitis, 609. — Chronic Laryngitis, 61 1. — Diphtheritic Laryngitis, 614.
— Edema of the Larynx, 614. — Abscess of the Larynx, 617. — Chondritis and Peri-
chondritis, 617. — Ulcers of the Larynx, 619. — Tuberculosis of the Larynx, 619. —
Syphihs of the Larynx, 622. — Tumors of the Larynx, 623. — Benign Tumors, 623. —
Malignant Tumors, 629. — Neuroses OF THE Larynx, 631.— Sensory Neurosis,
631. — Neuralgia, 631. — Paralysis of Superior Laryngeal Nerve, 631. — Paralysis of
Recurrent Laryngeal Nerve, 632. — Paralysis of the Abductors, 633. — Paralysis of
the Adductors, 634. — Paralysis of the Internal Tensors, 635. — Spasm of the Glot-
tis, 635.
V. Stricture and Stenosis of the Larynx and Trachea, 636. — Compres-
sion-stenosis, 637. — Occlusion-stenosis, 637.
VI. Malformations of the Larynx and Trachea, 638. — Tumors of the
Trachea, 639. — Tracheocele, 639.
VII. Bronchial Tubes, 640. — Injuries, 640. — Tumors, 640. — Tracheotomy,
640. — Intubation of the Larynx, 642. — Laryngectomy, 644.
VIII. The Chest, 645.— Wounds, 645. — Effusions into the Pleural Cavity, 645.
— Thoracotomy, 647. — Thoracoplasty, 647. — Schede's Operation, 647.
CHAPTER XII.
The Diagnosis and Treatment of Syphilis 648
Modes of Transmission, 648.— The Primary Sore, 649. — Differential Diagnosis,
650. — Treatment of Chancroid, 650. — Treatment of Chancre, 652. — The Secondary
Stage, 652.— The Tertiary Stage, 655.— Differential Diagnosis, 655. — Hereditary
Syphilis, 660.
CHAPTER XIII.
The Diagnosis and Treatment of Tumors 663
Characteristics of Benign and Malignant Growths, 663. — Connective-tissue
Tumors, 663. — Lipomata. 663. — Fibromata, 664. — Chondromata, Myxomata, Myo-
fibromata, Angeiomata, Gliomata, Neuromata, 665. — Sarcomata, 666. — Epithelial
Tumors, 666. — Warts, Villous Papillomata, 666. — Intra-cystic Papillomata, 666. —
Psammomata, Epitheliomata, 667. — Adenomata, 668.
14 COA^ViNTS.
CHAPTER XIV.
PAGE
Diseases and Injuries of the Neck 669
Congenital Malformations, 669. — Branchial Cysts, 669. — Branchial Fistula;, 670.
— Cellulitis of the Neck, 070. — Abscesses of tlie Neck, 670. — Contusions, 671. —
Wounds, 671. — Tumors, 671. — Sypliilitic Enlart;ement of the Glands, 671. — Tuber-
cular Glands, 671. — Malij^nant Lymphoma, or Ilodgkin's Disease, 672. — Actino-
mycosis, 673. — Other Tmnors of the Neck, 673. — Diseases of the Parotid
Gland, 673. — Parotiditis, 673. — Tumors of the Parotid, 673. — Diseases of the
Thyroid Gland, 674. — Goiter, or Bronchocele, 674.
CHAPTER XV.
Injuries and Diseases of the Breast 675
Piiysiolo^ical Changes in the Breast, 675. — Examination of the Breast, 675. —
Diseases of the Mammary Gland, 676. — Mastitis or Manimitis, 676. — Neurosis of
the Breast, 677. — Tumors of the Breast, 678. — Benign Tumors, 678. — Malignant
Tumors, 679. — Sarcoma, 679. — Carcinoma, 679. — Scirrhus, 6S0. — Cardinal Symp-
toms of Cancer, 680. — Medullary Cancer, 681. — Operation for Removal of the
Breast (Halsted's), 682.
CHAPTER XVI.
Diseases and Injuries of the Female Generative Organs . . . 685
I. Methods of Examination, 685. — Personal Histor)', 6S5.^Positions for
Examination, 686. — Vaginal Examination, 688. — Bimanual Examination, 689. —
Rectal Examination, 690. — Inspection of the External Genitalia, 691. — Artificial
Dilatation of the Uterus, 693. — Examination of the Urethra and Bladder, 694. —
Examination of the Ureters, 694. — Method of Catheterizing the Ureters, 694.
II. Anomalies of the Female Genital Organs, 695. — Hermaphrodism, 695.
— Anomalies of the External Genital Organs, 695. — Anomalies of the Hymen, 695.
— Hypertrophy of the Clitoris, 696. — Anomalies of the Internal Genital Organs, 696.
III. Traumatic Lesions of the Female Genital Tract, 698. — Injuries of
the Vulva and Perineum, 698. — Injuries of the Vagina, 698. — Injuries due to Par-
turition, 698. — Operations, 699.
IV. Disorders of Menstruation, 704. — AmenoiThea, 704. — Menorrhagia, 705.
— Dysmenorrhea, 706.
V. Malpositions of the Uterus, 708. — Anteflexion, 708.— Retro-positions,
709. — Bimanual Reposition, 709. — Knee-chest Reposition, 710. — Alexander's Ope-
ration, 712. — Hysterorrhaphy, 712. — Prolapsus Uteri, 713. — Inversion of the Ute-
rus, 714.
VI. Inflammation of the Female Genitals, 715. — Inflammation of the Vulva,
715.— Vaginitis, 716. — Inflammation of the Uterus, 717. — Acute Endometritis and
Metritis, 718. — Endocervicitis and Cervicitis, 719. — Chronic Endometritis and Me-
tritis, 719. — Chronic Inflammation of the Body of the Uterus, 723.
VII. Pelvic Inflammation, 724. — Acute Catarrhal Salpingitis, 724. — Chronic
Salpingitis, 725. — Hydrosalpinx, 725. — Hematosalpinx, 726. — Pyosalpinx, 726. —
Inflammation of the Ovaries, 727. — Acute Oophoritis, 727. — Chronic Oophoritis,
728. — Pelvic Peritonitis, 728. — Cellulitis, 728. — Chronic Pelvic Inflammation, 729.
— Pelvic Abscess, 729. — Treatment of Pelvic Inflammations, 730.
VIII. Tuberculosis of the Female Genital Tract, 733. — Vulva, Vagina,
733. — Uterus, 733. — Tubes, Ovaries, 734.
IX. Laceration of the Cervix Uteri, 735. — Causes, 735. — Diagnosis, 736. —
Treatment, 736.
X. Fibroid Tumors of the Uterus, 738. — Polypoid or Pedunculated
Fibroids, 738. — Submucous Fibroids, 739. — Interstitial fibroids, 739. — Subperi-
toneal Fibroids, 739. — Treatment, 741. — Alterative, 741. — Electricity, 742. — Sur-
gical Treatment, 742. — Removal of Appendages, Ligation of Uterine Arteries, Mor-
cellation. Vaginal Hysterectomy, Myomectomy, Abdominal Hysterectomy, 742.
CONTENTS. 1 5
PAGE
XI. Uterine Polypi, 746. — Polypi of the Cervix, 746. — Polypi of the Ute-
rus, 746.
XII. Malignant Diseases of the Female Genital Organs, 747. — Epithe-
lioma of the External Genitals, 747. — Sarcoma of the External Genitals, 748. —
Sarcoma of the Uterus, 748. — Carcinoma of the Cervix, 749. — Carcinoma of the
Body of the Uterus, 753. — Technique of Vaginal Hysterectomy, 754. — Abdominal
Hysterectomy for Cancer, with Removal of Part of Broad Ligament, 756.
XIII. New Growths of the Tubes, Ovaries, and Broad Ligaments, 759.
— New Growths of the Tubes, 759. — New Growths of the Ovaries, 759. — Ovarian
Cysts, 760. — Ovariotomy, 765.
XIV. Extra-uterine Pregnancy, 766. — Tubal Pregnancy, 766. — Tubal Abor-
tion, 767. — Tubal Gestation, 767. — Tubo-uterine Pregnancy, 768.
CHAPTER XVII.
The X- (or Rontgen) Rays in Surgical Diagnosis 771
Discovery of the jr-Rays, 771. — Apparatus Required for x-Ray Work, 778. —
Uses of the j:-Rays, 780.
Index 783
SURGICAL DIAGNOSIS AND TREATMENT.
CHAPTER I.
GENERAL EXAMINATION OF PATIENTS.
Introduction. — Year by year the scope of surgery is expanding,
and as new territory is added to his domain the surgeon must widen
his field of inv^estigation. Until a few years ago he worked within a
narrow sphere, and devoted about as little time to the study of diseased
conditions in the abdominal, thoracic, and cranial cavities as the modern
oculist gives to general medicine. All this is changed. To-day there
is no organ of the body beyond the legitimate field of surgery, no cavity
whose innermost recesses cannot be explored.
It is possible in many surgical diseases and injuries to take in the
situation at a glance and instantly to decide upon a plan of treatment ;
as, for example, in fractures, dislocations, diseases of joints, and in cer-
tain tumors ; but in the broader field of modern surgery every known
method of diagnosis must be employed. A systematic and complete
examination of his cases is therefore as necessary to the surgeon as to
the physician.
While the surgeon's case-taking need not, as a rule, be lengthy, it
should be systematic and comprehensive. The discovery of one dis-
ease or injury should not end the investigation. Every organ and
system should pass under review, so that there shall be no possibility
of any important point being overlooked.
To the student or the young practitioner the formation of a habit
of recording his cases in this manner will prove invaluable. By it he
trains his powers of observation, collects material from which he can
draw conclusions, and, most important of all, avoids errors into which
many of his seniors have fallen.
It cannot be denied that the wider application of operative pro-
cedures increases these dangers. To operate upon a pyosalpinx, and
afterward to find that the patient is not benefited owing to the existence
of long-standing tuberculosis in the lung, may be a triumph in tech-
nique, but it is a blunder in diagnosis. It is sadly disappointing, when
a patient submits to clamp and cautery for the relief of hemorrhoids,
to find, a few weeks later, that his days are drawing to a close by
reason of a carcinomatous liver, which existed but was not thought of
at the time of the operation. None but those who have suffered thereby
can realize what it is to have treated a fracture of the humerus and to
be confronted months afterward with a dislocation at the elbow that
was overlooked at the first examination.
2 17
1 8 SURGICAL DIAGNOSIS AND TREATMENT.
In the diagnosis of an}- surirical disease or injur}' a decision must be
arrived at by two lines of evidence — that derived from the patient or
the friends of the patient, and tliat obtained by the surgeon's own
objective examination.
Information Obtained from the Patient or his Friends. —
No matter how clear a case ma}' api)car or how urgent the demand
for our assistance, we should not neglect this part of our examina-
tion. If called to a case of fracture, do not immediately begin to
manipulate the injured limb. While removing your overcoat or
gloves it is easy to inquire how the accident happened or in what
position the patient was standing or lying when he was injured. A
few questions of this character will elicit information which may influ-
ence your examination and prove helpful in the diagnosis. For
example, a fall upon the outstretched hands is apt to produce Colles's
fracture, or upon the shoulder fracture of the clavicle, or upon the
knee — with a strong effort on the part of the patient to save himself —
fracture of the patella. A history of an injury caused by jumping from
a rapidly-moving railway or street car and landing upon the feet excites
our suspicion that a fracture of the fibula has been sustained.
In every case the following points should be noted under the head-
ing of history : Name ; address ; occupation ; age ; sex ; family history ;
heredity; habits, etc. ; previous residences; former diseases or injuries
and results ; previous operations.
1. Age has an important bearing upon our examination. Sarcoma
attacks persons of all ages, but particularly young people. Carcinoma
is exceedingly rare before thirty years of age, and common after forty.
Tuberculosis of bones and joints is most common in childhood. In-
flammation of joints in children is, in nearly all cases, an osteitis, while
in adults it not uncommonly begins as a synovitis. Goiter rarely
occurs before the ninth year.
2. Heredity. — Our ideas on the question of heredity have undergone
considerable change. Formerly it was supposed that a tubercular
child must, almost of necessity, be the offspring of tubercular parents.
While Baumgarten asserts that it arises more frequently by inheritance
than in any other way, the general opinion at present is that, although
the bacillus may undoubtedly be transmitted from parent to offspring,
the more frequent result of heredity is only a predisposition to the dis-
ease. In other words, the child of tubercular parents rarely, if ever,
inherits the disease ; he is more likely to acquire it when exposed to
the bacillus tuberculosis.
Syphilis is a disease in which heredity plays a most important part.
The poison can be transmitted through the ova and spermatozoa, so
that the characteristic lesions make their appearance before or shortly
after birth. It must also be borne in mind that the disease can be thus
transmitted long after the power is lost of communicating it by direct
contact.
Cancer is not now believed to be so markedly hereditary' as was
formerly supposed, although its tendency to run m families cannot be
denied. It would appear that races and nationality have an influence
upon heredity. The whites of the Southern States are more than twice
as liable to cancer as the negroes of the same region. The tendency
GENERAL EXAMIXATION OF PATIENTS. 1 9
to tuberculosis, on the other hand, is greater in the negro than in the
white. Jews are less liable than other whites to cancer and consump-
tion, but they are specially liable to diabetes and to certain degenera-
tions of the spinal cord in their declining years.
In examining for the evidence of heredity the patient should be
questioned concerning the health of his parents, brothers, sisters, aunts,
and uncles. It occasionally happens that an hereditary disease skips
over a generation (atavism) ; hence we must inquire into the histor)' of
the grandparents on both sides.
3. Sex. — Apart from diseases peculiar to each sex, there are certain
surgical diseases and injuries which, although common to both, show
marked preference for the one or the other. Cancer is more common
in females, owing to the frequencv with which it attacks the mamma
and the uterus. Sarcoma is more frequent in males, from the fact that
they are more exposed to blows and other traumatic causes which so
often precede sarcomata. The same rule applies to fractures. Goiter
is much more frequent in women.
4. The manner of living, habits, occupation, ability to endure fatigue,
residence, and, in the case of women, whether married or single, also
the number of children, if any, — all of these are important points in
evidence upon which we must return a verdict.
In the matter of living, the diet, habitation, hygienic surroundings,
and the clothing must be taken into account. The appetites, the use
of alcohol and tobacco, venereal excesses, and other abuses play an
important part.
Previous residences must be noted. Natives of Iceland are liable to
echinococcus ; residents of tropical countries are liable to abscess of
the liver. Certain districts are conducive to goiter, and others to cal-
culus of the bladder. Sterility in either sex and miscarriages in females
create a suspicion of syphilis, while the puerperal period in itself may be
a source of grave disease, as, for instance, extra-uterine pregnane}', in
the treatment of which some of the brightest victories of modern
surgery have been won.
Many cases of sarcoma can be traced back to a fracture or other
traumatism. Brain-abscess or blood-clot or epilepsy may manifest its
presence weeks or months after the receipt of a blow which caused
fracture of the skull.
History of the Present Disease or Injury. — The patient or his
friends should be required to give the particulars, as far as they can. of
the present disease or injur}', the manner in which the first departure
from health was felt, and the circumstances under which an accident
occurred, the direction and force of a missile, and the position of the
body of the injured person at the time of the accident. In cases which
are at all likely to come into court these points, although apparently
insignificant, should receive close attention, as they may attain great
prominence during the trial.
Examination of the Patient. — Having noted down the infor-
mation which can be obtained from the patient or his friends, the sur-
geon next devotes himself to a systematic examination of the case.
This is done under two heads: i. General; 2. Special.
General Examination. — Under this heading will be comprised
20 SURGICAL DIAGNOSIS AND TREATMENT.
(i) the general appearanee of the patient — whether emaciated or well-
nourished, well-developed or deformed ; the condition of his mind —
whether calm, excited, depressed, delirious, etc.
(2) The Position of the Patient. — Much valuable testimony may be
obtained by noting the position which the patient assumes while lying
in bed. A person in good health or only slightly ill will naturally lie
upon his back or in an easy posture on one or other side. In a state
of great weakness or when consciousness is impaired the patient is
inclined to slide down toward the foot of the bed. Dyspnea induces a
person to maintain a sitting posture, while inflammation of the lungs
or pleura causes him to lie in the posture which gives most steadiness,
usually upon the affected side. In peritonitis the sufferer lies on his
back with the limbs drawn up, and cannot even bear the weight of the
bed-clothes. In cerebral meningitis the head is drawn backward, bur-
rowing, as it were, into the pillow. In localized inflammation of the
brain the head is persistently held to one side. When the cerebellum
or crura cerebelli are the seat of disease, it is not uncommon to see the
whole body drawn sharply to one side, and immediately returning to
this position if disturbed.
(3) Surface-markings and Changes of Contour. — Under this head
will be noted any scars, deformities, changes in the shape of limbs, etc.
It will embrace tumors, deformities from old or recent fractures,
dislocations, etc.
(4) The Condition of the Skin. — {a) Color : Redness may be due to
hyperemia, by w^hich is meant an increase of the quantity of blood in
the vessels of the part, or to an escape of blood from the vessels
(extravasation.) It is a very simple matter to decide which of these
conditions is producing the redness. Light pressure will empty the
vessels in hyperemia and cause a momentary paleness ; upon extrav-
asations or purpura pressure has no effect.
Besides paleness or redness, certain modifications of color are
deserving of notice. One-sided redness of the face indicates localized
vasomotor paralysis and is suggestive of hemicrania. A characteristic
sallow hue }\\th shiny appearance is given to the skin in sudden and
severe hemorrhage. Prof Syme was in the habit of drawing our
attention to the peculiar appearance of the faces of those who suffered
repeated loss of blood from hemorrhoids. Cyanosis, or blue-red skin,
is due to an accumulation of carbonic acid and a deficiency of oxygen
in the capillaries. It arises in connection with disturbed respiration
and circulation through the lungs. It may also occur in the greater
circulation, and be either general or local according to the extent of
obstruction. Cyanosis is seen in the following conditions : spasm of
the glottis ; tumors of the larynx ; acute and chronic inflammation of
the larynx or trachea ; foreign bodies in the air-passages ; goiter or
other tumors which press upon the larynx or trachea ; mediastinal
tumors ; bronchitis ; aneur}^'sm of the aorta ; and in any condition
which prevents complete expansion of the lungs, such as pleuritic or
pericardial effusion, thoracic tumors, and peritonitis w^hen it produces
paralysis of the diaphragm, etc.
The yellow or jaundiced or icteric skin is of interest to us in the
surgery of the liver and gall-bladder. It is not, as a rule, an indication
GENERAL EXAMINATION OF PATIENTS. 21
of abscess of the liver ; in fact, its existence may be said to be an
argument against the diagnosis of abscess.
Obstruction in the hepatic duct or the common bile-duct produces
jaundice, while obstruction in the cystic duct does not. One of the
most common causes is the presence of gall-stones. It may also be
produced by any tumors which press upon the duodenal orifice of the
ductus communis choledochus, and especially cancer of the head of the
pancreas. A practical point worth remembering is that jaundiced
patients bleed more freely during operations than do others.
Scars are especially worthy of notice, but in no location are they so
important as on the scalp. A scalp wound dressed in the drug-store
style, with no regard for asepsis, may heal, to all appearance, in a satis-
factory^ manner, but at the same time germs may find their way through
the skull along the vessel-channels and lead to cerebral abscess later on.
(5) Tevipcratiirc. — High temperature is present in fever, inflamma-
tory disease, and some nervous conditions. It is important as indi-
cating the absorption of septic material from a wound or pus-cavity,
and is a reliable indication for a removal or change of dressings. After
operations of any magnitude there is during the first forty-eight hours
a rise of temperature known as fermentation or aseptic fever, which
may reach 102° F., without exciting any uneasiness.
Subnormal temperatures occur temporarily in severe hemorrhages,
in chronic diseases of the heart and lungs, and in most chronic wasting
diseases. A sudden fall of temperature, accompanied by weakness of
the heart and general prostration, is spoken of as collapse. Continued
low temperature is rare, but it may be found in abscess, in inflamma-
tion of the brain, and in some wasting diseases. In acute alcoholism
the temperature has been observed as low as 75"^ F.
Local Changes in Temperature. — A local increase in temperature is
indicative of inflammation or paralysis of the vasomotor nerves of the
part. A lowered temperature is indicative of disturbance of the circu-
lation. It is commonly found in venous thrombosis. In paralysis of
a nerve the local temperature is usually first increased and afterward
diminished.
The knowledge gained by the general examination will* point to one
or more of the special organs or systems of the body as the seat of
the disease. The examination will be continued by making a minute
and careful study of the special system or organ to which the symp-
toms so far point. Having exhausted that part, the other systems and
organs are systematically examined. Our special study, therefore, will
comprise —
1. The Vascular System ;
2. The Osseous System ;
3. The Joints ;
4. The Digestive System ;
5. The Genito-urinary System;
6. The Nervous System ;
7. The Respiratory System ;
8. Morbid Growths ;
9. The Female Generative Organs.
22 SURGICAL DIAGNOSIS AND TREATMENT.
CHAPTER II.
EXAMINATION OF THE VASCULAR SYSTEM.
I. THE HEART AND PERICARDIUM.
Having removed the patient's clothing so as to expose the chest,
the student will find it useful to begin by counting the ribs. The
novice may have a little difficulty in distinguishing the first rib. It is
covered in its outer half by the clavicle, but near the sternum it lies
below the clavicle. Follow the front of the sternum from its notch
downward. About \\ inches from the suprasternal notch the fingers
will feel a ridge on the bone. This is the junction of the manubrium
with the gladiolus, and is exactly opposite to the insertion of the
second rib. Having definitely settled the location of either the first or
second rib, it is an easy matter to count downward. (Mark with your
pencil the third costal cartilage on the right side and the sixth costal
cartilage on the left side : these points represent the upper and lower
limits of the heart in the healthy chest.)
Now mark a point half an inch to the right of the sternum, and
another point half an inch to the right of the left nipple, and you have
the horizontal limits of the heart. The right auricle lies behind the
cartilage of the third rib on the right side, and the left auricle behind
the third costal cartilage on the left side. Posteriorly the heart-dulness
is found between the fourth and eighth dorsal spines. The left auricle is
covered by the pulmonary artery. The right ventricle is partly behind
the sternum and partly to the left of it. Behind the right lies the left
ventricle, except a small portion at its apex.
The pericardium is the fibro-serous sac which contains the heart and
the portions of the great vessels which enter into or issue from its base.
It is attached above to the deep cervical fascia, and below (which is its
widest part) it is in connection with the diaphragm.
Two conditions of the heart which call for surgical interference are —
overdistention of the ventricles and effusion into the pericardium.
Overdistention of the Ventricles. — This occurs in acute pul-
monary congestion. When the lung-tissue in a violent onset of acute
inflammation becomes engorged with blood and the air-cells are filled
with exudation, the blood is forced with difficulty through the pul-
monary circulation, the right ventricle becomes overdistended, and,
unless relief is obtained, the condition becomes critical. The symp-
toms indicating overdistention are — great dyspnea, dulness on percus-
sion over a considerable area of one or both lungs, vocal fremitus, and
distress over the region of the heart.
In the treatment of this dangerous condition the heart may be
relieved of a portion of its blood and the distention lessened by tap-
ping its cavity. The most convenient method of doing this is to aspi-
rate the right auricle. Find the third interspace, and at a point close
to the right of the sternum insert the needle. The reasons for select-
ing the right auricle are — first, the wall is thinner than that of the ven-
tricles ; second, it has a greater antero-posterior diameter ; third, it is
least liable to change its position in relation to sun'ounding parts.
EXAMINATION OF THE VASCULAR SYSTEM. 23
Operation. — Sterilize the skin and instruments. Use a large-sized
aspirating needle attached to the tube of an aspirator, for the force of
the circulation is not sufficient to drive the blood through the needle.
The needle should be pushed directly backward until it enters the
cavity, and the operation should be performed as quickly as possible.
It is attended with great danger. I question whether it possesses any
advantages over the old method of bloodletting, which is attended with
very happy results in just such cases.
Effusion into the Pericardium. — Under normal conditions the
fluid which lubricates the inner surface of the pericardium is in the
form of vapor, thus allowing the heart to beat with the least possible
friction or impediment to its movements. In pericardial effusion these
favorable conditions are lost, and the laboring heart is compelled to do
its work in a pool of watery fluid.
In nearly every instance effusion into the pericardium is a sequel of
rheumatic fever. The symptoms are dyspnea, great distress in the pre-
cordia : as a patient once expressed herself to me, " The heart feels as
if it were bursting." The area of dulness is much increased, and may
extend as high as the clavicle. The dull area is generally pyriform or
quadrilateral in shape, with the base below and extending to both sides
of the apex of the heart. The movements of the left chest are im-
paired, the veins of the neck are enlarged, and a peculiar wavy motion
is felt when the hand is placed over the heart. The apex-beat is felt
higher up than in the normal condition, and to the left. By the stetho-
scope we find muffling of the heart-sounds and the absence of vocal
resonance and fremitus. If we examine the case before the pericardial
walls become separated from one another by the fluid, we may find a
pericardial friction-sound. This sound is not propagated beyond the
pericardium, and is wanting in the regularity of rhythm which charac-
terizes the endocardial murmur.
Many cases of effusion are slight and have a tendency to end in
absorption. In exceptional cases, however, the fluid increases and
threatens life. Then we should unhesitatingly resort to the operation
of paracentesis of the pericardium.
In the left fifth interspace mark with a pencil a spot 2 inches to the left
of the left border of the sternum. This, as a rule, is the best point at
which to aspirate the pericardium. The reasons for selecting this posi-
tion are — (i) it gets at the fluid in the lowest part of the pericardial
cavity, thus securing perfect drainage ; and (2) this point is well to the
outside of the internal mammary artery.
Operation. — Use a good-sized needle and aspirator. Push the
needle directly backward until the cavity is reached ; withdraw the
trocar quickly, leaving the cannula in position, so as to avoid puncturing
the heart-muscle. Draw off the fluid slowly and watch the effect.
In the case of a lady upon whom I thus operated the opening was
made in the sixth interspace, because the enormous amount of fluid
which was present distended the sac much below the usual limits. The
heart touched the cannula at every pulsation. The patient fainted
several times during the operation. Thirty-two ounces of serum were
withdrawn, and a good recovery was the result.
When the fluid is found to be purulent the proper treatment is to
24 SURGICAL DIAGNOSIS AND TREATMENT.
make an incision and employ drainage. Therefore, while the cannula
is still in position and pus is found to escape, use the cannula for a
<^uide, dissectini:^ carefully through the tissues until the finger can enter
the pericardial cavity. If sufficient room cannot be obtained or if the
drainage-tube cannot be kept open, it will be necessary to remove a
portion of a rib. The pericardium bears washing out and disinfecting
well, and is tolerant of mechanical and chemical irritations.
Injuries of the Heart. — Rupture of the heart is, fortunately,
rare. It has been known to occur as a result of a thrombus or an
embolus causing complete obstruction in one of the branches of the
coronary arteries. A sudden rupture of an aneurysm or an abscess
into one of the cardiac cavities has produced rupture. It has also been
noted as a cause of death in tetanus. The onset of the symptom is so
sudden and so fatal as to leave little for us to study in the way of
diagnosis.
Wounds of the Heart. — The circumstances under which we
would expect to find wounds of the heart are — violent compression
of the thorax, fracture of the sternum and costal cartilages, with frag-
ments driven inward, or wounds from the outside, such as stabs or
gunshot injuries. The organ has also been wounded by fishbones or
other foreign bodies penetrating it from the esophagus.
A wound of the heart does not necessarily occasion death. Strange
as it may at first appear, a stab wound penetrating this organ may be
followed by little or no hemorrhage. This is due to the peculiar
arrangement of the fibers of the cardiac muscles. In examining the
heart for wounds we must be guided by the following symptoms : Pain
is felt, and it is usually severe, but may be absent owing -to collapse.
In most cases there is syncope. If there be escape of blood into the
pericardium, we will find the area of cardiac dulness enlarged, owing
to the presence of the fluid. At the same time, the heart-sounds will
be less distinct, and in certain cases splashing may be heard. A sign
of pericardial hemorrhage is dyspnea.
Treatment. — The patient should be kept at perfect rest, with the
head lowered to avert anemia of the brain, and opium may be given to
relieve pain and shock. Unless the hemorrhage from the external
wound be copious and of itself threatening life, it is best not to check
it, lest the flow take place into the pericardium and cause death by its
presence there.
II. EXAMINATION OF THE VEINS.
The morbid conditions of veins which are interesting from a surgical
point of view are — Wounds, TJirovibosis, Phlebitis, Varix or ]^arieose
Veins, and Nevus. The examination is made by inspection, and some-
times by palpation and auscultation.
Wounds of Veins. — When a small vein is wounded it collapses
and hemorrhage from it is slight. A wound of a large vein is attended
with great danger, owing to the rapidity with which the blood escapes
from it. Besides this danger, most serious consequences can arise from
septic infection. The symptoms of venous hemorrhage are — a steady
flow of dark-colored blood, being in marked contrast to the light-red
EXAMINATION OF THE VASCULAR SYSTEM. 25
color and spirting of the blood from an artery ; pressure on the distal
side of the vein causes arrest of hemorrhage, while pressure on the
proximal side increases it.
Treatvioit. — In small veins perfect rest of the part, elevation of the
limb, and pressure on the distal side are all that are necessar}'. When
large veins are wounded the divided ends should be found and secured
with aseptic catgut ligatures. A longitudinal slit in a large vein can
sometimes be closed by picking it up with forceps and securing the
bleeding point with a ligature, without obstructing the lumen of the
vessel. If the longitudinal slit in the vein-wall is too long to be
grasped by forceps and ligated, it is possible to close it by a fine con-
tinuous silk or catgut suture. It is not necessar)' that a clot should
form at the point of ligation.
Thrombosis. — In its normal state a vein is a soft, unresisting tube.
The superficial vessels are readily seen and felt, while the deeper are
beyond observ^ation. When thrombosis takes place all this is changed.
The veins become transformed into hard, knotted cords, and some of
the deep as well as the superficial can readily be felt beneath the
examining fingers. Thrombosis is due to some alteration in the wall
of the vessel, to changes in the blood, or to both causes combined.
We look for it in parts where the circulation is most feeble, as, for
instance, in varicose veins or behind valv^es. In exhausting diseases,
such as typhoid fever or advanced phthisis, clots often form very
insidiously, without any apparent change in the vessel-walls. Foreign
bodies introduced into the lumen of a v^essel produce clots in a short
time, and this circumstance is made use of in the treatment of aneurysm.
The tendency of venous thrombi is to extend toward the heart, spread-
ing from vein to vein. The danger comes when the clot reaches a
vessel in which the current is too rapid. A portion of the thrombus is
liable to break off, and, being swept into the current of the circulation,
sooner or later becomes impacted in a vessel and constitutes an embolus.
Phlebitis, or inflammation of v^eins, has the knott}^ cord-like cha-
racter just described, but in addition there is acute inflammation of
the surrounding cellular tissue (Fig. i). The affected part is very tender
to the touch, and at times the skin is reddened. There is usually con-
siderable pain and stiffness, particularly on movement, and the discom-
fort is increased by allowing the limb to hang down. The limb is stiff,
heavy, and unwieldy. When the deep veins of the leg are inflamed,
there is usually edema about the ankle due to interference with the
return circulation.
The treatment includes rest, elevation of the limb, cold, acetate-of-
lead lotion, mild cathartics, light diet, and the proper treatment for the
diathetic disease which may be the cause, such as gout^ syphilis, or
rheumatism. If there is a tendency to the formation of abscess, use
warm antiseptic baths, and as soon as practicable get rid of the pus by
incision.
Varix, or varicose veins, are easily diagnosticated. They are
usually found in the lower extremity ; and the vein most commonly
involved is the internal saphenous. The vessels are dilated, thick-
ened, tortuous, and rise above the level of the skin. Sometimes the
varicose condition begins where the veins take their origin from the
26
Si'KGJCAL DIAGNOSIS AND TREATMENT.
CiH)illaiy s)'stcm. When such is the case the part shows a fine capilhuy
injection with an arborescent appearance.
We at other times find the limb presenting a marble-like character,
hard and swollen, but not pitting on pressure. This is apt to take on
an eczema of the skin, which later forms ulcers — the so-called varicose
ulcers. The danger attending varicose veins, and more particularly
l'"u;. I. — Phlebitis of the lower extremities in a child.
where ulceration is superadded, is the liability to bursting of the veins
and inevitable hemorrhage. A varicose vein cannot readily be mistaken
for anything else. It is possible, however, that a varix of the internal
saphenous may be mistaken for femoral hernia. The point is easily
settled. When the patient lies down the varicose tumor disappears ;
so does a femoral hernia. Ask the patient to cough or assume the
upright position ; both swellings reappear. But press upon the swell-
ing while the patient is in the recumbent position, then, still keeping up
the pressure, ask him to stand up ; if the swelling is a varix, it will
reappear ; if a hernia, it will not.
Varicose veins are produced by two conditions acting simultaneously :
first, increased local blood-pressure and obstruction of the return cir-
culation, and second, a specific pathological condition not yet satis-
factorily explained. The commonest causes are tumors in the pelvis,
pregnancy, diseases of the heart and lungs, and occupations which
require the person to stand long upon his feet. Obstruction or defect-
ive development of the vena cava is capable of producing varicose veins
of enormous extent, as was shown in a case reported by Dr. Derville.
Treatment. — Palliative. — Remove the cause by attention to the
bowels and by treatment of the disease which has produced obstruc-
tion in the veins. Much benefit can be obtained by wearing an elastic
bandage or stocking. Bandages of zinc glue are cheap and very
EXAMINATION OF THE VASCULAR SYSTEM. 2/
serviceable. They are applied as follows : A gauze roller bandage is
first applied to the leg, and over this a layer of the glue, at a tem-
perature sufficient to keep it fluid, is applied with a brush. After a
few minutes another layer of bandage, followed by a second coating
of glue, completes the dressing. The limb is kept at rest for an hour
to allow the bandage to dry. After dissolving the zinc glue the vessel
containing it should be left floating in hot water to prevent cooling.
Radical measures include the following : Exposure and ligation of
the vein, subcutaneous section with compression, multiple subcutaneous
ligatures, injections of pure carbolic acid into the tissues about the
veins, the use of acupressure needles and twisted sutures, and excision
of more or less of the diseased vein.
Nevus, telangiectasis, or mother's mark, is a disease affecting
both veins and capillaries. Nevi are easily recognized. Their most
common seat is on the face, and sometimes on the trunk. In size
they vary from a pin's head to an area the size of the hand or even
larger. When the nevus is composed of capillaries, the growth is
raised slightly above the skin and is of a scarlet or purple color. If
veins enter into its formation, it is either in the skin or beneath it. It
pulsates and is larger than the capillary nevus, and of a blue color.
To this form the name of cavernous angioma is sometimes applied.
If one of these growths be cut into or punctured, alarming hemor-
rhage is liable to follow.
Treatment. — Many operations have been resorted to for the removal
of nevus. Ligation and excision are the best. Ligation is best em-
ployed by passing a pin under the growth, and then placing a ligature
below the pin to constrict the whole mass. Larger nevi require double
ligatures, which can best be applied by passing a second ligature under
and at right angles to the pin, and tying the nevus in two halves.
Excision is very satisfactory when loose skin can be obtained to allow
the edges of the wound to come accurately together without puckering
or stretching. Injection of coagulating fluids and electrolysis have also
been employed, and good results have followed in many cases. It
must, however, be borne in mind that this treatment has occasionally
led to sudden death from embolism.
III. EXAMINATION OF THE ARTERIES.
Our inquiries under this head will comprise ivounds of arteries,
rupture of arteries, atheroma, inflammation of arteries, and aneurysm.
In a wound of any extent the question of hemorrhage is a prom-
inent one. It will be necessary to decide what arteries, if any, are
divided, and promptly check the flow of blood from them. Blood
flowing from a divided artery is bright red and comes in jerks. From
a vein it is purple and has a continuous flow or wells up out of the
wound. From capillaries bright red blood oozes out more or less
freely, and there is no spirting.
There are conditions in which the spirting of an artery cannot be
seen, as when the divided vessel lies at the bottom of a deep wound
and the blood wells up rapidly. The flow is then continuous, but its
persistence and profuseness are sufficient evidence that a large vessel
28 SCRGICAL DIAGNOSIS AND TREATMENT.
is involved. The position of the wound will indicate the arterial trunk
or branch from which the blood flows. The treatment will depend upon
the size and position of the vessel, and also upon the amount of blood
which is escapint^. In many cases the natural arrest of hemorrhage is
sufficient (the contraction of the coats of the vessel within the sheath
and the coagulation of the blood in the divided ends of the artery), in
others we must assist nature.
The readiest temporary method of arresting hemorrhage is by
pressure at the bleeding point or upon the artery above it. Never be
afraid of a bleeding poi>it ivlien yoii can plaee your finger npon it (not a
dirty but an aseptic finger). If you make pressure at the proper spot,
vcr}' little force is required, and this force can be easily maintained
until permanent control of the bleeding has been secured. Pressure
upon the artery above the wound is applied by the fingers, by a tour-
niquet, or by an Esmarch bandage. The brachial can be controlled by
pressure upon it in the middle of the arm, where it lies in the angle
on the inner side of the biceps. The subclavian can be controlled by
the thumb pressing the vessel against the first rib. The femoral at
Poupart's ligament lies midway between the symphysis pubis and the
anterior superior spinous process. It can be compressed most readily
by the thumbs of the operator, who stands in such a position that his
arms are almost straight. This position is not fatiguing, and can be
maintained for half an hour or so without difficulty. The femoral can
also be compressed on the inner aspect of the thigh at its entrance to
Hunter's canal. The aorta is compressed with difficulty, except in
children and emaciated people. It can, in them, be felt just above and
a little to the left of the umbilicus. The radial and ulnar can be com-
pressed just above the wrist, and the tibial for a short distance above
the ankle.
Tourniquets are necessary when continued compression is required.
The most simple is Esmarch's, which consists of a |-inch rubber tube
about 1 8 inches in length, with a hook at each end. It is simply
wound around the limb above the wound tight enough to compress
the artery. The dangers of Esmarch's bandage are paralysis of nerves
(by too long compression) and anemia. Sloughing has been produced,
particularly when the tourniquet has been applied for primary hemor-
rhage before amputation. It should be kept on as short a time as
possible. An emergency tourniquet can be made from a handkerchief
tied around the limb and twisted tightly.
Having got the bleeding under control, the next question is how to
arrest it permanently. The stoppage of the circulation by pressure or
the tourniquet has given the blood at the bleeding point time to coagu-
late, and if, when the pressure is slowly removed, no blood escapes,
the wound may be dressed, leaving the clot in position. When the
divided artery can be seen, it should be tied at both ends with catgut
or silk ligature. If the wound is not large enough to expose the ves-
sel, it must be extended and the bleeding points found and tied.
Heat is a valuable means of arresting hemorrhage from a number
of small vessels or oozing from a large surface. It is best applied by
using water as hot as can be borne by the hand.
Cold is also a good hemostatic. It is employed by exposing the
EXAMINATION OF THE VASCULAR SYSTEM 29
wound to the air or by ice or ice-water. Its action is upon the muscular
coats of the vessels, and is only of value when the bleeding vessels are
small.
Packing with iodoform gauze is required in niany cases, but except
where it is desirable to have the wound heal by the open method, as in
operations for the removal of diseased bone, it is seldom employed.
Acute Arteritis. — This is a rare disease, and some writers state
that it is doubtful if it has ever been diagnosed during life. The cases
in which tenderness and redness were observed along the course of an
artery having recovered, there was no opportunity to verify the diag-
nosis by post-mortem. In a case of symmetrical gangrene which came
under my care I was able to trace the radial arteries and the caro-
^^^'
J
Fig. 2. — Symmetrical gangrene without Raynaud's phenomena (Jonatlian Hutchinson).
tids by the tenderness and hard, cord-like feeling, such as is found
in phlebitis, and confidently pronounced the condition acute arteritis.
The patient, a little girl, died from occlusion of the middle cerebral
artery. The post-mortem clearly showed arteritis and an extension of
the inflammation from the carotid to the arteries of the brain, which
caused her death.
The symptoms which are indicative of acute arteritis are — tenderness
along the course of the vessel, a hard, cord-like feeling under the
fingers when the vessel is pressed upon, and at times obliteration of
the artery, followed perhaps by gangrene of the parts to which the
artery is distributed.
Chronic Arteritis. — This is very important to us from a diag-
nostic point of view. Chronic arteritis, or atheroma of the older
authors, is the condition which lays the foundation for aneur>^sm. It is
chronic inflammation of the internal coat, with fatty degeneration and
a tendency to the formation of calcareous deposits. We should look
carefully for atheromatous arteries in old people, in those who have
30
SURGICAL DIAGNOSIS AXD TREATMENT.
suffered from rheuniatisni, l^right's disease. L^out, or syphilis, and in
hard drinkers. We must bear in mind that atheroma affects the large,
while s}'philis attacks the smaller, arteries. The disease begins in the
inner coat, which becomes opaque and cloudy. The circulation in it is
disturbed, and in parts cut off, so that ulceration soon follows. The
middle coat does not become involved until late, and the outer coat is
affected last of all. It is only when atheroma has produced its evil
effects upon the artery that we can diagnosticate its existence during
life. These effects are calcification and aneurysm.
Following the change in the inner coat is an inflammation in the
middle coat, and a deposit of calcareous matter, carbonate of lime, and
phosphates. This gives the vessel a firm, hard feeling which has been
compared to a pipestem. Such a condition affects the circulation, the
vessel losing its elasticity, the flow of blood is impeded, the roughened
internal surface increases friction, and, as a consequence, thrombosis
and embolism are liable to occur. If the supply of blood is cut off in a
marked degree, we have senile gangrene as a result. The arteries are
also liable to become elongated and tortuous, as is often seen in the
temporals of aged people.
What we have to look for then is a hard, pipestem-like condition in
the arteries. The vessels may also be tortuous and elongated. The
subjects are old people, men much more frequently than women.
IV. ANEURYSM.
An aneurysm is a tumor containing either fluid or coagulated blood
and communicating with the cavity of an artery.
Aneurysms are classified as follows :
According to their causation they are spoken of as trainnatic and
idiopathic. A traumatic aneurysm is one in which the coats of a
Fig. 3. — Sacculated aneurysm (Keen and White).
healthy artery give way under a sudden injury, forming a tumor, the
sac of which is composed of the vessel-wall, the cicatrix, or a clot of
blood which closed the wound. Idiopathic aneurysms are those which
are produced by disease in the walls of the vessels. The sac is com-
EXAMINATION OF THE VASCULAR SYSTEM.
31
posed of one or more of its arterial coats. When the shape is taken
as the basis of classification two varieties are recognized : sacculated
when the wall at one side of the arter>' is expanded into a pouch
(Fig. 3), and fusiform when the coats are uniformly dilated in the
whole circumference of the vessel and for a considerable distance in its
length (Fig. 4). A dissecting aneurysm (Fig. 5) is a variety by itself
Fig. 4. — Tubulated or fusiform aneurysm (Keen and White).
Fig. 5. — Plan of a dissecting aneurysm (Holmes).
It usually begins in the breaking down of an atheromatous ulcer. The
blood makes its way between the arterial coats, stripping them asunder
and forming a sort of fistula in the v^essel-wall. After traversing the
wall for some distance the stream finds its way back into the vessel or
perforates all of the coats, and is extravasated into the surrounding
tissues.
The terms true and false aneur}^sm are of little practical value. A
true aneurysm is one in which all the coats of the artery enter into the
formation of the sac. This is only possible when the aneurysm is of
small size. A false aneurysm has the inner coat of the arten,^ much
altered and thickened, the middle and outer coats have disappeared,
and the wall of the sac is formed by the thickened connective tissue of
the surrounding parts.
In examining for an aneur\'sm our attention should be directed to
32
SCJ^GICAL DIAGNOSIS AXD TREATMENT.
the vessels upon w hich tlic greatest strain is thrown. The larger ves-
sels, too, are those generally affected. The arch of the aorta, the part
where the external iliac becomes the femoral, the parts of the arteries
from which branches arise, and the convexities of all the curves are the
most common seats of aneurj-sm.
The arteries of the brain and those of the lower limbs, particularly
the popliteal and the splenic, suffer frequently.
Symptoms. — Attention is usually directed to an aneur>'sm by the
pain which the patient feels. It is generally severe, and may be
described as sharp and lancinating (in that respect resembling carci-
noma), or it may be aching or burning like the pain of ulceration. As
the pain is due to pressure, the tumor is generally of considerable size
before this becomes a marked symptom. At times a nerve — the pop-
liteal, for instance — is flattened and stretched over the tumor. The pain
Fig. 6. — Aneurysm of the mammary artery (Jepson).
in such a case is intense, and is felt along the course of the nerve. If
aneur>'sm is located on one of the limbs or in a superficial position, we
expect to find a tumor (Fig. 6). The following questions must then be
answered :
(a) Does the tumor pulsate ? In the first stage of an aneurysm
(that is, while the contents are fluid) distinct pulsation can be felt. The
pulsation is peculiar ; it is eccentric, expansile, and synchronous with the
heart-beat. Place a hand on each side of the tumor, and with each
pulsation the palms will be separated from each other. An abscess
may have the fluid character of an aneurysm, and, if it happen to lie
over the situation of an artery, a pulsation will be communicated to it.
In this case the pulsation will be up and down, and not laterally.
EXAMINATION OF THE VASCULAR SYSTEM. 33
{b) Has it a bruit ? In an aneurysm, owing to the roughening of
the lining of the sac and to the circumstance of the blood rushing into
the cavity and out again, a peculiar sound can be heard, not only ov^er
the tumor, but also along the artery above and below the sac for a
greater or less distance. Sometimes this sound is blowing in character,
or it may be rasping like the noise made by a saw. There are malig-
nant vascular tumors which have bruits that might be mistaken for
aneurysm, but it must be borne in mind that the bruit of an aneurysm
is heard along the course of the artery as well, while in the case of
malignant tumor the sound is confined to the growth itself
{c) Can the size of the tumor be changed by pressure upon the
artery ? If we can make pressure upon the artery on the side of an
aneurysm nearest the heart, we find that the size of the tumor is dimin-
ished, for we cut off the supply-pipe which fills the cavity. If, on the
other hand, we press upon the artery on the side farthest from the
heart, the tumor is increased, because we obstruct the overflow-pipe
and increase the tension in the sac.
If aneurysms were always filled with fluid blood, the diagnosis
would be comparatively easy. It is only in their first stage that such
is the case. As the disease progresses there is always a tendency to
the formation of fibrinous layers, which by degrees change the charac-
ter of the tumor from a fluid to a more or less solid mass. This is
sometimes called the second stage. The effect of this solidity is natu-
rally to render the pulsation less distinct, so that in some cases it is
entirely lost. It may happen that the fibrin is not deposited evenly in
the sac ; in that case we may find pulsation in certain portions of the
tumor, but not in others. The tumor being solid, it will not be changed
in size by pressure above or below as in the case of an aneurysm in its
first stage. Still, as a rule, we have the bruit to rely upon, for it can be
heard not only over the sac, but above and below it along the course
of the artery.
(^) Are there any pressure-effects ? If the veins suffer from pres-
sure, we will find edema of the limb below the tumor. This, if long
continued, may terminate in ulceration or even gangrene. The effect
of constant pressure is to produce atrophy ; hence we have absorp-
tion of osseous tissue when bone is pressed upon, as, for instance, the
sternum in thoracic aneurysms. Pressure upon the trachea produces
difficulty of breathing, and almost a pathognomonic sign of aneurysm
of the arch of the aorta is a peculiar, brassy, unfinished cough, due to
pressure upon the recurrent laryngeal nerve of the left side. If
the esophagus suffers pressure, difficulty of swallowing will result.
Hiccough is produced by pressure upon the phrenic nerve, and when
the sympathetic nerve is pressed upon we see capillary congestion.
Pressure upon the thoracic duct prevents the chyle from entering the
blood and may lead to death by starvation.
When, in spite of all these inquiries, you are in doubt, an explora-
tion with an aseptic hypodermic needle may settle the point.
Mistakes to be Guarded Against. — Pulsating tumors which resemble
aneurysm are most likely to lead us to a false diagnosis. These are
the pulsating encephaloid, soft sarcoma, erectile tumors, and pulsating
tumors of bone. The history of the case, the existence of arterial
34
SURGICAL DIAGNOSIS AND TREATMENT.
degeneration in other parts of the body, and the characters already-
described will, however, as a rule, keep us from falling into error.
Treatment of Aneurysm. — Nature in many cases attempts the cure
of aneurysm, but seldom succeeds. The process of cure consists in a
filling of the aneurysmal sac by the deposit of successive layers of fibrin.
Our aim in treatment must be to imitate Nature. If we can cause the
circulation in the sac to become slower, either by occlusion of the
afferent or efferent vessel or by obliteration of the sac itself, the object
will be accomplished. Medical and surgical measures are at our dis-
posal. Of the medical methods, Tufnell's is probably the best. It
consists in confining the patient to bed in the recumbent position for
several months on restricted diet, with the view of reducing the watery
elements of the blood and increasing its solid constituents. The diet
is restricted to ten ounces of solid and six ounces of fluid nutriment
in each twenty-four hours. Opium is given to relieve pain, lactucarium
to produce sleep, and compound julap powder to produce watery dis-
charges from the bowels.
Surgieal Methods. — i. Compression. — This is a very old method,
having been used at least 200 years ago ; its early employment, however,
was confined to traumatic aneurysm. John Hunter in 1785 tied the
femoral artery in Hunter's canal and established a new principle — viz.
Fig. 7. — Compression of the femoral artery for popliteal aneurysm (after Esmarch).
that it is necessary only partially, and not completely, to intercept the
current through the aneurysmal sac. This is the aim of compression,
and it can be carried out at some distance from the seat of the disease,
as, for instance, over the common femoral when the popliteal is the seat
of aneurysm. Compression can be applied by the fingers (relays of
assistants keeping up the treatment until the end is attained) or by
compressing instruments (Fig. 7) or by flexion of the joints.
2, Rapid cure by tourniquet or by Esmarch's bandage.
3. Ligation. — (c?) Hunter's method : The ligature is applied on the
cardiac side of the tumor, one or more branches intervening between
the ligature jmd the sac. {li) Anel's method: The same as the
EXAMINATION OF THE VASCULAR SYSTEM. 35
preceding, without a branch between the Hgature and the sac. {c)
Brasdor's : Ligature on the distal side, without an intervening branch.
(d) Wardrop's : The same as the preceding, with an intervening branch.
\e) The old operation of Antyllus, in which the artery was tied, both
below and above the sac, close to the tumor. This method is now
adopted in cases of traumatic aneurysm only.
Other methods of treatment are galvano-puncture, the use of
coagulating injections, and the introduction of foreign bodies, such as
fine wire, into the sac.
V. SPECIAL ANEURYSMS.
Aneurysm of the Arch of the Aorta. — We cannot here follow
the line of investigation laid down for superficial aneurysms. Pressure-
symptoms play the most prominent part, and the structures pressed
upon will depend upon the position of the aneurysm and upon its size.
At the transverse portion of the arch there is less room for expansion
than at the other divisions of the vessel, owing to the shallowness of
the chest at this part. Consequently, the symptoms of pressure are
most marked, and make their appearance earlier, in this form of the
disease. In aneurysms of the ascending and descending portions the
tumor has more room, and hence the symptoms of pressure are longer
delayed.
{a) Pain. — From first to last pain is likely to prove the most promi-
nent symptom. Some patients will describe a sudden tearing pain as
of something " giving way " when in a violent effort the middle coat of
the vessel is ruptured, and thus forms the starting-point of the aneurysm.
Later, the pain is due to the stretching of fine nerve-filaments in the arte-
rial coats or to pressure upon neighboring structures. Anything which
increases blood-pressure in the sac will aggravate the pain, and under
such conditions the suffering may be excruciating. When the tumor
presses against the sternum in front or upon the spinal column behind,
a constant boring, dull pain is experienced, and erosion of the bones
results. In a small proportion of cases great pressure may be exerted,
and yet the patient may never complain of pain.
(/;) Bruit. — The characteristic bruit of aortic aneur>^sm is a soft,
systolic murmur heard over the tumor and sometimes along both
carotid arteries.
(r) Pressure-symptoms. — When the transverse or descending portion
is the seat of aneurysm, the recurrent laryngeal nerve of the left side,
which here winds around the arteiy, suffers from pressure. This pro-
duces its effect upon the laryngeal muscles, and the patient suffers
from a peculiar cough. The character of this cough is, that it does
•not afford any relief It has been aptly described as an " unfinished
cough."
Hemoptysis is a result of aortic aneurysm under the following
conditions: (i) The tumor may press upon the trachea, causing con-
gestion and rupture of the vessels which traverse its mucous membrane.
(2) The aneurysm may press upon the lung-tissue, cutting off the
blood-supply to a portion of the pulmonary substance and causing it to
break down. (3) The aneurysm may rupture into the trachea or
36 SURGICAL DIAGNOSIS AND TREATMENT.
bronchial tubes. The amount and character of the expectorated blood
will afford pretty fair e\'idence of its source. If it comes from the
trachea, it appears as a simple stainin<^ of the mucus and the quantity
of blood is never large. Coming from a portion of broken-down lung,
it has the character of phthisical hemorrhage. When the aneurysm
ruptures into the trachea or bronchi, the first appearance of blood may
be trifling in amount; but after the lapse of a few hours, when the
rupture has had time to enlarge, blood may be forced up in such
quantities as to end the patient's life in a few seconds. This is the
" bursting of a blood-vessel " which noxelists love to describe.
Aneurysm of the Ascending Portion of the Arch. — The
.symptoms peculiar to this aneurysm are —
{a) The presence of a tumor which can be felt to pulsate to the
right of the sternum in the second or third intercostal space. In
exceptional cases the tumor may be found to the left of the sternum.
At first it is obscure, but later, when by erosion the sternum becomes
thinned or even perforated by constant pressure, the thrill and pul-
sation may be distinctly felt.
Aneurysm of this portion of the aorta is especially dangerous,
owing to the anatomical fact that it is covered only by the thin serous
layer of the pericardium which allows of the coats becoming rapidly
distended and favors rupture into the pericardial sac.
In examining the tumor remove all clothmg from the chest and
place the patient in a strong light. Slight pulsations are best observed
by viewing the chest transversely from the side, the examiner's eye
being brought almost on a line with the front of the chest. Aneurysmal
pulsation is expansile, not only rising and falling, but expanding later-
ally with the heart-beats. To demonstrate this lateral expansion the
following simple expedients may be resorted to : {li) Cover the promi-
nence with a piece of adhesive plaster which has a slit cut down its
middle line. If the pulsation be expansile, the slit will be seen to
widen with each pulsation (Fagge and Pye Smith). {8) Fix light
paper columns or cones of cotton-wool to opposite points of the
tumor : if these cones be found to diverge with each pulsation, the
tumor is expansile ; or two single stethoscopes can be used in a sim-
ilar manner.
By palpation a pulsation or thrill may be felt. If this is observed in
the upper part of the sternum, it may be set down as an aneurysm of
the ascending or transverse portion of the arch.
[b) By auscultation a murmur may be heard over the aorta or aneur-
ysmal tumor, but in some cases this murmur is absent. In such cases
Sanson! recommends that the patient place within his mouth the small
chest-piece of the binaural stethoscope and close his lips over it. In
this way a distinct or loud systolic murmur may be heard in the case
of a thoracic aneurysm, the " vibrations being communicated to the
trachea and thence directly by the air-column to the ears."
Pain is usually present, and there is tenderness on pressure over the
seat of the aneurysm.
(r) The pressure-symptoms are manifested according to the growth
of the tumor and its encroachments upon the neighboring structures.
As it grows toward the right, the vena cava superior is the first to
EXAMINATIOX OF THE VASCULAR SYSTEM. 37
suffer pressure, and as a result there are v^enous engorgement and
edema of the upper hmbs.
Toward the left it presses upon the pulmonary artery, and produces
dilatation in the right side of the heart and pulmonary symptoms
resembling phthisis. As the tumor grows upward it presses upon the
upper lobe of the right lung or its bronchus. As evidence of this the
breathing becomes impaired, and later, when the air is shut out of the
lung, there is a dull area on percussion. If the recurrent laryngeal
nerve be compressed, there will be the peculiar unfinished cough
of aortic aneurysm.
It is not uncommon in large aneurysms to find the heart displaced
to the left and downward. Pressure upon the inferior vena cava is a
very rare symptom. It is manifested by edema of the lower limbs and
ascites.
Aneurysm of the Transverse Portion of the Arch. — As this
portion of the vessel lies behind the trachea, a tumor connected with it
is almost sure to interfere with respiration. Hence its most frequent
manifestations are a suffocative cough, severe dyspnea, and stridulous
breathing. Sometimes the pressure is exerted upon the left bronchus,
interfering with the expansion of the left lung and causing a deficient
respiratory murmur. The esophagus may be pressed upon, causing
difficulty in swallowing and symptoms of stricture. Pressure on the
left recurrent laryngeal nerve causes paralysis of the left vocal cord.
Sometimes the pupils are unequally dilated, the pupil of the affected
side being contracted. This is due to pressure on the branches of the
sympathetic nerve.
Tracheal tugging is an important sign of aneurysm in this locality.
The simplest way of observing this sign is that of Ewart. The ex-
aminer stands behind the patient, who is seated in a chair with his
head slightly thrown back and steadied against the examiner's chest.
The tips of the index fingers are placed beneath the cricoid cartilage,
which is gently raised by them. With each beat of the heart a tugging
sensation is experienced by the fingers. Surgeon-Major Oliver's
method is as follows : The patient is placed in the erect position,
directed to close his mouth and raise the chin to the fullest extent.
The cricoid cartilage is then grasped between the finger and thumb and
gently pressed upward. When a tugging is felt an aneurysm is present.
In all cases of suspected aneurysm the voice should be carefully
studied. A shrill or crowing voice or one lowered to a whisper or
assuming a falsetto character should attract attention. A loud, brassy
cough, which has been so well described as the unfinished cough of
aneurysm, is especially significant, and is due to pressure upon the left
recurrent laryngeal nerve. A laryngoscopic examination should never
be omitted, for the vocal cords frequently give evidence of pressure
when there are no other respiratory symptoms.
The evidence gained by the laryngoscope is thus summarized by
Sansom : " On examination the observer may see that in ordinary
inspiration there is little if any difference in the position of the two
vocal cords ; the left may be a little nearer the median line. The left
capitulum Santorini and the left aryteno-epiglottidean fold may be on
a somewhat higher level than their fellows on the opposite side. On
38 ■ SURGICAL DIAGNOSIS AND TREATMENT.
phonation, the patient being asked to make the sounds softly of " ah "
and " ay," the left vocal cord may be seen to remain fixed, while the
right advances to the median line, or the right vocal cord may be seen
to advance to the middle line and project beyond it. It may encroach
so far as to meet the flaccid left cord, the cartilages overlapping when a
high note is sounded. Thus, while the whole of the right cord is in
view, only a portion, about half or one-third, of the left cord can be
seen."
The size of the pupils should be carefully studied in the diagnosis
of thoracic aneurysm. In common with other intrathoracic growths,
aneurysms may cause destruction of .sympathetic nerve-elements by
their pressure. Destruction of nerve-elements in the aneurysmal sac
is followed by paralysis of the cilio-spinal branches of the sympathetic ;
there is a paralysis of the dilator muscle of the iris supplied by the
sympathetic, and consequently an unopposed action of the sphincter of
the pupil supplied by the third nerve (Sansom). The left pupil is the
one usually contracted, and this should be regarded as a strong con-
firmatory sign of aneurysm. Examination of the arteries of the upper
extremities and neck sometimes affords valuable evidence. The ascend-
ing portion of the aortic arch gives off no branches ; the transverse
portion gives off the innominate, the left carotid, and the left subclavian.
If the aneurysm be confined to the first portion, the pulse-wave in the
carotids, brachials, etc. will be unchanged. But let the innominate
become involved, and the arteries on the right side will show a dimin-
ished pulse-wave, while those on the left remain normal. In palpating
the arteries begin with those nearest the aorta — viz. the carotids ; then
the brachials ; and lastly the radials. The points to look for are
enfeeblement of the pulse-wave in the large arteries and delay in the
radial pulse. Aneurysm of the transverse portion of the arcJi involving
the innoniinate, or an aneurysm of the innominate itself, produces a feeble
pulse-wave in the arteries of the right side and a delayed or obliterated
right radial pulse.
Aneurysm of the Descending Portion of the Arch. — This
portion of the aorta lies near the spinal column, and consequently its
pressure-symptoms are associated with this bony structure. Pain is
felt near the spine in one or both interscapular regions, and it may run
round the chest-wall in the form of intercostal neuralgia. The pain is
described as aching or boring, like all pain due to erosion of bone.
When the destruction of osseous tissue has advanced far enough to
allow of pressure on the spinal cord paralytic symptoms speedily
develop. Other pressure-symptoms are — {a) upon the esophagus,
causing dysphagia or even stricture ; {li) upon the left bronchus,
causing enfeebled respiratory murmur on that side, sometimes bron-
chitis, pneumonia, or symptoms resembling phthisis. The aneurysm
may rupture into the esophagus, but more frequently into the pleura.
It is difficult to differentiate between aneurysm of the arch of the
aorta and a similar condition of the innominate, left subclavian, and left
carotid. The following points, as given by Wyeth, will aid in arriving
at a diagnosis : The tumor in aneurysm of the ascending arch is usually
first noticed to the right of the sternum, between the clavicle and the
third rib. The pressure-symptoms do not affect the voice until the
EXAMINATION OF THE VASCULAR SYSTEM. 39
tumor is recognizable in the right side of the root of the neck, where it
involves the right recurrent laryngeal nerve. Respiration may be inter-
fered with or cough produced by compression of the right bronchus.
This condition will be recognized by the hissing rales distributed over
the area of the right lung. Aneurysm of the transverse arch is usually
first recognized to the left of the sternum at about the same plane as
for the ascending segment. Laryngoscopical examination will demon-
strate that whatever of muscular paresis exists is confined to the left
vocal bands. If the tumor rises into the neck, its appearance will have
been preceded by pressure-symptoms of longer duration and greater
severity than in either innominate, carotid, or subclavian aneurysm.
Innominate aneurysm usually appears at the upper margin of
the sternum in the space between the two tendons of origin of the right
sterno-mastoid muscle or in the interclavicular notch. The disturbance
of the circulation through this vessel so affected may be recognized by
the difference in the force and character of the pulse-wave in the radial
arteries of the two arms. In aortic aneurysm, when the innominate is
not compressed by the tumor, the pulse-wave is the same in both arms.
It must, however, be borne in mind that in sacculated aneurysms,
springing, as they not infrequently do, from the arch in immediate
proximity to the orifice of the innominate, and rising to the root of the
neck in front of, or behind this artery, a positiv'C diagnosis is scarcely
possible. The pressure on the innominate may retard or weaken the
right radial pulse.
Aneur)^sm of the left carotid artery first appears at the left sterno-
clavicular articulation in the line of this vessel. The murmur is trans-
mitted toward the distribution of the carotid, and is not heard in its
fellow opposite.
When the left subclavian is involved, the swelling usually appears to
the left of the sterno-mastoid muscle, and the pulse in the left radial
differs from that of the right.
Treatment of Aortic Aneurysm. — The treatment of aortic
aneur^'sm may be considered under the following heads :
Rest is the first consideration, and should be resorted to at the
earliest possible period. It lessens the tendency to rupture of the
aneur>^sm, and it helps to arrest the growth of the sac by diminishing
the blood-pressure. A person in health having a pulse-rate of 70
while in the sitting posture will have a pulse of 78 when standing.
The difference between the recumbent and erect posture in a person
suffering from aortic disease is still greater ; hence a saving of many
pulsations may be effected in the twenty-four hours by keeping the
patient at rest.
Diet. — Tufnell's method of feeding is the best yet adopted. It con-
sists in giving ten ounces of solids and eight ounces of liquids in each
twenty-four hours. The diet list for such a patient is as follows :
breakfast, two ounces of white bread and butter and two ounces of
milk or cream ; dinner, three ounces of meat and three ounces of
potatoes or bread, and four ounces of water or claret ; supper, two
ounces of bread and butter and two ounces of milk or tea.
Mcdicijie. — lodid of potassium has proved itself the best drug, and
was first advocated by Balfour in Great Britain and Bouillaud in
40 SURGICAL DIAGNOSIS AND TREATMENT.
r^rancc. To commence the treatment, five grains should be taken
three times a day ; at the end of a week this should be increased to ten
grains, and later to fifteen or twenty grains thrice a day. These doses
can be keep up for weeks, months, or even years. When there is
excessive heart-action or palpitation, aconite in one- or two-minim doses
given every hour affords great relief Pain is controlled by hypodermic
injections of morphine.
Anesthesia is recommended by Sansom, not only as indispensable
during the operative procedures about to be described, but as a valuable
therapeutic measure previous to, and perhaps in substitution of, surgical
interference. The cases most suitable for treatment by anesthesia are
those in which there is severe pain, either continuous or paroxysmal.
Chloroform is given daily for several days, and the patient is kept under
its influence for several hours each time. The effect of prolonged
anesthesia is to allow time for coagulation of the blood within the sac.
Operative Measures. — Distal ligature is attended with a fair degree
of success. When the transverse portion of the arch or the innominate
or the portion of the aorta close to the innominata is the seat of aneur-
ysm, the right carotid should be tied or the right carotid and right
subclavian. Ligation of the left carotid has also been practised, and
with good results in several cases. The operation is less dangerous
than the tying of both vessels on the right side, collateral circulation
being carried on more easily.
Galvano-puncture is attended with considerable danger, but, as the
cases for which it is demanded are otherwise hopeless, the patient may
justly claim the chance which it holds out. Of 114 cases in which it
has been employed, 68 were improved (Petit, cited by Sansom). It is
employed as follows : Having taken all the precautions required for
making the operation antiseptic, two needles are pushed through the
skin covering the tumor and into the sac. The needles are then con-
nected with the poles of the battery and a current of from twent>' to
thirty milliamperes turned on. The positive needle is then moved
about in the sac so as to touch the wall of the aneur>'sm at different
points. This is kept up for ten to twenty minutes, after which the
current is gradually reduced and the needles disconnected. The
positive needle is first to be withdrawn. Should it be covered with
fibrin so as to prevent its withdrawal, the current must be reapplied in
the opposite direction until the needle is loosened. The object of this
operation is to cause coagulation of the contents of the sac.
The risks of the operation are — {a) The blood may coagulate in the
center of the sac, the clot remaining soft, and finally breaking up in the
blood-current, {b) Blood may spurt freely from the punctures made
by the needles, and death may follow from inflammation of the sac.
{c) Small coagula may be carried off in the circulation.
Introduetio7i of Foreign Substances into the Sac. — W'ire has been
passed into the sac through a fine cannula, and the cavity filled with
coils with the object of inducing coagulation. This measure has
been so unsatisfactory that it is now practically abandoned. Never-
theless, one or two cases have been cured in this manner. Macewen
introduces metallic needles into the sac, leaving them in position for
twenty-four hours, and then withdrawing them.
EXAMIXATION OF THE VASCULAR SYSTEM. 4 1
Aneurysm of the Carotid. — The common carotid is liable to
aneun'sm at any part of its course, but more particularly at its bifur-
cation. This arter}^ departs from the rule that aneurysm is more com-
mon in men than women, for in this case the sexes suffer equally.
Some authors speak of two varieties, the high and the low, the low
being confined almost entirely to the right side.
A tumor along the course of the common carotid with expansile
pulsation and bruit is very likely to be an aneurysm. Further evidence
would be the following pressure-symptoms : dyspnea, spasmodic cough,
and hoarseness from pressure upon the trachea, the recurrent laryngeal,
or the larynx ; difficulty of swallowing from pressure upon the esoph-
agus or upon the pharynx in the case of the internal carotid ; neuralgia
from pressure of the cervical nen^es ; contraction of the pupils from
pressure upon the sympathetic ; edema from pressure upon the internal
jugular or, in rare cases, upon the left subclavian.
In most cases the diagnosis is very easy, but when low down in the
root of the neck a positive opinion is difficult to arrive at, and in some
cases a clear diagnosis is impossible. It is impossible at times to say
that aneurysm of the carotid exists alone, for a similar condition of the
subclavian, the innominate, or the arch of the aorta may strongly simu-
late it. The rules for differentiating already given may aid in coming
to a decision. Cysts lying upon the common carotid should not lead
any one into error, for the character of the pulsation is not expansile.
Enlarged lymphatic glands are not likely to cause doubt, for these
occur in groups and are lobulated. A rare condition which might
give rise to a disastrous error is aneurysm of the internal carotid
pressing upon the tonsil and simulating an abscess. Abscess of the
tonsil is an acute disease, which, as a rule, runs its entire course in
about nine days, while aneurysm is a chronic affection, and must have
existed for many weeks before enlargement of the tonsil is produced.
Besides this, tonsillitis is attended with high fever and other symptoms
characteris'tic of local inflammation.
TrcatJiu'iit. — If there is sufficient room, the vessel should be ligated
on the proximal side of the aneurysm, otherwise on the distal side.
Vertebral Aneurysm. — Aneurj^sm of the vertebral arter)^ is, as a
rule, of traumatic origin. It may be confounded with aneurysm of the
carotid. The point may readily be settled by pressing upon the com-
mon carotid. If the artery be pressed firmly backward at its bifurcation,
the circulation in the sac will be diminished if in a branch of the carotid,
but unaffected if the vertebral is the divte.ry involved.
It cannot be too strongly impressed upon the examiner that rough
handling of an aneur^^sm is to be avoided, owing to the danger of
detaching a clot which might be carried off in the circulation to form
an embolus. That caution is particularly applicable to aneurysms in
this locality, for a detached clot might readily be carried to the brain
and produce disastrous consequences.
Orbital or Ophthalmic Aneurysm. — The ophthalmic artei-)^
may be the seat of aneurysm, either in the orbital cavity or within
the cranium. Many of the cases of orbital aneurysm are not true
dilatations of the artery, but pulsating tumors, angeiomata, or arterio-
venous aneurysms. The diagnosis is readil)' settled b}' pressure upon
42 SURGICAL DIAGNOSIS AXD TREATMENT.
the common carotid. If pulsation ceases, it points to the treatment,
which is ligation of the carotid — an operation whicii has been attended
with about 75 per cent, of cures.
Subclavian Aneurysm. — The artery is divided into three parts :
the first part on the rit^iit side ascends obliquely outward from the origin
of the vessel to the inner border of the scalenus anticus muscle. On the
left side it ascends vertically to gain the inner border of that muscle
(Gray). The second part passes outward behind the scalenus anticus.
The third part passes from the outer margin of that muscle beneath
the clavicle to the lower border of the first rib, where it becomes the
axillary.
Landmarks. — Near the outer border of the sterno-mastoid, and
about one inch above the clavicle, the pulsations of the artery can be
felt. Behind it is the first rib, against which the vessel can be readily
compressed. Stand behind the patient's shoulder and make compression
with the thumb in the downward direction and a little inward.
The third portion of the artery is the part most frequently involved.
Next in order comes the first part, while the middle portion, owing to
its having the firm, resisting scaleni muscles in front of it, is least likely
to be the seat of aneurysm. The right side is much more frequently
affected than the left. Generally speaking, the first indication of
aneurysm of the subclavian is a tumor felt behind the clavicle and to
the outer side or behind the sterno-mastoid muscle. In its full devel-
opment it forms an elongated tumor behind and above the clavicle, and
has a tendency to rupture before attaining a large size.
Errors in diagnosis are apt to occur — first, by mistaking a glandular
or other tumor for an aneurysm, just as in the case of the carotid.
The absence of expansile pulsation and the fluidity of the tumor
should remove all doubt. Second, it may be difficult to determine
from what vessel the aneurysm springs. The history will help us. An
aortic aneurysm produces pressure-symptoms, and often causes death
long before it reaches the position of the subclavian. On the right side,
therefore, the question is easily settled. On the left side aneurysm of
the subclavian is rare, but the diagnosis is more difficult. Attention to
the following points may be of service : A tumor in the neck appears
early in the case of subclavian aneurysm, late in the case of an aortic.
The return circulation in the arm is interfered with in the case of the
subclavian ; not at all or late when the aorta is affected. The radial
pulse is changed in rhythm and volume on the affected side in sub-
clavian aneurysm, while if the second or third portion of the arch of
the aorta is the seat, there is no change in the radial pulse until the
branches are affected.
Treatment. — Tufnell's treatment should first be tried. Compression
on the proximal side of the aneurysm is only possible when the third
portion is involved. Ligation of the artery is most successful when
applied to the distal side. As a last resort the artery may be tied at
the proximal side of the aneurysm and the arm amputated at the
shoulder-joint.
Axillary Aneurysm. — The right side is much more frequently
affected than the left, and in most cases the aneurysm can be traced to
an injury. The growth of the tumor is rapid, and may be found pro-
EXAMINATION OF THE VASCULAR SYSTEM. 43
jecting downward into the axilla, inward and against the thorax, in
some cases causing absorption of the ribs from pressure; or upward
under the clavicle, in which case the shoulder is elevated. The move-
ments of the arm are interfered with, the head is drawn to the same
side, and the elbow is abducted. The more prominent pressure-symp-
toms are pain running down the arm from the brachial plexus, and
edema from interference with the return circulation through the axillary
vein.
Trcatinoit. — Compression, either digital or instrumental, to the third
portion of the artery should first be given a thorough trial. Failing in
this, the vessel should be ligated at this point.
Aneurysm of arteries below the axillar}' are rare, and usually the
result of injury. They present no special difficulty in diagnosis, and
can be recognized by the general principles already laid down.
Aneurysm of the Abdominal Aorta. — Any part of the artery
may be the seat of aneurysm, but the most common position is near the
diaphragm. The whole arter\' may be expanded in the form of a large
fusiform aneurysm, or the tumor may be of the dissecting or sacculated
variety. One or other of the branches of the aorta may be involved or
even obliterated by pressure.
History. — There is generally a history of injury or severe muscular
effort or continued laborious employment. If the aneurysm is idio-
pathic, the disease of the vessel is likely to be extensive. In the early
period the symptoms are obscure.
Pain varies in character, sometimes continuous, sometimes parox-
ysmal — in some cases running along the course of the nerves, in others
confined to one fixed position. When pain is continuous, it is due to
erosion of the spinal column, and is characterized as gnawing or boring,
referred to the back, sometimes at a fixed point over one of the verte-
brje. This pain is relieved when the patient assumes the recumbent
position with the face downward : it is aggravated by localized pressure
and by such movements as stamping or riding in a jolting vehicle. An
advanced stage of erosion may result in paralysis due to involvement
of the spinal cord.
Pulsation. — The pulsation is expansile and attended with a bruit,
which can be heard not only in front, but behind. The most distinct
pulsation is found a little to the left of the middle line and near the
ensiform cartilage. This is especially the case when the aneurysmal sac
bulges forward. Pulsation, on the other hand, may be absent if the
sac points laterally and posteriorly. If the tumor is high up and
shielded by the pillars of the diaphragm, it may attain an enormous
size without showing signs of pulsation. In such cases the diagnosis
must rest upon the subjective symptoms, especially pain. In rare cases
a heaving pulsation is apparent near the dorsal and lumbar vertebrae
and the adjoining ribs and interco.stal spaces.
Prcssnrc-syuiptouis. — Pressure upward against the diaphragm pro-
duces dyspnea ; against the stomach and intestines, dyspepsia, colic, or
other disorders of digestion ; against the bile-duct, jaundice. One or
other of the abdominal organs, such as the liver or kidneys, may be
pushed aside. The tumor does not move with the diaphragrti. Although
it generally increases in size in the direction of least resistance, a small
44
SCA'G/C.U. jn.iGXOS/S AND TKEAIMEAV.
proportion of cases press clirectl)' upon the spinal column, producing
erosion of the bones.
lirrors to l)c Avoided. — In thin persons the abdominal aorta is readily
felt, and a strong pulsation, with a slight amount of expansion at each
diastolic movement, can be readily mistaken for aneurysm. Abdominal
pulsation, according to Douglas Powell, is due to vasomotor disturb-
ance, and may be induced by hemic, emotional, malarial, and reflex
causes. The advice of Sir William Jenner is worth bearing in mind :
" Instead of being your first, it should be your last idea that abdom-
inal pulsation is due to aneurysm."
Aneurysm of the Branches of the Abdominal Aorta. — An>-
of the branches may be the seat of aneurysm, but the vessels most
commonly affected are the celiac axis and the superior mesenteric. In
our decision we must be guided by the general character of aneurysm
Fig. 8. — Aneurysm of the celiac axis.
and the position of the tumor. When the celiac axis is the seat of the
disease the tumor projects forward toward the right side under the
liver. In the only case of this form of aneurysm that has come under
my observation the tumor was on the left side near the middle line.
The post-mortem revealed an aneurysm of the celiac axis about 4
inches in diameter (Fig. 8). When the superior mesenteric is involved
the tumor is more movable, except when the origin of the vessel is the
part dilated.
Iliac Aneurysm. — The common iliac or the internal or external
branch may be the seat of aneurysm. The tumor is soft, circum-
EXAMINATION OF THE VASCULAR SYSTEM.
45
scribed, expansile, and the bruit can be heard along the course of the
artery. Pain is not severe, except when the genito-crural or obturator
nerve is involved. Owing to the room for expansion, the pressure-
symptoms are not marked until the tumor has attained a large size. In
a few cases the veins have been obstructed, resulting in edema and
gangrene. Additional evidence can sometimes be gained by an exami-
nation per vaginam or rectum.
The errors in diagnosis to be guarded against are — i. Abscess in
the neighborhood of Poupart's ligament. The error is more liable to
occur from the fact that an aneurysm may contain pouches, which,
lying beneath the ligament, may fluctuate, but do not pulsate. Lancing
bv Dr. Rrown).
a supposed abscess under these circumstances would be a serious
blunder. 2. Pulsating sarcomata and tumors growing from the bones
are difficult to distinguish from aneurysm. Our reliance must be placed
upon the position of the tumor, its connection with bone, the want of
the characteristic bruit, and the general characters already described.
Treatmoit. — In the common iliac. Tufnell's treatment should be
tried. If this fail, proximal, with or without distal, pressure may be
successful. In the external iliac the same treatment should be em-
ployed, failing which the external or common iliac may be ligated.
Distal ligature in this locality has never been successful.
46 SURGICAL DIAGNOSIS AND IREATMENT.
Femoral Aneurysm. — Landmarks. — At a point midway between
the anterior superior sj)ine of the ilium and the symphysis pubis the
arter\- ean be feU pulsatin^^. From this point to the spur-hke tubercle
for the insertion of the adductor magnus on the inner side of the knee
draw a straight line. The femoral artery lies under the upper two-
thirds of this line. The profunda rises about I ,V or 2 inches below
the ligament.
The common, sujjerficial, or deep femoral may be the seat of
aneurysm. As regards the common trunk there is little trouble in
diagnosis, as the usual signs are well marked (Fig. 9). It is, however,
difficult to decide whether the dilatation is situated upon the super-
ficial or deep branch. If the pulsation of the superficial can be felt
overlying the deep vessel, the point is settled, but this is not always
possible. It is well to remember that the superficial is the branch
most commonly affected.
Treatment. — i. Proximal pressure; 2. Ligation If in Hunter's canal,
ligate the artery higher up ; if in Scarpa's triangle or if the profunda
is involved, either the common femoral or the external iliac may be
tied.
Popliteal Aneurysm. — Landmarks. — A line drawn down the
middle of the ham will overlie the vessel. The guide to it is the
outer border of the semi-membranosus muscle, under whose fleshy
belly the artery lies. Pressure upon the vessels should be made
against the bone nearer to the inner than the outer hamstring, and
considerable force is required to obstruct the flow of blood.
Next to the aorta, this arteiy is the most common seat of aneurysm.
This may be accounted for on the following grounds : i. The artery is
more subject to atheroma. 2. It is but slightly supported by sur-
rounding parts. 3. It is readily overstretched by undue extension of
the knee and compressed by forced flexion. 4. Embolus is liable to
lodge in it from the fact that the vessel breaks up into a number of
branches. Cases are not infrequent in which both limbs are affected
either simultaneously or consecutively. Both fusiform and sacculated
tumors occur-, but the latter is more common. The progress of a
popliteal aneurysm is usually rapid, except when the dilatation takes
place on the front of the artery and presses against the bone, in which
event its growth is slow.
The patient who is the subject of a popliteal aneurysm has probably
complained of supposed rheumatic pain in his knee, with stiffness of
the joint and weakness of the limb. Next a swelling is observed, and
later it is discovered that the swelling pulsates. In many cases the
disease develops suddenly as the result of some violent exertion. The
sac is easily emptied by pressure on the artery above the tumor, and
distended by compression on the distal portion of the vessel. The
bruit is distinct and runs down the course of the arter>^ If the sac
becomes filled with clots, these signs may be wanting, but there will
still be the history of a time when pulsation was distinctly felt, and in
a certain proportion of cases pulsation ceases to return after a greater
or less time. Synovitis is a complication likely to arise when the sac
presses forward against the joint. This aggravates the pain and
impairs movement.
EXAMINATION OF THE VASCULAR SYSTEM. 47
Treatment. — Flexion, proximal compression, elastic bandage, or
ligature.
Traumatic Aneurysm. — In the forms of aneurysm already de-
scribed the starting-point is a diseased condition or an overstretching
and partial rupture of the arterial coats. Traumatic aneurysm is the
result of a direct injury, a stab, or complete rupture of the artery, with
escape of its contained blood into the surrounding tissues ; that is, the
formation of an arterial hematoma. At first the blood may escape
freely from the vessel, but as it infiltrates the tissues the pressure
increases until it cheeks the hemorrhage.
The symptoms denoting traumatic aneurysm are the formation of a
pulsating, painful tumor immediately following a wound or injury of an
artery (Fig. 10). The bruit is generally distinct, and the pulsation in
the artery beyond the tumor is usually lost. Tension is a marked
symptom, and the skin shows a red, inflammatory character, with
increased temperature.
Should pyogenic organisms gain entrance, the formation of an
abscess will result, which on being opened is attended with dangerous
hemorrhage. Besides this danger, sloughing and even gangrene may
occur when an important artery is the seat of lesion or when tension
is not relieved.
Fig. 10. — Diffuse traumatic aneurysm of the brachial artery (White).
Errors in diagnosis may be made by mistaking an abscess for
aneurysm. Although the resemblance may be close, we must remem-
ber that an abscess cannot form in an artery as an immediate result of
injury. The stages of inflammation and suppuration must take several
days, while traumatic aneurysm occurs in a few hours. In cases of
doubt the introduction of an exploring needle will settle the point.
Treatment. — Apply an Esmarch bandage on the proximal side of
the aneurysm and cut down upon the tumor, turn out the clots, divide
the vessel completely at the injured points, and ligate both ends. Dress
the wound antiseptically. If the aneurysm is so situated that an
elastic bandage cannot be applied, dissect down upon the tumor, make
an opening large enough to admit the finger, and search for the bleed-
ing point. The flow of warm blood will act as a guide to the finger.
When the opening is found press upon it to stop further hemorrhage,
enlarge the wound, and turn out the clots. Now by means of an
aneurysm needle pass a catgut ligature around the artery above, and
another below the point compressed by the finger. In gunshot wounds
especially, when the aneurysm is on one of the arteries of an extremity
or when a large artery is involved near the trunk, and the blood-supply
to the limb is evidently cut off, rendering gangrene inevitable, amputa-
tion is the proper treatment.
48 SrRG/C.IL DLU;X0S/S .I.V/) JRKATMKNr.
Other blood-tumors bcann<; a close relation to aneurysm, but not
falling strictly within the definition, are certain tumors.
Cirsoid iriii'iirvsin is a tumor consisting of a number of small-sized
arteries elongated and dilated. The tumor is soft, bluish in color,
irregular in shape, and pulsating. It is always superficial, and is
readily distinguished from true aneurysm.
Arterial varix is to an artery what a varicose condition is to a vein.
It is a single small artery dilated and elongated.
Anairysnial varix is a communication between an artery and a \ein
without the intervention of a sac. We do not see it often now-a-days,
but in the good old days when bleeding was universal the condition was
quite common. If, instead of opening the vein alone, an unskilful
operator incised both artery and vein, and then, as was the custom,
applied a firm compress to arrest hemorrhage, an aneurysmal varix was
a common result. It occurs in this wise : By inflammatory action the
artery and the vein become adherent, leaving the wound in each still
permeable, allowing arterial blood to pass through at every pulsation
of the heart. The force of this current of arterial blood against the
weak wall of the vein causes dilatation, but no sac is formed. A
peculiar bruit attends this condition. Prof Spence of Edinburgh was
in the habit of comparing it to the sound of a blue-bottle fly in a
paper bag. Valentine Mott compared it to the purring of a kitten.
Besides the bend of the elbow, aneurysmal varix may affect the carotid
and internal jugular and the common femoral vessels.
Treatment. — Many cases require no treatment, except an elastic
bandage to prevent further enlargement. In cases attended with pain
and disturbance of the circulation pressure at three points may be
employed — viz. on the artery above, on the vein below, and over the
aneurysmal varix. This failing, operate as follows : Expose the varix
by dissection, place a ligature above and below the opening in both
artery and vein, and cut out the aneurysm.
Varicose Aneurysm. — It is always puzzling to the student to
distinguish between aneuiysmal varix and varicose aneurysm. They
are alike in this respect, that in both conditions there is a communication
between an artery and a vein. Both have a like cause — that is to say,
a wound of the artery and the vein. The results of that wound, how-
ever, are different. In aneurysmal varix the walls of both vessels
become adherent and there is no sac. There is really no aneurj^sm,
and you will notice that it is not called an aneurysm. It is the
adjective " aneurysmal " that is employed. In varicose aneurysm a
real sac is formed by the outpouring of blood between the artery and
the vein, while the opening in both vessels remains as in the former
case. It is a real aneur>'sm, and is so designated, for the noun
" aneurysm " is used.
Treatment. — The most satisfactory is that employed by Spence, who
cut down upon the artery above the sac, and also below it, ligating the
artery at each position. This operation shuts off the current from the
sac and allows coagulation to take place.
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 49
CHAPTER III.
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM.
Ix examining the osseous system we shall consider fractures, dis-
locations, inflammations of bone, tumors of bone, and deformities.
I. FRACTURES.
As a rule, the diagnosis of fractures is not difficult. In many cases
the diagnosis is made by the patient or his friends before the arrival of
the surgeon. This is usually the case in fracture of the femur, the
humerus, or both bones of the forearm or of the leg. There are some
fractures, however, which require considerable skill and judgment to
decide upon their nature, owing to the obscurity of the symptoms, the
amount of swelling, and the position of the bone.
As fractures come into the class of cases which we may designate
as emergencies, I shall take this opportunity to say a few words upon
emergency cases in general.
An accident, as a rule, creates a panic. Everybody " loses his
head," and the young surgeon is often perplexed and embarrassed.
When a messenger summons you to such a case do not allow his
haste to disconcert you. Compel him to take time to tell you the
three following things : i. The correct name and address of the injured
person, which you must carefully write down ; 2. Whether or not he
has been removed from the scene of the accident ; 3. W^hat the nature
of the injury is. Sometimes the messenger will tell you he ran off in
such a hurry that he did not wait to ask what had happened. As a
rule, howev^er, he can giv-e some idea of the condition of things. He
can tell whether the injured person is bleeding and whether he is con-
scious. If he can state how and under what circumstances the accident
occurred, the surgeon can form a fairly correct idea as to the proba-
bility of fracture or dislocation. These inquiries need occupy but a few
moments, and frequently sav'e much time and annoyance.
A business-like young surgeon will always have his satchel well
stocked and ready for emergencies. He should have in it at least the
following : Needles, prepared catgut, corrosive-sublimate tablets, iodo-
form and sublimate gauze, absorbent cotton, a few bandages, two
bistouries, six hemostatic forceps, a pair of scissors, a male catheter, a
hypodermic syringe, a bottle of chloroform, Esmarch's inhaler, a 4 per
cent, solution of cocain, a half ounce of collodion, a razor, a nail-brush,
and two plaster-of-Paris bandages.
When the patient has not been removed from the scene of the
accident before the arrival of the surgeon, a brief examination must
be made to ascertain the character of the injuries. If hemorrhage be
profuse and a vessel of considerable size be wounded, a tourniquet
may be applied temporarily until the patient is removed to his home
or to a hospital. If a limb be fractured or severely lacerated, a tem-
porary splint must be applied. The patient may complain of cold, and
no amount of clothing heaped upon him can make him comfortable.
50
SURGICAL DIAGNOSIS AND TREATMENT.
A hypodermic of morphine acts speedily and effectually, allaying pain,
causing the patient to feel a sensation of warmth and comfort. It is
also an excellent remedy for shock — better than alcoholic stimulants.
If the patient be unconscious, place him on his back with the head
slightly raised, care being taken to give the lungs free play by unbutton-
ing the clothing over the chest and removing the neckwear.
The utmost care should be observed in moving the injured person.
In a fracture of the lower extremity the fragments are liable to lacerate
the tissues or may even perforate the skin, thus converting a simple
into a compound fracture. One attendant should support the fractured
limb, and before transporting the patient on a stretcher the two limbs
should be tied together to prevent the injured member from rolling
outward by its own weight, or a blanket or coat may be rolled up and
placed against the outside of the limb as a support.
Arrived at the sick-room, the surgeon will find it to his advantage
to select two or, if necessary, three of the most intelligent of the
bystanders, while he quietly but firmly asks
all the rest to retire. This will relieve him of
a crowd of critical observers, while the favored
few who are asked to remain, feeling that a
compliment has been paid them, fall into line
as willing helpers.
Fig. II. — Partial or green-stick frac-
ture of the radius (Stimson).
Fig. 12. — Transverse fracture of
the femur (Gurlt).
In removing clothing the sound arm should be slipped out of the
sleev^e first, after which the injured arm can be liberated without much
trouble. In cases where much pain is suffered the scissors can be used
to rip up seams and remove the garments with the least disturbance
possible.
Classification of Fractures. — Fractures are classified as fol-
lows :
I. Incoinplctc Fractures. — This class comprises fissures of flat bones,
such as those of the cranium, in which the line of fracture does not
extend completely across the bone nor through its entire thickness. It
lAy CRIES AND DISEASES OF THE OSSEOUS SYSTEM.
51
can also occur in long bones when the continuity has not been entirely
lost, as in the so-called "green-stick" fracture (Fig. 11). Then there
may be a simple depression of a part of a bone as when a blow is
received upon the head which bends a portion of the bone inward.
The separation of a splinter of bone or of an apophysis is sometimes
spoken of as an incomplete fracture. We often hear of a bone being
simply splintered, but, as rule, such a diagnosis is evidence of doubt
Fig. 13. — Oblique fracture of the clavicle (Stimsdn).
in the mind of the surgeon as to the existence of fracture. When a
bone is splintered, it is usually by direct violence, as in the case of a
sword or bullet wound. The forcible contraction of a muscle may
splinter a bone at the point of insertion of the muscle.
2. Complete Fractures. — In this variety there is a complete breach
of continuity of the bone. According to the direction of the line of
fracture it is spoken of as transverse (Fig. 12), oblique (Fig. 13), longi-
FlG. 14. — Intercondyloid fracture of the
humerus (Stimson).
Fig. 15. — Comminuted perforating
gunshot fracture of the head of the
humerus (Army Med. Mus.).
tudinal, toothed, V-shaped or T-shaped. When the seat of fracture is
taken into consideration, we speak of fracture of the neck, shaft, con-
dyle, etc. When in the vicinity of a joint the fracture is spoken of as
intracapsular (within the capsular ligament), extracapsular (without the
capsule), or when extending into the joint as intra-articular. The
most common example of this is in longitudinal fracture of the lower
end of the humerus, when the fracture extends into the elbow-joint
52 SURGICAL DIAGNOSIS AND TREATMENT.
(Fig. 14). When a bone is broken into a number of fragments it is
said to be comminuted (Fig. 15).
3. Couipouud fractures, in which the broken bone communicates
with the exterior through a wound of the soft parts.
Diagnosis of Fractures in General. — In taking the history
of the case — which in the first instance may be oral — care should be
taken to note the nature and direction of the force which caused the
injury. Fractures occur by — i. Direct violence, as when a falling
body strikes the clavicle, fracturing the bone. 2. Indirect violence, as
when a person falls, the shoulder first striking the ground and thus
fracturing the clavicle. 3. Contre-coup, as when a blow upon the
head causes fracture, not at the point of contact, but at the opposite
point of the skull. 4. Muscular action, as when the patella is broken
by powerful contraction of the quadriceps. A violent effort in throw-
ing a ball has broken the humerus, and a desperate kick at a dog,
which all too nimbly gets out of harm's way, has been known to frac-
ture the femur. Forcibly throwing the head backward has broken the
neck. The ribs have been broken by violent coughing, and the ster-
num during the pains of labor. The coracoid process has been
wrenched off by the contractions of the coraco-brachialis, pectoralis
minor, and short head of the biceps ; so has the posterior part of the
calcaneum by the action of the muscles of the calf
The evidences necessary to prove the existence of a fracture are —
I. Deformity; 2. Abnormal mobility ; 3. Crepitus.
Make your examination gently and systematically ; at the same
time, do not allow your fear of causing pain to prevent your satisfying
yourself as to the real condition. The patient who makes a loud out-
cry when you try to elicit crepitus will be just as ready to cry out
against your reputation should you make a mistake in diagnosis.
Take the sound limb for a model, and, comparing the injured member
with it, satisfy yourself upon the following questions :
I. Is there deformity? In many cases a glance will settle this
point. When a long bone, such as the femur, is broken, an angle more
or less obtuse is formed by the fragments, and the segments of the
limb show a corresponding change in direction. When the fragments
slip past each other there may be seen a bunching caused by the con-
traction of the muscles, and the limb is shortened.
To satisfy ourselves more thoroughly on this point measurements
should be made. In the forearm and the leg both ends of the bones
can be felt and the measuring tape applied. In measuring the femur
fixed points on other bones must be taken. Place the patient flat
upon his back with both limbs close together and perfectly straight.
Apply the tape to the anterior superior spinous process of the ilium,
and carry it down to the top of the inner malleolus. In the case of the
humerus the acromion process is taken as a fixed point, and the tape
carried to the lowest point on the external condyle. It must, however,
be borne in mind that in many persons there is a difference in the length
of the limbs which may be unknown to the persons themselves. This
rarely amounts to more than a quarter of an inch, but in some instances
it reaches an inch or even more. Another source of possible error is
previous disease or injury which may have shortened one of the limbs.
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 53
Swelling is an almost constant accompaniment of fracture and a
source of deformity. It is often attended with heat and redness. On
the second or third day large blebs, filled at first with a yellow and
later with a bloody liquid, sometimes appear. These are more apt to
occur in fractures of the leg and forearm. Fractures caused by direct
v^iolence are liable to have injury of the soft parts, either immediate or
showing at a later period in the form of sloughing. Fractures by
indirect violence are often followed by extravasations of blood beneath
the skin (ecchymoses), and, as a rule, at some distance from the seat
of fracture.
2. Is there preternatural mobility ? If a joint-like movement is
found in the shaft of a long bone, the evidence of fracture is complete.
When the bone is broken near one or other extremity, however, this
abnormal mobility is not so easily recognized. A fracture at or near
a joint may be attended with an abnormal range of movement of the
joint or with a mov^ement in an unnatural direction.
3. Is there crepitus ? This is a pathognomonic sign of fracture.
It is the rough, grating sensation which is conveyed to the ear and
hand of the surgeon, and with accentuated force to the feelings of the
patient, when the broken ends of a bone are rubbed together. Crepitus
is discovered by grasping the bone firmly above and below the seat of
fracture, and causing sufficient movement of the fragments against each
other to produce the grating sensation already described. The moment
this is found cease further manipulation, for it will only do harm.
Indeed, in some fractures we should not try to find crepitus ; in others
we cannot find it if we try. In fracture of the neck of the femur with
impaction we shall do positive injury by seeking for crepitus, and in
immovable fractures, such as those of the cranium, crepitus is out of
the question.
4. What is the nature of the displacement ? When the line of frac-
ture is transverse to the long axis of the bone it is called a transverse
fracture, and the displacement, if any, is lateral or it may be overlapping.
If the line of fracture runs for some distance more or less exactly in
the same direction as the long axis, it is called a longitudinal fracture,
and in that case there is usually no displacement. The direction of the
fracture may be intermediate between these two, and then it is called
oblique. The tendency in this case is for the fragments to slip past
each other, causing shortening of the limb, while the ends of the bone
cannot be so distinctly felt as when there is a transv^erse fracture with
overlapping of the fragments.
The discovery of the Rontgen or x rays has placed in our hands a
most satisfactory means of diagnosing a fracture and of demonstrating
the actual position of the fragments. It is of especial value in fractures
in the neighborhood of joints, in ununited fractures (see Plate I.), and
in old injuries having an obscure clinical history.
Besides the foregoing signs, which are objective, there are certain
subjective symptoms which should be taken into account ; these are —
{a) Pain. — This is a constant accompaniment of fracture. A simple
contusion or a sprain is also attended with pain, and you may often
find it impossible to say whether the injury is a simple bruise or a
fracture. The safe rule in such a case is to give yourself and patient
54 SURGICAL DIAGNOSIS AND TREATMENT.
the benefit of the doubt and treat it as a fracture. Perfect immobiliza-
tion in splints is excellent treatment for a contusion or a sprain. The
removal of the apparatus on the second or third day will i)robabIy show
the case in a new li^ht, with swellini^ abated and pain absent. Then, if
you can satisfy yourself that the bones are unbroken, your error has been
on the side of safety. Pain, to be of any value to us as a symptom of
fracture, must be constant and limited to one particular spot. If after
a severe wrench of the foot, pain is felt over the fibula an inch or two
above the ankle, much increased on pressure, even if every other
symptom is wanting, we are justified in diagnosing a fracture. When
pressure upon one point of a rib causes pain at another point, the evi-
dence is strongly in favor of fracture.
(/;) Hciplcss)icss of the Part. — As a rule, the patient can make no
use of a fractured limb. The least motion causes suffering, so that
pain or the fear of it compels him to keep the part at perfect rest.
This has a salutary influence, for the movement of a fracture may be
attended with considerable danger. A person suffering from fracture
of the tibia may, by attempting to walk, force the fragments past each
other and out through the skin, thus convertisg a simple into a com-
pound fracture. The same is liable to happen in fracture of the fibula
or of the clavicle. If there be marked impaction, or if the periosteum
remain intact, or if one of a pair of bones is broken, it is possible for
the patient to use the limb. I had a patient who walked several hun-
dred yards after sustaining fracture of the neck of the femur, which
was firmly impacted, and cases are reported of persons walking about
for days in the same condition. In some cases of fracture of the
clavicle it is possible for the person to raise the arm above the head
on the affected side.
Errors in diagnosis are liable to occur by our not distinguishing
between fractures, separation of epiphyses, dislocations, contusions,
and sprains.
The greatest difficulty arises when the injury is in the neighborhood
of a joint, and especially when there has been time for swelling to take
place. Another disturbing element is the presence of previous disease
in the joint, such as synovitis or rheumatoid arthritis.
{a) Separation of Epiphyses. — This occurs in young children : the
injury is near the extremity of the bone ; when crepitus can be felt it
is of a softer character than that which is found in fracture ; in infants
crepitation is wanting. The displacement is slight, for, as a rule, the
periosteum remains intact and steadies the separated epiphysis. When
the bone is near the skin its end can be felt, and it is rounded and
smooth, not sharp and rough as in fracture. The most important
practical point in the diagnosis of this accident is that separation of an
epiphysis is liable to be followed by arrest of development. Repair
usually takes place by osseous tissue ; hence the bone ceases to grow
at the injured end, and if the patient has not completed his growth
permanent shortening will result. In a case which came under my
observation the femur was shortened one inch and a half in a young
man sixteen years of age, who sustained this injury w^hen a child. In
a single long bone, such as the femur or humerus, this shortening is
not so serious as when it occurs in one of a pair. When the accident
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 55
occurs at the lower end of the radius, an arrest of development fol-
lows, the styloid process of the ulna becomes abnormally prominent,
the use of the hand is seriously interfered with, and, a most disagree-
able deformity is the result. If our diagnosis is separation of the epiph-
ysis, this danger should be pointed out to the friends of the little patient.
{p) Dislocation. — Except in the presence of considerable swelling the
diagnosis between fracture and dislocation is not difficult. In disloca-
tion the joint is fixed, and cannot be moved except by force. When
the deformity is rectified there is no tendency for it to return. True
crepitus is wanting. It may be simulated by joint crepitus, effusion
into the sheaths of tendons, emphysema, and by the grating of osteo-
phytes in chronic osteo-arthritis. True crepitus, having once been felt,
can hardly afterward be mistaken by the surgeon. The greatest dif-
ficulty will arise at the elbow in cases where both dislocation and
fracture exist.
{c) Contusions. — The pain and helplessness caused by a severe con-
tusion may closely simulate a fracture or a dislocation. The pain, or
fear of it, compels immobility, and the rigidity of the muscles about a
joint under these circurfistances is puzzling. Putting the patient under
an anesthetic will greatly help us by relieving muscular contraction
and pain.
If, in spite of a painstaking examination, yon arc still unccrtai)i, treat
the case as a fracture and Zt'ait for tzuo or three days.
Complications of Fracture. — There are numerous conditions
which may complicate fracture. They may be considered under three
heads :
I. Complications due to a General Effect upon the System. — Of these
the most important is shock. The violence which causes fracture may
be so severe as to affect the nervous system seriously, not only on
account of injury to the bone, but to the soft parts as well. The ner-
vous excitement and mental condition also play an important part.
Shock is readily recognized by coldness of the skin and pallor of the
face ; frequent, irregular pulse, the artery appearing to empty itself
after each beat. The temperature is below normal, and may go
down to 95° or 94° F. The breathing is shallow.
Fever very frequently follows a fracture, and may partake of the
character of fermentative or traumatic fever, due to the extravasation
of blood and the absorption of the blood-ferment set free by the
injured tissues. The temperature rises to about 100° or 101° F. by the
evening of the second day, and is identical with the fever which follows
aseptic surgical operations. In the case of compound fractures, where
suppuration is allowed to take place, the character of the fever is
different and is persistent.
Retention of urine is a complication to be watched for, particularly
in fractures about the pelvis. A catheter should always be passed ; if
instead of urine a little blood escapes, while the patient states that the
bladder was full at the time of the accident, we may infer that the blad-
der is ruptured. If, however, the rent in the bladder is small or occluded
by a loop of intestine, clear urine may collect in the bladder and come
away through the catheter.
Fat-embolism is, fortunately, a rare complication. In the process of
56 SURGICAL DIAGNOSIS AND TREATMENT.
repair fatty degeneration takes place in the medulla, and perhaps in the
subcutaneous tissue. Under ordinary circumstances and in the vast
majority of cases this gives rise to no symptoms. Hut it occasionally
happens that through the open mouths of veins which have been torn
across a large number of these broken fat-cells are taken up and car-
ried back to the right side of the heart, and from there sent to the
lungs. The symptoms produced are collapse, coming on after an
interval of several days and not immediately, as is the case in shock.
It is a sort of secondary shock. The earliest indications are transient
attacks of dyspnea with irregularity of the heart-beat, and in some
cases slight hemoptysis. The pulse is small and rapid, and the breath-
ing shallow and sighing in the advanced stage, running into the Cheyne-
Stokes respiration. The mind becomes dull, weakness increases, and
in many cases convulsions intervene before the approach of death.
2. Complications Due to Confinement of the Patient to his Bed. —
Except in those suffering from other diseases or debilitated from age
the confinement necessary during the repair of fracture is well borne.
Constipation is very common, varying in degree from a simple inactiv-
ity to obstinate constipation, attended with jaundice or gout. Con-
gestion of the lungs is likely to appear in old or feeble persons whose
circulation is languid and who cannot bear to remain long in the re-
cumbent posture. Bed-sores constitute one of the most troublesome
and distressing complications ; they appear only in the debilitated. The
sacrum is the most common position, but they may occur over any of
the bony prominences where pressure is made either by the weight of
the patient or by ill-adjusted splints. Cleanliness is of the utmost
importance in the prevention of bed-sores. The use of an air-cushion
is also a great help, and when it can be possibly avoided the aged and
feeble should not be treated by rigid confinement.
3. Local Complications. — Laceration of the soft parts occurs to a
greater or less degree in almost every fracture. Attending this lacera-
tion is extravasation of blood, but except when this is severe no atten-
tion need be paid to it. The torn tissues speedily undergo repair and
collections of blood are rapidly absorbed. Even when a considerable
quantity of blood is poured out, forming a hematoma and raising the
skin above the subjacent tissues, simple pressure and patience will
bring the parts back to their natural condition. When, however, a
larger vessel is torn, we have what is, practically, a traumatic aneurysm,
and it must be treated as such. As long as the parts can be kept in
an aseptic condition a moderate amount of extravasation of blood is
not serious, but in compound fractures especially, where infection of
the wound may occur, it adds a dangerous element. Simple fractures
may also become infected by absorption of septic material through a
bruised skin covering, as in a case of direct violence in which cleanli-
ness has been neglected. Dead blood-cells and lacerated tissues form
a most fertile culture-soil for septic bacteria. Where such collections
can be got at in compound fractures, they should be carefully washed
out and drained. If they extend along the limb, enlarge the opening
and make incisions if necessary.
Laceration or rupture of the main arterial trunk of the limb is a
most serious complication. The most common accident of this kind
INJURIES AND DISEASES OF THE OSSEOC'S SYSTEM $y
occurs when the lower end of the femur is fractured and one of the frag-
ments is driven backward upon the popHteal artery. Even when the
bone fails to cut through the vessel, the inner and middle coats of the
artery may be ruptured, curling themseh^es up within, and the vessel
thus weakened gives way at a later period. Sometimes the rupturing
of the inner and middle coats may favor the formation of a clot ; in
such a case hemorrhage rarely occurs. When an arterial trunk is thus
divided the symptoms develop rapidly. Swelling of a tense elastic
character, steadily increasing, pain that is frequently excruciating, pul-
sation above, but none in the artery below the injury, rendering the
limb cold, edematous, and benumbed, — these are the prominent symp-
toms. When there is a wound the blood flows freely, coming in jets
when the opening is large and the vessel exposed, but when the exter-
nal wound is small and tortuous the blood may come away in a steady
stream.
In compound fractures when a large vessel is torn we have two
courses before us — either to find and ligate the vessel above and below
the laceration, or, failing in this, to amputate the limb. Bleeding under
such circumstances is difficult to check. In fractures by direct violence
we expect more laceration than in those caused in other ways. The
crushing of the soft parts, as when a car-wheel runs over a limb, de-
stroys not only the main vessel, but the collateral circulation. The
skin, owing to its toughness and greater resisting power, may seem
but little the worse of the bruise. Do not be deceived by this, for the
vessels and nerves may be utterly destroyed.
Treatment of Lacerated Arteries. — Place a tourniquet upon the limb.
Enlarge the wound and find the bleeding point. It is always difficult
to find an arter}^ that is torn in this manner. If the vessel cannot be
found in the wound, it is of no use to ligate it higher up, for, if the
collateral circulation be good, bleeding will continue ; if the collateral
circulation cannot be maintained, gangrene is a certain consequence.
We should, however, give a fair trial to compression of the vessel
higher up, for it will settle the question of collateral circulation, and in
many cases it has been successful in permanently arresting the hemor-
rhage.
In simple fracture, when we can feel that the circulation is not com-
pletely arrested, the limb retaining its warmth and sensation, it is best to
wait. The bleeding may cease, owing to pressure of the tissues, or the
wound in the artery may close and the extravasated blood become
absorbed. The limb should be placed in an deviated position, wrapped
in cotton to maintain an even temperature, and only such bandages and
splints applied as are necessary to keep the parts at perfect rest with
gentle compression.
If, however, the limb is found to be cold, the artery below the
injury pulseless, and the swelling tense and rapidly spreading, it is
evident that gangrene will supervene, and the only course is to
amputate.
Rupture of veins is rare. A fracture of the clavicle sometimes tears
the subclavian vein, and the popliteal vein has been ruptured by a frag-
ment of the femur. But, as a rule, the veins escape much more
frequently than the arteries. The cases in which they suffer are those
58 SURGICAL DJAGXOSIS AND TREATMENT.
in which the injury is severe and both arteries and veins are impHcated.
The symptoms are very similar to those ah'eady mentioned, with the
exception of pulsation. The treatment consists in making a free open-
ing into the swelling, turning out the clots, and ligating both ends of
the vein. Thrombosis and embolism are also complications which
must be taken into account. In one case reported by Southham
thrombosis appeared on the seventeenth day, in another on the six-
teenth, and in one reported by Tyrrell on the twelfth day.
Iiijiny to Ahi'vcs. — The nerves, owing to their strength and tough-
ness, are seldom injured in fracture. A nerve may slip between the
fragments, not only suffering injury itself, but preventing the union of
bone. The most common complication, however, is at a later stage,
and due to the nerve being caught in the callus, which in the process
of ossification exerts sufficient pressure to cause pain and interrupt the
nerve-function. Of all the nerves, the musculo-spiral is the one ^\•hich
is the most frequently involved. When the nerve is simply irritated
the symptoms are neuralgia, spasmodic contraction, and hyperesthesia.
When the nerve is compressed, the pain is constant, and, as degeneration
takes place, there is loss of power, wasting, and diminished sensibility.
Diagnosis and Treatment of Special Fractures.
The Nasal Bones. — A violent blow upon the nose, followed by
copious hemorrhage, should lead us to suspect fracture of the nasal
bones. This fracture is frequently overlooked both by patients and
surgeons. The swelling, which comes on rapidly, obscures the symp-
toms, and, as the nose is a very sensitive organ, patients are often
reluctant to submit to a thorough examination. The commonest
situation of the fracture is near the lower ends of the bones. The
fragments are driven backward, but sometimes they are found to be
forced to one side, and the septum is frequently involved. The fracture
is often compound, the fragment perforating the skin, the mucous mem-
brane, or both. Besides local pain, there are severe headache, copious
hemorrhage, and sometimes emphysema in the surrounding cellular
tissue.
In your examination look for deformity. This may be both seen
and felt, but may be masked by swelling. If not satisfied with an
examination of the external parts, look into the nostrils, and, if they
are filled with blood, explore them gently with a probe. Crepitus can
be felt, but usually the symptoms are clear enough without this, and
the manipulations necessary to find it might cause further laceration
and do harm.
Treatment. — If properly replaced, fractures of the nasal bones unite
VQ.xy rapidly. Hippocrates declared that perfect union took place in
six days. Hamilton relates a case in which a cure was effected in
seven days.
Take a small, strong instrument, such as a director or fine sound,
and press the fragments upward from the inside, while the finger and
thumb of the other hand mould the parts from without. It must be
borne in mind that the nasal passage at the point where pressure is
required is very much narrowed, owing, not only to the displaced frag-
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 59
merits, but also to the swelling in the mucous membrane. The canal
is so small that it will not admit objects much larger than a probe. A
lead pencil or an instrument wrapped in cotton is not suitable. When
such is used, it is stopped before it reaches the point at which pressure
is required, and the operator pushes upward against the nasal process
of the superior maxilla. Finding a resistance which cannot be over-
come, he, after repeated attempts, leaves the case with the bones un-
reduced. When the fragments do not remain in position after being
replaced, a nickel-plated needle may be passed through the nose from
side to side just below the fractured bones, and the parts held in place
by a rubber band crossing the nose from one end of the needle to the
other.
Hemorrhage can be stopped by injecting the nares with ice-cold
water or by the application of an ice-bag. If the hemorrhage cannot
be thus controlled, the posterior nares should be plugged. A good
method of effecting this is either by the india-rubber inflating tampon
or by the assistance of Bellocq's sound. By the former method the
india-rubber tube which is used has two dilatations upon it, so shaped
that when inflated they accurately fill the posterior and anterior nares re-
spectively. It is passed in while flaccid by means of a long probe, and
inflated when in position by means of a small syringe or by the mouth.
Reinflation is necessary from time to time. By the latter method a
pledget of lint or cotton-wool rather larger than the aperture to be
filled is taken, and round the middle of this is tied a doubled piece of
stout thread, a long loop being thus left on one side and two ends on
the other, one of which is cut off short. The sound is then armed
with a separate length of thread and passed closed through the nostril,
and when the end has reached the pharynx the spring is projected,
coils around under the soft palate, and appears with the thread in the
mouth. The thread is then pulled through the mouth, thus leavdng
one end through the mouth, the other through the nostril. By making
traction on the nose-end of the thread the pledget is guided by the
finger in the mouth into the posterior nares. The loop of thread is
firmly tied to an anterior loop, which is forced into the anterior nares,
and the other end is allowed to hang in the pharynx or outside the
mouth.
Fracture of the Malar Bone. — The most common position for
fracture of this bone is at the zygoma, and it is always caused by direct
violence. The prominence of the bone and the sharp outline of its
orbital margin make diagnosis comparatively easy. As a rule, this bone
is fractured in some serious injuiy which involves other bones of the
face and skull.
Fracture of the Upper Jaw. — -The whole bone may be driven
in by direct violence, causing extreme deformity, or the wall of the
antrum may be fractured, or the fracture may run along above the
alveolar margin, so that the teeth are movable as if they were a set
of false teeth. The diagnosis must be based upon the deformity, the
nature of the accident, hemorrhage, and mobility of the part. A guarded
prognosis should be given, as the brain or bones of the skull may be
seriously involved.
Treatment. — It frequently happens that direct pressure with the
6o SL-RG/CAL DIAGNOSIS AND 'J-REATMENT.
fingers is sufficient to correct the displacement and no retentive appa-
ratus is necessary. When the alveolar border is the seat of fracture
and the fragment is movable, it may be necessary to maintain the parts
in proper position by wiring the teeth in the detached bone to those
which arc still in ])osition.
Fracture of the I/Ower Jaw. — This fracture may result from direct
or indirect violence. The most frequent seat of injury is near the canine
tooth and immediately in front of the mental foramen. The angle, the
symphysis, the neck of the condyle, and the coronoid process must all
be examined. When the fracture is compound the breach of the soft
parts is generally in the mouth. The teeth are frequently loosened or
completely separated. By passing the fingers over the surfaces of the
bone any irregularity can be felt, and in most cases crepitus can be
produced. When the fracture is through the horizontal ramus one of
the fragments drops to a slight extent, owing partly to its weight, but
chiefly to the action of the muscles attached to the hyoid bone. When
the bone is broken at its neck the condyle is drawn out of its socket
by the action of the pterygoid, while the rest of the jaw is drawn
toward the opposite side by the other muscles.
Pain is severe, and particularly when any attempt is made at masti-
cation. The patient finds it difficult to speak, and steadies his jaw
with one hand.
Trcatnioit. — In simple cases the parts are easily kept in position. A
good retentive apparatus is the following, which I quote from Mansell
Moullin : " One webbing strap is placed beneath the jaw, carried
upward on either side over the temporal region, and fastened a little in
front of the vertex ; and a second is placed horizontally around the
forehead and below the occipital protuberance. Where they cross a
slit should be cut in the horizontal one to allow the other to pass
through, or they should be sewn together, and for additional security
they may be connected by a tape over the sagittal suture. Buckles,
protected underneath with little wash-leather pads, should be used to
secure them. In ordinary cases there is no tendency to displacement
forward ; but if, owing to the convexity of the lower margin of the
jaw, the vertical band is inclined to slip too far back, it may be secured
in position by a tape stitched to it and passed in front of the chin."
The four-tailed bandage is a time-honored appliance, but much inferior
to the above method, as it has a tendency to become loose and untidy.
A splint of gutta-percha moulded to the part is an excellent method
when, owing to the obliquity of the fracture, lateral pressure has a
tendency to displace one of the fragments inward.
Interdental splints of various kinds have been invented, and excel-
lent results have been obtained by wiring the fragments, either through
the medium of the teeth or by drilling holes in the jaw itself
Fracture of the Clavicle. — Of all fractures, this is the one met
with most frequently. It occurs generally as the result of indirect
violence, as when the patient falls to the ground, alighting upon his
shoulder.
The most common position of the fracture is in the middle of the
bone or a little farther toward the outer end. By direct violence any
part of the bone may be broken. The position assumed by a person
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 6l
with a fractured clavicle is so characteristic that a diagnosis can almost
be made from that alone. The head is inclined toward the injured
clavicle, and the free hand is used to support the arm on the injured
side. The shoulder slopes more than in health, and is drawn nearer
the middle line of the body. A projection may be seen over the clav-
icle, and if not seen it can be readily felt by passing the fingers along
the bone, when the exquisite pain at that particular point and the pres-
ence of a sharp projection leave no doubt of the nature of the injury.
It is not worth while looking for crepitus and increased mobility, as
the patient's sufferings are greatly aggravated by any manipulations.
The only exception to be made is when the fracture is at the coraco-
clavicular ligament. Here the symptoms to be relied upon are tender-
ness and slight crepitus when moderate pressure is made.
In children the fracture is often incomplete, the so-called grcoi-stick
fracture.
Displacement. — When the fracture is incomplete there is a simple
elevation about the middle of the bone. When the fracture is complete
the displacement is much more marked. The inner fragment remains
undisturbed, for it is steadied by the rhomboid ligament and the costo-
coracoid membrane below and the sterno-mastoid muscle above. Some-
times, however, the outer end of this fragment is drawn upward against
the skin, which it may even perforate. The outward fragment is the
one which is displaced — first, downward by the weight of the arm ;
second, inward by the action of the pectoral muscles ; third, forward
by the action of the serratus magnus and pectorals, which rotate its
outer end until it forms an angle with the true axis of the bone.
TreatmeJit. — To effect reduction the shoulder must be drawn in the
direction exactly opposite to the displacement — viz. upward, backtcard,
and outivard — and the parts must be kept in this position. The sim-
plest appliance for this purpose is Sayre's dressing. Take two strips
of adhesive plaster (spread on moleskin ; cotton is too weak) three
inches wide and of sufficient length to go once and a half around the
chest. Pass the end of one strap around the arm of the affected side
just below the axilla, and fasten securely, but not tight enough to inter-
fere with the venous circulation. Draw the shoulder well back and
carry the strap around the chest, so as to hold the arm with the elbow
a little behind the axillary line. Now place the forearm of the injured
side across the chest, so that the fingers point to the opposite shoulder.
Carry the second strip from the uninjured shoulder across the back to
the opposite elbow, and up along the forearm to the place of begin-
ning ; at the same time the elbow must be pressed forward, inward, and
upward (Fig. i6). Absorbent cotton or other suitable material should
be placed between the forearm and chest, lest retained moisture cause
irritation and perhaps ulceration of the skin. The parts may be still
further supported by a few turns of a bandage about the arm and chest.
Velpeau's bandage (Fig. i/) is a time-honored method of treating
fractured clavicle, but has no advantage over Sayre's dressing. Should
you happen to be so situated that suitable materials are not at hand, a
very efficient appliance can be made by the use of two good-sized
handkerchiefs or pieces of calico about one foot and a half square.
Fold each handkerchief till two opposite corners meet, then fold it into
62
SCA'G/C.I/. 7^/AGXOS/S AND TREATMENT.
a band about four inches wide. Around each shoulder pass a hand-
kerchief thus folded, and tie the ends in a single knot over the scapula.
Now draw the shoulders well backward, and retain them in this posi-
tion by tying the two ends of the right handkerchief to the two ends
of the left. The arm is next flexed across the chest, and a sling applied
to support the forearm and elbow. When Sayre's and Velpeau's
methods are objectionable, the patient may be placed in the recumbent
position with a sand-bag under the scapula of the affected side. The
shoulder is then weighted with anything that will steady the parts. The
fragments naturally coapt themselves in this position. When union has
partially taken place suitable bandages are applied until repair is
complete.
Union may be expected in about four weeks in adults, but it is well
to warn patients that there is always more or less deformity result-
ing from thickening of the bone. The thickened bone may even make
(■^
Fig. i6. — Sayre's adhesive-plaster dressing for
fracture of the clavicle (Stimson).
Fig. 17. — Velpeau's bandage.
pressure upon the nerves of the brachial plexus, as occurred in two
cases which came under my notice. This result is uncommon.
It is seldom that any complications attend fracture of the clavicle.
But it is possible, particularly in fracture caused by direct violence, to
have injur)^ to the vessels and nerves, and even perforation of the lung.
Laceration of the subclavian vein or the internal jugular is a serious
accident, and unless promptly treated is attended with fatal results.
Fracture of the Hyoid Bone. — This is a rare fracture. It often
occurs in hanging, in which case the body of the bone is broken, or by
the force of the thumb and finger when the throat is grasped by an
assailant. In this case one of the greater cornuae is the part to suffer,
or at the junction of the body with the cornua. Blows upon the throat
and even muscular contraction have been observed as causes.
Syiiiptoins. — The victim may feel a sensation as if a bone had
broken ; severe bleeding may take place, more especially if a fragment
has perforated the mucous membrane. There is difficulty in swallow-
ing, dyspnea, salivation, and inability to speak. Severe pain may be
felt in moving the tongue, and in some cases the tongue is drawn to
one side. The greatest danger is in death from edema of the glottis.
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 63
Treatment. — Pass a finger into the throat and draw the base of the
tongue as far forward as possible, while with the other hand the
depressed bones are moulded into proper position. No retentive
apparatus can be applied, and all that needs to be done is to keep the
parts at rest for a few days by not using the voice and swallowing no
food. Nourishment can be administered by the rectum.
Fracture of the Sternum. — Look for this fracture at or near the
junction of the manubrium and the body of the bone. It has been pro-
duced by lifting heavy weights, by severe straining during labor, or by
excessive bending of the body. It is usually simple and transverse, but
may be multiple. Two cases which I have attended were produced by
direct violence. The symptoms are not usually well marked. Dis-
placement may be slight, for the periosteum on the inner surface of the
bone is usually untorn. When the body of the sternum is fractured it
is usually in its upper half
Diagnosis must be based upon the history of the injury, localized
pain, and displacement felt by pressing the fingers over the bone.
Dyspnea and irregularity of the heart have been noted as symptoms.
The head and shoulders are bent forward to relieve the pain.
Treatment. — While the patient makes a deep inspiration force the
bone into position by direct pressure, aided, if need be, by extension of
the trunk. A broad band of adhesive plaster around the chest, with a
pad between the shoulders, is the best appliance for retention.
Fracture of the Ribs. — When a rib is fractured it breaks com-
pletely, green-stick fracture being rare. The man who can diagnose frac-
ture of the ribs and never make a mistake is a good surgeon. I have
seen more errors made in this fracture than in any other. The ribs most
liable to suffer are those from the fifth to the ninth. The first of these
is probably broken more frequently than is recognized ; the remain-
ing upper ribs are seldom fractured, and the false ribs perhaps never,
except in gunshot wounds. One or several ribs may suffer, and
one or several may be broken at two points each. Do not expect to
see any deformity unless several ribs are fractured and the chest-wall,
as sailors say, " stove in." External violence is the commonest
cause, and it may act in one of two ways : directly, as happened to a
patient of mine, who, while riding along in an open buggy, received a
severe blow from the end of the pole of a carriage which was following
too closely behind ; or indirectly, as when the chest is compressed and
the natural curve of the ribs is thus forcibly increased. Muscular
action has produced fracture in fits of severe coughing — a rare occur-
rence.
Diagnosis. — Our suspicion of fracture should be aroused if the
patient after an injury to the chest complains of pain on drawing a
deep breath or on coughing, and especially when pressure is made on
one particular spot in the chest-wall. Place your hand upon the pain-
ful spot and ask him to take a deep inspiration ; when fracture exists
a sensation of crepitus is felt by the hand, and the patient also feels the
sensation in his side. With the point of the fingers find the tenderest
spot and feel for any irregularity in the bone at that place. Next
place a finger on the suspected rib on each side of the fracture, and
you will perhaps find that mov^ement communicated to one frag-
64 SURGICAL DIAGNOSIS AXD TREATMENT.
nicnt is not transmitted to the others. Place your stethoscope or
ear o\-er the suspected spot, and crepitus may be detected on deep
breathing. Expectoration of blood is a common symptom, and so is
cellular emphysema. As a rule, emphysema, when it occurs, extends
over several square inches of the surface, but a few cases are recorded
in which it spread over nearly the whole body. If the fracture is com-
pound, we often find the intercostal artery wounded. The most common
seat of fracture of the ribs is at or near the angle, about four inches
from the vertebral column.
A contusion may closely simulate fracture, for it will produce pain
and difficulty of breathing which is diaphragmatic. A fracture may
show nothing more, for there may be no hemoptysis, and in some cases
it is impossible to elicit crepitus. When uncertain, give fracture the
benefit of the doubt ; immobilization of the chest-wall will give the
greatest comfort in contusion, and is also the proper treatment for
fracture.
Treatment. — Take a band of adhesive plaster about six to nine
inches broad and carry it around the chest, overlapping about one-
half. If this is not convenient, use several narrow strips of plaster, and
get complete immobility of the affected portion of the chest-wall by
apph'ing strips vertical!}'.
Fracture of the Scapula. — Great force is necessary to break
the scapula, for behind it are the elastic ribs and a cushion of
muscular tissue over which it readily slides when subjected to a blow.
Swelling occurs speedily, and makes the diagnosis more difficult than
in most bones, and hence errors must be guarded against.
Seven different fractures of the scapula are recognized — viz: i. The
body ; 2. The inferior angle ; 3. The superior angle ; 4. The spine ;
5. The acromion process; 6. The coracoid process; 7. The neck.
The Body. — Pass the fingers along the posterior border of the
scapula, at the same time placing the bone in such positions as elevate
its margins and render them more prominent. If fracture exist, there
will be overlapping of the fragments. Grasp the lower angle and
crepitus may be found, but it must be remembered that overlapping
on the one hand and wide separation on the other will prevent our
finding crepitus.
The Inferior Angle. — Lay the forearm across the back, and the
angle is thrown out so that the fingers can be easily pushed behind it.
If the angle is broken off, the displacement is forward and upward by
the action of the attached muscles.
TJie Superior Angle. — Place the hand of the injured side upon the
opposite shoulder, with the forearm lying across the chest. This throws
the superior angle into prominence, when it can be examined. The
symptoms of fracture here are obscure, as there is little displacement
and often great swelling. The treatment consists in keeping the arm
immobilized.
The Spine. — In thin persons the spine of the scapula can be readily
felt, particularly when the injured arm is placed behind the back. By
direct violence the spine may be broken off throughout its entire
length, including the acromion process, or a portion of it may be
broken off, leaving the acromion process attached to the body. The
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 65
displacement is slight, and the evidence must rest upon the mobility of
the fragment detached. The treatment is immobilization.
T/ie Acromion Process. — Fracture of this portion of the bone is
produced by direct violence, by indirect violence as when the humerus
is pushed violently upward, and possibly by muscular action in violent
contraction of the deltoid. Mobility, when it exists, is the most import-
ant symptom ; there may also be crepitus, and there is always tender-
ness on pressure. An error in diagnosis is apt to be made in cases
where the epiphysis at the external end of the spine has failed to unite.
This condition, combined with a contusion, might readily be mistaken
for fracture. Beginning posteriorly, run the fingers along the spine
toward the acromion to search for any irregularity, fissure, or depres-
sion. The acromion may next be grasped to test its mobility and to
elicit crepitus. Three separate lines of fracture are to be recognized —
viz. in front of the clavicle, through the articulation with the clavicle,
and posterior to the articulation. In the first of these the clavicular
attachment is not interfered with, and hence the position of the arm in
its relation to the body will not be changed. In the two latter forms
the clavicle is involved, and the result is that the shoulder assumes the
very position which it takes in fracture of the clavicle — viz. downward,
forward, and inward. Trcatvicnt. — Immobilize the arm at the side of
the body, the elbow a little forward, and the humerus pressed well
upward against the acromion.
TJie Coracoid Process. — The coracoid process can be felt in the space
between the anterior border of the deltoid and the pectoralis major.
When fractured by muscular action, as sometimes happens, the dis-
placement is downward by the action of the coraco-brachialis. When
not detached, the finger resting upon the tip of the process can detect
mobility, and perhaps crepitus. The treatment is immobilization of the
arm against the chest, with the elbow drawn slightly backward.
The Neck. — The most prominent symptom in this variety of fracture
is a falling down or flattening of the shoulder. The humerus sinks
down, owing to the loss of support from the triceps. When the arm
is pressed upward this deformity disappears, to return as soon as the
arm is left unsupported. Follow the axillary border of the scapula
upward, and in the axilla you will find a movable, hard lump. By an
upward and backward movement crepitus can be detected. The indi-
cation for treatment is to prevent sinking of the humerus. This can be
accomplished by the application of a Velpeau bandage or a strip of
adhesive plaster passing into the flexed elbow and over the shoulder
of the same side.
Fracture of the Humerus. — Fracture of the shaft of the
humerus is very easily diagnosticated. The deformity is usually well
marked. Pain is intense and helplessness complete. The fragments
can be felt through the skin and crepitus is readily detected. The
brachial artery is rarely injured, but the musculo-spiral nerve not
infrequently suffers, either by direct injury at the time of the accident,
or at a later period it may be compressed in the callus. In children
the fracture is generally transverse, and this is often the case also when
due to muscular exertion. In adults the common direction is obliquely
from above downward and outward. When the fracture is above the
66
SURGICAL DIAGNOSIS AND TREATMENT.
insertion of the deltoid, the upper fragment is drawn inward by the
muscles of the chest ; the lower fragment is drawn outward and
upward by the action of the deltoid. When the bone is broken below
the insertion of the deltoid, the relation of the fragments is not much
disturbed, for the muscles antagonize each other.
Probably, of all bones this is the one in which non-union or a false
joint is most likely to occur. The reason of this is not to be sought
in any fault of the bone itself, but from the fact that, owing to the great
leverage of the lower fragment, it requires the utmost care to keep the
parts completely immobilized. Non-union is also due in many cases to
the interposition of muscle or fascia between the fragments.
Treatment. — Bend the elbow to a right angle, and by extension in
the axis of the bone, aided by direct manipulation, replace the frag-
ments. Sometimes a considerable amount of traction is necessary to
effect this, and in the case of compound fractures the ends of the frag-
ments may have to be cut off A good retentive apparatus is the
shoulder-cap splint, long enough to reach the elbow and enveloping
two-thirds of the circumference of the arm (Fig. i8). If narrower than
this, a short internal splint should
be used. The arm is to be carried
in a sling and the elbow left un-
supported. A weight may be at-
tached to the elbow when the
patient is able to go about, and
this is especially indicated when he
is a muscular man. Plaster of
Paris is an excellent dressing. It
need not be made so bulky as to
render it objectionable from its
weight, on account of which some
writers have condemned it.
Fractures of the upper exd
OF THE humerus are divided into
those of the head, of the anatomi-
cal neck, of the tuberosities, sepa-
tion of the epiphysis, and fracture
of the surgical neck.
1. Fracture of the head cannot
be recognized during life.
2. Fracture of the anatomical
neck is a rare accident. When an
Fig. i8. — Apparatus for fracture of the hu-
merus at any point above the condyles.
anterior dislocation of the shoulder takes place, it is possible for the
anterior lip of the glenoid cavity to act as a wedge against which the
head of the humerus is broken off The same thing can occur when a
strong force applied to the elbow drives the humerus upward against
the scapula. It may also be the result of muscular action.
Diagnosis. — Grasp the tuberosities of the humerus, which can be
felt through the fibers of the deltoid, and rotate the arm. If the
tuberosities move with the shaft and crepitus is found, the fracture is
at the anatomical neck. When dislocation also exists the head can be
felt to move independently of the shaft.
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 6/
Trcatnioit. — The action of the deltoid and other muscles of the
■ shoulder tends to draw the shaft upward, while the head at the same
time slips downward. To obviate this, the proper treatment is to make
traction from the elbow and immobilize the arm. In most cases the
shoulder-cap with a folded towel in the axilla is a good appliance.
3. Fracture through the tuberosities is usually the result of direct
violence, and the bone is often comminuted and the fracture compli-
cated with extensive injury of other structures. When the greater
tuberosity is broken, it is generally as a complication of anterior dis-
location. It is recognized by the want of voluntary outward rotation,
by crepitus, pain, and swelling.
4. Separation of the epiphysis does not occur in persons over
twenty years of age. The symptoms are the same as those of the
surgical neck, except that true crepitus is wanting, and the end of the
bone, when it is possible to feel it, is more rounded than when frac-
tured.
5. Fracture of the Surg-ical Neck. — While the preceding fractures
of the humerus are rare, this one is quite common. It is produced by
direct violence or by a fall upon the elbow or hand. Grasp the head
of the humerus with the thumb and fingers of one hand and rotate the
elbow with the other. If crepitus and increased mobility are recog-
nized, the case is clear. The displacement may be such as to give the
appearance of dislocation at the shoulder. The point is easily settled
by means of Dugas's test. Place the hand of the affected side on the
opposite shoulder and bring the elbow to the side of the chest. If this
can be done, there is no dislocation. Another method is by Cal/azuays
test. Pass a tape around the acromion and under the axilla; if there is
dislocation, the affected side will measure about two inches more than
the sound one.
Treatment. — Considerable difficulty may be found not only in re-
ducing this fracture, but in keeping it in proper position. Firm traction
must be made until the lower fragment can be got into line with the
upper. A wedge-shaped pad formed of a towel in the axilla, with a
cup-shaped shoulder-splint, will usually prove satisfactory. If, how-
ever, displacement recurs, a weight must be attached to the elbow.
About five pounds is sufficient. A sling supporting the wrist is needed
in all cases.
When fracture and dislocation both exist the usual practice is to
attempt to reduce the dislocation, under an anesthetic, by direct
manipulation. Failing in this, two other courses are open : either to
set the fracture in the hope of reducing the dislocation at the end of
four or five weeks, or allowing a false joint to take place. Both of
these methods are unsatisfactor}^ A method which promises to give
much better results is one employed by Dr. McBurney in a case
reported in the Annals of Surgery for April, 1894. He thus describes
it : " An incision should be made through the soft parts down to the
bone, a hole drilled in the bone, a stout hook inserted, and direct trac-
tion made upon the upper fragment in the proper position " (Fig. 19).
Having reduced the dislocation, the fracture must be treated in the
ordinary way.
When impaction is found to exist, no attempt should be made to
68 SURGICAL DIAGNOSIS AND TREATMENT.
reduce it, for it will ensure bony union. In cases where no impaction
takes place there is a risk that nothing better than fibrous union will
be obtained.
Fractures at thp: Lowkr End of the Humerus. — When the
elbow is bent at a right angle three bony prominences are arrayed in
hne at the back of the joint. These are the internal cond)'lc, the
olecranon process of the ulna, and the external condyle. Any disturb-
ance of this relation will show that something is wrong.
The fractures to be met with at the lower end of the humerus are
clinically divided into — (i) those that are external to the joint, and (2)
those that involve the joint.
The fractures external to the joint are three in number — viz.: i.
Transverse fracture above the olecranon fossa ; 2. Separation of the
external epicondyle ; 3. Separation of the epiphysis of the same.
The fractures which involve the joint are —
1. T-shaped fracture ;
2. Separation of the internal condyle ;
3. Separation of the external condyle ;
4. Separation of the lower epiphysis.
Transverse fracture above the condyles is produced by falls upon
Fig. 19. — Fracture-hook.
the elbow, by direct violence, or by overextension of the elbow. The
direction of the line of fracture is sometimes transverse ; at other times
it is oblique from above downward and forward. At first sight the
deformity resembles that of dislocation of both bones backward. But
if the relation of the bony points already referred to is found to be
undisturbed, there cannot be dislocation. Besides this, the position of
the deformity is farther up the arm, causing an apparent shortening of
the humerus. The elbow-joint is flexed with the hand, generally in
pronation. In front there is a prominence, which is the lower end of
the upper fragment, while posteriorly there is a depression above the
olecranon which is bridged over by the tendon of the triceps. Add to
this the existence of shortening of the humerus, the presence of pre-
ternatural mobility, and, as a crucial test, crepitus, and no doubt can
remain as to the existence of fracture.
Treatment. — When the line of fracture is oblique it is difficult to
prevent shortening, as the action of the muscles tends to cause over-
lapping of the fragments. Both diagnosis and treatment are often
interfered with by excessive swelling, which must be got rid of before
the application of a permanent dressing. If the case can be seen and
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 69
the fracture set immediately after the injury, this swelHng will be pre-
vented. If seen later, the swelling can be reduced by cold applications,
followed after a few hours by gentle compression. For this purpose
absorbent cotton and a bandage are the best, great care being taken to
watch the fingers, lest circulation in the arm be interfered with. The
best splint is strong pasteboard, cut in a rectangular form, running
from the axilla to the wrist. After soaking in hot water this can be
moulded to the parts, and it closely adapts itself to the limb. The
splint should be applied along the posterior aspect of the arm and the
under surface of the forearm. A short anterior splint should be applied
down the arm, with a thick padding opposite the bend of the elbow,
with a view to prevent forward displacement of the upper fragment.
The arm must be carried in a sling.
Passive motion should be employed about the end of the second
week. Great care must be taken lest the newly-formed callus be
broken up and a failure of union result.
Fracture of the internal epicondyle may be a complication of dis-
location, or may occur by itself as a result of direct violence or by
muscular action. The diagnosis is often obscured by swelling, but in
many cases the bone may be grasped by the thumb and finger and
crepitus elicited. When external to the capsule of the joint, as the
separation of this process of bone usually is, the accident is not of
serious moment. Besides crepitus, the other symptoms are pain on
pronation and also on extreme flexion and extension, while a moderate
degree of either of the two latter movements is free from inconvenience.
Treatment. — Carry the arm in a sling with the elbow at a right
angle.
Fractures into the Joint. — i. The most important of this group is
a transverse fracture of the lower end of the humerus, with a vertical
fracture running from it into the joint. For convenience' sake we
speak of this as a T-shaped fracture. The cause is always direct vio-
lence. The lower end of the humerus is split between its condyles by
a wedge, and the wedge which splits it is the olecranon process of the
ulna. From the tip of this process, running backward along the
greater sigmoid cavity, is a ridge which, when driven with great force
against the humerus, cleaves the bone from its articular surface upward
and breaks it off transversely, producing the T-shaped fracture.
Diagnosis. — The symptoms are very similar to those of supra-
condyloid fracture, of which this may be regarded as an aggravated
form. The lower end of the humerus being split, the condyles are
spread apart, and consequently the end of the humerus appears to be
wider than normal. The radius and ulna are displaced upward and
backward, but the three bony points are still in line, so we have no
dislocation. The humerus is shortened and there is increased mobility.
Crepitus can be detected in two places — at the transverse fracture and
also when one condyle is rubbed against the other.
This is one of the most difficult of fractures to deal with. So
rapidly does swelling come on that it interferes with the diagnosis.
Reduction may be by no means easy, while union without more or less
stiffness in the joint is rare. The patient and his friends should be
explicitly warned on all these points the moment the nature of the
70 SURGICAL DIAGNOSIS AND TREATMENT.
injury is made out. Violent inflammation in the joint and around it
may be looked for, and deformity with bony ankylosis is exceedingly
common in spite of the most careful attention.
Treatment. — So unfavorable has been the prognosis in this fracture
that surgeons have been in the habit of putting the arm in the position
which would give the least embarrassment should bony ankylosis
result. That position is at a right angle or a little more. The first part
of the treatment will probably consist in dealing with a greatly swollen
and inflamed joint, more particularly if the injury is not seen almost
immediately after its occurrence. Reduction must, if possible, be
effected at once. Extension and counter-extension will disengage the
olecranon (the wedge which has split the humerus), and the condyles
which have been spread apart can then be pressed back into position.
The fragments must be brought into line with the shaft of the humerus,
and moulded, as it were, by direct manipulation. For the first week
this will need frequent attention, so that a faulty position can be recti-
fied. At the end of the second week the callus will have become so
firm that no further readjustment can be made. It has been the com-
mon practice to put this fracture up in exactly the same kind of splint
as that recommended for fracture above the condyles.
Within the last few years the treatment of fractures in the neigh-
borhood of the elbow-joint has received considerable attention. The
method of setting the fracture with the arm in the extended position
has been strongly recommended, and several cases have been recorded
to demonstrate the superiority of this plan. Unfortunately, the matter
has not been satisfactorily disposed of, for the success of the extended
position is by no means uniform. Dr. James S. Wight in the Ajinals
of Surgery for August, 1893, reports 10 cases treated in this manner, in
all of which bony ankylosis followed; 5 of these joints had to be
resected, and 4 others were treated by brisement force.
If the advocates of the straight position could show that uniformly
good results were obtained by this method, it would be wrong not to
adopt it, but that evidence is wanting. In the mean time, the safer
course is to put the arm up in that position in which, should ankylosis
take place, the limb will be most useful. Midway between flexion and
extension, in the main, gives the best results. I have had 3 cases so
treated in which the usefulness of the limb is perfectly restored and the
deformity insignificant
fracture of the Internal or External Condyle. — Owing to its
prominence the internal condyle is broken more frequently than the
external. When a person falls backward, as upon an icy sidewalk, it is
the internal condyle that is likely to be the first to come in contact with
the ground. The fracture is apt to run into the trochlear surface of
the joint. The external is rarely fractured : it may be the result of
direct violence or of a fall upon the hand.
The symptovis are very similar to those found in the T-shaped frac-
ture, but not nearly so severe. In the case of the internal condyle the
fragment is displaced upward and backward. This throws the exter-
nal condyle into undue prominence. By grasping the condyle between
the thumb and fingers crepitus can be discovered. When placed in
position, contraction of the triceps tends to renew the displacement.
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. J I
The same result follows pressure upon the ulna near the elbow. For
this reason the arm, when carried in a sling, should be supported only
at the wrist.
Treatment. — Carefully replace the fragment, and apply a rectangular
moulded splint along the back of the arm and forward to the wrist.
The forearm rests upon the splint with the palm downward, in order to
relax the flexors and the pronator radii teres.
The complications of this fracture are dislocation of the radius back-
ward and the formation of exuberant callus, which may impair the
movement of the elbow after union has taken place. Fracture of the
external condyle is treated by immobilization in a posterior rectangular
splint or a plaster-of-Paris cast.
Separation of the Epiphysis. — At the lower end of the humerus are
four centers of ossification — viz. one at the radial portion of the articu-
lar surface, which appears about the end of the second year and extends
inward to form the chief part of the articular end of the bone ; one to
form the inner part of the articular surface, appearing about the twelfth
year ; one for the internal condyle, appearing about the fifth year ; one
for the external condyle, appearing about the thirteenth or fourteenth
year. The outer condyle and both portions of the articulating surface
unite with the shaft at the age of sixteen or seventeen years. The
inner condyle becomes joined at about the age of eighteen.
In infants a common accident is to have the whole of the car-
tilaginous mass at the lower end of the humerus separated from the
shaft. The same may occur in children, and the joint may or may not
be involved. The most common cause is excessive adduction or abduc-
tion of the forearm with hyperextension.
The treatment is the same as for supracondyloid fracture.
Fracture of the Ulna. — The olecranon may be fractured by a
blow or a fall upon the elbow, or it may be wrenched off by forcible
contraction of the triceps muscle. If the periosteum remains intact,
the displacement is slight, but otherwise the fragment may be drawn
upward by the triceps to the extent of two inches or more.
Syjnptoms. — Diagnosis of this fracture is generally attended with
little difficulty. The nature of the accident and intense pain over the
point of the elbow are very suggestive. If there is no displacement,
crepitus can generally be felt ; if the fragment is drawn upward, its
absence from the normal and presence in the new position leave us no
longer in doubt.
Treatment. — When the periosteum is intact and the fragment remains
in contact with the ulna, no other treatment is necessary than a sling,
with immobilization of the arm or a plaster-of-Paris cast. In most
cases, however, the displacement will be considerable, and this treat-
ment will not suffice. The elbow must be placed in almost full exten-
sion, immobilized, and the fragment drawn down to its proper position.
The simplest way of doing this is by means of a piece of adhesive
plaster cut in the form of the letter U. The curve is placed on the
back of the arm just above the fracture, and the sides are drawn down
and applied to the sides of the forearm. Cutting down upon the frag-
ment and wiring it to the olecranon has been practised, but the cases
in which this should be resorted to are rare.
yi SURGICAL DIAGNOSIS AND TREATMENT.
Fracture of the coronoid process is rare. It occurs, as a rult-,
when there is backward dislocation of both bones. A fall upon the
hand when the elbow is extended will also produce it, and of course
it can be produced by direct violence. Muscular action does not cause
it, for the only muscle that is attached to it is the brachialis anticus,
and this is also attached to a considerable portion of the shaft of the
ulna. For this reason there is little displacement when the process
is broken off.
Syjiiptovis. — Extend the elbow-joint and the bones of the forearm
become displaced backward. Traction upon the arm brings the bones
to their proper place, but the moment this force is relaxed the bones
return to their abnormal position. Swelling exists to a considerable
degree. There is intense pain on pressure and also on flexion.
Treatment. — Flex the joint to a little less than a right angle and
immobilize with plaster of Paris or splints. Passive motion should be
gently begun at the end of a week. Union is generally ligamentous.
Fracture of the Shaft of the Ulna. — The ulna is weaker below the
middle than in its upper portion, and, as a consequence, fracture is most
common in the middle or lower third. From its exposed and subcuta-
neous position the bone is most frequently broken by direct violence
and the fracture is often compound. When the radius remains unbroken
the displacement in fracture of the ulna is not very marked. The arm
is comparatively helpless and movement is painful.
Treatment. — A plaster-of-Paris cast or a moulded pasteboard or
gutta-percha splint, grasping the whole of the forearm and the ulnar
side of the hand, is sufficient in ordinary cases. When the displace-
ment is angular and the fragments approach the radius, the treatment
must be the same as when both bones of the forearm are broken. A
practical point worth bearing in mind is that when the forearm is car-
ried in a sling the pressure falls upon the ulna and tends to displace the
fragments toward the radius. When firm splints or a plaster cast are
employed the ulna is guarded against this danger.
Fracture of the Radius and Ulna Together. — This fracture
is readily recognized. It occurs mostly in the lower and middle thirds
of each bone. The radius is, as a rule, broken higher up than the
ulna. The common cause is a fall upon the hand. Muscular action is
very rarely a cause.
In children a partial or green-stick fracture occurs more frequently
here than in any other bone.
The symptoms are pain, swelling, helplessness, mobility, and crepitus.
Treatment. — In green-stick fracture the child should be placed under
an anesthetic if necessary, and the bone straightened. When the frac-
ture is complete, traction is employed and the fragments adjusted by
direct manipulation. When the fracture is in the upper third of the
radius and above the insertion of the pronator radii teres, the biceps
supinates the upper fragment. This must be corrected by putting up
the forearm in the supine position ; otherwise the power of supination
in the limb will be lost. Another mishap to be avoided is the tendency
of the bones to approach each other. When the reduction has been
effected deep pressure should be made by the fingers before and behind
to ensure separation of the bones. The best retentive apparatus is an
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. "JT,
anterior and posterior splint a little wider than the diameter of the arm,
and carefully padded down the center to keep the bones apart. The
splints are made wide, so that when the bandage is applied it exerts no
lateral pressure. The forearm must be carried midway between pro-
nation and supination. A notable and expensive lawsuit occurred a
few years ago for the alleged reason that the doctors neglected the
maxim " thumbs up."
For the first week the limb should be frequently examined, and the
bones separated should they show a tendency to approximate. At the
end of the second week a light plaster-of-Paris cast can be applied.
Passive motion (pronation and supination) should be commenced about
the end of the third week. In this fracture, as well as in all other
conditions requiring immobilization of the forearm, care must be taken
to apply the bandage while the elbow is flexed. If applied in the ex-
tended position and the limb be afterward flexed, the bandage is thereby
tightened and there is a danger of gangrene. Another risk run in this
accident is that the radial and ulnar arteries are readily compressed by
the displacement of fragments of bone.
Fracture of the Radius Alone. — The head of the radius is
fractured mainly as a complication of dislocation of the elbow. Frac-
ture of the neck has been observed in a few cases. The injury is de-
tected by the examiner placing his fingers on the head of the radius
and rotating the forearm, when it will be found that the head does not
move with the rest of the bone. Additional evidence of the fracture is
gained when pronation and supination are lost and when pain is felt at
the seat of the injury by movement of the hand in either direction.
Trcatmoit. — A rectangular splint with a firm pad over the front of
the forearm ; passive motion about the third week.
Fracture of the Shaft of the Radius Alone. — The pronator
radii teres is inserted into the rough ridge in the middle of the outer
surface of the bone, and plays an important part in fracture of the
shaft. When fracture takes place above the insertion of this muscle
the upper fragment is displaced by the supinator brevis and the biceps,
and the lower fragment by the pronators ; consequently, the relative
position of the radius and ulna is not the same above and below the
seat of injury. When the bone is broken below the line of the inser-
tion of the muscle, the upper fragment is but slightly, if at all, dis-
placed, the pronator radii teres holding it in position ; the lower frag-
ment, however, is tilted inward toward the ulna through the action of
the supinator longus and the pronator quadratus.
Symptoms. — There is but slight displacement so long as the ulna
remains intact. Other convincing signs, however, are not wanting.
There is pain over the seat of the injuiy. Grasp the forearm just above
the wrist and rotate, and you will find that the upper part of the radius
does not move with the rest of the bone. Crepitus can be felt and
pronation and supination are lost.
Treatment. — When the fracture is above the insertion of the pro-
nator radii teres, the arm should be put up in a position of complete
supination. The upper fragment is in this position already, and we
cannot change it ; so we put the lower fragment in the same form, thus
bringing them into line. This is all very well in theory, but the posi-
74 SURGICAL DIAGNOSIS AND TREATMENT.
tion is a trying one, and patients can seldom be induced to submit to it.
Lying in bed with the arm fully extended and the palm upward will
serve the purpose. Or a rectangular splint may be applied to the pos-
terior aspect of the arm and forearm, the limb being carried in a sling
with the elbow drawn back, so that the middle of the forearm is at the
lateral middle line of the body.
When the fracture is below the insertion of the pronator radii teres
the indication for treatment is to prevent the upper end of the lower
fragment from being drawn inward. This might result in union with
the ulna, and as a consequence the loss of power to pronate or supi-
nate. Straight, flat splints wider than the diameter of the arm are to be
applied back and front, with carefully formed interosseous pads, and
the arm carried in a sling " thumb up." The hand should be un-
supported.
Fracture of the Lower End of the Radius, or Colles's Frac-
ture. — With the single e.xception of the clavicle, this is the most
common of all fractures. A person thrown from a carriage or running
Fig. 20. — " Silver-fork " deformity of Colles's fracture, photographed half an hour after the
accident (Keen and Wliite).
and falling forward instinctively puts out his hands to save himself
The weight of the body thus comes upon the wrists. A tremendous
strain is thrown upon the joint ; something has to give way, and it must
be either ligament or bone. Clinical evidence has shown that when it
comes to a contest between ligament and bone, the bone must yield.
In this case the radius is the bone to suffer, and it breaks about one
inch from its low^er extremity. The accident occurs at all ages, but is
more common in advanced life.
The direction of the fracture is usually transverse, and it is generally
impacted. It may be oblique, and the obliquity may be in either
direction. The displacement most generally met with is that of the
lower fragment driven backward.
Examination. — The accident happened by a fall forward or from a
height upon the hand, which received the weight of the body. When
the force came upon the bone the forearm was nearer a vertical than a
horizontal position. The patient carefully nurses the wrist on the palm
of the other hand. Pain is felt at the lower end of the radius. The
wrist and hand are helpless. A marked and peculiar deformity is
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 75
apparent, which resembles a " silver fork" (Fig. 20), and is so called.
Look at the dorsum of the forearm and wrist. The back of the hand
appears strangely long. Just above the carpus is a prominence. This
is the lower fragment driven backward. Immediately above it is a
depression, because the lower fragment is not in line with the upper.
Next examine the palmar surface. Just above the carpus is a depres-
sion where the lower end of the radius would be if it had not been
driven backward. Immediately above this is a prominence which is the
lower end of the upper fragment. Stand at the patient's elbow and
look toward the hand, and the appearance is very remarkable. The
hand is drawn toward the radial side, for impaction and displacement
have shortened the radius. The ulna looks as if it were about to come
through the skin. The fingers are flexed. Pronation and supination
are impossible. To find the line of separation make firm pressure
along the outer border of the radius. It will be found from one-third
to three-fourths of an inch above the articular edge.
Errors. — Do not mistake this for a severe sprain. A sprain cannot
show the same deformity. The patient may think he has a dislocation
of the wrist. A dislocation of the wrist is a very rare accident, and
cannot be confounded with this fracture except by the careless or
uninformed.
Treatment. — Reduction is difficult, owing to the impaction, which
must, in all cases, be relieved. Grasp the patient's hand with yours as
in the act of handshaking, make strong traction, and bend the wrist at
the same time toward the ulnar side. If this fail, place the wrist in
forced extension, and, while the hand is drawn upon, push the fragment
into place by direct manipulation. It is of the utmost importance to
the after-appearance of the limb that the posterior displacement should
be fully corrected.
When once the fracture is reduced there is no danger of its being
again displaced, and on this account the matter of splints is of minor
importance. When preferred, the posterior splint may end at the
wrist : the anterior one may end at the same level, or may be carried
to the palm with a pad at its lower end, over which the fingers may
rest or grasp. A plaster-of-Paris dressing is often employed, but
excellent results are obtained by using no splints at all. A band of
adhesive plaster about the wrist gives support and allows motion of the
fingers from first to last, which is a very important point.
When the anterior or posterior lip of the radius is broken off it is
known as Barton's fracture.
Fracture of the Metacarpal Bones. — These bones are broken
by direct violence, as in fistic encounters. The displacement is slight,
and crepitus may be wanting. The diagnosis is made by pain on
pressure and by pressing the corresponding finger upward.
Treatment. — A palmar splint, well padded, to correspond with the
natural concavity of the metatarsal bones.
Fractures of the phalanges are usually compound and the
result of direct violence. The diagnosis is easy, as the usual signs of
fracture are present. The treatment consists of the application of small
palmar splints well padded.
Fracture of the Pelvis. — Serious injuries are often met with
yd SURGICAL DIAGNOSIS AND TREATMENT.
about the pelvis. They may be caused by a loaded wagon running
over that part, or by the fall of heavy bodies, such as timber, rock,
or earth, or by the pelvis being crushed while in the act of coupling
railway cars, or by the kick of a horse. It is puzzling, even to the
most experienced, to discover exactly the extent to which the parts
have suffered. In all cases of this kind there are contusion and pain.
Fright often plays a prominent part, for the terrible sensation of feeling
that he is about to be crushed to death is sufficient to put an ordinary
person into a condition approaching collapse. The pelvis is strong,
and so constructed that it can resist a great force or bear an enormous
weight, but it has its weak points. The injuries for which we must be
on the lookout in accidents occurring in the manner described are —
P'ractures of the pelvic bones ;
Separation of the symphysis pubis ;
Rupture of the urethra ;
Rupture of the bladder ;
Injuries of the abdominal viscera.
The Pubic Bone. — A crushing force may fracture this bone. The
line of fracture runs through the upper ramus, just inside the ilio-
pectineal eminence, and through the lower ramus near its junction
with the ischium. Besides giving way in front, the pelvis may give
way posteriorly, either in the ilium behind the acetabulum or in the
sacrum, or partly in either bone and partly in the sacro-iliac synchon-
drosis. Instead of fracturing the bone, the force may cause separation
of either the pubic or sacro-iliac symphysis, or both. From a clinical
standpoint this is equivalent to a fracture.
Symptoms. — The displacement is sometimes very marked, not only
to the touch, but to the eye. In the absence of this evidence we rely
upon pain under direct pressure or when movement is made by grasp-
ing the wing of the ilium. If blood escapes from the meatus, we know
the urethra has been injured. A catheter may be passed, and if no
urine escapes, then the bladder is ruptured. This, however, may be the
case where there is no pelvic fracture : the same accident may happen
from a kick on the abdomen, especially when urine has not been voided
for some time before the injury is inflicted. The patient is unable to
raise the leg from the bed.
Treatment. — Immobilize the pelvis by a firm, broad girdle or plaster-
of-Paris cast. When double vertical fracture exists, employ Buck's
extension upon the limb as in fracture of the femur. If the fracture is
compound, see that drainage is perfect and asepsis maintained. Rupture
of the urethra will probably require perineal section.
The Sacrum. — Fracture of this bone is rare. The direction is
usually transverse, and it is always the result of direct violence.
Common complications of the injury are paralysis of the rectum, the
bladder, and the lower limbs. The displacement is angular, and cor-
rection is made by pressing the coccyx forward. The coccyx, when
fractured, presents the same symptoms as dislocation of the bone, and
requires the same treatment This injury is almost invariably fatal, as
the sacral plexus of nerves is involved.
The Coccyx. — Fracture of this bone is more often met with than
the last named, the result of falls, kicks, or gunshot wounds. Neur-
INJURIES AND DISEASES OE THE OSSEOUS SYSTEM.
77
algia of the coccygeal nerves is often present, due to pressure upon
them. The pain is continuous, and is called coccydinia.
Treatment. — The same as that for fracture of the pelvis. The addi-
tion of a V-shaped strip of adhesive plaster to hold the bone steady
may often be found beneficial in relieving the pain.
The Ischium. — A fall upon the buttock may fracture the tuber-
osities or the entire bone.
The Ilium. — A crushing force may break off the crest of the ilium.
Muscular action or direct violence may fracture the anterior superior
spinous process. The posterior inferior and the posterior superior
spinous processes may be broken by direct violence. The fracture is
recognized by the presence of a movable fragment with crepitus.
Treatment. — In all these injuries the pelvis must be immobilized and
the patient kept quiet in bed. Complications must be treated on
general principles.
Fractures of the Femur. — The Neck of the Femur. — When
Fig, 21. — Fracture of the small part of the
neck of the femur (Stimson).
Fig. 22. — Fracture at the base of the
neck of the femur, with spHtting of the
great trochanter (Stimson).
called to an old person who has fallen, be it in ever so simple a way, and
who suffers pain at the hip, be on the lookout for fracture of the neck
of the femur. A misstep or tripping over a slight obstacle such as a
mat, or even an attempt to prevent a fall, is sufficient to cause this frac-
ture in elderly people. The young and middle-aged, however, are not
exempt, but in them a greater force is necessary to break the bone. It
is more common in women, as is Colles's fracture.
The old classification of this calamity was into extra- and intra-
capsular fracture. This does not cover the ground, for many of the
cases partake of the characters of both divisions. It is better to speak
of fracture at the small part of the neck (Fig. 2i), and fracture at the
base of the neck (Fig. 22). The practical difference between these two
is this : In fracture at the narrow part of the neck impaction rarely
takes place, and bony union is possible, but not probable. In fracture
at the base of the neck impaction is the rule (often with rotation out-
78 SURGICAL DIAGNOSIS AND TREATMENT.
ward), and bony union is the rule. The symptoms of both are the
same.
Exauii)iatiou. — The patient hes in bed or on the spot where he fell,
complaining; of great pain at the hip, particularly when any attempt is
made to move him. In some cases, however, the pain is slight, and
the limb can be raised from the bed. This is where there is impaction.
It is possible also for the patient to walk.
The rule, however, is that the limb is helpless, and as it rests straight
upon the bed and you compare it with the other limb, the foot is seen
to be everted. If the foot is not everted, you will find the patient
cannot evert it as well as he can the uninjured member. Impaction
must be taken into account, for if this occur with the limb in the posi-
tion of inversion, the foot will remain in that position. The thigh at
its upper part has an unusual fulness and roundness. Pushing the
limb upward from the ankle or knee produces pain, as also does pres-
sure upon the neck or the trochanter. Pressure over the neck of the
bone in front shows that the tissues cannot be so easily depressed as
they can upon the other side. Measure the limb from the anterior
superior spinous process to the outer malleolus, and the injured limb
will show a shortening of one-fourth of an inch to two inches. To
prove that the shortening is at the neck, apply Nekton's measurement
as follows : From the anterior superior spinous process to the tuberosity
of the ischium. The trochanter on the injured side occupies a higher
position in reference to this line than does its fellow of the opposite
side. Bryant's line can next be used — viz. around the pelvis from one
anterior spine to the other. The distance from the tip of the trochanter
to this line will be found shorter on the injured side.
These cases are fruitful sources of malpractice suits, for it has often
happened that the evidence of fracture was obscure ; the patient was
disabled, but the injury was supposed to be only severe bruising. Do
not run any risk, but treat it as a fracture if you are in any doubt.
Signs of Impaction. — The foot is everted, the leg is shorter than
normal, pain is localized, and there is marked flattening of the trochanter
on the impacted side. When these conditions are present, crepitus
should never be sought for.
Treatment. — Union in old and enfeebled persons is doubtful. Should
they show the bad effects of confinement to bed, we must make the
treatment of the fracture a secondary matter and attend to their general
health. Traction should be employed gently, and impaction, if exist-
ing, should not be disturbed. Make the patient as comfortable as
possible, and guard against bed-sores. Sand-bags or cushions may be
used to steady the limb, or a plaster-of-Paris cast to include the whole
limb and the pelvis. Buck's extension, with a five-pound weight, will
allow the patient to sit up in bed, and will keep up just enough trac-
tion to make him comfortable.
Fracture of the great trochanter may occur as a result of direct
violence. The line of fracture falls outside the joint, and the patients
are able to walk, notwithstanding the injury.
The diagnosis is made by the existence of localized pain and by the
presence of a fragment which moves independently of the shaft of the
bone.
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM.
79
The trcat)ncnt is immobilization and rest. If the fragment be drawn
upward by muscular action, a bandage accurately applied will overcome
this tendency.
Fracture of the Shaft of the Femur. — This is a fracture which
answers all the characteristics of fractures in general. It may be pro-
duced by any of the ordinary causes of fracture — direct violence,
indirect violence, or muscular action. The direction of the line of
fracture is usually oblique, but in children it may be transverse (Figs.
23. 24).
Symptoms. — As the patient lies in bed the limb shows more or less
deformity. The muscles are bunched up and the thigh is shortened.
The fragments usually o-verlap, and this displacement is increased by
Fig. 23. — Transverse fracture of the shaft of the
femur immediately beneath the trochanter.
Fig. 24. — Fracture of neck at junction with
head.
the contraction of the muscles. The foot falls outward in eversion,
simply from its weight. When an attempt is made to lift the limb
intense pain is felt and abnormal mobility is apparent. Crepitus is
readily detected, but the other symptoms are so clearly evidences of
fracture that this symptom is unnecessary. Measurement from the
anterior superior spinous process to the outer ankle shows shortening.
Bryant's and Nelaton's measurements prove that this shortening is
not at the neck of the femur. When the hand is passed over the seat
of fracture and the limb is gently raised, the abnormal mobility is appar-
ent. Grasp the thigh gently, rotate the limb below, and you will find
that the upper portion does not share in the movement of the lower.
Treatment. — Make steady traction until the shortening is overcome.
Should a fragment of the bone pierce the muscle and skin, flex the
thigh upon the pelvis and the leg upon the thigh. This will relax the
muscle and the fragment will return to its place. Traction contin-
8o
SURGICAL DIAGNOSIS AND TREATMENT.
uously maintained in one form or other is the best treatment, and the
most satisfactory mode of traction is Buck's extension. The extending
force is a weight suspended by a cord which passes over a pulley.
It is applied in the following manner : Take a strip of strong adhesive
Fig. 25. — Adhesive plaster cut for Buck's extension (Stimson).
plaster four inches in width and long enough to reach from above the
knee down the limb, around the sole of the foot (where it is left loose),
up the other side, opposite to the place of beginning (Fig. 25). A piece
of wood five inches by three inches, with a perforation in its center, is
"V
:x
Fig. 26.— Adhesive plaster folded for Buck's extension (Stimson).
placed opposite the sole of the foot, and the adhesive plaster attached
to it by folding its edges over the wood (Fig. 26). Through the open-
ing in the wood a stout cord is passed, and a knot tied upon it to pre-
vent its being pulled back by the weight. The foot and lower third of
Fig. 27. — Buck's apparatus with Volkmann's sliding rest for fractures of the thigh.
the leg are next bandaged by a roller bandage ; over this the adhesive
strips are applied and attached to the sides of the limb as far as they
reach up the thigh. The bandage is continued upward over the plasters,
thus supporting them against the limb. The cord is next carried over
a pulley attached to the foot of the bed, and a weight varying accord-
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 8 1
ing to circumstances is attached to its free end. The weight should
run about a pound for each year of age from five to twenty. To
provide for counter-extension the foot of the bed is raised. To pre-
vent outward rotation the most convenient appliance is Volkmann's
sliding rest (Fig. 27). It is formed of two side-pieces eight inches apart
and two feet in length. They are united by two cross-pieces, and on
these rest a posterior splint and foot-piece. To this splint the leg is
attached. Various other methods of treating this fracture are in
vogue, such as Cripp's splint, Nathan R. Smith's anterior splint,
which is an improvement on the old double inclined plane, and
Hodgen's splint, which combines the principle of the double incHned
plane and Buck's extension. The two latter methods are of great
advantage when the fracture is just below the insertion of the psoas
and iliacus, and counteract the bad effect of tilting forward of the upper
fragment, which is common in fractures at this part of the femur.
Fractures of the Lower End of the Femur. — Fractures at the
lower end of the femur bear a close analogy to those at the lower end
of the humerus. The bone may be broken above the condyles (supra-
condylar). This fracture may be complicated by another at right
angles to it and running into the joint, a T-shaped fracture ; one or
other of the condyles may be detached, and lastly the epiphysis may
be separated. The lower end of the femur may be split by the wedge-
like action of the patella.
Supracondylar and T-shaped Fracture. — The direction of a frac-
ture just above the condyles is generally oblique, and the especial
danger is that one of the fragments may injure the popliteal vessels.
The obliquity is generally from above downward and forward. The
lower fragment is rotated by the gastrocnemius, and its fractured sur-
face is directed backward. If while the fragment is in this position
any traction be made upon the leg, the vessels are almost sure to be
injured. When the displacement is in the opposite direction — that is,
with the lower fragment projecting forward — the vessels are exposed to
danger from the pressure of the lower end of the upper fragment.
Diagnosis. — The pain and deformity, if any, are lower down toward
the knee than in other fractures of the shaft. Shortening is usually
apparent. Even with impaction the symptoms are easily recognized.
When the fragments are free, abnormal mobility and crepitus add addi-
tional testimony. Grasp a condyle in each hand, and if the fracture is
T-shaped the condyles can be moved backward and forward upon each
other. Besides this, they are spread apart, giving the appearance of a
greater width to the lower end of the femur. When the joint is
involved another important sign is observed : the synovial cavity
becomes distended with blood. If you find the popliteal space rapidly
filling up and an immense swelling forming, and, in addition to this, the
leg becoming cold and pulseless, you may know that the popliteal
artery is torn and bleeding profusely into the tissues. When the
artery is simply pressed upon, the limb also becomes cold, but this
takes place gradually, and the swelling in the popliteal space is
wanting.
Treatment. — This must vary according to the conditions present.
Be careful in making extension lest the vessels become pressed upon
82 SURGICAL DIAGNOSIS AND TREATMENT.
or torn. Gentle traction with direct manipulation is generally safe.
When the upper fragment projects backward, Buck's extension is a
suitable dressing. When the lower fragment has a tendency to back-
ward displacement, the gastrocnemius is the disturbing element which
must be disposed of This can be done either by dividing the tendo
Achillis or by treating the fracture on a double inclined plane. In
general, a plaster-of-Paris cast, with anterior and posterior coaptation
splints under the plaster, will fulfil all the requirements. When the
knee-joint is involved, the effusion and swelling must be got rid of by
pressure, cold applications, and, if necessary, by aspiration. Passive
motion of the joint should be begun not later than the end of the
fourth week.
Laceration of the popliteal vessels is a very serious complication.
When it occurs a tourniquet should be applied to the femoral artery,
the vessel cut down upon and tied above and below. The vein should
receive careful attention, as it may be injured as well. In this event
amputation is the only treatment.
Fracture of the Patella. — A fall upon the knee, or a fall or
blow combined with a strong effort on the part of the patient to save
himself, is likely to cause fracture of the patella. The direction of the
fracture is generally transverse. The line may be across the middle
or near the upper or lower end. Sometimes it is stellate or star-shaped,
and in rare cases it is split from top to bottom. An oblique fracture is
very rare. When caused by direct violence the fracture is often either
compound from the first, or it may become so at a later period by
sloughing of the soft parts covering the bone. When the fracture is
transverse the upper fragment is drawn upward by the action of the
quadriceps, and a gap exists at the seat of fracture.
It fortunately sometimes happens that the periosteum remains intact,
and thus little or no separation takes place.
Symptoms. — After such an accident (a fall upon the knee, a blow,
or struggle to avoid falling) pain is felt over the patella, and the patient
cannot extend the leg. The fragments are independently movable, and
a distinct transverse gap exists between them, which can be closed up
by moving the fragments toward each other.
Treatment. — If the periosteum has not given way and there is little
or no separation, a plaster-of-Paris cast from the ankle to the upper
third of the thigh is a good dressing. With wide separation something
more than this is necessary. A long list of appliances might be named
to meet the requirements of these cases. A posterior splint is applied,
and by oblique turns of a roller bandage the fragments are maintained
in their proper position. The patient must keep his bed with the
foot raised, thus counteracting the action of the quadriceps extensor
tendon.
A very useful and easily constructed appliance is Agnew's splint
(Fig. 28). A piece of board thirty inches long, five inches wide at one
end and four at the other, is slightly hollowed out to fit the thigh and
calf, leaving the middle plain to correspond with the flat surface behind
the knee. Four pegs are fitted into the sides in such positions as to
give attachment to the bandage which draws the fragments together.
The method of its application is seen in Fig. 29.
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 83
Should the above methods fail or should it be found impossible
from the first to keep the fragments in apposition, operative measures
should be resorted to. Sev^eral operative procedures have from time to
time been employed — for instance :
1. Open arthrotomy, with suturing of the fragments with silver
wire. This has been very successful in a large number of cases.
It has led to suppuration and fatal results have been reported. Under
strict antisepsis and in healthy subjects the risk to be run need not be
considered great. The operation consists in making a free incision
across the patella to expose the fragments. If the fracture is an old
one, the broken surfaces must next be freshened. Any fibrous tissue
which has recently formed, or any fascia or other tissue which has
come between the fragments, should be carefully removed. Holes are
drilled into the bone by directing the drill through the anterior surface
of each fragment obliquely from the attached border toward the poste-
rior edge of the fractured surfaces. Three sutures of silver wire are
sufficient, and when perfect approximation has been effected the ends
of the wire are cut off, and either hammered into the bone or left pro-
truding from the wound to be withdrawn later.
2. Subcutaneous suture has proved satisfactoiy and is easily per-
FlG. 28. — Agnew's splint for fractured patella. FiG. 29. — Agnew's splint applied.
formed. The method is as follows : After thorough disinfection of the
limb a long, half-curved Hagedorn needle, carrying a strong silk
suture, is inserted at one side of the ligamentum patellae, and carried
through the ligament to the corresponding point on the other side ;
the needle is then reinserted at the latter point, and carried up along
the edge of the fragments to a point above the patella, then through
the tendon of the quadriceps to the corresponding point on the other
side, and back to the place of beginning. The fragments are now
accurately approximated by means of tenacula, the suture drawn
tight, tied, the ends cut off, and the knot pushed beneath the skin.
The knee is dressed antiseptically, and placed upon a posterior splint
for one week, after which a plaster-of-Paris cast is worn for a month
constantly, and for another month during the daytime.
Barker's operation is probably an improvement on the ordinary
subcutaneous suture. The method of operating is as follows: With
the finger and thumb of the left hand steady the lower fragment, and
at its lowest point in the middle line of the ligamentum patellae make
a small incision by means of a narrow-bladed knife through the skin
and into the joint. Through this opening a stout-handled pedicle-needle
is passed into the joint behind both fragments. The upper fragment is
now pushed down as closely to the lower as possible, and the needle
thrust through the quadriceps tendon at the upper edge of the frag-
ment. The point of the needle, becoming apparent beneath the skin, is
84
SURGICAL DIAGNOSIS AND TREATMENT.
cut down upon and pushed to the surfece. A stout silk thread is passed
into the eye of the needle, which is withdrawn, carrying the thread
behind the fragments (Fig. 30). The end of the thread is withdrawn
from the needle's eye and left emerging from the lower opening. Again
the needle is passed through the lower opening, but this time it is made
to pass in front of both fragments and out at the upper opening. It is
threaded with the upper end of the silk and withdrawn, leaving the
thread in front of the fragments (Fig. 31). The fragments are approx-
imated and rubbed against each other to displace clots ; the ligature is
securely tied, cut off short, and the wounds closed. The bone unites,
in the great majority of cases, by fibrous tissue, and on this account
the after-treatment is more important in this fracture than perhaps in
any other. Although the separation of the fragments may, at the
outset, be to the extent of only half an inch, it is not uncommon to
have this distance increase until, at the end of several months, it may
Fig. 30. — Barker's operation for transverse
fracture of the patella (first stage).
Fig. 31. — Barker's operation for transverse
fracture of the patella (second stage).
reach five or even six inches. This may be explained in two ways —
either that no union has taken place at all, or the newly-formed fibrous
tissue has been stretched by allowing the use of the knee at too early
a period. In all cases of transverse fracture perfect immobilization
of the knee should be maintained for eight weeks, after which an
apparatus should be worn to prevent flexion for six months. The
stiffness in the knee resulting from such long-continued disuse passes
off gradually, and the fibrous tissue becomes so firm that it will not
stretch.
Fractures of the Leg-. — The weakest part of the tibia is at the
junction of the middle and lower thirds, and here it is most frequently
broken. When both bones are fractured the fibula gives way higher
up. Comminuted fracture is common even when the cause is indirect
violence. The tibia, for a considerable portion of its length, is covered
by little more than skin, and on this account it is specially liable to
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 85
compound fracture. When both bones are broken by direct violence,
it is generally on the same level and the direction is transverse. When
the violence is indirect the fracture is oblique and the fragments are
pointed. Beware of letting a patient attempt to walk when there is
suspicion of such a fracture, for there may be no apparent deformity
until his weight comes upon the limb. Then the oblique fragments
slip past each other, and, perforating the skin, a compound fracture is
the result.
Symptoms. — Deformity is generally so clearly marked as to be
apparent at the first glance. Pain is a prominent symptom, and is greatly
intensified on the slightest pressure. If the patient has to be moved
from the scene of the accident, be careful to secure the limb, lest the skin
give way. A pillow placed lengthwise under the leg and tied around
with several handkerchiefs makes a very soft and easy applicance,
while firmness can be given by placing strips of lath, shingle, or similar
pieces of wood at each side and behind.
Treatment. — A fracture-box slung from a cradle is a very comfort-
able apparatus for this fracture, but the most convenient of all is a
plaster-of-Paris cast. The form known as the Bavarian splint makes an
excellent dressing. It is thus employed : Take two pieces of flannel
(coarse house flannel is the be.st) long enough to reach from the
popliteal space to the balls of the toes, and three inches wider than the
circumference of the limb ; sew them together down the middle line for
the length of the leg ; for the remainder of their length they are cut in
two, to be applied to the foot. Place the leg upon the flannel, so that
the seam runs down the back and ends at the heel ; fold the inner
layers over and fasten them together down the front. Keeping the
foot exactly at a right angle, fold the end-pieces over it. Now place
the leg upon one side and you are ready for the plaster. The plaster
should be mixed to the consistence of cream. Spread over the inner
layer from the seam behind to the place where it is folded in front, and
press the outer one down upon this before it has time to set. As soon
as this has become firm turn the leg over and repeat the proceeding
upon the other side. When the plaster has properly set undo the
fastening in front ; you now have two side-splints admirably moulded
to the leg and united by a hinge formed by the seam at the back. All
that remains now is to trim off the edges and fasten the inner layer
down to the outer on the surface of the splint.
Fracture of the Tibia Alone. — The only difficulty in diagnosis of
fracture of the tibia alone is when the bone is broken transversely,
and where the swelling prevents our feeling the crest. Under other
circumstances fracture of the tibia is readily diagnosed. The inner
malleolus may be broken, the tubercle torn off by the action of the
quadriceps, and the spine or the head of the bone broken off or split
by the action of the crucial ligaments in violent twists of the knee.
False joint is liable to occur in fracture of this bone if the patient has
been attempting to walk or if complete immobilization of the fracture
has not been maintained. Fracture of the upper end of the tibia is
often transverse, and when so is the result of direct violence. The soft
parts are contused. The fracture may take the form of a T inverted,
the vertical part extending into the joint, causing synovitis. The frag-
86 SURGICAL DIAGNOSIS AXD TREATMENT.
ments may be separated by a blood-clot which may extend into the
synovial sac.
Tiratiiicnt for Fracture of this Form. — Apply cold compresses to
remove effusion and swelling. The leg should be put up in the double
inclined plane, care being taken not to have the incline too acute, as
the upper fragment may protrude through the skin, thus creating a
compound fracture. When the joint is not implicated a plastcr-of-
Paris bandage will suffice. If there are good reasons for keeping the
leg uncovered, then one splint (Cline's) on the inner side of the leg will
do, as the fibula when intact will serve as a splint on the external side.
Fracture of the Fibula Alone. — This is sometimes called the
"railroad fracture" or "street-car" fracture, because it is so com-
monly caused by jumping from a vehicle in motion. When a person
jumps from a rapidly-moving street-car, and comes forcibly upon his
feet with the toes pointing at right angles to the line in which he was
moving, a severe strain is thrown upon the fibula. Either the lateral
ligaments of the ankle or the bone must yield, and, as usual when a
contest between ligament and bone occurs, the bone is found to be the
weaker structure and is forced to give way. The bone may also be
broken at any part by direct violence and by violent contraction of the
biceps muscle.
Diag)iosis. — Wlien the fracture is at the upper end it is due to
muscular action, except when caused by direct violence. The displace-
ment, if any, is a drawing upward and backward of the upper fragment
by the biceps. Fracture in this part of the bone is of interest, owing
to the liability to injury of the peroneal nerve either at the time of the
accident or later by being caught in the callus. This complication is
recognized by pain along the nerve or paralysis of the peroneal group
of muscles. When the shaft is broken the displacement is angular
and the fragments overriding, with the lower end of the upper fragment
forward. The prominent symptoms are pain and tenderness at one
particular spot. Mobility is difficult to recognize, and crepitus often
impossible. To examine the bone press alternately with the thumbs
side by side over the seat of injury or forcibly twist the foot. In this
way mobility and crepitus may be found, and, even if they are not, the
loss of the natural spring of the fibula will be wanting. Instead of
springing back to its place, it will yield before the pressure. The
weakest spot in the fibula is two to four inches above the ankle, and
this is the commonest seat of fracture. To this special form the name
of Pott's fracture is given. Forcible eversion and abduction or in-
version and adduction will produce it. In the typical Pott's fracture
three separate lines of fracture exist : first, the fibula, two to four
inches above the upper part of the malleolus ; second, the inner mal-
leolus ; third, the outer lower edge of the tibia. The prominent symp-
tom is the displacement of the whole foot outward, carrying with it the
external malleolus, which is thus separated from the fibula. The internal
malleolus is thus rendered very prominent. Three points of localized
pain can be found, corresponding to the three lines of fracture above
mentioned. The skin over the inner malleolus is stretched, and may
even be perforated by that bony point. The foot moves too freely
from side to side in the space between the tibia and fibula, which is
INJURIES AND DISEASES OF THE OSSEOUS SYSTE.^f. 8/
now greatly widened. In some cases the foot slips backward, so that
the body of the astragulus lies behind the tibia.
Treatment. — For fracture of the upper end all that is needed is
immobilization with the knee flexed in order to relax the biceps. In the
shaft any displacement must be reduced by traction and direct manipu-
lation. Immobilization by a Volkmann's splint for a day or two, and
then by a plaster-of-Paris cast, will give good results.
Pott's fracture requires particular care, for the displacement is
greater and the deformity is more liable to return than in any other
fracture of the fibula. Grasp the leg firmly with one hand and the foot
with the other. Draw the foot forward and inward until the astragalus
can be felt lying up against the internal malleolus. Be careful to cor-
rect any backward displacement, for this is often overlooked.
Dupuytren's splint has had a long and useful career in the treat-
ment of this fracture. It is a lateral splint applied to the inside of the
leg and extending two or three inches below the foot. A wedge-
shaped pad is placed between the splint and the leg, the thick end of
the wedge being a little above the malleolus. By means of a roller
bandage the foot is drawn well toward the tibia, and, continuing the
bandage up the leg, immobilization is secured.
A neater and more steady appliance can be secured by moulded
plaster-of-Paris splints. The first of these is applied along the back of
the leg from just below the knee to the heel, along the sole of the foot
and beyond the toes ; the second begins on the dorsum of the foot,
runs obliquely to the outer side under the sole, and up the inner side
of the leg. Circular turns secure the splints just above the ankle and
below the knee. Care must be taken to keep the foot in good position
while the plaster is setting.
Fracture of the External Malleolus. — An in\\ard twist of the foot
will cause the astragalus to force the malleolus outward and produce
fracture. It gives way about an inch or an inch and a half above the
end of the bone.
Diagnosis. — Tenderness and pain on pressure and when the foot is
turned inward are the chief symptoms ; abnormal mobility and crepitus
are not readily found.
TreatnieJit. — Immobilization.
Fracture of the Astragalus. — Diagnosis is uncertain, except where
there is also dislocation or when the fracture is compound. If the
latter, it is best to remov^e the fragments when displaced, as good
results follow their removal.
The calcaneum may be broken by a fall or by muscular action.
When caused by the latter a fragment is broken off and carried upward
by the action of the powerful muscles of the calf When caused by
direct violence the fracture is generally comminuted. Have the patient
kneel and then compare the heels. The injured one is flattened and
broadened, and the tendo Achillis is relaxed.
The treatment is massage and immobilization, with use of the limb
as early as possible.
The metacarpal bones, when fractured, present few difficulties.
Pressure at the broken point causes pain, as also pressing of the cor-
responding toe backward. In the first and fifth toes crepitus and
88 SURGICAL DIAGNOSIS AND TREATMENT.
mobility are usually present. The displacement is so slight that in
simple cases all that is needed is rest, with the foot elevated, and
massage.
Compound Fractures.
The diagnosis of compound fractures presents no special difficulty.
In no department of surgical practice is better judgment or more
prompt action required than in their treatment. It is here that modern
surgery has obtained some of its most brilliant results. In uncom-
plicated cases a thoroughly antiseptic dressing converts a compound
into what is practically a simple fracture. The first dressing is of the
utmost consequence, for upon it depends to a \&xy great extent the
success or failure of treatment.
When the fracture is the result of indirect violence, or when a sim-
ple has been converted into a compound fracture by niiduc movement of
the fragments, there is little injury to the soft parts. In a compound
fracture by direct violence there is usually bruising, crushing, or lacera-
tion, which adds to the seriousness of the injury. The dressing in this
form of fracture should be as carefully carried out as the details of a
major operation. All instruments that are likely to be required should
be disinfected ; the parts in the neighborhood of the wound should be
washed and sterilized, as in any other operation. Most cases require
anesthesia. The wounded tissues demand the utmost care in their
purification. If plastered wdth dirt, machinery-grease, and other foreign
substances, olive oil should be applied, followed by alcohol, s.oap and
water, and corrosive-sublimate solution, i : 2000. Shreds of tissue or
structures which cannot possibly retain their vitality should be cut
away ; splinters and broken-off pieces of bone should be removed ;
bleeding vessels should be ligated and all hemorrhage stopped. Bear
in mind that to leave a nerve, a muscle, or a tendon unsutured is as
gross a piece of negligence as to leave a fracture unreduced. Having
attended to all these matters, the fracture is next in order. Before reduc-
tion of the fragments can be effected they may have to be trimmed off
by bone-forceps or even a portion removed by a saw. Drainage must
be secured by counter-openings, if necessary, and the cutaneous wound
sutured. A copious antiseptic dressing is applied, and a retentive
apparatus suitable for the particular fracture. When possible, an ap-
pliance which allows dressing of the wound without disturbing the
splints should be employed. Plaster of Paris can be made to fulfil most
indications, and suspension is also a valuable aid. If, in spite of all our
care, suppuration takes place, the wound must be dressed daily,
thorough drainage established, and the parts brought into an aseptic
condition as speedily as possible.
Amputation after Injury.
One of the most perplexing questions for the surgeon to meet is
"when to amputate." No rules can be laid down, for each case must
be judged upon its merits. A consideration of the following points
may help us :
I. Is the blood-supply permanently cut off? When the main artery
INJURIES AXD DISEASES OF THE OSSEOUS SYSTEM.
89
and its accompanying veins are destroyed, gangrene is sure to follow
an attempt to sa\'e the limb (Fig. 32). When the artery alone is lost,
the collateral circulation may be trusted to nourish the part.
2. Are the tissues devitalized ? The soft parts may be extensively
cut up, and yet if they are incised wounds good apposition of the dif-
ferent structures may be obtained and the part may be saved. It is
different if the parts are crushed and mangled. The wheels of -a
heavy railway car in running ov^er a limb not only comminute the
bone, but crush the very life out of muscles, nerves, vessels, and ten-
dons. The same may be said of powerful machinery. The skin may
reriiain intact and show nothing more than an unusual paleness, but it
soon sloughs, and, together with the deeper parts, becomes gangrenous.
3. Is it possible to prevent suppuration and septic infection ? As a
rule, this question can be answered in the affirmative. A thorough
purification of these parts, followed by a careful antiseptic dressing
Fig. 32. — Gunshot wound of forearm ; circulation cut off (from a photograph in the collection
of Dr. Lincoln, Wabasha, Minn.).
with provision for drainage, will warrant us in attempting to save
limbs which in preantiseptic days would have been sacrificed. In
cases of doubt, therefore, we can wait a few days without exposing the
patient to great risk.
4. If saved, will the limb be useful ?
5. Do the age and general condition of the patient admit of saving
the limb ? In children we can attempt much more than in adults.
The kidneys should receive careful attention. If the urine is of low
specific gravity or contains albumin, the chances of saving the limb
are very much lessened.
II. DISEASES OF BONE.
Inflattimation. — From a clinical standpoint the composition of
bone differs from other parts in only one particular — namely, the
90 SURGICAL DIAGNOSIS AND I'REATMENT.
presence of lime salts, which give firmness and hardness to the structure.
The pathological changes are the same in inflammation of bone as in
other tissues of the body — viz. hyperemia, dilatation of the blood-
vessels, increased rapidity of the circulation followed by stasis. Lymph
pours out through the walls of the vessels, the tissues become en-
gorged, but swelling can take place only to a very limited degree.
Pain is more acute and persistent, because the products of inflanmiation
are confined by unyielding tissue, which does not allow of expansion.
Pus, when formed, is long retained, because its pressure does not cause
atrophy rapidly, and it cannot get to the surface as readily as is the
case in soft tissues.
Any one of the three structures of which a bone is composed may
be the seat of inflammation — viz. the periosteum (periostitis), the bony
tissue (ostitis), and the medulla (myelitis). Periostitis alone very rarely
occurs, and the same is true of myelitis. The bony tissue is affected in
either case. So we speak of osteoperiostitis and osteomyelitis.
Inflammation is due to a variety of causes :
1. The result of injury. More or less inflammation attends every
fracture. There is in this case no suppuration.
2. The presence of pyogenic organisms. The staphylococcus aureus
and the streptococcus pyogenes are the germs most commonly found.
They may find a portal of entrance by an open wound, by the blood-
stream which carries them from a distant pus-depot, by the lungs, or by
the digestive tract. The presence of these germs produces inflam-
mation with suppuration.
3. A general infective disease, such as typhoid fever.
4. Special diathetic states, as syphilis and tuberculosis. These two
are not attended with suppuration, but liquefaction is quite common.
Osteoperiostitis. — Most of the cases of periostitis (so called) come
under this head, for when the periosteum is inflamed the superficial
layers of the bone are also involved. The common causes are exposure
to cold and wounds or contusions. The bones which are the most
superficial are those most likely to suffer, and on this account diagnosis
is more simple. In no class of cases, however, are errors more fre-
quently made, and the results are often serious. If the condition is not
recognized and promptly treated, the periosteum becomes thickened,
the vessels going to supply the underlying bone become occluded, pus
or inflammatory products separate the periosteum from the bone, and
death of bone follows. Prompt treatment prevents all this, and allows
the parts quickly to resume their healthy condition.
Diaf^nosis. — The bone most commonly affected is the tibia. When
the inflammation is non-suppurative, the constitutional .symptoms are
not prominent. There is always pain, and it is worse at night. Pass
your fingers over the painful part : the pain is increased on pressure,
and more or less swelling can be detected, giving the bone a spindle
shape. The soft parts covering the bone are red and edematous.
When there is suppuration there are marked fever, often chills, and
severe constitutional disturbance.
Treatment. — Keep the part at rest, and apply cold or warmth as the
patient finds one or the other more comfortable. If the symptoms
continue, puncture the part in several places with a disinfected needle.
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 9I
When suppuration is taking place, lay the part freely open by an
incision down to the bone and through the thickened periosteum.
This should be followed by a moist antiseptic dressing. When syphilis
is the cause of the disease, the constitutional treatment of syphilis
should be carried out, and incisions are unnecessary.
Osteomyelitis. — This is the most common form of inflammation
in bone. The medulla is rarely affected alone, and hence myelitis need
not be considered clinically. Both bone and medulla are simultaneously
affected, and we name the condition osteomyelitis. The inflammation
may be local, general, or septic. Slight injuries may produce inflam-
mation of bone which ends by resolution, leaving the bone-layers
unchanged. In the severer forms, and particularly in chronic inflam-
mation, destruction of bone takes place. If death of bone occurs in
mass, it is called necrosis ; if it is molecular, we call it caries.
Septic Inflammation of Bone. — This occurs under two condi-
tions. The first variety is seen in adults and is associated with an
open wound. Before the days of antiseptic surgery, amputations, com-
pound fractures, and many cases of open wound connected with bone
were followed by septic osteomyelitis. Fortunately, these cases are
now comparatively rare. After amputation in which septic infection
of the bone takes place, the medulla is observed to be discolored,
bleeding readily and protruding beyond the bone, so as to form a
fungus-like growth. The discharge is abundant, sero-purulent, and of
a very offensive odor. In very severe cases the destructive process is
rapid, and the patient dies of pyemia or septicemia in two or three
days.
The second variety is a disease especially common in childhood. It
occurs without wound or fracture, and has its starting-point at or near
the epiphyseal line. The femur and the tibia are the bones most com-
monly affected. Boys suffer three times as often as girls. About half
the patients are between thirteen and seventeen years of age. The
pyogenic germs gain access, not by an open wound, but by the vascular
or lymphatic system.
Diagnosis. — Although the symptoms of osteomyelitis are generally
very plain, the most serious errors in diagnosis are quite common. A
young adult is seized with intense pain in the thigh, and in a ver>' high
fever is compelled to lie in bed. A careless practitioner may diagnose
his case as rheumatism, forgetting that acute rheumatism attacks the
joints, and not the shafts of the long bones, and that it is seldom con-
fined to a single joint. Weeks or months later a large portion of
necrosed femur has to be removed by operation. Sometimes the
febrile symptoms impress the attendant to the exclusion of local con-
ditions, and a diagnosis of typhoid fever is made. Another case may
show marked redness of the skin, which of itself is sufficient to lead
some persons to a diagnosis of erysipelas. Except in the early hours
or days of the disease these mistakes are unpardonable.
The syjnptonis are —
1. High fever, with or without a chill. The temperature is high
from the beginning, and does not show the gradual daily increase with
morning remissions so characteristic of typhoid fever.
2. Pain of a peculiar gnawing or boring character, worse at night.
92 si'NG/CA/. d/.h;\os/s and treatment.
This pain is situated in the shaft of the bone near a joint, but not in
the joint. Movement causes intense pain, due to the action of the
muscles upon the inflamed area, and not to friction in the joint. There
is ahvays sensitiveness on pressure.
3. Changes in the overlying parts. When the inflamed area is
deeply seated no change in the soft parts is observed in the early
stage of the disease. After several days the superficial layers of bone
become affected, then the periosteum, and lastly the overlying soft
parts. By this time the swelling can be observed — redness of the skin
and fluctuation indicating the presence of pus. When the outer layers
of bone are first affected these symptoms occur earlier. In either case
delay in treatment is disastrous, for hour by hour the periosteum is
being separated from the bone, and with it the nutrition of the osseous
tissue is cut off Necrosis is the inevitable result. The neighboring
joint is in imminent danger, for, sooner or later, the inflammatory
process will extend to it, distending the capsule with effused fluid, into
which pyogenic organisms may be brought through the blood-vessels
or lymphatics.
After the formation of pus and its evacuation through a natural
opening or by incision an exploration can be made with a probe.
When healthy bone is touched the probe produces a dull sound and
the periosteum gives a firm and roughened sensation. Carious bone is
gritty, and the probe can be easily driven into it. Necrosed bone gives
a clear, high-pitched note, is usually smooth, and, if separated, the
diseased portion is movable.
Treatment. — There are few diseased conditions in which delay in
treatment is so dangerous as here. Fomentations, iodin, cold appli-
cations, and medication are delusive and a waste of valuable time.
These are cases in which symptoms should not be treated. The pain
may be the leading symptom, and in an unguarded moment you may
give a hypodermic injection of morphin. The patient feels better for
a time, but the destructive process is still going on. A high tempera-
ture may induce you to give one of the coal-tar derivatives, such as
acetanilid. This also is a mistake. A profuse perspiration, with a fall
of temperature, may follow, but the security is such as the ostrich finds
when he hides his head in the sand.
The only treatment that can prove of any avail must be radical.
The bone must be cut down upon, drilled, or trephined, and a free exit
given to the pent-up products of inflammation. Tension once relieved,
pain will soon cease. Evacuate the pus, scrape out the bone-cavity,
irrigate with corrosive-sublimate solution to destroy remaining germs,
and pack with iodoform gauze. The temperature will speedily fall.
When the medulla is extensively diseased it is well to trephine at two
or more points and scrape out the intervening tissue. It is better to
take too much than too little, and the whole medullary canal of a long
bone, such as the tibia, is often removed with advantage.
The after-treatment consists in keeping the limb at rest on a suitable
splint, securing perfect drainage, and guarding against sepsis. The
constitutional and hygienic treatment consists in nourishing diet, cod-
liver oil, quinin, and fresh air.
Necrosis. — One of the objects of early and radical treatment of
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 93
the inflammatory process in bone is the prevention of necrosis. The
stripping off of the periosteum, or the pressure produced by hyperemia
and the other processes in the Haversian canals or the medulla, cuts
off the blood-supply to a greater or less area of bone. This portion dies,
and the process is called necrosis. It is gangrene of bone. Two or
three months usually elapse before the dead portion of bone becomes
detached. During this time profuse suppuration is taking place, which
is a great tax upon the patient's strength. As soon, therefore, as the
dead bone has become detached, or even before in certain cases, no
time should be lost in removing it. The necrosed piece of bone is
called a seqiicstnun, which simply means that it is separated from the
sound portion. If the process is long delayed and nature has had
time to make attempts at repair, more or less new bone is thrown out.
This is especially the case when the periosteum and the outer layers
of bone remain healthy. The new bone forms an osseous envelope
around the sequestrum, and to this envelope the name involiicniui is
given. It is often found to be pierced by one or more openings, due
to ulceration through the periosteum and bone-layers outside the
sequestrum. These openings are called cloaca. In removing dead
bone these are important. Through a cloaca we can pass a probe
or finger and determine the existence of a sequestrum, and by cut-
ting away a sufficient area of the involucrum we can remove the
sequestrum.
ScquestrotojHv, or the operation for the removal of necrosed bone, is
performed as follows : When the bone to be removed is in one of the
extremities, the limb should be elevated for four or five minutes and a
rubber bandage applied on the proximal side of the disease. Should
the sequestrum present at one of the cloacje and be of small size, it may
be grasped by forceps and pulled away. In most cases a free opening
will have to be made by first cutting through the soft parts and then
chiselling away the involucrum. The sequestrum can then be taken
away as a whole or in pieces. The next procedure will be to scrape
away the granulation tissue which lines the cavity. The parts are
well irrigated and packed with iodoform gauze, which must be changed
about twice a week, or more frequently if there is much discharge.
Chronic Inflammation of Bone. — Cases of chronic inflam-
mation are for the most part tubercular, pyogenic, syphilitic, or
malignant, and follow a chronic course from the beginning.
Chronic suppurative osteomyelitis may occur as a primary affection
or it may take place at the site of a former acute attack. It has a
decided preference for the long bones, and its victims are generally
children and adolescents. The cancellous tissue near the extremities
of the femur and the tibia is often the starting-point. The disease is
generally circumscribed, and has a tendency to produce two opposite
conditions, one being abscess and the other overgrowth. Abscess is
liable to form in the interior of the bone, and especially in the lower
end of the femur and either end of the tibia. Overgrowth is due to
the constant irritation which chronic inflammation produces. The
increase in the growth may be considerable, and is sometimes sufficient
to cause deformity. In tubercular cases the bone may be lengthened,
but shortening and atrophy are more common.
94 SCRGICAI. DIAGNOSIS AND TREATMENT.
Syjuptoiiis. — I'ain is the most prominent symptom. It is of a gnaw-
ing or boring character and often very severe. There is always
increased pain on pressure over a Hmited area, and this sign is of great
value in forming a diagnosis. The pain is worse at night. It may
disappear at times, giving the patient a respite for days, weeks, or even
months, to return again with its former severity. If you grasp the
bone, it will be found to be enlarged.
Trcatmoit. — When a case presents the characters above described
there is only one thing to be done, and that is to get rid of the pus
which is confined and secure drainage from the diseased area. In my
collection of specimens I have a small piece of bone removed by
trephine from the lower end of the tibia of a boy fourteen years of age.
The portion of bone removed contained a small abscess large enough
to admit the end of the little finger, and this comprised the whole of
the diseased area. Recovery was rapid.
When the tender point is found an incision should be made over it
down to the bone. The periosteum having been separated by an
elevator, the bone can be explored by a fine drill at different points.
If pus is found, or even a suspicion of it, a trephine is applied and a
piece removed, going well into the center of the bone. Should there
still be no appearance of an abscess, the drill may be used to penetrate
the walls of the trephined cavity. When pus is reached, a free exit
must be given to it, and all the diseased part scraped away with a
Volkmann's spoon. After thorough irrigation with i : 2000 solution of
corrosive sublimate the cavity is packed with iodoform gauze and an
antiseptic dressing applied. Even if no pus be found after cutting
into the bone, benefit will result, for, tension having been relieved,
the terrible gnawing or boring pain will cease. If the operation be
done with proper antiseptic care, it will do no possible harm. Better
that a mistake be made by trephining a healthy bone than that a dis-
eased bone should go unrelieved. In case of doubt, trephine.
Tubercular Ostitis. — The favorite situations of this form of
disease are the bones adjacent to the hip-, the knee-, and the elbow-
joints, and also the bones of the wrist and ankle. The progress of
the disease is ordinarily slow, and in its early stages very insidious.
The pain is often spoken of as " starting " in character. In some cases
it is so light as to be scarcely noticed, but pressure always reveals its
existence. The early symptoms may be little more than an impair-
ment in the movements of the limb with rigidity of the muscles of the
neighboring joint. Local elevation of temperature may be observed.
Tubercular inflammation tends to the formation of fluid in the part
affected. This collection is sometimes erroneously spoken of as an
abscess. It contains vast numbers of the tubercle bacilli, but the
micro-organisms of pus are wanting. Should such a cavity be laid
open without antiseptic precautions and pus-germs find entrance, a
double infection will be the result, and the most serious consequences
are liable to follow. This is why the older surgeons found it so dis-
astrous to open tubercular joints or psoas abscesses.
The symptoms that distinguish tubercular from other inflammations
of bone are —
I. Atrophy of the muscles. The parts both above and below the
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 95
seat of disease become wasted to such a degree that simple disuse is
not sufficient to account for it.
2. Spasm of the muscles. This is generally observed when the
patient is dropping off to sleep. The muscles acquire a persistent
rigidity which is very noticeable in the early stages of spinal caries
and in hip-joint disease. Flexion of joints is almost sure to occur,
the flexor muscles gradually overcoming the extensors until serious
deformity results.
Treatment. — Tuberculosis is greatly influenced by keeping the part
at rest, and if adopted in the early stage of the disease immobilization
may be sufficient to produce arrest of the tuberculous process. Con-
finement to bed, plaster-of- Paris dressings, and suitable splints will fulfil
this indication. The general principles of treatment in tuberculosis will
also need to be kept in view, such as good hygienic conditions, nour-
ishing food, and remedies directed to the improvement of the patient's
strength. Some excellent results have been obtained by local injec-
tions of iodoform, of chlorid of zinc, or of acid phosphate of lime. Clin-
ical experience has shown that in most cases where arrest of the tuber-
culous process has taken place the bacilli have been encapsulated by
infiltration of the healthy tissue surrounding them. They have been,
as it were, enclosed by a wall which they cannot break through. The
object of the injections above mentioned is to produce this condition,
and at the same time to destroy the vitality of the bacilli. Iodoform is
probably the least irritating and the most satisfactory of this class of
remedies. It can be used in a solution containing one part of iodo-
form and ten of glycerin. By means of a needle long enough to reach
the diseased area this fluid is injected in small quantity every three,
seven, or ten days.
A method of treatment has been recommended by Bier which is
worth consideration. Clinical evidence having shown that tubercles do
not multiply in parts supplied by too much blood, an artificial chronic
congestion is secured by wearing an elastic bandage above the seat of
the disease. This bandage is applied at more and more frequent inter-
vals, and as tightly as the patient can bear it, until at last he is able to
wear it almost constantly.
When the above methods are unsuitable, or in cases where they
have failed, an operation should be resorted to for the removal of the
diseased area. Scraping and removal of the infected tissues must be
more thorough here than in pyogenic ostitis. The walls of every sinus,
the medulla of infected bone, and every suspected deposit of tubercle
in the soft parts, such as the skin, tendon-sheaths, or synovial cavities,
must be thoroughly scraped. When the disease extends into a joint the
question of resection or amputation will have to be considered.
Syphilitic Diseases of Bone.— The bones most liable to this
form of ostitis are the long bones and those of the skull and the face.
The frontal is the one most frequently affected of all the bones. Pain,
worse at night, is an early symptom, and may even appear before the
eruption on the skin. At first it has the character of a periostitis, but
later smooth, firm, flat elevations about one or two centimeters in
diameter can be felt ; these are tender on pressure. They yield readily
to treatment, but run on for an indefinite period if let alone. lodid of
96
SURGICAL DIAGNOSIS AND TREATMENT.
potassium and the mercurials act as specifics. No operative inter-
ference is required.
Fragilitas Ossium. — An abnormal brittleness of the bones by
which they are liable to fracture on the slightest cause is known as
fragilitas ossium. This condition may be congenital, the bones even in
utero being fractured, and the fragility continuing until mature life,
when it may cease. The disease may also be the result of debilitating
conditions which compel long confinement to bed. Other causes are
syphilis, malignant tumors, the early stage of rachitis, general paralysis,
and tabes.
Treatment. — Nothing can be done further than to guard against
accident and to treat the fracture in the ordinary manner.
Rachitis. — Rachitis, or rickets, is a disease of infancy and childhood
having as its leading features a deficiency of lime salts in the bony
framework and absorption of bone already formed. It is generally
seen among the poor in crowded, unhealthy portions of cities, where
Fig. 33.-
-Rachitic curvature before operation. FiG. 34. — Rachitic curvature after operation.
(From photographs in the collection of Dr. T. S. Roberts.)
ventilation is bad and the general surroundings are unhealthful. It
begins about the first or second year of life, rarely after the sixth. Its
starting-point is the epiphyseal line, where there is found a deficiency
of lime salts, and at the same time an increased growth of cartilage.
Hence the bone is wider and thicker at this part. The child is loose-
jointed, the ligaments being relaxed, and movements of the articulations
frequently cause pain (Figs. 33, 34). When the spinal column is the
seat of the disease one or other of the various spinal curvatures may
result. Rachitic children are often hydrocephalic, and deformities of
the brain are not uncommon.
Symptoms. — One of the earliest indications of rachitis is perspiration
about the head, particularly during sleep. The child is restless, and
rolls his head from side to side on the pillow. There is constipation ;
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 97
the urine is increased in quantity and loaded with phosphates. Enlarge-
ment of the epiphyseal end of the bones will be most likely to occur
at the lower end of the radius and the ribs. The forehead and the
frontal eminences are enlarged. The changes in the ribs produce the
characteristic pigeon's breast. Teething is delayed. The anterior
fontanelle fails to unite, and the want of growth results in a dwarfing
of stature. Bronchitis, catarrhal affections, and pneumonia are common
complications, and, in some instances, causes of death. About 90 per
cent, of the cases improve under proper management.
Treatment. — The treatment of this affection may be surnmed up
under two words — nutrition and hygiene. Removal from crowded, ill-
ventilated dwellings to the pure air of the country, sea-air, and sea-
bathing are invaluable. Of drugs, the best are cod-liver oil, syrup of
the iodid of iron, phosphorus, and the lactophosphate of lime.
Osteomalacia. — While rickets is a disease of childhood, osteo-
malacia, mollities ostium, or malacosteon is a disease of adult life. The
most frequent subjects are pregnant women or those who have borne
children. In men it is rarely found. Its cause has never been clearly
explained. Among the causes assigned are defect of lactic acid, defec-
tive nutrition, ovarian and uterine disorders, and changes in the trophic
nerves. The leading feature of the disease is a progressive softening
of the bones, resulting in all sorts of deformities, going on from bad to
worse, and ending in death from exhaustion or from some complication,
such as disease of the lungs, bronchi, or pleura.
Symptoms. — Its early history is obscure. Pain is one of the most
important symptoms. It occurs at a number of points of the body,
and is liable to be mistaken for rheumatism. The sex of the patient
and the existence of pregnancy with large deposits of phosphates in
the urine should excite suspicion. When osteomalacia has advanced
so far as to cause bending and deformities of the bones, no doubt can
exist of the terrible character of the malady.
Treatment. — The treatment is by no means satisfactory. Some cases
are mild and have a tendency to remain almost stationary ; others pro-
gress to a fatal termination in spite of every form of treatment. The
best hygienic surroundings are indispensable, and deformity should be
prevented by the use of protective dressings. Pregnancy should be
avoided, as it has an especially injurious effect upon the disease. The
medical treatment consists in the administration of cod-liver oil, phos-
phates, and lime salts, but they produce little if any benefit. Removal
of the ovaries and uterus has had some advocates, and a few cases
have been reported in which there was decided benefit from the
operation.
Actinomycosis. — Until recent years this disease was confounded
with sarcoma, owing to the fact that its microscopical structure bears a
close resemblance to the round-celled variety of these tumors. It is
now known to be a disease due to a specific germ. Infection usually
takes place through the mouth, either from a wound or a carious tooth.
It may also find a portal of entrance by way of the lungs, where,
reaching the pulmonary alveoli, it sets up a broncho-pneumonia.
The chief characteristic of the disease is a chronic inflammation which
closely resembles that caused by the tubercle bacillus.
7
98
SURGICAL DIAGNOSIS AND TREATMENT.
Syniptcwis. — An enlargement of the lower jaw or an ill-defined
swelling in the submaxillary region or a nodule of the skin is generally
the first symptom. The progress of the disease is slow, but steady.
The lymphatics and blood-vessels are not involved until a late period.
Pain and swelling are not marked until suppuration begins. Then the
local and constitutional symptoms become as marked as they are in
acute cellulitis or in diffuse osteomyelitis. As the disease progresses
secondary deposits take place with caseous nodules and abscesses, no
part of the body being exempt. To the naked eye there is nothing to
distinguish the growth from sarcoma or granulation tissue. The
special character of the disease must be settled by finding the micro-
organisms which produce it.
The granulation tissue and the pus contained in it are filled with round
bodies like millet-seeds of a yellow color. The fungus itself is easily
recognized by its star-hke masses of mycelium.
TiratJHcnt. — When recognized early the diseased part should be
thoroughly removed, and when this can be done the prognosis is
favorable.
Tumors of Bone. — The benign tumors of bone are exostoses,
fibromata, and enchondromata ; the malignant are sarcomata and
carcinomata.
Exostoses are localized overgrowths of bone (Fig. 35), the term
Fig. 35. — Exostosis of head of the tibia.
hypertrophy being applied when the whole extent of the bone is
increased in size. Their structure is the same as bone itself, and they
are divided into two classes, according to their density, the ivory or
eburnated and the cancellous. The ivory variety is commonly found
on fliat bones, and a favorite position is the frontal sinus, where it may
grow to considerable size, resulting in horrible deformity. This form
is often associated with syphilis. The cancellous variety affects the
long bones. Exostoses are often hereditary, and in that case are gen-
erally symmetrical and multiple. They begin to grow in childhood,
and their starting-point is the junction of the shaft with its epiphysis.
They grow from cartilage, which is gradually converted into cancellous
tissue, and generally cease to enlarge when the bone to which they are
attached has reached its full development (Fig. 36).
Diagnosis is easy. The tumors are painless, hard, and fixed, closely
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM.
99
connected with bone, and can be readily felt or seen. Exostoses give
little trouble, except under the following conditions ; when they inter-
fere with the free use of a joint, especially in flexion : when by their
pressure they cause atrophy or ulceration of the overlying soft parts ;
or when they occur in the inner surface of the skull and press upon the
brain. Even in the last-mentioned condition no serious cerebral dis-
turbance may result, and the existence of a tumor may be discovered
only after death.
Treatment. — Where no inconvenience is caused no treatment is
Fig. 36. — Osteoma growing on the under surface of the scapula (from a photograph in the
collection of Dr. Graham, Washington, D. C).
called for. The growth can be bfoken off if it be attached to the bone
by a narrow pedicle, but in most cases it is best to cut down upon and
remove the tumor.
Chondromata, or Cartilaginous Tumors. — These growths are
found chiefly on the extremities ot the long bones and in connection
with the small joints of the hands and feet (Fig. 37). If composed of
purely cartilaginous tissue, they are benign, but, unfortunately, they
often contain a mixture of sarcomatous elements which places them
within the category of malignant growths.
lOO
SURGICAL DIAGNOSIS AND TREATMENT.
Chondromata occur on the surface or in the center of bone, in the
former case being very easy of diagnosis, in the latter exceedingly
difficult. They have a tendency to become cystic.
Syjiiptojiis. — A slowly-growing tumor, elastic and firm, of less density
than bone and irregular in shape, situated at the extremity of a long
bone or at the small joints of the hands or feet, is suggestive of chon-
droma. Pain is not present unless a nerve be pressed upon, which
does not often occur. When the growth is central it cannot be diag-
FlG. 37. — Lad twenty years of age with multiple chondromata (after Steudel).
nosed until it has attained considerable size, and even then its nature
often remains in doubt until after its removal.
Treatment. — The only effective remedy is extirpation. The growth
itself may be removed and the surrounding parts scraped away, or it
may be necessary to remove a part or a whole of the bone to which it
is attached. In some cases nothing short of amputation will suffice.
Fibromata. — The commonly chosen seats of fibromata are the jaws
and the base of the skull. The growth begins, as a rule, in the peri-
osteum and is pedunculated. Rare cases occur in which the starting-
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. lOI
point is the center of the bone. A tumor composed purely of fibrous
tissue is rare. With the exception of epuhs and naso-pharyngeal polypi,
the tumors of a fibroid character are fibro-sarcomata. Fibromata grow
slowly, have a tendency to become cystic, and often cease to enlarge
when the bony skeleton has arrived at maturity.
Diagnosis. — Fibrous tumors are irregular in shape, firm to the touch,
but not so hard as bone, with which they are, as a rule, connected.
The so-called naso-pharyngeal polyp commencing on the under surface
of the sphenoid bone fills in time the naso-pharynx, the posterior nares,
and the antrum. These growths are dangerous on account of their
tendency to free hemorrhage. When the patient reaches the age of
about twenty-five years the polyp ceases to grow and atrophy com-
FlG. 38. — Osteosarcoma of femur (from a photograph in the collection of Dr. jepson,
Sioux City, Iowa).
mences. Unless hemorrhage is frequent and copious it is advisable to
delay treatment in the hope that this favorable change may take place.
Treatment. — Remove either by extirpation of the tumor alone or by
resection of the portion of bone from which the growth has originated.
Malignant Tumors of Bone. — Carcinoma of bone is exceed-
ingly rare, and is always secondary or due to simple extension of the
disease from neighboring structures.
Sarcomata, on the other hand, are common, and are distinguished
from all other tumors of bone by the rapidity of their growth (Fig. 38).
No bone in the body is free from liability to this form of malignant dis-
ease, but certain bones are especially prone — viz. the lower end of the
femur and the upper end of the tibia ; that is to say, the bones on each
side of the knee-joint. The jaw is also a common situation, and the
I02
SURGICAL DIAGNOSIS AND TREATMENT.
disease here constitutes one of the forms of epulis. Injury, such as
fracture or bruising of a bone, frequently precedes the growth and
must be considered an exciting cause. Sarcomata in bone, as else-
where, may occur at any age, but the great majority of cases are found
in early life. After forty years of age the disease is very rare.
If we classify the tumors according to their histological structure,
we have three varieties — round-celled, spindle-celled, and giant-celled.
The malignancy exists in about the proportion of the size of the cell.
The round cell and spindle cell are found in tumors of the most rapid
growth, while the giant-celled neoplasms grow slowly and have fewer
malignant characters.
Fig. 39. — Round-celled sarcoma (from a photograph in the collection of Dr. Graham,
Washington, D. C).
A sarcoma is classed among malignant growths for the following
reasons :
(i) It infiltrates the surrounding structures.
(2) The lymphatic glands become involved sooner or later.
(3) It occurs in the form of secondary deposits in other parts, the
lung being specially liable to this metastasis.
Clinically, sarcomata of bone may be divided into two varieties,
periosteal and central.
Periosteal Sarcomata. — These are the most malignant of bone-
tumors, being composed, as a rule, of round or spindle cells (Fig. 39).
There is a special tendency in this variety to affect different organs, so
that, although no sign of the disease is seen in the stump after an
amputation, a secondary deposit in the lung may carry off the patient.
IXJCRIES AND DISEASES OF THE OSSEOUS SYSTEM.
lO-
The deeper, more vascular layer of the periosteum is the starting-point.
While the tumor is small the external layer of the periosteum is stretched
over it, but in the course of time this
gives way, the growth breaks through,
and rapidly infiltrates the surrounding
tissues (Fig. 40).
Central sarcomata begin at the ar-
ticular ends of the long bones or in
the cancellous tissue of the short ones.
They are not so malignant as the peri-
osteal variety, and in the early stages
are not easily recognized. As the
tumor increases in size its pressure
produces atrophy of the bone, until
nothing is left but a thin shell of
osseous tissue, which cracks beneath
the fingers like an egg-shell. The
fracture of this weakened bone from
some trivial cause may be the first
thing to excite suspicion of the real
nature of the disease.
Symptoms. — The early s)^mptoms
of sarcoma are frequently obscure.
Pain, which may be mistaken for
rheumatism, is generally present. It
is worse at night, and may be very
severe. In many cases there is a his-
tory of a traumatism. In a young
person a rapidly-growing tumor at the
seat of a newly-united fracture or in
one of the bones near the Jcnee-joint
must be looked upon with suspicion.
The following questions may be considered :
{a) Is there swelling of the bone ? If there be a periosteal sarcoma,
a distinct swelling will be felt, usually along one side of the bone, fusi-
form in shape, and avoiding the extremity of the bone. The swelling,
in the central variety, appears at a much later period, is more globular
in shape, and has egg-shell crackling when pressed upon by the fingers.
It is found at the cancellous end of the bone.
ip) Does the tumor pulsate ? Pulsation is a character of the central
variety, and of the periosteal when connected with the flat bones. This
pulsation is readily distinguished from the expansile, heaving pulsation
of an aneurysm. Even should a thrill and bruit be present, they are
only observed over small portions of the tumor. Pressure has little or
no effect upon the size of the swelling, and pulsation in the arter>^ below
is not impaired, except when the growth compresses the main vessel
against the bone.
The consistence of the tumor is subject to great variety. Sometimes
it is hard and dense, at other times soft and fluctuating. Should spon-
taneous fracture occur, followed by a tumor of rapid growth, a diag-
nosis of central sarcoma could be made with confidence.
Fig. 40. — Recurring sarcoma of the
humerus (from a photograph in the
collection of Dr. Strickler, New Ulm,
Minn.).
104
SURGICAL DIAGNOSIS AND TREATMENT.
In any case of doubt an exploring needle of moderate size can be
thrust into the growth. If it be a sarcoma, the needle will be found to
penetrate the bone, and through the cannula may escape myeloid cells
or other elements which can be examined microscopically.
Diagnosis. — The conditions likely to cause errors in diagnosis are —
1. Chronic inflammation of bone with necrosis. Cases of this kind
are exceedingly puzzling, and no amount of care will ensure against a
mistaken diagnosis. When the course of ostitis is very slow and free
from pain, when there is much inflammatory thickening without the
formation of abscess, and the sequestrum has formed in the manner
known as " slow necrosis," the nature of the disease can in some
instances be settled only by free exploration. I have known two cases
in which all treatment was abandoned and a diagnosis of sarcoma made,
which afterward proved to be necrosis of the femur near the hip-joint.
2. Inflammation in a neighboring joint may mask the symptoms of
a sarcoma which has its seat in the cancellous extremity of a long
\
\
t
Fig. 41. — Acromegaly (from a photograph in the collection of Dr. T. P. Findley).
bone. If care be taken to look for all the characteristics of joint-
disease, mistakes are not likely to happen. The position of the limb,
the pain (worse at night), and the effusion of fluid into the joint are
very expressive, while the history of a tumor in the bone, beginning
not at, but near, the joint, is indicative of sarcoma.
3. Syphilitic gummata. The difficulty in this case can be removed
by putting the patient upon iodid of potassium for a few days. If the
growth be syphilitic, it will steadily diminish.
4. Aneurysm of bone. This condition, if it ever occur, must be
exceedingly rare.
Tr^eatnient. — In either form of the disease the only chance of success
lies in early and complete removal. If the tumor is situated on an
INJURIES AND DISEASES OF MUSCLES, TENDONS, AND BURSM. 105
extremity, amputation affords the only hope. The operation should be
at or above the nearest joint.
In periosteal sarcoma of the femur amputation at the hip-joint is
justifiable, but when the tumor involves the middle or upper third of
the bone the case is practically hopeless. Recurrence of the disease
will take place, either in the stump or in some internal organ, notably
the lung.
Acrotnegaly. — This disease, first described by Marie in 1886, is
attended with a remarkable enlargement of the bones of the face, head,
pelvis, thorax, feet, and hands (Fig. 41). Although the affection is of
a nervous origin, the bony enlargement is a true hypertrophy, and first
appears in the hands, feet, and lower jaw. The disease is generally
symmetrical. There is usually freedom from pain ; the joints do not
become ankylosed ; it follows a very long chronic course, and up to
the present time no treatment has been found which has any effect
upon the disease.
CHAPTER IV.
INJURIES AND DISEASES OF MUSCLES, TENDONS, AND
BURS/E.
The injuries to which muscles are liable are bruises, strains, ruptures,
and wounds.
A blow, a violent and prolonged contraction, or overuse will result
in a condition known as a strain. The muscle is tender to pressure ;
there is more or less swelling, stiffness, weakness, and pain, especially
when the muscle is brought into action. The injury is found in groups
of muscles, such as the deltoid, the pectorals, biceps, and pronator
radii teres (the " lawn-tennis arm "). The adductor muscles of the
thigh are affected in prolonged and severe horseback-riding. Any
muscular exertion to which the individual is unaccustomed will produce
it. A blacksmith can swing his hammer all day and feel no ill effects,
but a man unused to such labor will find, after the first day's toil, that
his arm is powerless.
Treatment. — Rest and hot bathing or fomentations.
Rupture. — Under a violent muscular effort or as the result of a
severe blow the muscular structure may be ruptured. A few fibers
may give way or the whole tnuscle may part in its continuity. The
patient experiences a sudden and severe pain, perhaps attended with an
audible snap, and immediately finds that the muscle has lost its power
in whole or in part. On examination there will be found a depression
or gap at the seat of rupture, and swelling due to extravasated blood.
Sometimes the quantity of blood is so great as to produce a hematoma.
At a later period there is discoloration of the skin. The function of
the muscle is, of course, impaired or even lost, and this may result in
permanent weakness of the limb. In debilitated conditions of the body,
as in convalescence from typhoid fever, the muscles may suffer laceration
from trivial causes, owing to their fibers having undergone granular
degeneration.
I06 Sl'RGICAL DIAGNOSIS AND TREATMENT.
Treatment. — The most important point in treatment is rest in the
position which most relaxes the ruptured muscle. The torn ends may-
be approximated by properly applied compression. In cases of com-
plete separation in healthy muscle sutures should be employed. In
diseased muscle this is useless, as the stitches will tear out. Union is
effected by the interposition of connective tissue, the length of the
band depending upon the degree of separation.
Wounds. — By accident or in the course of an operation wounds
of muscle may be made, and are subcutaneous or open. The symp-
toms are retraction of the divided ends and hemorrhage.
The treatment consists in early and accurate approximation by cat-
gut sutures. The union is commonly by fibrous tissue.
Myalgia. — Pain in a muscle or group of muscles is a common
ailment depending upon overuse, exposure to cold, and to a variety of
causes, such as lead-poisoning or syphilis.
The diagnosis of pain in a muscle or group of muscles is important.
If a patient complains of pain over the deltoid, for example, and the
pain is increased when he raises the arm from the side of his own voli-
tion, while no pain is felt if the surgeon moves the arm and at the same
time the muscles are kept relaxed, it will prove that the muscle is the
seat of pain. Placing the limb in such a position that the muscles are
stretched will also produce pain. Hence we have this rule : When a
muscle is affected active movement produces pain, passive movement
is painless ; over-extension or passive stretching is painful. Ligament-
ous pain is elicited by any movement, either active or passive, that
stretches the ligaments. A certain amount of passive motion can take
place in a joint without stretching either muscles or ligaments, and this
amount is unattended with pain. If you continue this movement and
pain is then felt, it may be set down as having its seat in the ligaments.
The treatment is heat, electricity, massage, and sedative applications.
Myositis (inflammation of muscle) follows an injury, but, as a rule,
this is unimportant compared to the effect upon other tissues. Muscular
rheumatism, so called, is a form of myositis, and is often produced by ex-
posure to cold. Gonorrhea is often attended by muscular pains (one of the
forms of gonorrheal rheumatism), and may also be regarded as myositis.
A chronic form of myositis is often observed in syphilis. It gives
a wood-like hardness to the parts, and a common situation is the
sphincter ani muscle.
Symptoms. — The symptoms of mj^ositis are stiffness of the affected
limb and pain, which is worse at night and increased whenever the
affected muscles are brought into action. Constitutional symptoms,
such as fever, chills, etc., are seldom present.
Suppurative myositis is by no means common, except in the case
of the psoas muscle. It has been observed as a localized inflammation,
resulting- in muscular abscess and due to some local irritation, such as
a foreign body or traumatism. Diffuse suppuration m muscles has, m
a few instances, been observed. It appears to occur under the same
conditions as diffuse osteomyelitis. The entrance of pyogenic- organ-
isms is by a wound or through one of the mucous surfaces.
Still more rare is the disease known as acute progressive myositis,
which involves the whole of the muscular system and ends in death by
INJURIES AND DISEASES OE MUSCLES, TENDONS, AND BURS.E. lO/
asphyxia or pneumonia. It is probably due to bacteria the nature of
which has yet to be determined.
Myositis ossificans (Figs. 42, 43) is a pecuHar form of muscle-
FlG. 42. — Myositis ossificans, showing the ab-
duction of the arms (Stephen Paget).
Fig. 43. — Myositis ossificans, showing the
contraction of the left sterno-mastoid, the
masses of bone in the latissimi dorsi, and
the extreme amount of abduction of the
arms obtainable (Stephen Paget).
The
inflammation in which bony plates form in the muscular tissues,
most common situation is the dorsal region.
Permanent Shortening- of Muscle, or Contracture. — Long-con-
tinued inactivity of muscles, as in the bed-ridden, is liable to result in
contracture. These cases are generally of a mild character, and the
muscles rapidly regain their normal condition under proper exercise.
Chronic inflammation of the muscle itself, descending neuritis, and
sclerosis following lesions of the cortex produce the most serious
forms of permanent shortening.
Trcatvient. — In the milder forms massage and passive motion usually
suffice. In the severer cases tenotomy may be required. If the division
of a tendon is likely to result in too wide a gap, the tendon can be
lengthened, as recommended by Anderson (Fig. 44), by first splitting it
in the middle line, and then sliding the ends
to the proper position and suturing them.
Tenosynovitis, inflammation of ten-
don or thecitis, is a common affection. A
favorite situation is at the wrist, due to
over-exertion of the flexor tendons in
workmen, such as stone-cutters and others,
who use a hammer or other tool con-
tinuously. Any tendon, however, may be
affected. The disease occurs in three
forms — acute, suppurativ^e, and chronic.
The acute form is due, as a rule, to
overwork. The course of the tendons is
sensitive to pressure, and the overlying skin is hot and in some cases
B— ,
L
1
Fig. 44. — Anderson's method of
lengthening a tendon.
I08 SURGICAL D/. I GNOSIS AND TREATMENT.
reddened. I^vcry movement of tlie muscle is attended with pain. The
surfaces of the tendon and its sheath become rou<;hened, and produce
a crepitant sound which has been compared to the rustUng of silk. In
aggravated cases the exudation not only involves the tendon-sheath,
but the adjoining cellular tissue, so that the swelling may extend from
the wrist down over the dorsum of the hand and up the arm to or
beyond the elbow. Instead of simple serous fluid, the exudation may
contain blood, and the pain, heat, and tension may be excessive. This
variety may run into the chronic or the suppurative form of the disease.
Chronic tenosynovitis is nearly always of tubercular origin. The
tendons of the forearm are those most commonly involved. The prog-
ress is slow and is attended with the formation of granulation tissue,
in which can be found the tubercle bacilli in large numbers. Accord-
ing to the density of this granulation tissue will be observed swelling
along the tendons, firm or fluctuating. In some cases small bodies
resembling rice or melon-seeds are formed in the sac, either floating in
the fluid or attached to the walls.
Besides cases due to tuberculosis, chronic tenosynovitis is frequently
a result of the acute form of the disease. This may be due to some
constitutional dyscrasia, such as gout or rheumatism, or it may be a
consequence of adhesions. Long-continued disease of a limb after
fracture or other injury is liable to result in such adhesions, which, if
not completely broken up by passive movements, are a constant source
of pain and inconvenience.
Suppurative Tenosynovitis. — This is most frequently met with in
the form of thecal abscess or whitlow in connection with the flexor
tendons of the fingers or thumbs. It was formerly not uncommon as
a result of septic infection after amputations, and also as playing a
part in pyemia and septicemia. Whitlow begins generally as the result
of a slight injury or wound which admits septic organisms. Having
once gained an entrance, the germs follow the course of the lymphatics,
which in these situations is toward the tendon-sheath, the periosteum,
and the bone. The dense, resisting structure of the sheath and its
tendon gives no room for expansion, and hence the intolerable pain
and throbbing which characterize whitlow. Two varieties of whitlow
are recognized — the superficial and the deep. The superficial variety
occurs about the nails and affects one or several fingers at the same
time. The subjects of the disease are delicate children or debilitated
persons. In some instances it runs its course in a few days or even
hours, ending in the formation of serous fluid, which is reabsorbed ; in
others ulceration takes place, and the nail is undermined and eventually
cast off. Deep whitlow is a much more serious affair. The palmar
aspect of the last phalanx of one of the fingers is the common situ-
ation. The finger becomes painful in a day or two after an injury ;
then it begins to throb, particularly when allowed to hang down ; the
patient passes sleepless nights ; the pulse increases in frequency and
the temperature rises. Suppuration is taking place, and nothing but
the evacuation of pus and the relief of tension will get rid of the
suffering.
Treatment. — At the \'er}^ commencement of the disease the hand
may be placed for an hour or longer in a hot solution of corrosive sub-
INJURIES AND DISEASES OF MUSCLES, TENDONS, AND BURS.E. IO9
limate in the hope of destroying the germs and averting suppuration.
If at the end of two or three days the symptoms show no sign of
abatement, the only treatment of value is free incision. When the
terminal phalanx is affected the tissues should be divided down to the
bone. In the case of the first or second phalanx the pus is probably
no deeper than the tendon, so that opening the sheath is sufficient, and
relief will speedily follow. The rest of the treatment consists in strict
antiseptic dressings.
Ganglion — or " weeping sinew," as some of the old surgeons
called it — is a collection of fluid in connection with a tendon-sheath.
Its favorite situation is the back of the hand or wrist, w^here it appears
as a round, firm tumor of varying density, causing little or no incon-
venience, except in such occupations as require constant use of the
affected tendon. This little tumor is a cyst containing the synovial
fluid, but generally changed to a jelly-like consistence. Sometimes
the tendon-sheath is distended for some distance, and the fluid contains
melon-seed bodies and is thick and gelatinous. This form, sometimes
called compound ganglion, is found in the palm, while the simple cyst
is common on the back of the hand and wrist. The causes are strains,
overuse, or slight injuries frequently repeated.
Treatment. — Three methods of treatment are in vogue :
1. Subcutaneous rupture. This may be effected by a quick and
forcible pressure of the thumb or a smart blow. The contents of the
cyst are forced along the sheath or into the surrounding tissues, and
are then absorbed. The objections to this method are that the cyst
rapidly refills, and it may then be so thick and strong that it cannot
thus be ruptured.
2. Subcutaneous division by a small knife or flat needle.
3. Cutting down upon the cyst and excising it is the most effectual
of all methods, and when carried out aseptically is perfectly safe.
Compound ganglion is a serious affection, and the results of the
most careful treatment are often unsatisfactory. Syme's method of
freely laying open the sheath was successful in his hands even before
he resorted to antiseptic surgery. The sheath should be opened above
and below the annular ligament, the melon-seed bodies removed, and
thorough drainage effected. Suppuration is disastrous, for it is almost
sure to extend to the joint, and the tendons themselves are liable to
slough. This operation should never be undertaken except under the
most rigid asepsis, and in any case a guarded prognosis should be
made.
Dupuytren's contraction is an affection of the hand found in
men (rarely in women) of middle or advanced life. Its characteristics
are flexion of the fingers at the metacarpo-phalangeal joint ; the palmar
fascia is tense and firmly adherent to the skin, while great resistance is
felt when an attempt is made to straighten the fingers. In aggravated
cases the fingers are tied rigidly down into the palm of the hand. It is
generally associated with gout, but engineers, fitters, and other mechanics
are liable to suffer from it.
Ti'eatvient. — In the early stages massage and passive movements of
the affected fingers may arrest the progress of the deformity. A splint
may be worn at night, and a variety of complicated appliances have
no
SURGICAL DIAGNOSIS AND TREATMENT.
been invented by instrument-makers. These have not been very satis-
factory. When the finger is so far contracted as to form a right angle,
operative treatment is necessary. Various procedures have been resorted
to. Adam's method consists in subcutaneous section at many points
with a fine tenotomy knife. The hand having been carefully tlisinfected
and held in an deviated position for a few minutes to limit the amount
of hemorrhage, incisions are made in the palm at those points where
the skin is still movable over the fascia. This is continued down the
fingers, each resisting point being severed until the digits can be thor-
oughly extended. The small openings can be sealed by iodoform and
collodion, and the hand placed immovably upon a palmar splint for
three or four days. Passive motion should then be continuously carried
out. In favorable cases two weeks suffice to effect a cure.
Diseases of Bursse. — Between tendon and bone, over bony
prominences, and in fact at any point where there is much friction,
bursse exist, either congenital or acquired. They may communicate
with the cavity of a joint, in which case they must be regarded as
offsets of the synovial sac. In most cases they are simply cavities in
the cellular tissue.
Wounds of bursae, if not infected, heal rapidly. Punctured and
lacerated wounds and contusions are liable to prove troublesome, owing
to the friction of the adjacent structures. The treatment of such injuries
is by rest, thorough cleansing, drainage, and pressure.
Bursitis, or inflammation of bursse, is commonly met with in
the form of " housemaid's knee," the bursa in front of the patella being
the seat of inflammation (Fig. 45). The
" student's elbow " is an inflammation of the
bursa over the olecranon, due to pressure of
the elbow upon a hard table while absorbed
in study. The bursa lying between the tendo
Achillis and the os calcis is another that is
liable to inflammation. It is recognized by a
swelling which occupies the space on each
side of the tendon, and is distinguished from
an effusion into the ankle, which would ap-
pear in front of the joint.
Bursitis may be acute, chronic, or sup-
purativ^e.
Acute bursitis is nearly always the result
of injury. The housemaid upon her knees
scrubbing floors bruises the prepatellar bursa
and inflammation follows. Syphilis, gout, and
tuberculosis are also regarded as causes. The
early symptoms of bursitis are swelling, red-
ness, pain, and pyrexia. The bursa being, in its natural state, an
unfilled cavity, a certain amount of fluid can collect without pro-
ducing tension ; hence pain is not an early symptom. In super-
ficial bursae diagnosis is easy, but in the case of deep bursae it may
be difficult. Here we have little or no swelling to guide us, and our
reliance must be placed upon our knowledge of the action of the mus-
cles. Inflammation of the bursa under the deltoid is recognized from
Fig. 45. — Prepatellar bursa,
contents aspirated ; no return
(from a photograph in the col-
lection of Dr. Lincoln, Wa-
basha, Minn.).
INJURIES AND DISEASES OF JOINTS. I 1 1
the fact that rotation of the arm is free from pain when the Hmb is in
the position of moderate abduction, but excessively painful when by
forced adduction or abduction the sac is made tense. In the case of
the bursa under the psoas we have freedom from pain when the thigh
is rotated in the position of flexion, but intense pain when this move-
ment is carried out with the limb in extension.
Suppuration is recognized by the occurrence of a chill or a marked
rise in temperature with increased severity of all the symptoms.
Chronic bursitis is a sequel of the acute form or may result from
tuberculosis or syphilis.
Trcatinejit. — In the acute form rest, cold applications, and pressure
may be tried. If these measures do not give relief, the sac should be
aspirated and firm pressure maintained by means of a bandage. When
suppuration takes place the cavity should be laid open, irrigated with
corrosive sublimate i : 2000, drained, and dressed antiseptically.
CHAPTER V.
INJURIES AND DISEASES OF JOINTS.
I. INJURIES OF JOINTS.
In examining any joint we must keep before our minds the follow-
ing structures, any or all of which may be implicated when an articula-
tion is injured or diseased : viz. the bones, articular cartilages, synovial
membrane, ligaments, and muscles. The common injuries of joints are
contusions, sprains, wounds, and dislocations.
Contusions. — Direct violence, such as blows, kicks, or falls upon
a joint, is important, from the fact that more or less hemorrhage may
take place into the articular cavity, causing distention and affording a
good culture-soil for septic germs should they chance to gain an
entrance. When the bruise is not severe and no hemorrhage results,
rest and the application of warm fomentations will soon restore normal
conditions.
Sprains are more serious. A forcible twist of a joint, as when a
person " turns his ankle," is liable to cause more or less laceration of
the tissues. The ligaments may be stretched or torn across, and may
detach a thin scale from the bone, the synovial membrane may be rent,
the muscles may be lacerated or overstretched, and their tendons thrown
out of their grooves. In severe sprains the bones themselves are wrenched
asunder, but slip back into place. Between a sprain of this kind and a
dislocation the only difference is that in the one case the bones return
to their normal position, while in the other they remain dislocated. It
is a common saying that a bad sprain is worse than a fracture, and to
a certain extent this is true. If much laceration of tissues occur and
the most careful treatment be not employed, permanent weakness of
the joint may result.
The symptoms of sprain are —
112 SL'KGICAL n/AGiXOSIS AND TREATMENT.
(i) Severe pain following a forcible twist or wrench of a joint.
Sprains occur, as a rule, when the muscles are, so to speak, taken off
their guard, and the same is true of dislocations. If the muscles were
prepared for the strain and thrown into strong resisting contraction, it
is doubtful whether sprains or dislocations would ever occur. The
pain is of a severe and sickening character. The patient becomes
deathly pale, nauseated, and perhaps falls fainting to the ground. As
the more intense pain passes off a feeling of numbness succeeds, with
a dull aching due to pressure on the nerves. Movement of the limb
causes unbearable pain. There can usually be felt one or more spots
which are intensely tender to pressure. These correspond to the
lacerated ligaments.
(2) Swelling sets in almost immediately, particularly if there be
rupture of vessels in or about the joint. When the swelling is due to
inflammatory exudation, it is longer delayed, and may not be observed
until the end of twenty-four or forty-eight hours.
(3) Discoloration of the skin follows the injury, varying in hue from
a greenish-yellow to black, and if there be much extravasation of blood,
the tissues about the joint may be filled with it.
Errors in Diagnosis. — Sprains may be mistaken for dislocation, for
fractures near joints, or in the case of the ankle for talipes valgus.
Differential Diagnosis betzveen Sprain and Dislocation.
Sprain. Dislocation. .
Deformity.
Only the result of swelling. Great deformity, and bones felt in abnormal
position.
Pain.
Pain of a peculiar sickening character, after- Severe pain, even when at rest, not relieved
ward numbness, relieved by pressure and until reduced,
rest.
Mobility.
Normal mobility, except as impaired by Want of normal mobility, both in direction
swelling and pain. and degree.
Fracture of the lower end of the fibula is often difficult to dis-
tinguish from a severe sprain of the ankle. The diagnosis can be
settled by finding the characteristic deformity of this fracture and a
particularly tender spot over the fibula by digital pressure.
Spurious talipes valgus (flat-foot) need not cause any difficulty, as in
this case there is a history of a gradual and prolonged debility, and not
a sudden wrench as in sprain.
Treatment. — In mild cases cold applied immediately after the injury
will tend to prevent swelling and effusion into the joint by constricting
the blood-vessels. If seen several hours after the accident, hot fomen-
tations generally afford most relief Perfect rest in the elevated position
is of the greatest importance, and will relieve pain better than liniments
or lotions. Of all appliances, a flannel or an elastic bandage applied
over a thin sheeting of absorbent cotton gives the greatest support and
relief to the joint. In the case of the ankle care should be taken to
fill in the hollows around the malleoli with cotton before applying the
INJURIES AND DISEASES OF JOINTS. I 1 3
bandage. When there is much laceration of Hgaments the joint should
not be used until perfect repair shall have taken place, otherwise there
is a risk of permanent weakness. In cases of ordinary seventy it is
sufficient for the patient to lay up for a few days, and then, with the
joint firmly bandaged, he can move about on crutches in the case of a
sprained ankle or knee, or with the arm in a sling when the wrist or
elbow is the injured joint.
Massage is of great value in protracted cases, or even in the early
stages when the acute inflammation has subsided. It can be employed
as follows : Raise the limb and relax the muscles. Begin with very
hght movements, commencing above the joint, where there is still no
swelling, and working downward to the articulation. The direction of
the movements must always be toward the trunk, using the thumbs,
the pulp of the fingers, or the palm of the hand according to the part
of the limb that is being manipulated. The tender spots are the last
to be touched. Swelling by this means gradually subsides, and as the
circulation improves absorption rapidly takes place. Attention is next
paid to the parts where extravasation is greatest, and by the thumbs or
fingers these spaces are rubbed, moving in small circles upon the skin,
and gradually increasing the pressure as the structures can tolerate the
operation. Passive motion of the joint can be combined with these
movements, for even in the case of ruptured ligaments a considerable
degree of motion can be effected without throwing the ligaments into
a state of tension.
Wounds of Joints. — Wounds of joints must always be looked
upon as serious injuries. They are common among artisans, such as
ship-carpenters, who work with edged tools.' As gunshot injuries they
are common, and they also occur as complications of dislocations and
fractures. Even in non-penetrating wounds of joints the injury is a
serious one, for if the wound be allowed to suppurate the cavity of the
joint may be opened into and become the seat of serious mischief.
Large wounds, laying open to view the articulating surfaces of the
joint, are self-evident and easily diagnosed. In perforating wounds,
however, it is not always easy to prove that the joint has been cut
into. The most important sign is the escape of the synovial fluid more
or less mixed with blood. It can be readily recognized by its viscidity
when a drop of it is examined between the thumb and finger. If the
amount of this fluid is large, it may be regarded as pathognomonic of a
wound of a joint. It may happen that a small bursa is opened into
which does not communicate with the articulation, but in this case the
amount of fluid is small, and it ceases to come away after the first gush,
while in the case of the true synovia it can be made to ooze out on
flexion and extension of the joint. When no synovial fluid escapes,
the rapid filling of the joint with blood would be strong evidence of a
penetrating wound.
Treatmoit. — Provided the wound is made by an aseptic instrument
and no infection is allowed to gain access to the joint, these wounds
are free from danger. An incision in the synovial membrane or in any
other of the joint-structures, if kept thoroughly aseptic, will heal as
readily as in any other tissues. The danger lies in the ease With which
septic germs gain an entrance, and in the difficulty of keeping the
8
114 SURGICAL DIAGNOSIS AND TREATMENT.
wound tliorouy;hl\' drained. Asepsis here is evcrythin<^ in treat-
ment.
Before touching the wound itself the skin for a considerable dis-
tance around should be thoroughly washed with soap and water, and
afterward with cither alcohol or turpentine, and lastly with corrosive-
sublimate solution. The limb should be wrapped with sterilized towels.
After cleansing the wound from all clots and impurities, the finger,
scrupulously clean, assisted, if need be, by a probe, should explore
the wound. It is often necessary to enlarge the wound in order that
pieces of clothing carried in by the bullet or penetrating object and all
particles of bone can be effectually removed. After thoroughly irri-
gating the joint with sterilized water a drainage-tube is inserted, pass-
ing through the joint from side to side if necessary. A full antiseptic
dressing and immobilization of the limb on a splint complete the ope-
ration. Should the joint become septic, the wound and every sinus
about it must be opened up, washed out, and drained, and the process
repeated as often as necessary. In gunshot wounds, which form a very
dangerous class of these cases, the bones are often so destroyed as to
require the removal of a considerable part of their articular ends. It
is better to make an atypical resection rather than the typical operation,
in order to leave the joint as little impaired as possible. Such cases
are apt to result in bony ankylosis.
Treves strongly advocates constant irrigation of the joint night and
day to avoid the retention within the cavity of septic and decomposing
materials, and excellent results have been obtained in very unpromising
cases.
When thorough drainage can be maintained there is little likelihood
of great tension in the joint. Should this occur, the fluid must be got
rid of by free openings and extra drainage-tubes. When there is
danger of ankylosis resulting the limb should be kept in the position
w'hich will be most useful to the patient in the event of a stiff joint.
Dislocations. — When one of the bones entering into the forma-
tion of a joint is permanently displaced from its normal relations with
the other bones, it is said to be dislocated. In sprains a temporary
displacement may take place, the bones immediately returning to their
normal relations.
Dislocations are classified as traumatic when the result of violence ;
patlwlogical when the bones have become displaced owing to destruc-
tive changes in the joint, as, for instance, in disease of the hip or knee ;
congenital when occurring in titcro and as a result of non-development ;
complete when the articular surfaces are entirely separated or only touch
each other at their edges ; incomplete, or subluxations or partial, when
the surfaces are not completely separated. For every ten cases of
fractures you meet with, you may expect one of dislocation. Dis-
locations occur at any time of life, but the most common period is
between twenty and thirty years of age.
The causes of dislocation are predisposing and immediate. Some
people are naturally loose-jointed ; their ligaments are lax ; the area
of contact between the articular surfaces is small ; and, altogether, the
joints have not the normal power of resistance. A joint distended
with fluid is thereby predisposed to dislocation. The immediate causes
INJURIES AND DISEASES OF JOINTS. II5
may be summed up in a few words — external violence and muscular
action.
In examining a patient for dislocation, always strip the suspected
joint of all clothing, and also its fellow on the opposite side of the
body, which will serve for purposes of comparison. Four features
must be kept in mind, and, as a rule, these four will settle the ques-
tion. They are — Loss of symmetry ; want of normal mobility ; change
in direction of the axis of the dislocated bone ; constant pain, relieved
only by reduction.
In certain forms of dislocation the end of the displaced bone can be
felt in its abnormal position. A systematic manner of making the
examination would be the following :
{a) History. — Falls are common causes of the accident. A fall upon
the shoulder is likely to dislocate the upper end of the humerus or
fracture the clavicle. A fall upon the outstretched hand will dislocate
the elbow of a child, but fracture the humerus of an adult.
(/;) Inspectio7t. — A glance may decide the change in outline and
show an unmistakable displacement of the bones. The eye may be
assisted by measurements, as in dislocation of the hip, where shorten-
ing or lengthening of the limb affords important evidence. The head
of the humerus in the axilla may press upon the veins and cause edema
of the arm.
(r) Palpation. — The finger can be placed over the bony prominences
and their position determined, as in the case of the condyles of the
humerus and the olecranon at the elbow. Motion, both active and
passive, must be tested. Voluntary movements are always restricted,
and may be entirely lost. Passive motion cannot, as a rule, be tested
until the patient has been placed under an anesthetic. When super-
ficial palpation affords no satisfactory evidence deep pressure will
frequently do so.
Should these methods fail to satisfy the surgeon, he can gain much
additional evidence by placing the patient under an anesthetic. Motion,
which was before restricted on account of pain, can now be freely
tested, and any want of normal mobility accurately determined.
Great care must be taken to exclude fractures in the neighborhood
of the joint, severe sprains, and separation of the epiphyses. Crepitus
is pathognomonic of fracture, but in some cases it is wanting. It may
be present in dislocations, owing to the fact that a dislocation and frac-
ture may exist together. A dull rubbing sound, due to the movement
of a dislocated bone on tendons or fascia, must not be mistaken for
crepitus.
In obscure cases, and especially when dislocation and fracture are
combined, the .i'-rays may settle the diagnosis in a most satisfactory
manner (see chapter on " The Rontgen Rays in Diagnosis ").
When we consider the structure of a joint, it is not difficult to
understand what takes place when dislocation occurs. One or more
of the ligaments must be torn : rarely does stretching alone occur.
The pain of dislocation is produced by two factors — viz. the violence
to the ligaments and the pressure of the head of the bone in its new
position. The capsule of the joint also suffers, and it is quite common
to have this membrane torn. In joints of the ball-and-socket variety
Il6 SURGICAL DIAGNOSIS AND TREATMENT.
the bone is pushed through a rent in the capsule, and in some cases
affords no little trouble to get it back through the opening which it has
made. The muscles also suffer, for they not infrequently are over-
stretched, lacerated, or torn from their attachments, perhaps bringing
away a scale of bone with them. The bones thcmscKcs do not always
escape. At the shoulder-joint the dislocated head of the humerus
often breaks off a piece of the rim of the glenoid cavity ; the head of
the femur may detach a part of the lip of the acetabulum ; the coronoid
process of the ulna may be carried away in backward dislocation of the
elbow.
Complications may give no end of trouble. Fracture and disloca-
tion combined are found at the shoulder, the elbow, the hip, aiid in fact
may occur at any joint. The displaced bone may compress arteries,
veins, nerves, and neighboring organs ; the bruising and tearing of
soft parts may add to the seriousness of the injury, and the bone may
be driv'en through the skin, thus forming a compound dislocation. In
view of these conditions it is most important that a dislocation be
reduced at the earliest possible moment. Pain, which continues as
long as the part remains overstretched, will cease almost as soon as
the bone is replaced ; the displacement, when once rectified, has no
tendency to return ; the rent in the capsule speedily heals and the nor-
mal condition of things is restored. The only conditions which war-
rant delay in reducing a dislocation are great swelling and inflammation
in and about the joint, also profound shock from associated injuries.
While I mention the existence of swelling and inflammation as a reason
for delay, I would also urge that when it is possible reduction is the
very best means of getting rid of these conditions. Shock is important
as prohibiting the use of anesthetics or painful manipulation.
Trcatmoit. — Two difficulties confront us in reducing a dislocation :
The bone may not readily come back through the rent which it has
made in the capsule or it may become locked against another bone or
be caught in a ligament, tendon, or dense fascia. The other obstacle
is the contraction of the muscles which pass over the joint. Immedi-
ately after a dislocation the muscles become relaxed, but after a time
they regain their contractility and become rigidly contracted. This
action tends to push the ends of the bones farther and farther past each
other, and greatly increases the difficulty of bringing them back to
position. To overcome this, steady traction must be made upon the
muscles until by sheer fatigue they become relaxed. Under an anes-
thetic relaxation is immediate and complete.
Two methods of reduction are in vogue :
I. Extension and Counter-extension. — By this method steady traction
is made until the muscles relax or perhaps iDCCome torn, and the bone by
sheer force is freed from its unnatural position, when with a snap the
muscles draw it into its proper place. A good example of this method
is seen in the case of the shoulder-joint, where, by placing the heel in
the axilla to steady the trunk, traction is made upon the arm. and the
bone slips back with a dull sound into the glenoid cavity. The older
surgeons were in the habit of reducing luxations of the hip by means
of pulleys and cords, which, adding immensely to the power, caused
something to give way. We seldom see mechanical appliances of this
INJURIES AND DISEASES OF JOINTS. 11/
description now, for in the second method we have something more
rational and scientific, and at the same time generally applicable.
2. Manipulation. — This is adapted to the ball-and-socket joints, the
articulations which are most complicated and likely to give most
trouble. The procedure aims to relax the muscles, and then by suitable
movements to free the head of the bone from its entanglements, bring
it back through the rent in the capsule, and finally into its normal
position. These manipulations will be described under Special Dis-
locations. The after-treatment of dislocations is the same as that of
sprains. Little is needed in the way of retentive apparatus, for there is
but slight tendency to recurrence. At the same time, the joint should
be kept at rest to allow the torn structures to heal and to regain their
normal firmness and strength. Inflammation is seldom a source of
trouble, but should it take place cold applications or evaporating
lotions are generally all that are demanded. Care must be taken not
to keep the joint too long at rest, for adhesions may result which will
impair its movements. Passive motion, cautiously carried out, may be
begun by the end of the first week, and massage, as in the case of
sprains, will be found a valuable adjunct.
Old dislocations are difficult to deal with. Changes in the structures
take place which, after a time, render reduction a physical impossibility.
The muscles become fibrous, and are liable to rupture before they can
be stretched to their former length. The head of the bone in its new
position becomes surrounded with fibrous tissue, forming a new socket.
Over the normal socket, as at the acetabulum or glenoid fossa, the
capsule is stretched and may become firmly attached, so that the bone
cannot be brought back to position. Still, it sometimes happens that
good results are attained even after long periods of luxation. In a boy
ten years of age the writer reduced a dislocation of the femur into the
obturator foramen after an interval of fifty-six days, in another after
twelve weeks, both by manipulation ; and in a dislocation of the lower
jaw after a period of six months.
In the treatment of old luxations the same methods as are suitable
for recent dislocations may be tried. Much greater force will, however,
be necessary to break up the adhesions that have formed and to stretch
the muscles to their former length. It is difficult to judge of the amount
of force that it is safe to employ in cases of this kind. A moderate
amount of traction will be of no avail, and too much may lead to
serious consequences. The neck of the humerus or of the femur may
be broken, vessels may be torn across, and even when every obstacle
has given way and the bone is brought to its original position, the last
state may be worse than the first. As a guide in the management of
such cases the following directions may be useful : Always put the
patient under an anesthetic. Break up the adhesions by manipulation
and rotation, and avoid any leverage which is apt to fracture the bone.
Wrap the limb in a wet towel to prevent injury to the skin. If manip-
ulation fail, try the pulleys. Traction must be slow and steady, and
sudden jerks avoided. While this is being done the surgeon, by
direct manipulation, follows the head of the bone, and as soon as it is
brought down endeavors to force it into its socket.
Compound dislocations must be treated on much the same prin-
ii8
SURGICAL DIAGNOSIS AND TKEATMENr.
ciples as compound fractures. We have here the serious comphcation
of a wound into the joint, and the dani^er of infection by septic germs,
and consequently suppurative arthritis. It will often be a nice point to
decide whether the proper course is to amputate or to attempt to save
the limb. The amount of laceration and destruction of tissue, the
interference with vascular supply, and the probability of securing a
useful limb will have to enter into the calculation. At the knee the
displaced bone may press upon the popliteal vessels so as to rupture
their inner coats, while the outer are left intact. While the absence
of hemorrhage would lead us to suppose that the vessels were uninjured,
their giving way at a later period will lead to the most serious results.
When the conditions seem favorable for saving the joint the greatest
care must be taken in the dressing of the wound. Fragments of bone
must be removed, the joint freed from all contamination, such as dirt
or clothing, and thoroughly irrigated. Reduction is generally easy.
The wound should be dressed in the usual manner and the limb im-
mobilized by a splint. Thorough drainage is of the utmost conse-
quence. When operative interference is demanded the choice will
rest between excision of the joint and amputation of the limb.
Diagnosis of 5pecial Dislocations.
The I/Ower Jaw (Fig. 46). — There is only one direction in which
the lower jaw can be dislocated, and that is forward. One side may
be displaced (unilateral dislocation), or
both sides (bilateral). The injury is easily
recognized. The causes are muscular
action and indirect violence. The acci-
dent always happens when the mouth is
open. The patient presents a peculiar
appearance when the dislocation is bi-
lateral. The mouth is widely open and
speech is difficult. The labials he cannot
pronounce at all. He holds his hand
against the jaw to prevent further dis-
placement, and saliva dribbles from his
mouth. Place your fingers at the angle
of the jaw, and you will find in front of
the ear a depression instead of the natural
prominence caused by the condyle. In
front of this there is a prominence due to
the new position of the bone and to the
contraction of some of the fibers of the
masseter muscle. The jaw can be moved
downward to a slight degree, but this is all. Pain is severe, owing to
stretching of the parts, except it be a case in which the jaw has been
repeatedly dislocated. When only one side of the jaw is the seat of
luxation, the symptoms, although not so marked, are equally charac-
teristic. The lower jaw appears to be pushed toward the opposite side,
and therefore its teeth do not fit normally against those of the upper.
The face is not much distorted, and pain is only felt at one side.
Fig. 46. — Dislocation of lower jaw.
INJURIES AXD DISEASES OF JOINTS. II9
In young persons a partial dislocation is sometimes met with in
which the condyle is displaced slightly forward when the mouth is
widely opened as in yawning. The patient learns to rectify the
position by pressing the chin upward.
Errors in Diagnosis. — i. Congenital dislocation of the jaw has been
mistaken for traumatic unilateral dislocation. In the congenital form
the movements are but slightly impaired or are even normal, which is
never the case in the traumatic variety. The upper teeth project
beyond the under teeth. There is absence of salivation, and one side
of the face is longer than the other.
2. Chronic rheumatoid arthritis is another disease which may be
mistaken for dislocation. The history shows that the condition has
come on slowly. It is a disease of old age, there is no salivation, and
the same condition exists in other joints.
Treatment. — The patient, seated in a chair, has his head supported
by an assistant. Protect your thumbs by folds of a clean handkerchief,
and, placing one over the molar teeth on each side, press steadily down-
ward, while the fingers at the same time tilt the chin upward. The
thumbs should be placed as far back as possible. When great
difficulty is experienced, as in old dislocations, one side can be reduced
first, and the other afterward, care being taken lest the first be again
displaced while the second is being reduced. In very obstinate cases,
although these are uncommon, great force has to be employed. A
wedge of cork or wood may be placed between the molar teeth and the
chin drawn upward with strong force ; or a tourniquet may be placed
over the head and under the chin, and screwed slowly and steadily up
until the jaw is brought into place. A powerful pair of forceps may
be introduced between the last molar teeth and their blades separated
forcibly. In some cases, direct pressure, made backward upon the
coronoid process, will prove successful. It rarely happens that this
process becomes entangled in the fibers of the temporal muscle. When
this occurs depress the chin before attempting to elevate it.
lExamination of Injuries about the Clavicle and Shoulder.
— The most convenient position for the examination of injuries about
the shoulder is- to have the patient seated upon a stool or chair with his
back toward you. Place your fore fingers in the suprasternal notch
and pass them outward. You can in this way easily decide whether
the ends of the clavicle are in position. The clavicles are subcutaneous,
and by passing the fingers along their upper borders any irregularity
in their shape will decide the existence of fracture. From the outer
end of the clavicle the finger can be run along each acromion process
and spine of the scapula to the posterior border of this bone. Note
any tender spot or any irregularity in the bone. Next take the
shoulder, and, placing the hands flat, with a thumb upon each acromion
process, note whether the head of the humerus can be plainly felt
beneath the hand. Press upon the deltoid muscle and feel for the
glenoid fossa of the scapula. If the glenoid fossa can be felt, it is proof
of dislocation of the humerus, and then the head of the bone must be
sought for. It will be found in one of three locations — under the
glenoid fossa, under the clavicle, or under the spine of the scapula.
When you have found the head of the humerus rotate the bone
120 SL'KG/C.IL DLl GNOSIS AND TREATMENT.
gcntl}' by grasping the elbow, and notice whether or not the head moves
with the rest of the bone. If there be fracture, crepitus can be felt.
Next examine the coracoid process. There is a groov^e between the
pectoralis major and deltoid which allows you to feel it without much
difhcult}-. Into this groove press the points of your fingers and find
the process. Observe whether it is movable or whether pressure upon
it causes pain or crepitus. From this point the fingers can be passed
around the shoulders to note any difference in contour on the two
sides.
To examine the axilla raise the arm gently from the side, and with
the fingers in the axilla feel for the head of the humerus and note any
undue prominence, always comparing the uninjured with the injured
side.
To examine the scapula, place the forearm of the patient behind his
back, which throws the lower angle of the scapula out from the chest-
wall. The margins of the bone can be followed with the fingers, the
inferior angle grasped, and crepitus or mobility noted. Up to this point
your examination has been made with the patient's back toward you ;
now stand in front of him. Have him hold both arms alike, and note
any difference in their outlines. Look for any angularity in the arm or
forearm which would indicate fracture, or for undue projection of the
point of the elbow which would be evidence of dislocation.
We continue the examination by following the shaft of the humerus.
Place a thumb on the inner side of the surgical neck of each bone, and
with the fingers grasp the outer side ; in this way the hand can be run
down along the bone to the elbow in search of any projecting frag-
ments or other deformity. Should any such be found, grasp the arm
above the suspected spot with one hand and with the other rotate the
elbow for crepitus.
To Bxamine the Blbow. — Still standing in front of the patient,
take his elbows into the palms of your hands, with your fore finger
resting on the tip of the olecranon, the thumb on the outer epicondyle,
and the middle finger on the inner epicondyle of the humerus. In the
normal condition of the joint these three bony points are in line. Any
deviation from this should be noted. Look for a gap in the olecranon
which would indicate fracture, or for the sigmoid notch of the ulna
which would point to dislocation. Now move the joint and observe
whether its action is free and painless. Place the thumb of your left
hand just below the outer condyle, and with the right rotate the
patient's wrist ; the head of the radius will be felt rolling beneath the
thumb. Should this mov^ement be painful, you may suspect fracture ;
the existence of crepitus will leave no doubt. Grasp each epicondyle
in its turn, and attempt to move it upon the rest of the bone, and note
the power of the patient to pronate and supinate the forearm. The
olecranon is subcutaneous, and the fingers can be run along it in search
of fracture. Usually a large gap into which the end of one or more
fingers can be placed will be found when this process is fractured. To
complete the search follow the tendon of the triceps down to its
insertion into the ulna.
Dislocation of the Clavicle. — The dislocations of the clavicle
are seven in number — three at the sternal end, three at the acromial
INJURIES AND DISEASES OF JOINTS. 121
end, and one of both ends simultaneously. At the sternal end the
accident is rare, owing to the great mobility of the shoulder, which
prevents any severe strain upon the sterno-clavicular joint, except
when the force is acting upon the clavicle directly. We have here an
illustration of the rule that when it comes to a test between ligaments
and bone the bone has to yield. A force acting upon the clavicle will
almost surely break the bone before it can be torn from its attachments
to the sternum. When dislocation takes place it is in one of three
directions — \\z. forward, backward, or upward.
Forward dislocation is the most common. The bone can be
readily felt as a prominence in front of the sternum, while an exam-
ination of the suprasternal notch will show its absence from the normal
position. The portion of the sterno-mastoid muscle which is attached
to the clavicle is put upon the stretch, and throws the patient's head
downward and forward ; movement of the shoulders forward is attended
with severe pain.
Backward dislocation is also easily recognized by a depression
at the normal position of the end of the bone. Very disagreeable
symptoms are produced if the bone is sufficiently displaced to cause
pressure upon the esophagus or trachea, in the one case causing
dysphagia, in the other dyspnea.
Upward dislocation is the rarest of the three forms, and is really
a variety of the backward dislocation, for the bone is always displaced
backward as well as upward. The bone fills up the suprasternal notch
and lies between the sternal portion of the sterno-mastoid and the
sterno-hyoid muscles.
The most important of these three is the backward dislocation, for
very prompt action may be required to save the patient's life when the
trachea is pressed upon by the displaced bone.
Treatment. — One method of reduction serves for all of these forms
of dislocation. Seat the patient upon a low stool with his back toward
you. Place his elbows close to the sides and a little in front of the
median lateral line. Then with your knee against his spine and between
his scapulae grasp the shoulders and bring them backw^ard. If the bone
does not slip into position at once, direct manipulation can be employed
to aid in the reduction. When these measures fail, place a large pad
in the axilla, and, using the arm as a lever, press the elbow in toward
the side.
Reduction, however, is the smallest part of the treatment ; the dif-
ficulty is to keep the bone in position after it has been replaced. This
can be readily understood when we recollect that the articular surfaces
are flat and smooth, the ligaments are usually ruptured, while even the
unavoidable movements of respiration are sufficient to disturb the joint.
In forivard dislocation a double figure-of-8 bandage is probably the
best appliance. A firm pad or a well-padded splint is placed between
the shoulders and the bandage passed over each alternately to bring
the shoulders back as far as possible. Velpeau's method is the best
for dislocation backward or backward and 7ip%vard. It consists in
placing a pad in the axilla and in drawing the elbow forward and
upward across the chest, so that the hand of the affected side can be
placed upon the opposite shoulder. The elbow, forearm, and hand are
122
SURGICAL DIAGNOSIS AND TREATMENT.
then flexed firmly in position by strips of adhesive plaster. In all cases
it is necessary to place over the end of the bone a pad covered with
adhesive plaster to keep it from slipping, and hold it in position by a
roller bandage. It is absolutely necessary to keep the arm rigidly
immobilized for at least three weeks, after which the bandage may be
to a certain extent relaxed, but no movement should be allowed for
three or four weeks longer.
Dislocation of the Acromial End (Fig. 47). — The cause is usually
a fall or a blow upon the shoulder. The direction is commonly upward
or upward and outward, so that the end
of the clavicle is carried over the end
of the acromion process. Reduction is
very easily effected by pressing the arm
upward and backward, when the end of
the clavicle can be replaced by direct
manipulation. Should crepitus be felt
during this movement, it may be set
down as due to a fracture of the edge
of the articulation. Should there be
any doubt about the outer end of the
clavicle itself being broken, measure-
ment of the bone and comparison with
its fellow of the sound side will settle
the question. It is exceedingly difficult
to keep the bone in position after re-
duction. The best method is probably
that recommended by Stimson. Take
a piece of strong adhesive plaster three
inches wide, and, applying the middle
of it to the point of the elbow flexed
to a right angle, bring the ends up
over the end of the clavicle before and
behind the arm, and allow one to overlap the other on the shoulder.
The forearm is carried in a sling, and the arm bound to the side by a
broad bandage passing round the body.
Dislocation of the Sternum. — It is difficult to distinguish this
injury from fracture. It is generally associated with fracture or dis-
location of the ribs or the costal cartilages. When uncomplicated
dislocation takes place, it is either the manubrium dislocated from the
body or the ensiform cartilage from the body.
Diagnosis is not usually difficult. The bone being subcutaneous, a
change in its outline can be felt. The junction of the manubrium with
the body corresponds with the end of the second costal cartilage. This
relation will be found to have been disturbed in dislocation.
Reduction is effected by requiring the patient to draw a deep
breath while the fragments are directly pressed into position. Should
this fail, forcible flexion of the trunk backward will prove a valuable
aid. Many cases have remained unreduced and little or no incon-
venience resulted.
The cnsifonn cartilage may be dislocated, so that its point is directed
forward or backward. It causes no great inconvenience as a rule,
Fig. 47. — Upward dislocation of acromial
end of right clavicle (Keen and White).
INJURIES AND DISEASES OF JOINTS.
123
although vomiting has been attributed to a backward displacement.
When the symptoms are severe enough to warrant interference, reduc-
tion can be effected by drawing the cartilage forward by the fingers or
by a sharp hook inserted through the skin.
Dislocation at the Shoulder. — In a joint so freely movable and
so exposed to violence it is not surprising that dislocations at the
shoulder occur as frequently as all other dislocations combined. The
glenoid cavity is shallow, and the head of the humerus finds no such
deep socket to rest in as the head of the femur finds in the acetabulum.
The capsule is weak, loose, and easily torn. The joint is dependent
upon muscles and tendons for its support, while the great length of the
humerus affords a powerful leverage which can force the joint asunder
without difficulty. The aspect of the glenoid fossa is forward and out-
ward. The head of the humerus can be displaced from it in three
directions — viz. forward, backward, and downward, very rarely upward.
Forward Dislocations. — Two varieties of this form are recognized :
Fig. 48. — Kocher's method of reducing dislocation of shoulder : first movement, abduction
and external rotation.
1. Subcoracoid, when the bone has little more than slipped off the
glenoid fossa and lies under the coracoid process.
2. Subclavicular, when the head of the humerus has travelled farther
forward and lies beneath the clavicle. Some authors give a third
variety, when the head of the bone lies a little farther inward than the
coracoid, and call it intracoracoid.
Of the three varieties the subcoracoid is the most common. The
bone lies about a finger's breadth below the coracoid process. The
inner and lower portion of the capsule is torn along the edge of the
glenoid fossa. Some of the muscles about the joint may be torn, such
as the subscapularis, the supraspinatus, the infraspinatus, and the teres
minor. Injury to the bones themselves is not uncommon. The
greater tuberosity may be torn off, or the head of the humerus may
be bruised by forcible contact with the edge of the glenoid fossa.
124
SURGICAL DIAGNOSIS AND TREATMENT.
Syiiiptoins. — Following the method of examination already outlined,
we observe —
1. C/ia)ii^f of Con four- -The deltoid is flattened, and the normal
fulness of the shoulder on its anterior and outer aspect is lost. The
injured elbow hangs at a little distance from the side. The axis of the
humerus passes a little in front of the glenoid fossa. The anterior fold
of the axilla is lowered.
2. Abnormal Position of Bony Prominences. — Instead of the normal
bony resistance below the front and outside of the acromion, a depres-
sion is felt, while a well-marked prominence is felt farther forward and
below the coracoid process. Press upon this prominence with your
fingers and you will find that it rotates with the arm.
3. Impaired Mobility. — Active movement is painful and perhaps
impossible. Passive movement is greatly limited. The arm can be
abducted, but cannot be so far adducted as to allow the hand to be
Fig. 49. — Kocher's method : second movement, advancement of elbow forward, upward, and
inward, still maintaining external rotation.
placed upon the opposite shoulder or the elbow- against the front of the
chest. When measurement is desired, both arms should be placed in
exactly the same position and the tape stretched from the tip of the
acromion process to the olecranon.
When the dislocation is farther forward the symptoms are the same,
except that the elbow is farther from the side, and the head of the
humerus is felt in its new position — viz. intracoracoid, or subclavicular.
Treatment. — i. Manipulation. — Kocher's method (Figs. 48, 49, 50)
of manipulation is the best. Flex the elbow to a right angle and press
it closely to the side. Make external rotation — i. e. turn the forearm
as far as possible away from the chest, when the head of the humerus
will roll outward in front of and below the acromion. Keep up the
external rotation, carry the elbow well forward and upward, rotate the
arm inward, and lower the elbow. This movement may be aided by
an assistant's directly manipulating the head of the bone in the later
INJURIES AND DISEASES OF JOINTS.
125
Steps, or by the use of a band in the axilla to draw the head of the
humerus outward.
2. Extension and Countcr-cxtcnskvi. — An old method of reducing
all forms of dislocation of the shoulder was to have the patient placed
on a table, couch, or the floor, when the surgeon, removing his boot
Fig. 50. — Kocher's method : rotation inward, the hand being carried toward the opposite
shoulder.
and sitting beside the thigh of the patient, placed his heel in the axilla,
to make counter-extension, while, grasping the wrist of the affected
limb, he steadily drew upon it until the bone slipped into position.
While this method is applicable to all dislocations of the shoulder, it
Fig. 51. — Reduction of dislocation of humerus.
is not without its disadvantages. Rupture of the axillary vessels has
more than once occurred. It should never be resorted to in the aged
or in those whose arteries are diseased. When traction has to be
employed it is better to make it in a direction at right angles to the
126
SURGICAL DIAGNOSIS AND TREATMENT.
body. Place a folded sheet around the chest and have an assistant
hold it firmly on the sound side. Then, grasping the injured limb by
the forearm and elbow, draw directly outward, while the assistant
makes counter-extension by the sheet (Fig. 51). Or, while the patient
is l)'ing down, make traction on the arm until the muscles are over-
come ; then, using the clenched fist of your disengaged hand as a
fulcrum, bring the arm forcibly in toward the che.st.
Backward Dislocation. — Two dislocations backward are recog-
nized :
1. Subacromial, when the head of the humerus lies below the
acromion and its anatomical neck rests against the edge of the glenoid
fossa. ■ This is not very common.
2. Subspinous, when the bone goes a little farther, resting below the
spine of the scapula.
Symptoms. — The want of symmetry will be shown by a loss of
fulness of the shoulder in front and an increase behind. The head of
the bone is generally felt without difficulty, lying behind the glenoid
fossa. The elbow lies close to the side and the arm is rotated inward.
The coracoid and the anterior edge of the acromion stand out with
unnatural prominence. Voluntary motion is lost ; passive motion is
painful and restricted.
Downward Dislocation. — This form is rare, but when it does occur
the symptoms are very characteristic (Fig. 52). The accident occurs
Fig. 52. — Subglenoid dislocation (Stimson).
when the arm is abducted with sufficient force to tear the capsule, with
rotation or direct force downward, so that the head of the humerus
slips below the glenoid cavity. Sometimes the head of the bone is
INJURIES AND DISEASES OE JOINTS. 12/
directly below the glenoid, but most commonly it is below and a little
in front. The name subglenoid is given to both of these varieties. In
rare cases the bone has slipped below the glenoid cavity with the arm
placed upward and close to the side of the head. This variety has
been called hixatio crccta.
The syinptoins of subglenoid dislocation are very similar to those of
the subcoracoid, only more pronounced. A striking feature is the
marked angularity given to the shoulder by the prominence of the
acromion.
Treatment. — As the bone lies upon or close to the axillary vessels,
great care must be taken lest these be injured. Complete relaxation
of the muscles must be secured under chloroform. Traction can then
be made in moderate abduction, while, at the same time, the bone can
be helped back into position by direct manipulation.
Upward dislocation is a curiosity. Several cases have been
reported. One of these occurred during an epileptic convulsion.
Another was produced by a blow upon the acromion while the arm
was raised. A fall upon the elbow caused the third. The recognition
of the head of the bone in its unnatural position is not difficult. Both
active and passive motions are restricted. The elbow is directed back-
ward to a slight degree and the arm lies close to the side.
Errors in diagnosis are liable to occur by mistaking a dislocation for —
1. Fracture of the neck of the scapula;
2. Fracture of the surgical neck of the humerus ;
3. Separation of the greater tuberosity of the humerus ;
4. Fracture at the anatomical neck.
In all of these the elbow can be made to touch the side, while in
dislocation it cannot. Crepitus is also an unfailing guide in nearly all.
Separation of the greater tuberosity will prove the most puzzling, and
the point will be to decide between it and subspinous dislocation. In
both cases a tumor will be felt upon the scapula. It is either the
detached tuberosity or the head of the humerus. In the one case it
rotates with the humerus (dislocation) ; in the other it is small and is
not affected by rotation.
Dislocations at the Klbow. — This joint, being made up of three
bones with the two prominences of the ulna, is subject to a great variety
of dislocations. To avoid unnecessary complications I shall classify
them as follows :
1. Common Dislocations. — {a) Dislocation of the radius and ulna
together backward and diagonally backward and outward ; {b) Dis-
location of the radius separately.
2. Rare Dislocations. — [a) Dislocation of both bones forward, out-
ward, or inward; {b) Dislocation of the ulna alone; (c) Dislocation of
both bones separately, the one being driven forward, the other back-
ward.
Dislocation of both Radius and Ulna. — Examination. — Place the
patient upon a chair and stand in front of him. Grasp the two elbows
in the palms of your hands, and place your thumbs on the external
epicondyles, the middle fingers on the internal epicondyles, and the tips
of the fore fingers on the tips of the olecranon processes. When the
joint is extended these three points should form a line transversely to
128
SURGICAL DIAGNOSIS AND TREATMENT.
the axis of the arm. When the elbow is bent the tip of the olecranon
sinks below the epicondyles. Any disturbance of these relations will
indicate that something is wrong with the joint — either dislocation or
fracture.
Backivard Dislocation of Both Bones (Fig. 53). — In this case the
olecranon is carried far back, and the distance between it and the epi-
condyles is increased. The head of the
radius is felt at the back of the outer con-
dyle. The greater sigmoid notch of the
ulna can be felt at the back of the joint,
and the tendon of the triceps stands out
prominently. Passive flexion and extension
are greatly restricted. There is usually
considerable swelling and pain.
Treatmeiit. — While an assistant holds
the lower end of the humerus, and at the
same time pushes it slightly backward,
make traction upon the forearm in the
extended position. This is generally suf-
ficient to overcome the action of the mus-
cles and to bring the coronoid process of
the ulna in front of the humerus, where it
belongs. A time - honored plan, often
spoken of as Sir Astley Cooper's method,
is to place your knee on the bend of the
elbow, and, grasping the wrist, flex the
joint strongly over the knee as a fulcrum.
If any difficulty is experienced in either of
these methods, the patient should be anes-
thetized.
After reduction the limb should be immobilized for about three
weeks. During this time massage will be found useful, but passive
motion is unnecessary, and may even prove harmful. Any stiffness of
the joint which remains after removing the splints rapidly disappears
under exercise of the limb.
Compound dislocation at the elbow is a serious matter. When
there is much injury to the end of one or more of the bones, the
destroyed portions must be removed as an atypical resection ; other-
wise reduction should be effected, thorough drainage established, and
the principles carried out which are applicable to wounds of joints.
Forxvard Dislocation of Both Bones. — This accident is always the
result of great violence, and the injury is almost sure to be complicated
with fracture of the olecranon. In this variety the olecranon lies in
front of the humerus or may find its way into the coronoid fossa. The
arm is bent to nearly a right angle, and the forearm is supinated.
When the normal position of the olecranon is examined, there will be
found a flat, broad surface caused by the lower end of the humerus.
When the olecranon is broken off, it is retained on the posterior aspect
of the joint, but drawn upward by the triceps. Fortunately, this dis-
location is rare.
Treatment. — The obstacle to reduction is the olecranon, which, if
Fig. 53. — Dislocation of the elbow
backward (Stimson).
INJURIES AND DISEASES OF JOINTS.
129
not fractured, must be disengaged from the coronoid fossa and made to
slip over the articular end of the humerus to its normal position.
After thoroughly relaxing the muscles under an anesthetic, hold the
forearm at a right angle, make extension from the wrist and counter-
extension from the lower end of the humerus. When the olecranon is
disengaged from the coronoid fossa make direct pressure downward
upon the anterior aspect of the forearm, close to the elbow. Examine
carefully, after reduction, to make sure that the head of the radius is in
its proper position.
Imvard Dislocation of Both Bones. — This is an incomplete dislo-
cation. The olecranon will be found out of its normal position and
toward the inner aspect of the joint. The external condyle will be
more prominent, and the internal less prominent, than on the sound
side. When there is not much swelling the head of the radius
can be detected on the articular surface of the humerus about its,
middle.
Treatment. — ]\Iake extension and counter-extension in the flexed
position (combined with direct pressure), gradually bringing the arm
into the position of full extension.
Ontzvard Dislocation of Both Bones. — The inner condyle of the
humerus is naturally more prominent than the external, but in this
accident the prominence is greatly exaggerated, while the external
condyle can with difficulty be felt. The hand is pronated, and the
elbow bent to an angle of about
120° (Fig. 54).
Treatment. — Extension and
counter-extension with direct lat-
eral pressure..
The very rare deformity known
as divergent dislocation, in which
the ulna and radius are dislocated
separately, needs no special men-
tion.
Dislocation of the Radius
Alone. — This can take place in
five directions — forward, back-
ward, outward, inward, and down-
ward.
Foriuai'd dislocation is recog-
nized by finding a tumor in front
of the humerus which rotates with
the elbow, while a depression is
found in the normal position of
the head of the radius at the ex-
ternal condyle. Supination of the
hand causes pain, while pronation
is not impaired. The arm can be
extended without difficulty, but
common complication of this injury is fracture of the shaft of the ulna.
Treatment. — In some cases reduction is difficult or even impossible,
while in others it proves very simple. Extend the forearm, make
9
Fig. 54. — Outward (supra-epicondylar) dislo-
cation of the elbow (Keen and White).
flexed only to a right angle. A
130 SURGICAL DIAGNOSIS AND TREATMENT.
steady adduction to disengage the head of the bone, and then by direct
pressure force it into its proper position.
Backzvard (dislocation of the radius is rare. The tumor in this case
is felt behind the humerus, and moves with rotation of the radius.
When the ulna is fractured the tendency is for the radius to be pushed
upward, the forearm at the same time being abducted. Reduction is
effected by direct pressure upon the head of the radius.
Oittzcard dislocation is exceedingly rare, and is readily diagnosed by
the position of the head of the bone at the outer side of the elbow.
Inward dislocation cannot occur without displacement of the ulna
as well.
Dozvnu'ard dislocation, an accident of young, loose-jointed children,
is caused by forcibly drawing upon the hand of a child of three years
of age or less. After a jerk the child cries with pain and cannot use
the arm. The limb hangs by the side with the forearm slightly pro-
nated. On examination there is tenderness over the head of the radius,
and the bone may be felt to be displaced downward. It is supposed to
be below the orbicular ligament.
Treatment. — Steadily supinate the arm, when a slight click will be
felt and no more inconvenience will be experienced.
Dislocation of the Ulna Alone. — This is a rare accident. It
cannot be displaced forward without fracture of the olecranon. When
dislocated backward the marked prominence of the olecranon behind
and the trochlea in front leaves no room for doubt.
Old, unreduced dislocations at the elbow are difficult to treat. If
the patient is young and there has been disturbance of the periosteum
at the time of the injury, new bone has probably been thrown out
which forms an insuperable barrier to the movements of the joint.
The displaced olecranon becomes firmly bound down by adhesions to
the posterior surfaces of the humerus, and should the limb become
fixed in an extended position, it is almost useless to the patient.
Three courses are open to the surgeon :
1. Forcible flexion of the joint, with or without fracture of the
olecranon.
2. Open arthrotomy, with division of all the tissues which prevent
movement.
3. Resection of the joint.
Dislocation at the Wrist -joint. — Examination of the Wrist and
Hand. — The bones of the wrist and hand being subcutaneous, any
irregularity due to displacement or fracture is readily detected by the eye
or palpated by the fingers. Run your fingers over the dorsum of the
carpal, metacarpal, and phalangeal bones and note any irregularity.
Grasp the extremities of each bone, and ascertain whether there be
movement or crepitus.
Dislocation of the Lower End of the Ulna. — This can occur
backward or forward. In either case the end of the ulna stands out
prominently, can be recognized in its new position, and frequently over-
laps the end of the radius.
Direct pressure is sufficient to replace the bone.
Dislocation of the carpus from the radius. This may take place
in four directions — forward, backward, outward, and inward.
INJURIES AND DISEASES OF JOINTS. I3I
These deformities present no difificulties in their diagnosis. It must
be borne in mind that dislocation at the wrist is very rare compared
with two other injuries for which it is Hable to be mistaken. These are
Colles's fracture and sprain. Careful attention to the symptoms of
Colles's fracture — the silver-fork appearance, the position of the styloid
process of the radius, and its relation to the ulna — will leave no room
for doubt. In this fracture the styloid process is below the prominence
on the back of the wrist, while in dislocation of the carpus forward the
bones form a rounded prominence on the front of the wrist, behind
which is a sharply-defined line representing the lower end of the radius.
Of the carpal bones the semilunar is the one which is most fre-
quently dislocated singly. The displacement is forward. Except when
swelling is great the deformity is easily recognized.
Treatjnent consists in replacing the bone by direct pressure.
Dislocation at the Carpo-metacarpal Joints. — The most frequent
and the most important of these is found at the base of the metacarpal
bone of the thumb. The direction is backward, and the luxation is
frequently incomplete. The head of the bone can be felt between the
tendons of the extensor primi and secundi internodii pollicis. Reduc-
tion is readily effected by extension, counter-extension, and direct pres-
sure. Immobilization should be maintained for one or two weeks, as
the displacement is liable to return.
Metacarpo-phalangeal Dislocation. — This is most frequently seen
in the thumb. Small and insignificant as this joint appears, the difficulty
of reducing a dislocation here is often very great, owing to the inter-
position of the anterior ligament with the sesamoid bones.
The phalanx is generally displaced backward and overlaps the
metacarpal bone. A very troublesome complication of this injury
arises when the glenoid ligament is turned upward and lies between
the phalanx and the metacarpal bone. This may occur during attempts
at reduction.
Treatment. — Make strong extension and press the thumb downward
until the anterior edge of the base of the phalanx overlaps the lower
end of the metacarpal bone. Then flex the thumb, and the bone slips
into its place. Sometimes the glenoid ligament and the heads of the
flexor brevis form a sort of button-hole through which the end of the
phalanx must be manipulated. This can be done by direct pressure
combined with rotation, first to one side and then to the other.
Dislocations of the Phalanges. — These offer no difficulty in diag-
nosis and seldom prove obstinate in reduction. To obtain a grasp upon
them various devices have been resorted to, of which the best and
readiest is the clove hitch.
Dislocations at the Hip-joint. — Examination of the Hip. — The
patient, divested of ordinary clothing, should be placed upon a table or
firm mattress. In the case of females a thin night-dress or sheet cover-
ing the body need not interfere with the examination and renders the
ordeal less embarrassing. See that the body lies perfectly straight, and
that a line from one anterior superior spine of the ilium to the other
lies at right angles to a line from the ensiform cartilage to the sym-
physis pubis.
I. Inspection. — With the spine resting its whole length upon the
132 SURGICAL DIAGNOSIS AND TREATMENT.
table observe whether one or both knees are flexed. The knee being
pressed down upon the table, observe if the spine becomes lordosed
(arched forward). If this occur, it is strong evidence of disease of the
joint, of psoas abscess, of sacro-iliac disease when complicated with
psoas abscess, or of inflamed bursa; beneath the psoas.
Does the suspected limb lie parallel to its fellow ? The thighs are
normally directed inward in women, slightly so in men. If the thigh is
abducted, it is evidence of the early stage of coxitis or of .synovitis of
the hip.
Adduction of the thigh points to dislocation on the dorsum ilii and
to the later stages of joint-disease.
Observe whether the limb is rotated in or out. Eversion occurs
in fracture of the neck of the femur or when the synovial cavity is dis-
tended, as in synovitis, or when there is tension of the psoas and iliacus
muscles as in abscess. Inversion is evidence of dislocation or of the
later stages of morbus coxce.
2. Measurement. — The limb can be best measured from the anterior
superior spine of the ilium to the external malleolus. Shortening indi-
cates at least two of the forms of dislocation — on the dorsum ilii and
into the sciatic notch. It is also a sign of fracture of the neck of the
femur and of advanced hip-disease. Do not be misled by the apparent
lengthening of a limb. This is due to a simple tilting of the pelvis.
3. Mobility of the Joint. — Grasp the knee with one hand, place the
other upon the outer side of the pelvis, and put the joint through the
several movements of flexion, extension, adduction, abduction, and
rotation. Observe carefully whether the pelvis moves with the
femur ; if so, whether this is due to bony ankylosis or to rigidity
of muscles, and whether the movements are attended with pain. The
patient's attention should be diverted, otherwise it will be difficult ta
determine how much muscular rigidity is due to his fear of being hurt.
When doubt on this point still remains, give an anesthetic, and if
rigidity passes off you may know' it was due to muscular contrac-
tion.
4. Exami7iation of the Bones. — Begin with the trochanter ; compare
the two sides, and then, applying the palm of the hand, press inward
firmly and gradually against the neck of the femur. Pain or tenderness
under this test is evidence of inflammation of the neck or head of the
femur. The head of the bone may be sought for on the dorsum ilii,
the buttock, or near the pubis. Grasp the iliac crests and press them
toward or apart from each other. Pain felt in these movements should
direct attention to inflammation in the sacro-iliac joint.
Dislocations at the hip can never be intelligently studied without
first having mastered two small and apparently insignificant structures
that enter into the formation of the joint. One of these is the Y-liga-
ment, so called, and the other is the obturator internus muscle.
Before Prof Henry J. Bigelow of Boston revolutionized the treatment
of dislocation at the hip the great obstacle to reduction was supposed
to be the resistance of the powerful muscles about the joint. Dr.
Bigelow cut away all the other muscles, and still found that these two
structures, the Y-ligament and the obturator internus muscle, were
sufficient to produce all the varieties of luxation of this joint, and also-
INJURIES AND DISEASES OF JOINTS.
133
to constitute the obstacles which prevent the return of the bone to the
acetabulum.
What is the Y-ligament ? It is a portion of the capsular ligament
which is thick and strong, and remains untorn when the head of the
bone makes a rent in any other part of the capsule. The capsular
ligament is a sort of tube surrounding the joint. It arises from the
circumference of the acetabulum and the parts surrounding, and is
inserted near the junction of the neck of the femur with the trochanter.
The human being walks erect, and naturally a severe jolt transmitted
to the joint, as in jumping from a height, is likely to dislocate the bone
upward. To prevent this the capsular ligament is much thicker and
stronger on that side, and forms a powerful band which helps to keep
the joint in position. This part of the capsule, which goes under the
various names of the " Y-ligament," the " ilio-femoral ligament," and
" Bertin's ligament," arises from the
anterior inferior spinous process of the
ilium, and from the bone below as far
Fig. 55. — The Y-ligament.
Fig. 56. — The obturator internus muscle
as the border of the acetabulum. This dense band, sometimes a quarter
of an inch in thickness, passes down toward the great trochanter, where
it divides into two "branches, thus forming an inverted letter Y. One of
these branches is inserted into the anterior and superior part of the great
trochanter. The other goes farther down, and is inserted into the femur
close to the lesser trochanter (Fig. 55).
Bear in mind, that in all dislocations at the hip this ligament remains
untorn, while every other structure may be lacerated. By its tension is
determined the different positions which characterize the deformity, such
as flexion, inversion, eversion, adduction, or abduction of the limb.
TJic obturator intcrmis muscle, the other structure which plays an im-
portant part in some dislocations, arises inside the pelvis from the inner
surface of the obturator membrane and from the bony edge of the
134
SURGICAL DIAGNOSIS AND TREATMENT.
foramen. Its fibers converge into a tendon which passes toward the
lesser sciatic notch, where it winds around a trochlear surface, and is
inserted into the upper border of the great trochanter in front of the
pyriforniis (Fig. 56).
Dislocations at the hip-joint are four in number — two back-
ward and two forward.
If a dislocation is backward, it is either on the dorsum ilii or into
the sciatic notch ; if forward, it is either on the obturator foramen or
on the pubis.
Dislocation upon the Dorsum Ihi. — Supposing a person to fall
from a height, his abducted knee first striking the ground and with the
body bent forward, the force will come upon the posterior wall of the
capsular ligament and the ligamentum teres, both of which will yield
readily. The limb, being abducted, loses the support of the great mus-
cles, and the head of the femur slips out of its socket backward. It
must land in one of two places, the sciatic notch or the dorsum ilii.
The same accident is liable to occur when a person is bending forward
and a heavy body falls upon his back or hips. While the bone is slip-
ping backward the Y-ligament becomes tense, and would prevent the
displacement but for one thing. The femur
rotates inward, so that, w hile the Y-ligament
holds the trochanter firmly enough, the head
of the bone slips outward. This accounts for
one of the characteristic signs — viz. inver-
sion of the foot. The head of the femur
being thrown backward and the Y-ligament
still on the stretch, the knee is of necessity
thrown forward ; both of these deformities
continue until the luxation is reduced. The
capsule is torn at its posterior part, and also
some of the muscles about the joint, such
as the quadratus femoris, the obturator in-
ternus and externus, and the pyriformis.
Symptoms. — The limb is shortened from
one to two inches. The knee is directed to
the sound limb, and the toes lie upon the
instep of the opposite foot. The head of the
bone can, in some cases, be felt in its new
position on the dorsum ilii (Fig. 57).
Dislocation into the Sciatic Notch. —
This is also a backward dislocation, and
presents the same symptoms as the iliac
variety, only to a less marked degree.
The shortening is not more than three-
quarters of an inch to an inch. Inversion
of the toes and adduction of the thigh are
also present, but less marked than in the
former case. The toes of the injured side rest upon the ball of the
great toe of the opposite foot. There is little difficulty in diagnosing
these two dislocations from one another, nor would a failure to do so
result in any serious consequences, as the treatment is the same. The
Fig. 57. — Dislocation on dorsum ilii.
INJURIES AND DISEASES OF JOINTS.
135
mistake most likely to be made is to fail to distinguish between sciatic
dislocation and fracture of the neck of the femur with inversion of
the foot. In most cases of fracture there is eversion of the foot, but
with impaction there may be inversion ; hence the necessity for careful
examination. The following are the important differences :
Sciatic Dislocation.
Frequent in middle life.
Result of violence.
Slight.
Absent.
Impaired.
Fracture of Femur with Inversion.
History.
An injury of old age.
Often slight violence.
Shortening.
Well marked.
Crepitus.
Present unless impacted.
Mobility of Limb.
Often increased.
Inversion of Foot.
Inversion is persistent until the dislocation is The foot may at any time become everted by
reduced. relief of the impaction.
Tuvior.
An abnormal tumor may be obscurely felt The upper fragment often fails to move with
behind the acetabulum, which moves with the rest of the femur,
the rotation of the thigh.
Dorsal Dislocation with Eversion. — In the rare instances in which
this form occurs the outer branch of the Y-ligament ruptures, and
allows the head of the femur to slip inward, thus causing eversion of
the foot, instead of inversion, as in the ordinary form of the luxation.
Treatment of Backiuard Dislocations. — Prof Bigelow's reduction by
manipulation is a great improvement on the older methods (Fig. 58).
The patient lies on his back upon a low
table, completely anesthetized. Grasp the
ankle of the dislocated limb with one hand
and the leg below the knee with the other.
Flex the leg on the thigh, and the thigh
upon the abdomen until it forms a right
angle with the surface of the table. Adduct
the knee until it is carried over the middle
of the sound thigh. Next cause the knee
to describe a circle outward and downward
until the leg is brought to the table and lies
extended by the side of its fellow. What
has been done in this maneuver ? By
flexion of the thigh you have relaxed the
Y-ligament. When you adducted the thigh
with outward rotation the head of the bone
was lifted over the edge of the acetabulum
and it dropped into its normal position.
Backward Dislocations below the Ten-
don of the Obturator Internus. — If you examine Fig. 56, you will
Fig. 58. — Reduction of dislo-
cation on dorsum ilii (after Bige-
low),
136
SURGICAL DIAGNOSIS AND TREATMENT.
SCO the position of the obturator internus muscle. In the ordinary
backward dislocations of the femur the head of the bone passes above
the muscle. In the variety of dorsal dislocation which we now have
to consider it passes bcloiv the muscle ; and this is the important part
which the obturator internus plays in luxation of the hip. The bone,
having slipped out of its socket and passed below the obturator inter-
nus tendon, does so while the thigh is in a flexed position. As soon,
however, as the thigh is brought down from this to a straight position,
the head of the bone, being firmly held at the trochanter by the Y-liga-
ment, slips upward over the tendon, which now winds tightly around*
the neck of the ferrjur between the head and the acetabulum. No
wonder the old surgeons pulled and dragged with pulleys until they
either caused something to break or gave up the fight and called the
case one of " irreducible dislocation."
Treatment. — The patient lying on his back, proceed as follows :
First movement : Carry the knee across the opposite thigh to a
position of extreme adduction.
Second movement : Sweep it upward horizontally toward the abdo-
men. This will allow the head of the bone to come down below the
tendon.
Third movement : Raise the thigh to a vertical position, and the
bone, disengaged from its entanglement with the obturator tendon, will
lie in the position of an ordinary backward dislocation. From this
point reduction can be effected as described under backward dislo-
cation — viz. adduction until the knee is carried over the middle of the
sound thigh. Then describe a circle upward, out-
ward, and downward until the leg is brought to
the table.
For-ward Dislocations. — These have a direc-
tion downward and inward. Two dislocations are
found under this heading :
I. Into the Obturator Foramen. — This acci-
dent occurs while the person, standing with the
thigh abducted and flexed, receives a blow upon
the back of the pelvis, or it can be caused by
forced abduction alone. The Y-ligament remains
untorn, and, as the head of the femur is driven
forward and inward, the thigh is flexed and ab-
ducted. The symptoms are very characteristic.
The patient stands with the injured limb a little
in advance of its fellow. There is apparent length-
ening, but this is due to a tilting of the pelvis.
Measurement may even reveal a slight amount of
shortening. The hip is flattened, the adductors
tense, and the head of the bone in some cases can
be felt on deep pressure (Fig. 59).
Treattnent. — Place a towel around the upper
end of the thigh, and, while an assistant drawls out-
ward upon it at right angles to the middle line of the body, make alter-
nate flexion and extension of the thigh upon the body. This is the
simplest method, and probably the best. By it the wTiter succeeded in
Fig. 59.— Thyroid dis
location.
INJURIES AND DISEASES OF JOINTS.
137
slip only a little past the
This variety is therefore
two cases^ — one at the end of eight weeks, and the other after the expi-
ration of three months.
Another method is as follows : Flex the thigh to a right angle,
adduct and make traction at the same time, and then rotate inw'ard
while lowering the knee (Fig. 60).
2. On the Perineum. — The bone has to
obturator foramen to lodge in the perineum.
an exaggerated form of the preceding dis-
placement. Flexion and adduction are now
more marked, and there may be a slight
degree of shortening.
Pubic Dislocation. — This occurs usually
while the limb is in a position of over-
extension, or it may be caused by a fall upon
the knees or feet. The bone can occupy one
of several positions in the neighborhood of
the pubis, but the most common is the ilio-
pectineal eminence. The head of the femur
Fig. 60. — Reduction of dislocation into the thyroid
foramen (after Bigelow),
Fig. 61. — Dislocation of head of femur
upon the pubes (after Hamilton).
cannot only be felt, but even be distinctly seen, in its unnatural position.
The toes point outward. There is flexion of the thigh, and if the knee
be pressed down upon the table the spine will be found to arch upward
in compensation. In backward dislocation the injured thigh lies across
the opposite limb, but here the reverse is true, and it takes a direction
outward (Fig. 61).
The injury most liable to be mistaken for this luxation is fracture of
the neck of the femur, yet there need be no difficulty in settling the
question. If the patient be anesthetized, the outward rotation can be
rectified in fracture, but immobility will be found in dislocation.
There is shortening in fracture which can be removed by traction.
In almost every case the head of the bone can be distinctly felt in
dislocation.
Treatment. — First movement : Flex the thigh. Second movement :
Abduct the thigh and make traction in the line of the axis of the femur,
138 SURGICAL DIAGNOSIS AND TREATMENT
while an assistant at the same time presses the head downward and
outward toward the acetabukim.
Rare Forms of Dislocation. — Of all cases of dislocation at the hip-
joint, the dorsal luxations occur in 50 per cent., the ischiatic in 30 per
cent., the obturator in 1 1 per cent., the pubic in 7 per cent. This leaves
2 per cent, of cases in which the bone is found outside any of these
regions. One of these is downward upon the tuberosity of the ischium.
It is very rare, and when it does occur the displacement is often changed
into one of the more common varieties. Thus the bone can slip upward
and backward, becoming a dorsal, or forward by adduction and ever-
sion, forming a dislocation into the obturator foramen.
Treatment. — Flex the thigh and then make traction.
Another rare luxation is directly upward (supracotyloid). Only a
few cases of this kind have been reported. The symptoms are eversion
with abduction. The trochanter is moved upward and backward, and
the head of the bone can be felt on deep pressure.
Diagnosis between Contusion over the Great Trochanter a}id Dis-
location at the Hip-joi)it. — A person suffering from a fall or a blow
upon the great trochanter may present some symptoms which are
difficult to distinguish from dislocation. The pain may be so great as
to render movement impossible ; the limb may be apparently shortened,
owing to the patient's trying to find the easiest position. When there
is doubt an anesthetic will make diagnosis easy. Motion is then free
and normal if the injury is only a bruise, but is restricted in the case of
a dislocation. Measurement will show a change in the length of the
limb in the case of a dislocation, but none when the injury is a bruise.
Palpation will settle the position of the head of the bone.
Congenital Dislocation of the Hip. — This is, in the majority of
cases, due to arrested development, and the displacement is most com-
monly upward upon the dorsum ilii. In some instances the head of
the femur is normal, but it is quite common to find the neck shorter and
inclined to be horizontal. The ligamentum teres is sometimes thick-
ened and stretched, owing to its having to support the weight of the
body. In some cases it is wanting or very much atrophied. The
acetabulum, although never entirely absent, shows a want of devel-
opment. It may be oval and flattened, or it may be small and shal-
low, with absence of its cartilaginous rim. The muscles around
the hip also exhibit a lack of development. As a result of this dis-
location the pelvis undergoes certain changes. The crests of the
ilii approach each other, while the tuberosities of the ischii become
farther separated.
Symptoms. — The dislocation is seldom recognized until the child
begins to walk, when a peculiar waddling gait is the first symptom to
attract attention, and it is noticed at the same time that the back is very
much arched (Fig. 62). The child very easily becomes fatigued, but
seldom is there any complaint of pain.
By Nelaton's measurement (from the anterior superior spine of the
ilium to the tuberosity of the ischium) a displacement of the trochanter
upward will be found varying from half an inch to one or two inches.
By gentle traction on the leg the trochanter can be brought down,
and measurement will show that the leg has thus been lengthened,
INJURIES AND DISEASES OF JOINTS.
139
but as soon as the traction is discontinued the trochanter will be found
to return to its former position.
The two conditions with which this deformity is likely to be con-
fused are bow-legs and infantile paralysis. The resemblance to bow-
legs is marked in double congenital dislocation. A child with extreme
bow-legs has a waddling gait and a tilted pelvis, but the position of the
trochanter in relation to Nelaton's line will be found sufficient to settle
the question. Infantile paralysis of one leg may bear a close resem-
blance to unilateral dislocation, while the laxity of the joint may
Fig. 62. — Double congenital dislocation of hip (from a photograph in the collection of Dr.
J. E. Moore).
closely simulate luxation. But here, again, the position of the tro-
chanter in relation to Nelaton's line will settle the diagnosis.
Dislocation at the Knee-joint. — Two bones may be dislocated
at the knee-joint, the tibia and the patella. The tibia can be dislocated
in five directions — forward, backward, outward, inward, and rotary.
Forward dislocation is probably the most common. The head of
the tibia can be felt projecting in front of the condyles of the femur,
w^hile the latter bulge backward into the popliteal space. Numbness is
often felt as a result of the stretching of the nerves, and the artery and
veins may be seriously injured or even ruptured.
Treatment. — Extension, counter-extension, and direct pressure.
140 SURGICAL DIAGNOSIS AND TKEATMENT.
Backward dislocation is generally caused by direct violence in the
region of the knee. The head of the tibia may be felt bulging back-
ward into the popliteal space, while in front there is a corresponding
depression immediately below the patella. The leg is in a position of
extreme extension, and slopes forward so as to form an obtuse angle
with the front of the thigh. The dislocation is frequently compound,
and the most serious feature of it is the injury of the popliteal vessels,
which, though apparently free from harm at the time of the accident
may have their coats so stretched that they give way at a later period,
followed by gangrene of the leg.
Treatment. — Traction and direct pressure.
Lateral luxations are rare and require no special description.
Rotary Dislocations. — The only case of this kind seen by the
writer occurred to a lumberman whose foot was held firmly in a deep
track in the frozen snow while his body swung round upon the limb.
The displacement was recognized and reduced by his fellow-workmen.
Dislocations of the Patella. — This bone, being freely movable,
may be displaced by direct violence, by muscular action, or by both
forces combined. The most common displacement is outward. It
sometimes happens that the bone is tilted upon its edge (vertical dis-
location), and cases are recorded in which the bone was completely
turned front backward. The patella being a superficial bone, the diag-
nosis presents no difficulty. The dislocation can easily be reduced by
relaxing the quadriceps and placing the bone in position by direct
pressure.
Dislocations of the Fibula. — The upper end of the fibula is
rarely dislocated. The most common displacement is outward and
forward. It can occur backward and also upward. The displacements
are readily recognized, and reduction by direct pressure is easy. At the
lower end of the fibula the few dislocations that have been reported
were backward.
Dislocation of the Ankle. — Examination of the ankle-joint
after injury is often a difficult matter. Swelling is likely to be great,
and pain so intense that manipulations cannot be borne by the patient.
The injuries that must be taken into account are fractures of the lower
end of the bones of the leg, fracture of the astragalus, dislocations of
the foot from the astragalus, dislocation of the astragalus from the
tibia, dislocation of the astragalus alone, sprains of the ankle, and
inflammatory disease in the joint.
These injuries will at once divide themselves into two great classes,
one being attended with deformity, the other without deformity.
I. Injuries without Apparent Deformity. — Carefully note the seat
of any pain or tenderness. Grasp each malleolus separately and attempt
to move it independently of the foot. If crepitus can be felt and the
malleolus be found movable, it will be evidence of fracture of the
malleolus. If, besides fracture of the lower end of the fibula, there
be found increased lateral mobility of the ankle-joint, you may decide
that the internal malleolus is broken as well, or that there is laceration
of the internal lateral ligament. The injury is Pott's fracture.
If you have failed to find any fracture, ask the patient to stand upon
the injured foot. Should this cause intense pain, you may suspect
INJURIES AND DISEASES OF JOINTS. 141
fracture of the astragalus. Move the foot and you may find deep
crepitus ; then your diagnosis may be positive. Should the results
of your examination be negative, make careful measurements of the
length of the leg, the distance between the heel and the malleoli, also
between the malleoli, the tubercles of the scaphoid, and the base of
the fifth metatarsal bone. Thus you can detect partial displacement of
any of the bones which might not be apparent to the eye.
A severe pain behind either malleolus, with swelling and tenderness,
should excite suspicion. Examine carefully for the tendons which pass
behind these bony prominences. Possibly there is a depression where
the tendon ought to be, or the tendon may be felt like a thick cord over
the side of the malleolus. If on the inner side, these symptoms will
indicate dislocation of the tendon of the tibialis posticus ; on the outer
side, that of the peroneus longus.
2. Injuries with Deformity. — The foot is displaced outward or
inward. If outward, it is evidence of one of three injuries — viz.
{a) Pott's fracture ; \li) Dupuytren's fracture ; (r) Subastragaloid dis-
location.
If inward, it is also evidence of three injuries — viz. {a) Dislocation
of the ankle inward ; {U) Subastragaloid dislocation inward ; {c) Dis-
location inward of the medio-tarsal joint.
Note carefully the form and position of the heel. If it is elongated
or unduly prominent, you are likely to find one of the following : {a)
Fracture of lower end of tibia ; {t>) Dislocation of ankle backward ; \c)
Subastragaloid dislocation backward.
If the heel is flattened, it may be the result of one of three injuries :
(a) Dislocation of the foot forward ; {li) Subastragaloid dislocation for-
ward ; () arrest of development on one side of the lower jaw ;
ic) congenital dislocation.
In cases of marked hypertrophy of the tongue constant pressure
may produce displacement of the teeth and even dislocation of the jaw.
Burns and scalds, followed by extensive cicatricial contraction, may
draw the chin or lower lip down to the sternum. Sucking the thumb
may cause deformity of the jaw.
In the diagnosis of diseases of the jaw it is convenient to divide
them into two classes — acute and cJironic.
The acute forms are inflammatory, and the most common are
abscess of the gums or alveoli and periostitis.
When Burns characterized toothache as the " hell of all diseases,"
he no doubt drew his inspiration from an attack of periodontitis ending
in abscess, vulgarly called " gum-boil." The cause of this common
affection is suppurating pulp. The diagnosis is easy. There is a his-
tory of the characteristic pain of toothache ; tenderness and swelling
are felt by passing the finger along the gums. The tooth is elongated
and tender on tapping. The face on the affected side is swollen, and
finally a collection of pus takes place. If the suppuration is near the
surface, it readily finds exit or can be released by simple puncture ; it
may find its way through the skin and open about the lower margin
of the jaw. Necrosis in that case is a common result.
Treatment. — In the early stage the gum may be painted with iodin.
Fomentations by means of a small compress of lint or absorbent cot-
ton dipped in hot water and repeatedly applied relieve the pain and
hasten suppuration. When the pus is near the surface of the gum,
simple puncture will suffice ; when deeper a free opening should be
made. The tooth causing the trouble should receive the attentions of
a dentist and be either saved or extracted.
Periostitis or osteo-periostitis is to be diagnosticated when the
inflammation spreads over a considerable portion of jaw, attended with
high fever, the loosening of several teeth, and excessive tenderness.
Chronic Affections of the Jaw. — A chronic affection of the
jaw must be necrosis, periostitis, or a tumor.
INJURIES AND DISEASES OF THE DIGESTIVE SYSTEM. 1 8/
Necrosis results from tuberculosis, syphilis, a decayed tooth, or a
traumatism. It may follow one of the zymotic diseases, and it is
common among those who have to breathe the fumes of phosphorus.
It is always preceded by severe pain and inflammation. Suppuration
takes place, and one or more sinuses result. Through one other of
these openings a probe can be made to touch the necrosed bone. If
only one sinus exists and the probe is felt to touch a smooth surface, it
is likely to prove the root of the tooth. It must be remembered that
here, as elsewhere, the external opening may be no indication of the
position of the diseased portion of bone. The opening may be on the
face, the neck, or even in the nose.
Treatment. — While the treatment is the same as for necrosis in other
parts of the body, one or two special points must be kept in mind.
The sequestrum should be removed, if possible, from the inside of the
mouth, and no attempt at detachment should be made until the seques-
trum is perfectly loose ; otherwise the soft parts, especially the vessels,
may be injured.
Chronic periostitis is, as a rule, syphilitic. The common situations
are the outer side of the lower jaw and the hard palate. There are
generally other indications of specific disease, and, should the surgeon
be still in doubt, he can settle the point by putting the patient upon
antisyphilitic treatment.
Phosphorus Necrosis. — With better attention to the sanitary condi-
tions of factories phosphorus-poisoning is much less common than
formerly. The disease is usually extensive and its course rapid, so
that a patient may apply for advice whose jaw is necrosed to a con-
siderable extent without his being aware of it. Diagnosis will depend
upon the history and the ordinary signs of necrosis.
Tumors of the Jaws. — Epulis ilTii, upon, and doXa, gums) is a mor-
bid growth improperly named. Instead of being connected with the
gums, it is a tumor growing from the periosteum of the alveolar process
and sockets of the teeth. When first recognized it appears to be making
its way from about the neck of some particular tooth (Garretson).
Simple, Benign Epulis. — The most common form of epulis is that
which is connected with the pulp of a tooth, the epulo-pulp-fungoid
tumor. It originates in the exposed tooth-pulp, and by gradual
increase covers the gum adjacent to the affected tooth. After a time
it ulcerates and discharges a sero-purulent fluid, or it may undergo
ossification. Another variety of epulis is the erectile or nevoid. Both
of the foregoing are simple and benign in character.
Malignant Epulis. — Malignant epulis begins like the benign forms,
but its rapid growth, its vascular character, its purplish color, and its
tendency to form a fungous mass protruding between the teeth and
bleeding on the slightest provocation reveal its serious nature and
demand its radical removal.
Treatment. — The benign forms require the removal of the involved
tooth and the portion of the alveolar process which forms its socket.
The malignant epulides must be dealt with as cancerous tumors. Not
only the socket, but a portion of the jaw, must be removed. The
doomed section of the maxilla should be sawn through by two vertical
cuts, and the intervening portion removed by strong forceps.
1 88 SURGICAL DIAGNOSIS AND TREATMENT.
In the diagnosis of tumors of the jaws the first question to settle is
whether a gi\en tumor is cystic or sohd. Cystic tumors are not un-
common in this situation. A cystic tumor is smooth, and rises above
the surrounding bone by gradual elevation. Fluctuation may be
detected in tiie growth, or the bony cyst- wall may crackle like an egg-
shell under the pressure of the fingers. When these conditions are
found, examine the teeth at that part and in all probability you will
find one tooth missing. Or it may be that the deciduous tooth at that
point has never been cast off. These tumors are liable to be mistaken
for malignant disease of the bone, but the surface is perfectly smooth,
the patient is generally )'oung, and the growth is painless ; all of which
argue against malignancy. When this smooth tumor is cut down upon,
the thin bone readily gives away and a cavity is opened up. Explore
this cavity, and out will pop a tooth which lay loose in a thick
mucilage-like fluid or perhaps turned upside down. Even when crack-
ling is absent the smoothness of the tumor should arouse suspicion,
and this will be confirmed by finding that one of the permanent teeth
has never been cut. It is a good rule never to remove a tumor of the
jaw without first cutting into it. While these dentigerous cysts are
mostly confined to young persons, too much stress must not be laid
upon that point. In a case upon which I operated a short time ago
the tumor was smooth and apparently as hard as ivorj- ; there was no
crackling, and the patient was fifty years of age. The tumor contained
a large molar tooth.
The cyst can be reached by an external incision, but when practi-
cable an opening from the inside of the mouth will prove just as satis-
factory, and has the advantage of leaving no disfiguring scar.
Another form of cystic tumor common in the lower jaw is irregular
and lobulated. This is imdtilocitlar cyst, which in the majority of cases
is a cystic degeneration of a sarcoma or carcinoma. Total extirpation
is the only treatment.
Solid Tumors of the Jaws. — These are naturally classified as
benign and malignant.
In the diagnosis of solid tumors of the jaw begin by examining
the face, mouth, and nose. The consistence of the tumor should be
felt by first placing the fingers outside the cheek and rolling the skin
over the growth ; then the fingers should be placed in the mouth and
a bimanual examination made. Having satisfied yourself of the con-
sistency of the tumor, pass the fingers over the hard palate and back-
ward over the soft palate to the posterior nares. The nostril will
require careful examination, and this can be carried out by throwing a
strong light into it and testing any suspicious growth with a probe. If
in this examination a growth is found attached to the turbinated bones, it
is a polypus. A tumor in the antrum will also show itself in the nostril,
but at the same time there will be expansion below the eyelid and
perhaps protrusion of the eyeball.
The non-malignant tumors are the following :
I. Fibromata. — The growth of these tumors is slow, and they are
generally painless. They start from the periosteum, and especially
from the periosteum of an alveolus, which renders these growths liable
to be mistaken for epulis. When they arise from the periosteum the
INJURIES AND DISEASES OF THE DIGESTIVE SYSTEM. 1 89
growth is smooth or lobulated, firmly attached to the bone, and freely-
movable over the surrounding parts. When the endosteum is the
starting-point the tumor gradually expands the jaw, and if allowed to
grow attains an enormous size. If the growth is in the upper jaw, the
antrum or nasal fossae are apt to be encroached upon. We recognize
pressure upon the antrum by observing the following points : The
outer wall of the antrum below the orbit bulges forward. If the floor
of the orbit is pressed upon, the eyeball protrudes. Examination by the
mouth will show that the roof of the mouth is flattened or depressed.
2. Enclwiidromata, or cartilaginous tumors, are not common. They
are more rapid in their growth than fibromata, are much harder, and
111
Fig. 90. — Recurrent ossifying enchondroma (Heath).
are more nodular (Fig. 90). The lower jaw and the antrum are favorite
situations.
3. Ostconiata, or osseous tumors, are still more rare. They are
harder even than the cartilaginous tumors, and may take the form of
exostoses or may present the appearance of a general thickening of
the whole bone.
Treatjnent. — Fibromata, enchondromata, and osteomata should all
be treated by thorough removal of the growths. The enchondromata
are apt to recur after removal.
Malignant tumors are —
I. Carciiioinata. — Primary cancer of the jaw is rare. The majority
of cases are those in which the disease spreads from the nasal mucous
membrane or from the palate (Fig. 91). In either case great destruction
of tissue may take place without any marked tumor being developed.
A probe passed through a small external opening may reveal a large
cavity, while there is no evidence of a cancerous mass by external
appearances. Three characters of malignant tumors must be kept in
mind — viz. rapid growth, destruction of bone, and fungation into the
190
SC-A'G/C.IL 1)/AGA'0S/S AND TREATMENT.
inoutli. Fibrous, cartilaginous, and osseous tumors are slow in grow-
ing ; thc\- are hard to the touch, they do not affect the general health,
and are painless, and, except when they exert pressure upon neighbor-
ing parts, they do not involve the surrounding structures. Carcinoma
is soft and has a tendency to fungate. It is painful, soon telling on the
general health of the patient, and involving adjacent structures, espe-
cially the lymphatic glands. Fungation is strongly characteristic of
cancer. It must be borne in mind, however, that benign tumors, par-
ticularly of the lower jaw, may in the course of time break through the
skin and form a fungating mass. This, however, is slow of growth,
Fig. 91. — Epithelioma of the left malar and superior maxillary (Heath).
as was also the tumor which gave rise to it, and it is more healthy in
appearance than a cancerous fungus.
2. Sarcomata. — The round-celled or medullary sarcoma is found
most frequently in the upper jaw, and bears a close resemblance to
medullary cancer. Its leading characteristics are rapidity of growth,
softness, and tendency to fungate. In the majority of cases the disease
begins in the antrum. As the tumor increases in size it produces symp-
toms which vary according to the direction taken by the growth. The
projecting mass may show on the cheek, causing closure of the nasal
duct, producing epiphora and edema of the eyelids. In other cases the
growth takes a direction inward, and forms fungous masses in the nose
or mouth. Sometimes the disease starts in the hard palate, the alveolus,
or the nose. The difficulty here is to diagnosticate between cancer,
nasal polypus, and the results produced by decayed teeth. Practically,
the diagnosis between carcinoma and sarcoma is of slight importance,
as the treatment is the same for both. For purposes of treatment it is
sufficient to decide that the tumor is malignant, leaving the histological
characters to be decided after removal of the crrowth. Yet there are
INJURIES AND DISEASES OF THE DIGESTIVE SYSTEM. 191
certain clear distinctions to be noted. Sarcoma involves the neighbor-
ing parts, but not the glands, while carcinoma readily spreads to the
glands. The spindle-celled variety of sarcoma has a tendency to
spread along the periosteum, and becomes softer and softer with each
recurrence. Probably the greatest difficulty lies in distinguishing
between malignant tumors and inflammatory processes. A sarcoma is
so similar to an abscess as to puzzle the most experienced. Yet there
is an absence of the inflammation and pain which always precede an
abscess. A collection of pus due to the carious root of a tooth
would show a history of toothache with evidence of dental caries.
The probe is not always a sure guide. If roughened bone be felt, it is
not necessarily necrosis, for the bone can be laid bare in the same
manner by the ravages of carcinoma or sarcoma.
Tiratinciit. — Malignant tumors of the jaw can only be dealt with in
one way — complete removal. Within the last few years reports of
cases alleged to have been cured by injections of the toxins of ery-
sipelas with bacillus prodigiosus have appeared in the medical journals.
In several cases I have given this method of treatment a most patient
and careful trial, but in every instance with disappointing results. For
the present, at least, our hope must lie in the direction of early and
complete removal. Recurrence is the rule, even where the whole of
the lower jaw is taken away.
Operation on the Upper Jaw. — Small tumors confined to the
alveolus can readily be removed by strong cutting bone-forceps,
without any external incision. Tumors of considerable size have
also been extirpated in this manner, although the difficulty of deliver-
ing the tumors through the mouth has sometimes been so great as to
necessitate an incision of the angle. Large tumors involving a con-
siderable portion of the bone require resection of the entire jaw. The
method is as follows :
First Step. — An incision is made along the infraorbital ridge from
the malar bone to a point just below the inner canthus, thence along
the side of the nose around the ala to the middle line, and lastly
through the middle line of the upper lip. The flap formed by these
incisions is dissected from the bone and turned outward, divided vessels
are ligated, and hemorrhage arrested by pressure with hot sponges.
Second Step. — The incisor teeth on the affected side are next
remov^ed, a narrow-bladed saw passed into the nostril, and the hard
palate and alveolus divided. With a Hey's or other suitable saw sec-
tion is made of the malar bone in a line with the spheno-maxillary
fissure and also of the nasal process of the upper jaw. The
saw can be supplemented, if necessary, with bone-forceps. Powerful
forceps, preferably Fergusson's lion-forceps, are next made to grasp
the jaws, and by a powerful wrench the bone is separated from its con-
nections, and when quite loose the infraorbital nerve and soft palate are
severed with a knife. Should any diseased tissue still remain, it can be
removed with gouge and chisel. After ligating any spurting vessels
the cavity can be filled with hot sponges for a few minutes and all
hemorrhage arrested. The flap is now replaced, and the incision
accurately closed through its whole extent with sutures of catgut,
except the lip, where silkworm gut is perhaps more reliable. The
192 SURGICAL DIAGNOSIS AND TREATMENT.
cavity of the check is filled with iodoform gauze, and an external
aseptic dressing, retained by a light flannel or gauze bandage, completes
the operation. Even before the advent of antiseptic surgery wounds
of the face healed readily by first intention, and these operations were
wonderfully free from mortality. With careful asepsis and the use of
disinfectant mouth-washes the progress of recovery is rapid, and the
sufferings of the patient are reduced to a minimum. When the disease
is not so extensive as to require removal of the whole jaw a shorter
incision is demanded. Division in the middle line of the lip and down
to the ala of the nose may be sufficient. When the orbital plate is not
involved, the saw can be made to cut horizontally below it, and the
palate when healthy may be spared by making the saw-cut immediately
above it.
Both upper jaws have occasionally been removed. Probably the
best of the methods adapted for this formidable operation is that
employed by Mr. Dobson of Bristol,' who in 1872, in a woman of
fifty-two, divided the lip in the middle line and carried the incision up
each side of the nose.
Operations on the Lo^wer Jaw. — When the tumor is small and
involves only the alveolus, it can be removed with bone-forceps. If
the mucous membrane covering the lower jaw be freely divided, a
great portion of the bone can be removed without any external incision.
In extensive disease it may be necessary to remove one-half or the
whole of the bone. When an external incision is necessary, it can be
made just below the lower border of the bone with a division of the
lower lip in the middle line ; but this later incision is not always necessary.
After separating the bone from the soft parts the jaw is divided in the
middle line and strongly drawn outward, while the soft parts are
separated back to the articulation, and the bone disconnected at the
jaw by dividing the ligaments with knife or scissors.
The question of saving the periosteum cannot be entertained if the
disease is malignant, but in non-malignant tumors and in necrosis this
membrane should be carefully preserved. All bleeding points being
secured by ligature, cautery, or pressure, the incision is accurately
closed and an external dressing applied. The after-treatment consists
in giving fluid nourishment by a tube, and keeping the mouth thoroughly
disinfected by detergent washes, of which the glycerinum acidi car-
bolici applied with a camel's-hair brush, as recommended by Heath, is
one of the best.
Diseases of the Tempore -maxillary Articulation. — This is
one of the few joints which escape tuberculosis, but it is liable to
rheumatic arthritis, and one or both sides may be the seat of the disease.
It is chronic in character, and may result in absorption of the inter-
articular cartilage and in outgrowths from the bone. True ankylosis
does not take place. This disease is readily diagnosed from its painful
and chronic character, and from the protrusion of the chin either
directly forward or to one side according as the disease affects one or
both articulations.
Acute inflammation is the result of injury, or it may be the exten-
sion of the inflammatory process from the ear or some neighboring
1 Brit. Med. Journ., 1873.
INJURIES AND DISEASES OF THE DIGESTIVE SYSTEM. 1 93
part. It then follows the course of arthritis in other parts, and should
suppuration take place ankylosis is not an unlikely result.
Closure of the jaws may be temporary or permanent. The tem-
porary closure is usually reflex in origin, due to the irritation produced
by the cutting of a wisdom tooth or the failure of a tooth to appear,
owing to want of room or to an abnormal position. Some of the cases
are hysterical. Permanent closure may be due to ankylosis following
suppurative arthritis. Another frequent cause is cicatrization following
ulceration or injuries of the mucous membrane of the cheek ; and often
through profuse salivation the lower jaw becomes closely bound to the
upper, so that the teeth cannot be separated sufficiently to admit solid
food. Sometimes the gums are adherent, especially if there is necrosis
of the alveolar process.
Treatment. — When there is complete ankylosis or intractable closure
the operation of Esmarch is probably the best. It consists in the
formation of an artificial joint in front of the contraction, and admits
of at least limited motion of the jaw. It simply consists in the
removal of a piece of bone of a w^edge shape in front of the masseter
muscle.
Diseases of the Tonsils.
The tonsils are subject to the following diseases : tonsillitis, hyper-
trophy, calcareous and cheesy concretions, sarcoma, and carcinoma.
Tonsillitis, popularly called quinsy, is readily distinguished from
other diseases. It is an acute, local, inflammatory affection, generally
following exposure to cold, but depending upon a more remote cause,
such as a tubercular or rheumatic diathesis. The onset of the attack
is marked by pains in the limbs, difficulty of swallowing, chills, and
general malaise. The temperature rises quickly, and may reach 104°
or 105° F. If the throat be examined at this stage, one or the other
tonsil will appear swollen and violently inflamed ; the redness extends
to the fauces, and the glands beneath the angle of the jaw are swollen
and tender. By degrees swallowing becomes more and more painful.
To add to the patient's discomfort, large quantities of mucus and saliva
are constantly being secreted and must be expectorated. Speech is at
first changed to a nasal twang, and later may be almost lost, and when
the patient attempts to swallow fluids they run out of the nose. If
resolution does not take place (which it happily does in many cases about
the third or fourth day), suppuration occurs, and about the ninth day
the abscess ruptures, and the patient, experiencing immediate relief,
speedily recovers.
Sometimes the second tonsil becomes affected, and then the swell-
ing is so great as almost to close the throat. When both are affected
at the outset, it is strong presumptive evidence that the attack is due to
a septic cause.
Treatment. — At the outset a brisk purgative should be giv'en, and
10 minims of tincture of belladonna every three hours. If, after forty-
eight hours, the inflammation still progresses, the case will probably
go on to suppuration. A hypodermic of morphin with atropia, given
at bedtime, will give great relief and arrest the secretion of the sticky
mucus which is so distressing. The formation of pus and the pointing
13
194 SURGICAL DIAGNOSIS AND TREATMENT.
of an abscess slunikl not be waited for. An early incision which freely
opens up the tonsil will anticipate the abscess and cut short the disease
by several days. In lancing the tonsil use a strai^^ht, sharp knife,
wrapped round with adhesive plaster to within an inch of the point.
The incision, if kept within the line of the molar teeth, will run no
risk of woundiiiL^ the internal carotid artery, and, as the parts are so
sparint^ly supplied with nerves, the operation is practically painless.
Follicular tonsillitis is recot^nized by small, yellowish-white swell-
ings about the size of a pea which cover the surface of the tonsil. As
these little abscesses burst they form ulcers, which may run together
and produce large ulcerated patches with edges swollen and under-
mined.
Hypertrophy is a result of repeated attacks of acute tonsillitis. It
ma\', however, be due to a chronic catarrhal affection of the tonsil.
Tuberculous children are specially liable to this affection. The enlarge-
ment can be readily seen when the patient opens the mouth, and in
some cases the glands almost touch each other. Respiration is inter-
fered with, especially during sleep, the child sleeping with the mouth
open and breathing in a noisy and unpleasant manner. There is usually
no pain, unless there be attacks of acute inflammation ; the enlargement
is slow and steady.
Treatment. — Excision of the tonsil is the only effective remedy.
For this operation several tonsillotomes have been invented, of which
Mathieu's is perhaps the best (Fig. 92). An assistant should steady
Fig. 92. — Mathieu's tonsillotome.
the patient's head, and with his fingers below the angle of the jaw-
press the tonsils inward. The instrument is applied (taking care that
the lower portion of the tonsil lies well within the grasp of the instru-
ment), and with a rapid movement the required portion of the gland is
removed. Bleeding has often proved troublesome after removal of the
tonsil, the hemorrhage coming from the tonsillar branch of the facial.
To arrest it, pressure should be made from the inside with a piece of
gauze held in a pair of forceps while the fingers make pressure from
without. In this way the tonsil can be compressed so as to control the
flow of blood, and this can be further aided by the application of strong
astringent solutions, as the tincture of perchlorid of iron. It is rarely
that ligation of the carotid has to be resorted to.
Calcareous and cheesy concretions are found of various sizes,
sometimes large enough to increase the size of the tonsil to an enor-
mous extent, or so small that they are only accidentally discovered
when the tonsil is excised. Besides the discomfort caused by their
size, concretions often cause inflammation of the tonsil.
Treatment. — Remove the concretion by cutting down upon it and
turning it out of its bed, or by removing the redundant portion of the
tonsil in which the concretion is lodged.
INJURIES AND DISEASES OF THE DIGESTIVE SYSTEM. 1 95
Tumors of the tonsil are rare, the form most hkely to be met with
being sarcoma.
Sarcoma occurs in young persons, usually below twenty years of
age. It forms a tumor which steadily increases in size and soon begins
to ulcerate, death often resulting from hemorrhage. The growth forms
a well-defined tumor which does not involve the neighboring glands.
This feature distinguishes it from carcinoma.
Carcinotna of the tonsil is of the epithelial variety. It is seldom
found as a primary affection, but as an extension from the disease in
adjoining organs it is not uncommon. In the early stages a primary
cancer of the tonsil is difficult of diagnosis, and is generally set down as
a simple hypertrophy of the gland. As the disease progresses, how-
ever, the lymphatics become involved, nodules form about the angle of
the jaw, and the general characters of carcinoma become manifest.
Treatment. — Unfortunately, even the total extirpation of the tonsil is
unsatisfactory for either form of malignant disease, as the growth is
almost sure to return. In sarcoma, the tumor being more sharply
defined and the neighboring parts free from disease, the prospect of
cure is better. The tonsil can be removed, either by the mouth or by
an external incision extending for about three or four inches along the
anterior border of the sterno-mastoid muscle, beginning at the ear and
ending below the level of the tumor. If necessary, a second incision
may be made along the lower border of the jaw. Dissecting through
this space, the tumor is reached, lying within the superior constriction
of the pharynx. A more radical operation, however, is necessary, and
the method devised by Czerny is probably the best. After a pre-
liminary tracheotomy he makes an incision from the angle of the mouth
to the anterior border of the masseter muscle, and from this point
downward to the os hyoides. Mikulicz makes his incision from the
mastoid process to the greater cornu of the hyoid bone. In either
operation the lower jaw is divided about the position of the first molar
tooth, and turned backward so as to give room for the deep dissection.
The Pharynx.
The diseases of the phar>mx requiring special attention from a
diagnostic standpoint are retropharyngeal abscess and tumors of the
pharynx.
Retropharyng-eal abscess is, in many cases, a result of caries of the
cervacal vertebrae. It may, however, occur as a sequel of scarlatina or
as an extension of inflammation from neighboring parts, especially the
glands. It is most commonly met with in tubercular children. The
first symptoms to attract attention are difficulty of swallowing and
dyspnea. If the patient be subject to disease of the cervical vertebrae,
these symptoms are almost certain to indicate an abscess between the
back of the pharynx and the cervical vertebrae. Examine the patient's
mouth, and you will find projecting from the back of the pharynx,
usually to one side of the middle line, a swelling which fluctuates, is
soft and boggy, and does not disappear on pressure. The patient in
some cases cannot move the head without intense pain, but this is due
to disease in the vertebrae. As the abscess increases in size it extends
196 SURGICAL DIAGNOSIS AND TREATMENT.
laterally, and if allowed to go untreated causes a bulging in the neck
just behind tiie sterno-mastoid muscle. Rarely it burrows into the
posterior mediastinum.
Trcatnioit. — As soon as the presence of pus is determined an open-
ing should be made into the tumor. The patient's head being steadied
by an assistant and held slightly forward, depress the tongue, and with
a long straight bistoury make an incision near the middle line into the
abscess. The bodies of the cervical vertebrae lie directly behind, so
that there is no danger of cutting any important structure. If the
abscess is large, and there is danger of suffocating the patient by too
rapid an outflow of pus, an aspirator can first be used to remove a suf-
ficient quantity to lessen the swelling, after which the abscess can be laid
freely open with a knife.
When the abscess is of old standing and points in the neck behind
the sterno-mastoid, it can be opened externally. An incision is made
through the skin at the bulging point, and, after the manner of Hilton,
a grooved director, followed by dressing-forceps, is pushed into the
abscess and the opening freely dilated. It should then be thoroughly
irrigated and dressed in the usual manner. This method is in many
ways preferable to the opening on the inside, as it allows external
drainage and averts the unpleasantness of pus discharging into the
mouth.
Tumors of the pharynx are rare. In most cases the growths
are congenital, and may be papillomatous, fatty, or fibroid in character.
If the tumor pulsates, it is likely to prove an aneurysm of the internal
carotid artery.
Diagnosis of Diseases and Injuries of the Esophagus.
The following are the conditions to be sought for in an examination
of the esophagus :
Malformations. — Branchial fistuL-e may occur at any of the
three positions which correspond to the branchial clefts of the embryo.
The lowest of them is at the sternal end of the clavicle ; the middle,
opposite the thyroid cartilage ; and the highest, between the thyroid
cartilage and the hyoid bone. A permanent congenital fistula existing
at one or more of these points may be set down as a branchial fistula.
Such fistulje may be capable of admitting nothing but a probe, though
the external opening may be much larger farther in, and may expand
to the dimensions of a good-sized cyst. When pressure is made along
the course of the fistula a mucous fluid is found to exude. Sometimes
it suppurates and gives rise to a constant discharge of pus.
Pouches, or diverticula in the esophagus, with stricture, are some-
times congenital. An infant may be found to suck well, but the milk,
instead of being swallowed, runs out of the mouth. As the child
receives no nourishment, emaciation rapidly follows. An important
symptom of dilatation above a stricture is the regurgitation of large
quantities of milk at a time, and the evidence that the milk has never
reached the stomach, not being curdled nor of acid reaction.
Stricture of the esophagus may be spasmodic, cicatricial, malig-
nant, or due to the pressure of a tumor.
INJURIES AND DISEASES OF THE DIGESTIVE SYSTEM. l^'j
Spasmodic stricture is met with in young or middle-aged women of
hysterical temperament. The patient complains of a sensation as if a
ball were rising in her throat, the so-called " globus hystericus." The
difficulty of swallowing comes on suddenly without any perceptible
cause, and it may be that the dysphagia is confined to certain articles
of food, or the patient may swallow perfectly when unobserved. Pass
a bougie down through the esophagus, and it will be found to reach
the stomach without obstruction.
Fibrous or cicatricial stricture has a well-defined cause. A child
gets hold of some lye or other caustic liquid and drinks it, severely
burning the mouth and digestive tract. In the process of healing the
tissues contract, and the esophagus at one or two points becomes almost
closed. The most common seat of such stricture is at the level of the
cricoid cartilage ; that is to say, at the beginning of the esophagus.
The history of these cases is usually very clear and the diagnosis not
difficult. Food is taken into the mouth, passes beyond the pharjmx,
but sticks in the gullet and soon returns. The patient is emaciated and
undeveloped.
In the diagnosis of stricture due to any cause the passage of the
bougie (Fig. 93) gives the most satisfactory information. It is done as
Dilators for esophageal stricture.
follows : The patient, seated in a steady chair, holds the head well back
so as to bring the mouth and esophagus in line. The bougie, moistened
with hot water, is passed to the back of the pharynx, and while the
patient attempts the act of swallowing, it is pressed gently into the
esophagus. Should resistance be met with, no force should be used,
but the instrument withdrawn and gently pushed in another direction.
Bougies of different sizes should then be employed, in the hope that
one can be made to pass through the stricture and into the stomach.
Many forms of bougie have been invented. Those most commonly
employed consist of whalebone stems upon which ivory knobs of dif-
ferent sizes can be screwed.
Malignant or cancerous stricture is found in persons about or
after the period of middle life, and more frequently in men than in
women. The symptoms develop slowly. The difficulty of swallowing
comes on by degrees — first as regards solids, and later liquids. Pro-
gressive emaciation is noticed, and there may be a slight discharge of
bloody mucus and pus. In cases of this kind the glands of the neck
should be carefully examined, and a systematic search should be made
for cancer in other organs. The passage of bougies, if resorted to at
all, must be done with great care, lest they greatly aggravate the dis-
ease. There is another diagnostic method which is perfectly harmless
and generally reliable. This is auscultation. If the patient be asked
198 SURGICAL DIAGNOSIS AND TREATMENT.
to take a mouthful of water, and the stethoscope be placed over the
lower third of the esophagus, the fluid can be heard to trickle through
the stricture.
The esophagoscope is an instrument that may sometimes be
employed to advantage in the diagnosis of stricture, carcinoma, and
foreign bodies in the esophagus. It is an endoscopic instrument which
can be passed through the pharynx and down the whole length of the
gullet. An electric-light attachment illuminates each part as it comes
into view. Considerable experience and dexterity are required in its
management.
Trcatiiiciit. — Several methods of treating stricture of the esophagus
are practised :
1. Dilatatio)i by Bougies. — When the stricture is simple and not very
rigid the passage of the largest bougie which can be inserted is daily
employed, and the size increased as the stricture dilates. The patient
is fed on liquids, milk, eggs, strong broth, etc.
In many cases the esophagus above the stricture is sacculated,
rendering it impossible to pass instruments from above.
2. Retrograde dilatation was first performed by Von Bergmann in
1883. The first step of the operation deals with the stomach, and is
either a gastrotomy or a gastrostomy according to circumstances. The
gastric opening should be large enough to admit one or two fingers
besides the dilating instruments. A larger opening is unsafe, as it
allows leakage of the stomach-contents into the peritoneal cavity,
while too small an opening makes it difficult to find the cardiac orifice
(Woolsey). The second step is the dilating of the stricture. With the
fingers in the stomach opening find the cardiac orifice, and guide a
strong uterine, pharyngeal, or Otis dilator up through the stricture and
stretch it.
Instead of dilators, it may be more expedient to use other methods
in stretching the strictured part. A thread can be swallowed to the
end of which is attached a shot, or a knot can replace the shot. By
means of this thread bougies can be pulled up from below. Abbe
followed a plan in his second case which appears to answer the pur-
pose admirably. After opening the stomach the stricture was dilated
as much as possible in the manner just described. He then by means
of a " string saw " cut the remaining tissue, so as to admit of complete
dilatation. The wounds were closed, and after a few days bougies were
passed from above.
Bernays employs a " rosary bougie," made by taking the olivary
bulbs from the ordinary whalebone bougies, and, after perforating
them in their long axes, he threads them on strong silk. The smallest
size is placed at the upper end of the chain, and kept from slipping by
a knot on the thread. By regular gradation the size is increased to the
largest bulb that can be used.
Treatment of Malignant Strictiirc. — For obvious reasons the use of
dilating bougies is not suitable in malignant stricture. Two methods
are left to us, the one dealing with an artificial opening, the other with
the wearing of a tube to keep the stricture permanently dilated.
Excision of the growth has been resorted to, but the cases where
such treatment is available are few and far between.
INJURIES AND DISEASES OF THE DIGESTIVE SYSTEM. 1 99
Esophagostomy is the operation of making an artificial opening in
the esophagus. It of course must be made below the stricture, and, as
it is impossible to prove how far down the esophagus the disease
extends, the operation is very unsatisfactory. The incision is the same
as for esophagotomy, only lower down.
When an artificial opening has to be resorted to, the stomach offers
the best field, as it is farther from the disease and is comparatively easy,
and yet the results of gastrotomy for malignant disease are exceedingly
bad. Like all operations which aim only to relieve, and not to cure, it
can never be looked upon with favor. This, however, it will do — it
will (particularly if resorted to before he is exhausted) allow the patient
to receive nourishment and prevent starvation, and lessen the suffering
which attends ev'ery attempt to pass food along the esophagus.
Of the many methods of performing gastrostomy, that of Witzel is
probably the best. In this operation the fistula is made to pass through
both the rectus and transversalis muscles. As the fibers of the muscles
run at right angles to each other, their contraction may be relied upon
Fig. 94. — Witzel's method for gastrostomy,
showing application of sutures in wall of
stomach, imbedding tube obliquely therein.
Fig. 95. — Sutures tied, completely im-
bedding tube for some distance.
as an efficient sphincter. The second important feature of this ope-
ration is the enfolding of the tube in the wall of the stomach, the
stomach-wall being stitched over the tube so as to form an oblique
cone (Figs. 94, 95).
The Ssabanejew-Frank operation may be preferred by some ope-
rators. It consists in drawing up a cone of the stomach through the
ordinary Fenger incision and under a bridge of skin to a point above
200
SL.RG/CAL D/AGA'OS/S AND TREATMENT.
the border of the ribs, where it is fixed and opened. This secures a
curved fistula with a bridge of stretched skin acting as a sphincter
(Figs. 96-99).
P^GS. 96-99. — Frank's method of gastrostomy in carcinoma of the esophagus.
As an improvement upon any of the foregoing methods Symonds
has invented tubes which can be passed down to the stricture, and, fitting
accurately there, liquids can be passed through without difficulty. The
tubes are from 4 to 6 inches in length, made of gum elastic upon a silk
web, and having a highly polished surface within and without. At the
upper end the tube is funnel-shaped to rest upon the stricture, and
slightly flattened anteriorly to fit the more accurately against the
cricoid cartilage. Two perforations in the rim of the funnel are for the
attachment of a silk thread. In the introduction of the tube the
stricture is first accurately located and its position indicated on the
INJURIES AND DISEASES OF THE DIGESTIVE SYSTEM. 20I
bougie. With a whalebone guide the tube is slipped very gently down
to the stricture, and through it until the funnel meets with resistance.
The guide is withdrawn, and the silk thread which is attached to the
funnel is then made fast to the ear or secured to the cheek with adhe-
sive plaster. After two or three days it will be found that a larger
tube can be inserted as the stricture dilates. The second and larger
tube may be left in position several months.
II. DISEASES AND INJURIES OF THE ABDOMEN.
Examination of the Abdomen. — For this examination the
patient should lie upon a firm table or bed, the head and shoulders
should be slightly raised, and the knees flexed to an angle of about
ninety degrees. This posture relaxes the abdominal muscles suf-
ficiently. If the head and shoulders be raised too high, the antero-
posterior diameter of the abdomen will be increased and it becomes
more difficult to palpate the organs. The abdominal cavity includes
everything within the peritoneum, and for diagnostic purposes it is
convenient to consider the abdominal and pelvic regions as one cavity.
The anterior wall of this cavity is lozenge-shaped, the four corners of
the lozenge being at the ensiform cartilage, the pubes, and the loins.
This wall is composed of skin, fat of indefinite thickness, muscles,
fascia, and peritoneum. In our examination it lies between us and the
structures within, rendering palpation difficult, and by the contraction
of the muscles presenting appearances which are likely to mislead.
Patients wath thin, lax abdominal walls are easily examined. The most
difficult subjects are males whose abdominal walls are thick and fat.
It is customary to divide the abdomen into nine regions. This is
done by drawing upon the skin two vertical and two horizontal lines.
The vertical lines e.xtend from the middle of Poupart's ligament to the
cartilage of the eighth rib. The upper transverse line is at the level of
the ninth costal cartilage, and the lower at the highest point of the crest
of the ilium. Beginning from above downward, w^e have thus mapped
out, in the middle, the epigastric, umbilical, and hypogastric regions ;
on the right side, the right hypochondriac, the right lumbar, and the
right iliac ; on the left side are the left hypochondriac, lumbar, and
iliac. The contents of these regions are as follows :
In the epigastric region are found, from before backward, the left
lobe of the liver; part of the anterior wall of the stomach with the
cardiac and pyloric orifices ; the gastro-hepatic omentum and foramen
of Winslow. Close to the foramen are the hepatic artery, the hepatic
and cystic ducts, and the origin of the ductus communis choledochus,
the portal vein, and the vagus. Behind the stomach lie the duodenum,
the pancreas, the celiac axis, the superior mesenteric artery, the solar
plexus, the aorta, and the vena cava inferior.
The right hypochondriac region is occupied by the right lobe of the
liver, behind which is the gall-bladder, a small portion of the transverse
colon, and the upper end of the right kidney with its suprarenal capsule.
The left hypochondriac region contains the cardiac end of the
stomach, the spleen and gastro-splenic omentum, the left flexure of the
colon, the upper end of the left kidney, and its suprarenal capsule.
202 SL.KC/C.1L n/A GNOSIS AXD 'JKKATMEN7\
The umbilical region is occupied by the bulk of the small intestine,
the great omentum, mesentery, aorta, and vena cava inferior.
The lumbar regions contain the ascending colon on the right, the
descending colon on the left, the right and left kidney respectively with
their ureters, some loops of small intestine, and ccllulo-adispose tissue.
The hypogastric region contains the great omentum, portions of
the small intestine, the bladder when distended, or the uterus when
enlarged.
The iliac regions contain on the riglit side the cecum, and on the
left the sigmoid flexure.
Subjective Symptoms. — The patient suffering from disease or
injury in the abdomen may complain of pain, fulness, weight, distention,
burning, or undue motion. Of these pain is the most important and
most frequently met with. It may be sudden in its onset, as in colic,
or it may be chronic, as in gastric carcinoma. We can form a fairly
reliable opinion of the nature of a case from the character of the pain
as described by the patient.
Position of the Pain. — As a rule, when pain is referred to one par-
ticular part it indicates disease in the organ or structure which is the
seat of pain. Care must be taken to differentiate between pain in the
abdominal wall and in the internal organs. If the skin is affected, the
pain is sharply localized ; there is tenderness to touch, and there may
be redness, showing erythema, ulceration, erysipelas, etc. Pain in the
nerves is generally neuralgic ; there is usually tenderness at one or
more points ; it has a sudden onset and an equally sudden disappear-
ance, and there is absence of fever. Herpes zoster is attended with vio-
lent pain before the appearance of the vesicular eruption. Disease of
the vertebrae or the pressure of an aneurysm on the spinal column pro-
duces a pain which is intermittent in character, and is felt in the middle
line between the ensiform cartilage and the umbilicus. When the mus-
cles and fascia are affected the pain increases with motion of these
muscles, as in coughing, laughing, or bending the body.
Sudden pain occurring in paroxysms, attended with vomiting, rapid
pulse, cold sweats, pallor of the skin, and more or less collapse, is sug-
gestive of intestinal, renal, biliary, or uterine colic. If it occur in the
course of typhoid fever or ulceration of the stomach or intestine, it is
very suggestive of perforation and escape of the contents of the hollow
viscera into the peritoneal cavity. The rapid development of peri-
tonitis would confirm the suspicion. But the severity and suddenness
of the pain must not be explicitly relied upon. Such pain is found in
simple gastralgia, enteralgia, or obstruction of the intestine. These
will receive closer attention when respectively dealt with.
Pain over the whole abdomen is generally caused by peritonitis or
rheumatism. If peritonitis, there is great tenderness on pressure, the
limbs are drawn up to relax the abdominal walls, and the weight of the
bed-clothes cannot be borne. Rheumatism is recognized by the slight
amount or absence of fever, by the aggravation caused by movement,
by the presence of uric acid and urates in excess.
Fulness, weight, and distention are subjective symptoms of minor
importance, due to enlargement or displacement of the various organs,
the presence of tumors, or the presence of inflammation.
INJURIES AND DISEASES OF THE DIGESTIVE SYSTEM 203
Objective Symptoms. — An examination of the abdomen embraces
inspection, palpation, percussion, auscultation, and, in exceptional cases,
exploratory puncture or exploratory incision.
Inspection. — Stand at the patient's feet, and as he lies in the posi-
tion already described any changes in form or contour can be readily
noted.
The size and shape of the abdomen are the first to be considered. In
children the abdomen is naturally more protuberant and proportionally
larger than in adults. Large eaters have large bellies, and some peo-
ple have their abdominal walls and omentum enormously thickened
with fat. When due to such conditions the abdominal enlargement is
proportionate to the enlargement of other parts of the body, while in
ascites or tumors the size of the abdomen strongly contrasts with the
wasted condition of the chest and limbs.
Ascites is characterized by general enlargement, and the contained
fluid gravitates to the flanks, causing them to bulge outward, while the
anterior wall is flattened. Change of position will be followed by cor-
responding change in shape, the upper parts becoming flattened, while
the lower bulge. In excessive distention from ascites these signs do
not hold good, for all parts are tense ; the swelling is uniform and
unchanged by posture.
Accumulation of gas in the intestine is an important symptom. It
may be due to simple indigestion, and in such a case is usually of slight
importance. It is an accompaniment of typhoid fever. Surgically, it is
met with as one of the alarming results of peritonitis following opera-
tions or as the effect of obstruction in the large intestine.
Large tumors of especial organs, as the spleen, liver, or gall-bladder,
may, on inspection, present the appearance of general enlargement of
the abdomen, but further examination by palpation and percussion will
locate a tumor in the position to which it belongs unless it is so large
as to fill the abdominal cavity.
Local Enlargement. — When we observe a local enlargement of any
part of the abdomen, our attention is naturally drawn to the organ or
organs which normally occupy that position. And this is a pretty safe
rule, for a tumor of any organ always begins to grow in the normal
position of that organ, and encroaches by degress upon the neighbor-
ing regions. Thus a tumor of the kidney may be felt in the umbilical
region, but its first appearance is in one or the other lumbar space, and
it never reaches the umbilical until it has filled the lumbar region.
The color of the skin is not very suggestive. In ascites and edema
it is pale and glistening ; in Addison's disease there may be an areola ;
in pregnancy there is not infrequently a bronzing of the skin between
the pubis and umbilicus. Enlarged veins may be easily perceptible
beneath the skin, as in cirrhosis of the liver or in cases where a tumor
exists large enough to make pressure upon the vena cava and thus
interfere with the return circulation.
Movements. — The upper portion of the abdomen takes part in the
movements of normal respiration, especially in males. Movement is
restricted in peritonitis, in general enlargement, and when tumors occupy
the upper portion of the abdomen. When tumors are in contact with
the aorta, pulsation may be communicated to the morbid growth and
204 SURGICAL DIAGXOSIS AND TREATMENT.
be perceptible through the abdominal walls. If the patient is placed*
upon his hands and knees, the tumor falls awa)- from the aorta and
pulsation ceases.
Movements of the stomach may be observed in thin subjects, espe-
cially when the viscus is much enlarged or displaced downward ; hence,
dilatation may be diagnosticated by inspection alone. Sometimes peri-
staltic waves of the stomach may be observed passing from left to right.
If intense and persistent, this condition is spoken of as " peristaltic rest-
lessness " of the stomach.
Peristaltic movement of the intestines is a common symptom when
there is narrowing or obstruction of the lumen of the bowel. In the
case of the large intestine the wave may be traced along the course of
the colon, but when the small intestine is involved the movx^mcnt is
observed in the umbilical region.
Palpation. — Of all the methods of examination of the abdomen, this
is the most important, and can be brought to a high state of efficiency
by cultivation. The abdominal walls must be well relaxed by raising
the head and shoulders and by bending the knees. If the examining
hand is cold, dip it in warm water, and two points will have been
gained — the sense of touch will be more acute, and the abdominal mus-
cles will not retract, as they are sure to do when they are touched by
icy fingers. The recti muscles are especially prone to contract, and
great care is necessary at times to distinguish this rigidity from a tumor.
The point is readily settled by directing the patient to throw the rectus
into action while the fingers are placed upon it. Most patients cause
contraction of the recti by the simple movement of raising the head
from the pillow. If this does not succeed, direct the patient to sit up,
when the very first movement wall be contraction of the recti. Per-
manent localized contraction of the muscles is indicative of inflamma-
tion in the parts beneath.
Palpation should be commenced by placing the palm of the hand
over the umbilical region, and by a gentle motion (rolling the skin
over the subjacent parts) pressing it steadily downward. If no tumors
be felt, the hand without much difficulty can be made to feel the spinal
column and the aorta down to its bifurcation. From this region the
palm is rotated outward, and the ulnar side of the hand pressed gently
but deeply into the lumbar and iliac regions. This will enable you to
palpate the brim of the pelvis and the upper part of the common iliac
vessels. Without relaxing the pressure the hand is made to roll the
abdominal wall over the parts beneath, when any irregularities, if pres-
ent, can be readily felt. One area after another is gone over in this
manner, the hand still firmly applied, and sliding, when necessary, over
the skin. If inspection has revealed a local enlargement, palpation will
confirm it and give an idea of the shape, consistence, and character of
the growth or other cause. When a tumor is found, we must settle the
following points in connection with it :
1. In which region is it situated, and in connection with what organ ?
2. Is it circumscribed or diffuse ? This is determined by passing the
fingers around it as far as possible, and between it and the abdominal
bony boundaries.
3. Is it solid or liquid ? In tumors of dense structure, such as car-
INJURIES AND DISEASES OF THE DIGESTIVE SYSTEM. 205
cinoma, a feeling of hardness can be recognized, fluid tumors can be
detected by their fluctuation, but between these two extremes are many-
grades of consistency which are very difficult to determine.
4. Is it movable or fixed ? The hand should be placed upon dif-
ferent parts of the tumor, or the whole tumor grasped by the hand and
its mobility tested. If freely movable, note the effect of change of
posture. It often happens that the patient can bring the growth into
prominence by lying in one particular position.
5. Is its surface smooth or irregular, and is its consistence uniform?
The points of the fingers moving the abdominal wall over the tumor
will detect a nodular surface if it be present, as well as any irregularity
of consistence, such as would result from the formation of cysts or
abscesses in solid growths.
Palpation bv the vagina is a means of diagnosis which is of wide
utility. By means of it tumors in the pelvis can be felt between the
finger of one hand in the vagina and the other hand on the abdominal
wall. The connection of the tumor with the uterus, ovaries, tubes, or
broad ligament can be settled and its pedicle or base localized.
Palpation by the rectum is valuable in the diagnosis of tumors low
down in the pelvis or involving the rectum itself It was recommended
a few years ago as an aid to the diagnosis of appendicitis, but I am not
aware that it has ever been extensively employed. In cases of great
uncertainty, as in supposed stricture of the rectum high up, it may be
necessary to introduce the whole hand. The procedure is difficult and
not free from danger. I have had recourse to it but once, and have
never met with any one who advocated it as a valuable method of
diagnosis.
Percussion. — This is not so important as palpation, of which it may
be regarded as a variety. The practised diagnostication will bring out
distinct sounds where the tyro finds only indefinite thuds. To percuss
to the best advantage we should imitate the action of the piano. A
little hammer strikes the wires with a sharp, quick stroke and rapidly
rebounds, leaving the string to give out by its vibration a full, clear
sound. The finger of the left hand represents the piano-wire, the mid-
dle finger of the right hand represents the hammer ; the motion should
be at the wrist, and the percussing finger should be brought dow^n with
a sharp, quick tap, and made to fly back as quickly as possible, leaving
the vibration of the part percussed to give out a clear, unrestricted
sound. Applications of percussion will be considered under the special
organs.
Auscultation. — This method is valuable in the diagnosis of aneur-
ysms, the demonstration of placental and uterine bruits, the friction-
sound of peritonitis, and the pulsation of the fetal heart.
The phonendoscope is an instrument of considerable value in exam-
ination of the abdomen and thorax. It was invented by Bianchi of
Florence, aided by Bazzi, the celebrated Italian physician. It is a
modification of the stethoscope, the sound being amplified by means
of a resonator similar to the receiver of a telephone. Its utility as
claimed by the inventor lies in the following directions: i. It enables
us to appreciate normal and pathological sounds in the various organs
of the body — sounds that are not audible by any other means of aus-
206 SURGICAL DIAGNOSIS AND TREATMENT.
cultation ; 2. By it may be determined the position, thickness, and
relations of separate organs. It is thus employed : The instrument
is placed upon the skin over the organ to be examined ; the index
finger of the right hand gently strokes the skin near the instru-
ment, producing a distinct vibratory sound which varies according
to the size, density, and thickness of the organ under examination.
The stroking is continued fartiier and farther from the instrument
until a change in the sound indicates that the examining finger has
passed from the organ under examination to one of different
conducting power. The points at which this change takes place can
be marked upon the skin and the limits of the organ accurately
defined.
In examining the liver the instrument should be successively placed
in the following positions : beneath the ensiform cartilage ; in the right
mammillary line in the seventh intercostal space ; in the ninth inter-
costal space over the mid-axillary line. Yo\ the stomach, place the
instrument in the following positions : the seventh intercostal space
in the left mid-clavicular line ; on the linea alba near the left free edge
of the ribs and below the greater curvature. In this examination the
cardia, the pylorus, the coils of the intestine, and the nature of their
contents, whether fluid or gaseous, can be determined.
In examining the colon, place the instrument in the right iliac fossa
for the cecum, and beneath the free border of the ribs in the anterior
axillary and mid-axillary lines for the ascending colon ; for the trans-
verse colon, on a line running from right to left a little above the
umbilicus. The descending colon is examined by placing the instru-
ment beneath the left free border of the ribs and also in the left iliac
fossa. In all cases heavy strokes are necessary to detect fluids, and
light strokes to detect gases.
When a tumor is to be examined, the instrument should be placed
over the center of the growth.
Exploratory Puncture and Incision. — As a general rule, the
exploring needle is dangerous in the abdominal cavity, and at this day
is seldom or never resorted to by the best surgeons. When every
other method of diagnosis has been carefully and exhaustively tried,
and there is still doubt as to the question whether a given growth can
be safely removed, it is proper to make an abdominal section. In the
hands of a skilful operator a simple incision, to admit one or two
fingers and explore gently the abdominal contents, is practically devoid
of danger, and in a sense safer than the puncture of an exploring
needle. On the other hand, there is nothing so mischievous as the
idea that it should be resorted to in every case which offers obscure
symptoms. The case may be obscure for want of skill and experience
in the examiner ; to subject a patient to an operation as an outlet for
ignorance is cruel and unwarrantable.
When such an incision is decided upon, every preparation should be
made for any radical operation which may be called for. The incision
should at first be made only sufificient to admit one or two fingers.
Through this opening a search can be made of the whole peritoneal
cavity, after which the incision can be extended by scissors upward or
downward as required. Unless it is reasonably certain that the radical
INJURIES AND DISEASES OF THE DIGESTIVE SYSTEM. 20J
operation can be successfully carried out, the parts should be disturbed
as little as possible and the opening closed.
Injuries of the Abdomen.
Contusions. — Owing to the looseness and mobility of the abdo-
men, bruises and blows may produce the most serious results without
any visible marks upon the skin. Shock is always pronounced, and
death has often occurred with no other symptom, post-mortem ex-
amination failing to reveal any structural lesion. Contusion of the
abdominal wall may cause laceration of vessels and the formation of a
hematoma in the sheath of the muscles or the areolar tissue. Hema-
tomata are found most frequently in the flanks and may attain an enor-
mous size. If they remain aseptic, absorption rapidly takes place, and
no treatment except rest is necessary. Should they continue to enlarge
by persistence of the bleeding, they should be incised, the bleeding ves-
sel ligated, or the cavity packed with gauze. When sepsis sets in incis-
ion and drainage are demanded. A blow while the muscles are in a
state of rigid contraction may cause their rupture, leaving a weak spot
which may later be the seat of a ventral hernia. Rupture of muscle
may also occur during severe labor or in the violent contractions of
tetanus. Debilitating diseases, such as typhoid fever, weaken the mus-
cles and predispose them to rupture. The symptoms of ruptured mus-
cle are pain and tenderness. When the rupture is extensive a depres-
sion is found between the ruptured muscular structures. The treat-
ment is rest and soothing applications. It may be practicable in some
cases to cut down upon the injured part and suture the divided portions
of muscle. It sometimes happens that septic germs find an entrance
to bruised and lacerated tissues, and an abscess in the abdominal wall
is the result. Such an abscess is surrounded by widespread indura-
tion, and its contents, when evacuated, are often foul-smelling like
those of an abscess near intestine. The parietal peritoneum is occa-
sionally ruptured, and the result may be peritonitis.
Injury to the Viscera from Abdominal Contusions. — The diagnosis
of these internal injuries is always attended with difficulty. Shock is
the most prominent symptom. The patient lies in a state of collapse.
If this increases, we may assume that some organ has been ruptured
or that hemorrhage is taking place. Hemorrhage is manifested by
increasing pallor, paleness of the gums and lips, yawning, sighing,
dilatation of the pupils, and by dulness on percussion when enough
blood has been poured out to fill a part of the abdominal cavity. When
an organ is ruptured we must wait for secondary effects. The bladder
is the organ most easily examined. A soft catheter can be introduced.
If clear urine escapes and in considerable quantity, we may know that
there is no rupture ; if, on the other hand, a small amount of urine
comes away and it is stained with blood, it is significant of rupture. It
is seldom that an empty bladder is ruptured, except in cases where
there is also fracture of the pelvis.
The Stomach. — Rupture of this organ may be suspected when
there is blood-stained vomiting. This, however, is not a sign of great
value, for it may be due to bruising of mucous membranes, and, besides,
208 SIKGICAL D/AGA'OSIS AND TREATMENT.
if the laceration in the stomach be extensive, there will be no vomiting,
for the contents will escape into the peritoneal cavity. Pain in the epi-
j^astrium is significant of rupture of the stomach ; pain antl tenderness
around or below the umbilicus point to the intestine as the seat of rup-
ture. Escape of gases into the abdomen and inflation sufficient to give
resonance over the normal position of the liver are also very suggestive.
A distended stomach is more liable to suffer rupture than one compar-
atively empty, and the part of the organ generally torn is that near the
pylorus. When the posterior wall of the stomach is ruptured the con-
tents are confined by the lesser omentum and an abscess may result.
The intestine is most easily ruptured at the point which is most
fixed — viz. the end of the duodenum. The .symptoms will be con-
sidered under Wounds of the Abdomen.
The liver, owing to its size and weight, is liable to rupture. The
symptoms are those produced by hemorrhage. Fracture of ribs over
the liver, followed by collapse and other signs of hemorrhage, would be
very strong presumptive evidence of rupture.
Treatment. — Except when the shock is slight and a positive diag-
nosis can be made, treatment must be expectant. Perfect rest must be
enjoined, nourishment must be given by small enemata, thirst quenched
by small pieces of ice, and stimulants avoided or very sparingly em-
ployed. Pain may be removed by hypodermics of morphin. The prog-
nosis is much more grave when internal organs are ruptured. These
are usually desperate cases. The patient tosses from side to side,
finding no easy posture until death relieves him, or the collapse deepens
till the end arrives. Rupture of the bladder calls for immediate ope-
ration, as does also any form of internal hemorrhage, provided the
state of the patient warrants such interference.
Wounds of the Abdomen.
Wounds of the abdomen very naturally divide themselv^es into two
classes: (i) Non-penetrating wounds; (2) Penetrating wounds.
The most common causes of abdominal wounds are stabs and gun-
shot injuries. A free incised wound can be readily examined and its
depth ascertained. After washing out the clots the edges can be
held apart and the divided tissues seen or felt. When, however, the
wound is a small penetrating one, as a stab made by a knife-thrust or
a bullet, the question of penetration is not so easily settled. Here
the greatest care must be observed lest septic matter be carried into
the peritoneal cavity. The skin around the wound and the wound
itself should be carefully cleansed and disinfected. A director should
then be passed into the wound and the opening enlarged by careful
dissection down to the end of the director. Then another careful
search should be made, and if the director can be made to pass farther,
the dissection should be continued until it is clearly demonstrated
whether the wound ends in the abdominal wall or enters the peritoneum.
A non-pcnetratiiig zuound is not a serious matter. The parts having
first been carefully disinfected, sutures of silk or silkworm gut are used
to obtain perfect apposition of the parts, as in celiotomy, and a dress-
ing applied. The danger of such wounds lies in the fact that the
INJURIES AND DISEASES OF THE DIGESTIVE SYSTEM. 2O9
abdominal wall is weakened at that spot, and hernia is likely to follow.
The patient should lie in bed for at least three weeks to give the parts
time to become firmly united. He should afterward wear an abdominal
belt or supporter, and should avoid severe muscular effort for many
months.
Penetrating zvounds are further divided into two classes : {a) those
without visceral complications ; {b) those in which one or more of the
viscera are perforated. When the external wOund is large, the peri-
toneum divided, and the intestine or stomach protruding, the case is
self-evident ; and all that remains to be done is carefully to wash the
protruding viscera with sterilized water, return them to the abdominal
cavity, and close the wound. The escape of omentum is also proof of
penetration. In cases of stab or bullet wounds with small tortuous
tracks it is usually necessary to explore, by dissection, in the manner
already described. Penetrating wounds without visceral lesions often
do well when treated antiseptically. The peritoneum should be sutured
by itself by means of catgut, and a row of silkworm-gut stitches can
be used to close the remaining structures.
Symptoms of Visceral "Wounds. — In the examination of a
stab or gunshot wound of the abdomen the course of the missile
should be carefully noted. A bullet is not often deflected here, as in
the case of the skull, and a line between the points of entrance and
exit will in most cases indicate the region transv^ersed and the organs
perforated. It may be set down as a rule that a bullet passing through
the abdomen from side to side perforates the intestine in from four to
fourteen places. A bullet passing antero-posteriorly about the level of
the umbilicus gives a probability of no visceral perforation. The diffi-
culty of diagnosis will be seen as we take up the symptoms one by one.
Shock. — A non-penetrating wound of the abdominal wall may be
attended with profound shock. A penetrating wound which divides
the intestine in several places has been known to be so free from shock
that the patient has walked several blocks or even one or two miles.
Vomiting may be a marked symptom in non-penetrating wounds,
so that it is no proof of visceral wound. The same may be said of pain
and pallor of the skin.
Hemorrhage. — The blood that gushes from the parietal wound
counts for little, as it is the flow from some muscular vessels in the
wall. Blood from a wounded internal organ is poured out into the
peritoneal cavity, and produces constitutional effects which are difficult
to distinguish from shock. We must be guided by the ordinary
symptoms of hemorrhage, such as pallor of the face, lips, gums, and
conjunctiva, yawning, sighing, fainting, thirst, and jactitation. Besides
these, a careful examination should be made by percussion. Blood
collecting in the abdominal cavdty soon gives dulness in the flanks,
which changes with position, as happens in ascites.
Escape of stomach or intestinal contents through the external
wound is convincing evidence, but this happens only when the opening
in the viscus is opposite to that in the parietes and is not tortuous.
When the contents of these organs escape, they do so into the abdom-
inal cavity, and give no evidence until peritonitis has set in.
Emphysema signifies very little^ for it may be produced by air,
u
2 10 SURGICAL DIAGNOSIS AND TREATMENT.
which has entered the wound from without, jTist as Hkely as by gas
which has escaped from the alimentary tract.
Hydrogen-test. — To Senn we are indebted for a very valuable aid
in the diai,niosis of wounds of the stomach and intestines. Hydrogen
is a liarmless gas which can be injected into the alimentary canal in
any quantit)% producing no other effects than distention and disinfection.
The gas is prepared in the usual way from pure sulphuric acid, zinc,
and water, and collected in a rubber receiver which holds not less than
three or four gallons. The tube from the receiver is inserted into the
rectum, and, while an assistant holds it in position and presses the anus
about it to prevent escape, the gas is slowly forced into the bowel. If
the ear or stethoscope be placed over the position of the ilio-cecal valve,
a gurgling sound will indicate the passage of the gas into the small
intestine. Should there be a perforation of the intestine, the gas escapes
into the peritoneal cavity, and thence through the external wound,
where it can be detected by a hissing sound or may even be ignited
w^ith a match ; or, if it should fail to escape by the external wound, it
will fill the abdominal cavity, getting between the liver and the parietes,
and giving a resonant note in the normal position of hepatic dulness.
When this test is to be applied to the stomach, a soft stomach-tube is
employed and the gas injected as before. The hydrogen-test may also
be found valuable in deciding the question of penetration. The gas is
injected into the wound of entrance. If there is no penetration of the
peritoneum, the hydrogen will pass along the bullet-track and escape
by the wound of exit. Compress the wound of exit and increase the
gas-pressure, and emphysema will be felt along the course of the bullet.
If there is penetration, the whole abdomen will quickly become dis-
tended and tympanitic.
Objections to the use of hydrogen are the dangers of over-dis-
tention, the difficulty of returning the bowel to the abdominal cavity,
and the fact that it frequently fails as a test.
Prognosis. — Wounds of the abdomen must always be looked upon
as of the utmost seriousness. In considering the probability of recov-
ery it is safe to estimate the three divisions as follows :
1. Non-penetrating wounds, prognosis favorable. Careful anti-
septic treatment will result in prompt healing. Accurate apposition by
sutures and prolonged rest in bed will guard against ventral hernia.
2. Penetrating wounds without visceral injuiy, while more dan-
gerous than the preceding, are not necessarily fatal, a large portion
recovering without intra-abdominal treatment, provided nothing of a
septic nature has entered the abdominal cavity.
3. Penetrating wounds with visceral injury. These are almost
surely fatal, death resulting from hemorrhage or peritonitis. When a
large vessel is wounded or when there is profuse parenchymatous
hemorrhage, as from the liver or spleen, death follows quickly. A
wound of the stomach or intestine allows the escape of the contents of
the injured organ into the peritoneal cavity. Peritonitis speedily fol-
lows, and death takes place within forty-eight hours, more from shock,
perhaps, than from sepsis. There is a bare possibility that recovery
may follow even so desperate an injury as this. The stomach or intes-
tine, being empty at the time of the accident, may at its injured point
INJURIES AND DISEASES OF THE DIGESTIVE SYSTEM. 211
form an adhesion with a neighboring serous surface, and the general
peritoneal cavity be thus protected. This contingency, however, is too
remote to enter into our calculations in making a prognosis. In this
third class of cases nothing but prompt operative interference with the
view of arresting hemorrhage or closing wounds in the viscera will
change the prognosis. The mortality after these operations may be
set down at about 62 per cent.
Treatment. — A non-penetrating wound must not be treated with
indifference. The shock is often severe, and frequently it is so more
from fricfht than from the extent of the traumatism. Soldiers have
been picked up on the battle-field in a state of profound shock, and
have quickly rallied and gone on fighting when assured by the surgeon
that the supposed fatal injury was only an abrasion of the skin. The
treatment of a non-penetrating wound consists in disinfecting the wound
and surrounding parts. None but perfectly aseptic fingers and instru-
ments should be used in exploring the wound. Care must be taken in
application of sutures to restore the abdominal wall to its original
strength and thus prevent ventral hernia. When drainage is called
for, a few strands of catgut are better than non-absorbent drainage-
tubes.
In penetrating wounds, when the omentum or viscera protrude,
these structures must be examined for injury. They should then be
carefully washed with sterilized water and returned to their normal
position. The peritoneum should be closed by a continuous catgut
suture and the abdominal wall by silkworm gut or strong silk. When
the wound is of considerable size, the greatest care should be taken to
guard against a subsequent hernia ; this is best averted by keeping the
patient in bed for three or four weeks, and by having him wear an
abdominal belt or support for several months afterward.
Penetrating wounds with visceral injury either forbid interference or
demand the promptest action. If the patient is evidently sinking, and
his general condition such that he cannot endui-e a prolonged operation,
he would better be left alone.
Two conditions demand operation : (i) Profuse internal hemorrhage ;
(2) Perforation of stomach or intestine large enough to allow the escape
of its contents.
No rules can be laid down as a guide in such cases ; the condition
of the patient and the special indications must be left to the surgeon's
individual judgment. When there is profound shock it is necessary to
employ suitable remedies and wait for reaction. Symptoms of peri-
tonitis should not be waited for. When they appear the case is almost
beyond hope. Adhesions by this time will have taken place and per-
forations cannot be found. The perplexing point to the surgeon is
this : There is evidently perforation, but the patient's condition does not
appear serious enough to demand operation. On the other hand, if he
waits for these serious symptoms to come on, the case will then be
beyond hope. It is unquestionable that the earlier an operation can be
resorted to the better will be the result. Coley has shown that of 39
cases operated upon within twelve hours, 18 recovered. Of 22 ope-
rated upon after twelve hours, only 5 recovered.
Operation. — Iiistnniioits Required. — Besides the ordinar}^ instru-
212 SURGICAL DIAGNOSIS AND TREATMENT.
mcnts required for an abdominal section, there should be at hand the
follo\vin<^ :
Four intestinal clamps ; ten round milliner's needles for enteror-
rhaphy threaded with fine silk ; stout catgut for suturing wounds in the
solid viscera.
Preparation of tJic Paticiit. — For the relief of shock and for pro-
longing anesthesia a hypodermic injection of ] grain of morphin and
Toif ^'"'^iii of atropia should be given. If there is indication that the
stomach is the seat of injury, this organ should be emptied by the
stomach-tube and washed out with w'arm sterilized water. The bowels
can be emptied by an enema containing a little salt. Some advocate
the use of whiskey as a stimulating enema. The whole abdomen
should be thoroughly washed and disinfected and the wound carefully
cleansed.
The Ineision. — Except when the position of the external wound
would strongly indicate to the contrary, a median incision is to be
chosen. It gives better opportunities for examining intestines and
stomach and a broader field in which to search for bleeding vessels.
No rule, however, can hold good here. The course of a bullet or the
direction of a stab wound will afford a pretty safe indication of the
organs injured, and these must be reached by the incision which best
exposes them.
Arrest of Hcniorrliage. — When hemorrhage is the prominent symp-
tom, a free incision is necessary to bring the bleeding points into view.
If one of the solid organs be wounded, the character of the bleeding
will be parenchymatous. A wound in the liver should be treated with
a suture of stout catgut or packed with a strip of iodoform gauze, the
end of which is left projecting from the parietal wound. A profusely
bleeding kidney may require nephrectomy ; a wounded spleen may
bleed so profusely that nothing but splenectomy will suffice. When
there is a copious flow of blood, which accumulates as fast as it can be
sponged out, the aorta should be compressed by an assistant. This
requires a larger incision than ordinary, to allow the hand of the assist-
ant to reach the vessel just below the diaphragm. Compression of
the aorta in this manner controls the flow of blood from all the
abdominal organs, and gives the operator time to find the bleeding
points. The vessels of the mesentery are best controlled by ligature
en masse.
Perforations. — Having checked all hemorrhage, a rapid search must
be made for perforation of the stomach or intestines. As soon as an
opening is found it should be immediately closed with pressure-forceps,
and held in the angle of the wound by an assistant while the operator
continues his search. Every opening, as soon as discovered, is clamped
in a similar manner until all are secured. Greig Smith advises the use
of abdominal irrigation during the whole of the time that closure of
visceral wounds is being carried out. It cleanses the abdomen and
thus saves time, and if water at a temperature of i io° F. be employed,
it W'ill prove an excellent remedy for shock.
Suturing the Perforations. — One by one the wounds are closed.
Sponges are arranged around the abdominal opening and the intestine
or stomach brought out. Lembert sutures are the most suitable. The
INJURIES AND DISEASES OF THE DIGESTIVE SYSTEM. 21 3
lacerated edges of the intestinal wounds are turned inward and the
serous surfaces brought together. Four to six sutures should be
applied to every inch of incision, and the best material for this purpose
Fig. icx>. — Czemy-Lembert suture.
Fig. ioi. — Jobert's suture tor partial division of
gut : a, serous ; b, muscular ; c, mucous coat.
is fine silk. Wounds in the intestine should be sutured transversely to
prevent constriction of the lumen ; in the stomach the direction should
be in the long axis of the organ. When the bowel is wounded near
Fig. I02. — Lembert continuous stitch.
its mesenteric border gangrene is apt to result, as there is a danger of the
blood-supply being cut off from that part of the intestine. This may
necessitate the removal of a portion of the bowel. A section of the
b-=^.
Fig. 103. — Jobert's suture for complete trans-
verse division of gut : a, serous ; b, muscular ; c,
mucous coat.
Fig. 104. — The suture tightened,
showing Lembert's suture introduced
to give additional security.
bowel will also require removal when there is a double perforation or a
laceration so large as to destroy a great part of the circumference of
the tube. When this has to be done the mesentery attached to the
condemned part of intestine is tied off in sections with fine silk before
214 SURGICAL DIAGNOSIS AND TREATMENT.
removal of the bowel. When the intestine is simply contused, the
injured portion may be turned inward and sound serous surfaces
brou^^ht together with Lembert sutures; then, should sloughing take
place, the necrotic portion will fall within the bowel. Each wound
after having been sutured is carefully washed, and, if possible, rendered
more secure by an omental graft. This is accomplished by taking an
adjacent portion of the omentum and laying it upon the contused or
sutured surface of bowel, retaining it in position by two catgut sutures
loosely tied. Adhesions will be hastened if the opposing surfaces are
first scratched by the point of a needle.
Irrigation of the Abdominal Cavity. — Having closed every perfora-
tion and stopped all bleeding points, the cavity of the abdomen is next
thoroughly washed out with warm water. If this has been kept up
during the preceding steps of the operation, very little time will be
required for a final flushing. In any case a full stream of warm steril-
ized water or mild antiseptic solution is allowed to flow into the cavity,
while the bowels are moved gently about to allow the fluid to reach
every part, and this is kept up until the water returns as clear as it went
in. The cavity is then dried with warm sponges.
Drainage is necessary, as a rule, when there has been gross infection
by the extravasation of visceral contents or when there is a continu-
ance of parenchymatous hemorrhage. The parietal wound is closed
by means of silkworm-gut sutures, as in any abdominal section.
After-treatment. — When the intestine has been the seat of operation
perfect rest of the organs, even from their own peristaltic action, is
necessary. The stomach and upper part of the small intestine are
rested by taking no food into the mouth for three or four days, and
then only liquids, such as peptonized milk, diluted peptons, or jellies.
Opiates are recommended for the purpose of restraining peristalsis. It
is doubtful whether this is a wise procedure. If the dose of morphin
and atropia be given just before the operation, as already advised, its
effect will be to keep the intestines quiet for some time. Adhesions of
serous surfaces take place rapidly, and, if union is to occur at all, it
will be pretty firm at the end of twenty-four hours or even in less time.
The arrest of peristalsis is not necessary beyond this, and opiates are
certainly contraindicated as interfering with the absorbent action of the
peritoneum. When a drainage-tube is employed care must be taken to
keep the fluid drawn out at frequent intervals by means of an exhaust-
ing syringe. Should the temperature rise and other symptoms of sepsis
set in, it is probably because the peritoneal cavity is shut off around
the drainage-tube and a collection of pus is taking place. The best
thing to do in this case is to remove the drainage-tube, insert one
finger into the opening, carefully break up the newly-formed adhesions,
and wash out the collection of pus by irrigation. I am confident of
having saved at least two cases of general peritoneal sepsis in this
way. 6
When all goes well, liquid food can be given by the stomach at
about the end of the third day, and solid food in an easily digested
form at about the end of a week. The parietal wound is treated as in
other abdominal sections, care being taken to allow a good firm cicatrix
to form before the patient is allowed to go about, and an abdominal
INJURIES AND DISEASES OF THE DIGESTIVE SYSTEM. 21 5
support should be worn for sev^eral months with the view of preventing
ventral hernia.
III. EXAMINATION OF THE STOMACH.
Inspection. — Valuable data in the diagnosis of diseased conditions
of the stomach can be obtained from the amount of distention of the
organ. A flat, collapsed condition at the epigastrium is sometimes
seen when there is obstruction at the cardiac orifice ; bulging and tume-
faction occur when the pylorus is the seat of stricture. Tumors in the
anterior wall or at either orifice may cause a bulging at the epigastrium.
Peristaltic movements may be observed in certain cases. Normal
waves begin at the cardiac end and extend to the pylorus. Anti-
peristaltic waves take the opposite course, and are an indication of
stricture at the pylorus. These movements are increased by the use of
the faradic current, or by the application of the ether spray, or by
striking the abdomen with a wet towel.
Palpation. — The first thing to be sought for is localized pain,
which can be readily detected by making gentle pressure with the
fingers over the region. Any inequalities in the abdominal wall should
be carefully noted and a tumor sought for. Sometimes a growth is
lower down than the normal position of the stomach, its own weight
causing it to sink to a lower level in the abdominal cavity. Dilatation
of the stomach may force a pyloric tumor downward. In its early
stages a tumor of the pylorus is freely movable, later it becomes fixed.
Percussion. — The whole of the stomach cannot be outlined by
percussion. On the right side the liver overlaps a portion of the organ,
while the lung encroaches upon it on the left. The lower limit is
about midway between the ensiform cartilage and the umbilicus, and
passes in a curve to the lower border of the end of the tenth rib. In
percussing the stomach it is convenient to begin with the right hypo-
chondriac region. From liver dulness we come abruptly upon the
tympanitic stomach, and find no difficulty in determining where one
begins and the other ends. On the left side the pulmonary resonance
is easily distinguished from the tympanitic note over the stomach. At
the lower border considerable difficulty may be met with. The stomach
here is bounded by the colon, and it may happen that the note in both
has the same pitch. As a rule, however, the note over the stomach is
more tympanitic, louder in tone, and lower in pitch than that over' the
colon, so that in the majority of cases the lower border of the stomach
can be accurately mapped out. Allowances must always be made for
the nature and amount of the stomach-contents. When the organ is
full the note is dull and muffled, and the area of dulness corresponds
with the degree of gastric distention. Change of position will be found
to change the percussion-note. Gas rises to the surface, giving a
tympanitic resonance, while fluid gravitates to the most dependent parts
and affords a dull note.
As an aid in ascertaining its exact size, Piorry suggested filling the
stomach with water. About a liter is given the patient to drink, and
he is examined when standing. The stomach thus distended gives a
dull note, in contrast to the tympanitic sound produced when the colon
is percussed.
2l6 SUKU/CAI. D/AGiVOS/S AND TREATMENT.
The metliod of Dchio consists in ^ivinj^ the water in fractional
quantities. The hter of water is divided into four parts, each part
being taken separately at short intervals, and an examination made
after each dose. The area of dulness is marked upon the abdomen
after each examination. This method is valuable in detecting dilatation
of the stomach and atony of the organ. When the area of dulness
descends below the umbilicus, it indicates dilatation. When the dull
area descends rapidly after each addition of water, atony of the gastric
muscle may be diagnosticated. The lower limit of a healthy stomach
never descends below the umbilicus.
Frielich was in the habit of distending the stomach with carbonic-
acid gas. The patient took 2 grams of sodium bicarbonate dissolved
in water, and then an equal quantity of water containing 2 grams of
tartaric acid. A rapid disengagement of carbonic acid takes place in
the stomach, which so distends it that the contour of the organ may
be seen through the abdominal wall. This method is not free from
danger, as the distention may be excessive and is always beyond con-
trol. Sometimes the quantity of gas is not sufficient to distend the
stomach.
The method of Runeberg is the most satisfactory. It consists in
distending the stomach with air by means of a tube to which is
attached a rubber bulb. The quantity of air is thus under direct
control, and the stomach is examined in different degrees of dis-
tention. At the end of the examination the air can be withdrawn
through the tube. All these examinations are greatly aided by the
use of the phonendoscope. (See ^Examination of the Abdomen.)
The stomach itself is movable, rising beneath the chest-wall when
pushed upward by abdominal distention, and sinking lower into the
peritoneal cavity when anything depresses the diaphragm. An enlarged
liver encroaches upon the stomach from the right, and an enlarged
spleen from the left. Contraction of the liver, on the other hand,
increases the area of stomach-resonance.
Auscultation is of little value in the diagnosis of stomach-diseases.
Splashing, gurgling, and metallic sounds may be produced by rapid
voluntary movements of the diaphragm, by the natural movements of
the stomach itself, by moving the patient quickly from side to side, or
by pressing upon the stomach and suddenly relaxing the pressure.
If you direct the patient to swallow fluid and place your stethoscope
over the esophagus, two sounds are heard : the first is a spurting sound,
and is due to the passage of the liquid along the esophagus ; the
second sound is produced by the escape of the fluid from the esophagus
into the stomach. In healthy conditions the interval between these two
sounds should not exceed ten seconds ; in cases of constriction of the
cardiac orifice the interval may be extended to a minute or more.
Chemical exaniiiiatioii of stoinach-conicnts (see Cancer of the
Stomach).
Injuries and Diseases of the Stomach.
The chest-wall above and the thick muscular abdominal wall in
front protect the stomach from external injury. A sharp instrument
can readily pierce the organ, but a blow from a blunt object throws the
INJURIES AND DISEASES OF THE DIGESTIVE SYSTEM. 21/
abdominal muscles into strong contraction, and the stomach readily
yields before the pressure or slips from under the force. If, however,
the stomach contain a considerable quantity of food or be distended
with gas, rupture may take place. One or more coats may give way
or the whole thickness of the gastric wall may be lacerated, permitting
the contents to flow into the peritoneal cavity, and producing death by
peritonitis within forty-eight hours. When one coat only is ruptured,
it is usually the peritoneal, that being less elastic than either the
muscular or mucous covering.
Syniptoiiis of Rupture. — When only the peritoneal coat is ruptured,
the symptoms are pain and localized peritonitis. The torn perito-
neum almost immediately becomes adherent to the peritoneal sur-
face of some other organ, adhesive inflammation throws out a bar-
rier against further mischief, and the process of repair rapidly takes
place. A localized peritonitis, following a blow or kick over the
stomach, is very suggestive of this form of rupture, and such a condi-
tion should be treated by placing the organ at perfect rest by with-
holding food for several days and by nourishing the patient with
nutrient enemata.
When the mucous or muscular coat is ruptured hemorrhage into
the stomach is the prominent symptom. Vomiting of blood must
therefore be regarded as very important when it follows a traumatism in
the epigastric region. Rupture of the whole thickness of the stomach-
wall is followed by the most serious symptoms. Shock is severe and pain
is intense. The contents of the stomach are poured out into the abdomi-
nal cavity, and the symptoms of general peritonitis rapidly appear.
Some patients never rally from the first shock ; others die of peri-
tonitis in about two days.
Tvcatinoit. — If ever there is a condition requiring prompt and
immediate heroic measures, it is here. Once the diagnosis of complete
rupture has been made, there is not a moment to be lost. A free
incision, beginning at the ensiform cartilage and extending to the
umbilicus, is required. The rent should then be sought and brought
to the surface. If situated at the posterior wall of the stomach, the
gastro-colic omentum must be divided before the laceration can be
reached. Having brought the edges of the rent to the abdominal
wound, the stomach should be washed out with sterilized water, after
which it should be sutured by two rows of silk stitches, the one passing
through the muscular and mucous coats and cut short. The second
row takes the peritoneum and passes into the muscular coat, so that it
buries the first row and brings the peritoneal surfaces together. Any
stomach-contents found in the peritoneal cavity should be mopped out
with sponges, and, if there be general contamination, the whole should
be flushed with sterilized water or Thiersch's solution. Drainage is
necessary when the contamination has been extensive or long con-
tinued. The after-treatment requires stimulation by hypodermics of
strychnia or brandy and perfect rest to the stomach.
Foreign Bodies in the Stomach. — Children frequently swallow
coins and other small bodies with impunity. I had until recently in my
possession a pocket-knife blade, one and three-quarter inches in length,
which passed through the alimentary canal of a four-year-old boy.
2l8 SURGICAL DIAGNOSIS AND TREATMENT.
The blade was somewhat eroded, but the boy was none the worse for
the mishap. Bodies which pass through the pharynx and esophagus
are pretty sure to pass through the remainder of the digestive tract,
particularly if the friends abstain from the common practice of giving
purgatives. Food should be allowed which ensures the formation of
bulky stools, and for this purpose an exclusive diet of mashed potatoes
and milk answers admirably.
Mechanical Fixation of the Stomach. — When from injury,
disease, or as a sequel of celiotomy the stomach becomes adherent to
the parietes, considerable suffering and inconvenience may result. Such
cases are often set down as gastric neurosis. Landerer of Leipzig has
reported three cases of intense gastralgia attended with vomiting and
tenderness at the epigastrium. In the first case a band of adhesion
was found between the parietal peritoneum and the stomach, the
removal of which was followed by perfect recovery. In the second
case the stomach was found adherent to the left lobe of the liver,
and recovery followed the breaking up of the adhesion. The third
was produced by a small umbilical hernia, to which a section of the
stomach the size of a small apple was firmly adherent. All the
symptoms subsided after freeing the stomach and stitching the her-
nial ring.^
A case is reported by Dr. Davis of Omaha in which persistent
attacks of vomiting, severe gastric pain, nervousness, cardiac depres-
sion, and high temperature were finally traced to a small hernia in the
linea alba, to the sac of which was attached a band of omentum.
Tracing the omentum inward, it assumed the form of a band the end
of which was adherent to the greater curvature of the stomach.
Division of the band and radical treatment of the hernia effected a com-
plete cure.
Landerer points out a very simple and reasonable symptom of this
condition. // is the production of pain in the stomach from movement of
the visciis. Washing out the stomach and movements of the body
which cause a dragging of the stomach at the adherent point are
followed by long-continued pain.
Ulcer. — Ulcer of the stomach until a recent date was regarded as
entirely within the domain of medicine. At present it may be looked
upon as an outpost on the frontier of surgery. Perforating ulcer has
long been recognized. Its starting-point is in a small arterial branch
which becomes occluded, and thus the supply of blood is cut off from a
portion of the stomach-wall. Necrosis of the area thus cut off follows.
The necrosed part takes the form of a cone with its apex toward the
peritoneal and its base at the mucous coat. The destruction of tissue
is hastened by the action of the gastric juice, and the slough, coming
away en masse or by molecular death, leaves an ulcer which the term
" perforating " aptly describes. Not infrequently severe hemorrhage
follows, and by repeated losses of blood the patient may be brought to
a state of great anemia and even unto death itself
Symptoms. — Two leading symptoms attract our attention in gastric
ulcer — a fixed pain with localized tenderness on pressure, and vomiting
soon after taking food. Surgically, we are interested in ulcer from the
' Annual of Universal Medical Sciences, 1894.
INJURIES AND DISEASES OF THE DIGESTIVE SYSTEM 2I9
fact that perforation is a not infrequent termination. Haslan of Bir-
mingham, England, describes perforating ulcers under three classes :
1. Where no adhesions have formed around the base of the ulcef,
and the stomach-contents pass at once and freely into the peritoneal
cavity. The location of ulcers of this class is usually on the anterior
surface of the stomach The symptoms here are sudden and severe,
almost identical with those following rupture of the stomach. Shock
is more or less marked ; there are abdominal pain and tenderness on
pressure, with the train of symptoms which make up the sum-total
of general peritonitis. The duration of life after perforation occurring
in this manner ranges from seven hours to five days, the majority dying
within twenty-four hours.
2. Where adhesions around the base of the ulcer have fixed the
stomach to some adjacent organ, the leakage causing a localized peri-
tonitis. Suppuration follows perforation of this class, but the collec-
tions of pus are shut off from the general peritoneal cavity. The diag-
nosis here must rest upon the history of gastric ulcer, the occurrence
of localized peritonitis, followed by induration, and such other signs as
indicate a collection of pus.
3. Cases in which adhesions have formed between the stomach and
some hollow viscus or serous cavity, into which an opening from the
stomach becomes established. In this way the stomach-contents have
found their way into the colon, the pericardium, or the pleura.
Treatment. — In the first class of cases clinical experience teaches us
that there is only one termination — death — and that the fatal issue
occurs in the majority of cases within twenty-four hours. Any attempt,
therefore, which gives a hope of placing the patient in a more favorable
position is justifiable. The operation recommended consists in making
an incision above the umbilicus a little to the left of the middle line, in
order to avoid the falciform ligament. The patient, being the subject of
shock, must be treated for this condition by hypodermics of str}xhnin
and by surrounding him with hot bottles. The most common seat of
ulcer is found to be at or near the lesser curvature. As a rule, the
portion of the stomach which presents at the parietal wound in this
operation is the greater curvature or the part a little above it. The
finger should be made to pass over the surface of the stomach upward
and backward in search of the perforation, and, as already stated, it
will be found at or near the lesser curvature. The succeeding steps
of the operation are identical with those in the operation for rupture
of the stomach.
Gastric Fistula. — In the rare cases in which adhesions form
between the stomach and the abdominal wall and shut off the peri-
toneal cavity before the occurrence of perforation a gastric fistula may
be the result. A similar condition may arise after a wound of the
abdominal wall which extends into the stomach, or the fistula may be
intentionally made for the relief of a constriction at the lower end of
the esophagus or at one or other of the orifices of the stomach.
Treatment. — The operation for the closure of the gastric fistula will
vary according to the length and connections of the fistulous tract. If
the fistula is short and the stomach in close connection with the abdom-
inal wall, the closure can be effected without opening the peritoneal
220 SURGICAL DIAGNOSIS AXI) IREATiMKNT.
cax'ity. An incision about two inches in length down to, but not
through, the peritoneum exposes the opening in the stomach. The
edges of the whole fistulous tract should next be thoroughly freshened
by paring them with a sharp knife or scissors.
Four rows of sutures are then applied, as follows :
1. Fine silk pa.ssing through the mucous and submucous coats.
2. Catgut sutures to include the remainder of the stomach-wall.
3. A deep row of catgut to unite the deep layers of the abdominal
wall.
4. A row of silkworm gut to unite the skin. Over this a copious
aseptic dressing is applied and retained by long strips of adhesive
jilaster. The stomach is kept at rest by giving all nutriment by the
rectum for the first four or five days.
When the fistulous tract is larger and the stomach is not in close
connection with the abdominal wall, the peritoneal cavity must be
entered. The stomach is completely separated wherever it is found
to be adherent to the parietes, and the opening closed as in wounds of
this viscus.
Cancer of the Stomach. — " Obscure in its symptoms, frequent in
its recurrence, fatal in its event." Such is the description of cancer of
the stomach given by Brinton.
Of the tumors found in connection with the stomach, carcinoma is
by far the most common. Sarcoma is exceedingly rare. Benign
tumors are seldom found in this locality, and, if they do exist, require
no surgical treatment. Of all cases of cancer, 35 to 45 per cent, occur
in the stomach, which is more liable to the disease than any other part
of the alimentary canal except the tongue and lips. The maximum
liability lies between the ages of fifty and sixty. It is rare before the
thirtieth year, and congenitally it almost never occurs.
True to the pathological law that carcinoma is most likely to occur
where two kinds of epithelial cells meet, cancer of the stomach begins,
as a rule, either at the cardiac or pyloric orifice. One-half of all cases,
according to Bernays, begin at the pylorus. Of 903 cases analyzed by
Gussenbauer and Winnewarter, 542 were pyloric. The pylorus is per-
haps more susceptible, owing to repeated slight injury due to the
passage through it of hard or indigestible masses of food. It is quite
a common thing to find post-mortem old cicatrices in the mucous
membrane of this locality, which, combined with the clinical fact that
cancer has a tendency to occur in scar-tissue, gives some show of
reason to the theory.
Next in frequency of situation is cancer of the greater curvature.
In other positions the disease is extremely rare. Once the neoplasm
has started, it tends to grow toward the lumen of the stomach. The
mucous membrane is the structure first affected ; next the submucous
loose connective tissue ; and only in the last stage are the muscular
and serous coats invaded. Early and accurate diagnosis is of the
utmost importance, and I would submit the following points as a
practical mode of procedure in any case of suspected gastric cancer :
I. History. — If a patient more than forty years of age gives a
history of disturbed digestion dating back for several months or a
year, combined with cardiac or pyloric stenosis, the suspicion of cancer
INJURIES AND DISEASES OF THE DIGESTIVE SYSTEM. 221
of the stomach must be entertained. Pain, as a rule, is not felt until
an advanced stage of the disease. Vomiting occurs without much
effort and with little nausea. At first the vomit consists chiefly of
mucus, remnants of food, and watery fluid mixed with bile, but by
degrees the stomach-contents are expelled in a more and more undi-
gested state. It is not until ulceration has become established that
blood is vomited. The blood may be in small amounts as bright-red
streaks in the mucus, or the quantity may be large and changed in
appearance according to the length of time it has remained in the
stomach and the changes it has there undergone. Then it may be in
bright-red or brownish-red clots or coagula, vaiying in shade from
brown chocolate color to black. This, the so-called " coffee-grounds "
vomit, was formerly supposed to be pathognomonic of cancer of the
stomach, but experience has proved this to be an unreliable sign, for
other diseases are attended with " coffee-grounds " vomit.
At the same time it must be borne in mind that, as a rule, the blood
remains longer in the stomach in cancer than in other diseases, and
" coffee-grounds " vomit has therefore considerable significance, con-
sidered with loss of strength and progressive emaciation. The fat and
muscles rapidly waste away, and ere long the patient becomes decidedly
emaciated.
2. Physical Examination. — In all cases of abdominal examination it
is convenient to map out by means of a colored pencil the abdominal
areas — viz. epigastric, right and left hypochondriac, etc. Besides these
I would draw a line from the points of the false ribs on either side to
the umbilicus. On the right side this line with the linea alba and line
of the false ribs forms a triangle in which tumors of the pylorus are to
be sought for. On the left side the line marks the boundary of normal
stomach-dilatability. If the stomach falls below this line, we may say
that there is abnormal dilatation. For a thorough examination the
patient should be anesthetized.
3. Inspection. — Standing at the patient's feet and looking down upon
him, we can observe an)' irregularity in the abdominal wall. A growth
in the stomach may be visible as an elevation over the situation of the
organ. A depression in the epigastrium points to obstruction in the
esophagus, a fulness in the epigastrium to pyloric stenosis.
4. Palpation and Percussion. — We may expect to find a tumor in
three-fourths of the cases. A tumor at the cardiac orifice is hard to
find by palpation, owing to its distance from the surface. It is only
when it has attained considerable size that its presence is clearly demon-
strated. At the pyloric end, however, the tumor is more easily felt, and
its common position is between the ensiform cartilage and the umbilicus,
a little to the right of the middle line. Having found the growth, we
may ask ourselves the following questions :
First. Is the tumor movable ? Its weight may drag it downward,
so that it falls below the line we have marked upon the skin from the
border of the false ribs to the umbilicus. If freely movable, it is an
indication that there is no invasion of neighboring organs. Still, this
rule cannot be insisted upon, for in one recorded case the tumor was
freely movable, and yet the adhesions were so strong and so numerous
that the operation had to be abandoned. On the other hand, fixation
222 SC'KGICAL D/AGXOS/S AND TREATMENT.
docs not certainly indicate extension of the disease to neit^hboring
structures. W'lien it has become adherent to the hver and diaphragm,
it rises and falls with respiration. Dilatation of the stomach may cause
mobility of the tumor. If the stomach be greatly dilated and the
pylorus fixed in an abnormal situation, it strongly suggests extension
of the disease. If irregularity of the surface of the growth coexists
with these conditions, we may certainly infer that the disease has spread,
and then operation is out of the question (Greig Smith).
Second. Is the stomach dilated ? This can be ascertained by dis-
tending the organ. Frerichs employed for this purpose carbonic-acid
gas generated outside the body — for example, from an inv^erted siphon
of mineral water. Safer and more satisfactory is the method of Rune-
berg, which consists in introducing a stomach-tube and then insufflating
air by the double bulbs of a spray apparatus. As a rule, we have other
reasons for introducing the tube, so that the inflation of the stomach
with air gives very little additional trouble. Besides percussion of the
stomach, we may with advantage employ succussion in its two forms —
viz. digital and total or Hippocratic. The writings of Bouchard have
brought this matter of examination into considerable prominence. It
is thus employed : The patient lies on his back with the abdominal
muscles relaxed. The surgeon makes a series of rapid taps with the
extremity of the fingers on the abdominal wall along the line running
from the umbilicus to the edge of the false ribs on the left side. If a
certain amount of liquid and gas is present, we obtain in this way a
sensation of splashing to which Bouchard attaches great importance.
The presence of a gastric succussion-sound when it is perceived below a
line extending from the umbilicus to the border of the false ribs on the
left side indicates a permanent dilatation of the stomach. It is import-
ant only when obtained a long time after a meal, and especially when a
patient is fasting in the morning (Mathieu).
The significance of dilatation lies in the fact that it corroborates
obstruction at the pylorus. Contraction, on the other hand, argues in
favor of obstruction at the cardiac orifice.
5. Examination of the Contents of the Stojuach. — The surgeon is
not justified in neglecting this means of diagnosis in any chronic
gastric disease. As the procedure is not yet so generally employed
as its importance demands, I may perhaps be pardoned if I very
hurriedly run over the steps of most practical utility in aiding diag-
nosis.
It is important in the examination of the stomach-contents that a
uniform method should be followed.
Different results will be obtained at different periods of the digestive
process. A scanty diet will not call forth the activity of the gastric
glands to the same degree as a hearty meal. For conv^enience and
uniformity, a so-called test breakfast is given on an empty stomach, and
the contents are drawn off an hour to an hour and a half afterward.
This breakfast consists of an ordinary dry roll without butter, and about
two-thirds of a pint of wx^ak tea or coffee without milk or sugar.
Such a repast contains albuminoids, sugar, starches, non-nitrogenous
extractives and salts, thus offering the stomach all the ingredients that
are usually taken, while at the same time liquefaction takes place
INJURIES AND DISEASES OF THE DIGESTIVE SYSTEM. 223
rapidly, and there are no solid pieces of food, such as meat, to plug the
opening in the stomach-tube.
The patient having taken the test breakfast at about 8.30 a. m., pre-
sents himself at 9.30 or 10 for examination. To obtain the stomach-
contents, the simplest plan is that known as Ewald's expression method.
A soft-rubber stomach-tube is passed, and when the end has entered
the stomach from twenty-three and a half to twenty-five and a half
inches from the incisor teeth, the patient, by contraction of the abdomi-
nal muscles, forces the stomach-contents through the tube into a
receiving vessel. This fluid is then filtered, and, as a rule, presents the
appearance of an amber-colored liquid resembling normal urine.
Before proceeding further we must bear in mind that during digestion
the stomach normally has acid contents. Ewald and Boas by numer-
ous experiments found during the normal digestion of the test break-
fast the following three stages :
1. As early as ten or fifteen minutes after a meal the stomach-
contents often are acid. The acidity depends upon the free acids, acid
salts, or both. The free acid is the lactic acid. Up to thirty or forty-
five minutes the lactic acid predominates, while the color-tests for
hydrochloric acid are negative.
2. Then comes a stage in which both hydrochloric and lactic acid
can be found.
3. The lactic acid disappears, and only hydrochloric acid can be
found after the first hour. The secretion of hydrochloric acid begins,
however, immediately after the food is taken.
A sample, therefore, drawn one hour and a half after the test break-
fast should be acid, showing a total acidity of 40 to 65 per cent, as
we shall afterward explain, and this acidity should be due to hydro-
chloric acid in the proportion of 14 to 24 per cent. The questions we
have to answer are as follow :
1. Are the stomach-contents acid ? Litmus-paper quickly settles
this point.
2. How acid are the contents? or, in other words, what is their total
acidity ? This is obtained by trituration of volumetric solutions and
the burette. We need for this purpose a burette and two solutions.
The first is a decinormal solution of caustic soda. The atomic weight
of caustic soda (NaHO) is 40. Forty parts, then, of soda in one
thousand parts by weight of distilled water is a normal solution (40 to
I liter). A decinormal solution is one-tenth of this strength, or 4
grams to a liter. The other reagent is a solution of phenol-phthalein
in alcohol. Phenol-phthalein is a buff-colored powder freely soluble in
alcohol. It remains colorless in acid or neutral solutions, but assumes
a carmine color in alkaline solutions.
Fill Mohr's burette with the decinormal solution of caustic soda.
Into a glass beaker pour 10 c.c. of filtered stomach-contents and add
one or two drops of the phenol-phthalein solution. (It gives a milky
character to most stomach-contents, but that does not interfere with
the test.) Next add very gradually the solution in the burette. As
the drops fall upon the fluid in the beaker a carmine color is produced
which disappears on shaking. This will continue as long as the contents
of the beaker are acid. When the carmine color no longer disappears
224 SURGICAL DIAGiVOSIS AND TREATMENT.
on shaking, stop and read off the number of c.c. of dccinormal solution
of caustic soda which have been employed. Suppose 9^- c.c. have been
used to neutralize 10 c.c. of stomach-contents. Ten times that c[uantity,
or 95 c.c, would be required to neutralize lOO c.c. It is convenient to
express this as a percentage according to the amount of decinormal
solution used. In this case 95 c.c. were required to neutralize 100 c.c.
Hence we express it as 95 per cent, total acidity. The normal acidity
after the test breakfast is 40 to 65 per cent. So that in the sample
before us the total acidity is too great, being 30 per cent, above the
normal limit.
At this point I might state that if we knew that the total acidity is
due to hydrochloric acid, we can readily calculate the amount of acid.
Each c.c. of soda solution used represents .003646 of the hydrochloric
acid. We have used 95 c.c, which, multiplied by .003646, equals
.346370 per cent. The normal limit is y^jj to y^^'^fj- of i per cent.
The next point is to determine whether the acidity is due to the
presence of free acids or to acid salts. The readiest method is by the
use of Congo-red paper. Dip a piece of Congo-paper into the fluid and
slowly dry it. The bright red is changed to a sky-blue, showing the
presence of a free acid.
3. What acids are present ? The most important are hydrochloric,
lactic, butyric, and acetic.
For the detection of hydrochloric acid the best test is Giinzberg's
reagent. It surpasses the anilin dyes and all the other tests, being so
delicate as to show hydrochloric acid when it is as low as i in 20,000.
The reagent is made as follows :
Phloroglucin, gr. 30;
Vanillin, gr. 15 ;
Absolute alcohol, 5J.
Nothing can be more simple than the application of this test. Take
a small porcelain dish and place upon it two or three drops of the gas-
tric contents, and add an equal quantity of the reagent. Now gently
heat the dish over a spirit lamp, and as the fluid evaporates around the
edges will be seen a bright rosy-red color. Blowing upon it, and thus
aiding evaporation, brings out the color more distinctly. This is proof
positive of the presence of hydrochloric acid, and from the intensity of
the color may be roughly estimated the amount of hydrochloric acid
present. We know that the limit of reaction lies at i to 20,000. By
successively diluting the stomach-contents one-third, one-fifth, one-
tenth, till the reaction is no longer obtained, we can roughly estimate
the amount of hydrochloric acid.
The next acid to search for is lactic acid. Until recently it was
believed that the presence of any of the organic acids was patho-
logical, since it was proved that the only acid secreted by the gastric
glands is hydrochloric acid. Ewald and Boas, however, found that
lactic acid can generally be detected in the early stages of digestion in
healthy stomachs, and that this condition is normal. If organic acids
are found in the later stages in such quantities that they can be detected
with the ordinary reagents, then they always have a pathological sig-
INJURIES AND DISEASES OF THE DIGESTIVE SYSTEM. 225
nificance. They are the results of fermentation of some of the sub-
stances acted upon by the gastric juices, such as sugar and albumins.
Lactic acid can exist under two conditions : (i) as the result of
fermentation ; and (2) as it exists normally in meat in the form of
sarcolactic acid. In chemical character these two forms do not differ
from one another.
The simplest test for lactic acid is the neutral ferric-chlorid solution.
A diluted solution of this salt turns canary yellow in the presence of
lactic acid. The only difficulty about this test is that we have to dis-
tinguish between two shades of yellow. We are indebted to Uffelmann
for an excellent improvement upon this method. He takes a few drops
of a neutral ferric-chlorid solution and adds one or two drops of pure
carbolic acid (or about 10 c.c. of a 2| per cent, solution of carboHc
acid) ; he then adds water until the solution assumes a beautiful
amethyst-blue color. If to this fluid be then added even a trace of
lactic acid, the canary-yellow color is produced ; fatty acids produce an
ashy-gray color ; if inorganic acids are present, the solution is decolor-
ized. So delicate is the test that lactic acid can be detected in solutions
containing i : 2000. «
4. What is the digestive power of the stomach ? The albuminates
are changed in the healthy stomach into propeptones and peptones,
which are thus examined :
{a) Propeptones. To a small quantity of the filtrate add an equal
part of a saturated solution of sodium chlorid. If propeptone is
present, it is precipitated, and the more turbid the fluid becomes the
greater is the quantity of propeptone. When no precipitate is formed,
add a drop or two of acetic acid ; the precipitate quickly follows if
propeptone is present. On heating, the precipitate is dissolved, but
returns as soon as the fluid cools.
{6) Peptone. After precipitating the propeptone and filtering, the
filtrate is made strongly alkaline by the addition of a solution of sodium
hydrate. A few drops of a i per cent, solution of sulphate of copper
are then added. A violet-red or purplish color is produced if peptone
is present
[c) Pepsin. A disc i mm. in thickness and i cm. in diameter of the
white of a hard-boiled q%^ is added to 5 c.c. of the filtrate in a test-tube
and kept at the temperature of the blood. If pepsin is present, the &^^
disc is digested and disappears in from two to six hours. If the filtrate
contains no hydrocHloric acid, a few drops of the dilute acid should be
added.
[d^ Rennet ferment. To 5 c.c. of milk in a test-tube add three or
four drops of the filtrate. After thoroughly mixing place the tube in a
glass of warm water. If rennet ferment be present, the milk will
become curdled in from ten to fifteen minutes.
Starchy foods are converted into dextrin, erythrodextrin, achroodex-
trin, and maltose. The test for all of them is Lugol's solution (iodin
0.1, potassium iodid 0.2, distilled water 200). A few drops of the
solution are added to a small quantity of the filtrate. The result is as
follows :
{a) Dextrin turns the fluid blue.
if) Erythrodextrin turns it red.
226 SURGICAL DIAGNOSIS AND TREATMENT.
ic) Achroodcxtrin discolors the solution.
(r/) Maltose does not change the color of the solution.
Wliat do we learn by this examination ? Simply this : If hydro-
chloric acid be present in normal amount, it is strong evidence against
cancer. If it be absent or greatly diminished, it is very strong cor-
roborative evidence of the existence of a cancer. Much discussion has
taken place on this question. When Vander Velden expressed the
opinion that cancer of the pylorus accompanied by dilatation of the
stomach leads to suppression of hydrochloric acid, the view was
rapidly applied to all forms of cancer of the stomach indiscriminately.
Later investigations showed that this statement could not be main-
tained in its entirety, yet it has led to results of great diagnostic and
therapeutic significance. When the new growth is confined to a small
area, when the accompanying catarrh of the mucous membrane is
moderate, and when there is no atrophy, then the secretion of hydro-
chloric acid may remain ample. Clinically, however, one of these
features is absent, and the secretion of hydrochloric acid is entirely
annihilated or is reduced to the smallest quantity. It is true that other
conditions of the stomach give rise to a diminution of the secretion.
These conditions are atrophy and amyloid degeneration of the mem-
brane, mucous catarrh, and certain neuroses, but, notwithstanding all
this, the absence of hydrochloric acid seldom fails clinically to cor-
roborate a diagnosis of cancer of the stomach.
The significance of lactic acid has been recently receiving atten-
tion. Boas uses as a test meal flour soup quite free from lactic
acid, and states that this acid was never found in any conditions
except those of carcinoma. His results have been confirmed by
Dr. D. Stewart*
Ischochymia, or the retention of chyme in the stomach, is a symp-
tom of great value. In this condition the organ has not the power to
empty itself, and contains food even while the patient is fasting. As a
rule, it is associated Avith dilatation of the stomach, and the commonest
cause of dilatation is stricture at the pylorus. But dilatation is not
necessarily present, for it does not usually appear until the stricture at
the pylorus has existed for some time. The value, then, of ischo-
chymia as a symptom lies in the fact that it can be recognized at an
earlier period in the disease than that at which dilatation can be detected.
To recognize the condition it is necessary to examine the stomach-
contents while the patient is fasting. Einhorn instructs his patient to
have at his supper on the night preceding the examination soup, meat,
bread, and some rice, as this latter is very easily recognized, and, as a
rule, retained in the stomach when there is stricture of the pylorus.
The stomach-tube is employed in the usual manner, and if no chyme
can be withdrawn by expression, it is necessary to wash out the stomach.
If ischochymia is present, the rice and particles of the other articles of
diet are found in an undigested state.
Microscopic examination may sometimes throw light on the case.
In the vomited matter, in the gastric contents obtained after a test
breakfast, in the washings after lavage, or in the tube after an explora-
tory examination shreds or small particles of tissue may be found.
1 Medical Record, Mar. 9, 1S95, quoting from Medical News.
INJURIES AND DISEASES OF THE DIGESTIVE SYSTEM. 22/
These should be examined under the microscope, and may decide the
question of cancer.
Examination of the urine may be employed for further testimony.
The presence of indican, which is the form in which indol is eliminated
from the urine, is perhaps suggestive of cancer, but as it may be found
in almost any wasting disease, its diagnostic value is not worth men-
tioning. Its qualitative determination is very easy. Take lo c.c. of
hydrochloric acid and i c.c. of chloroform. To this add lo c.c. of
urine, and by means of a glass rod add one or two drops of a con-
centrated solution of chlorid of calcium. The mixture is next shaken,
and, if indican be present, the chloroform assumes a blue color, due to
the formation of indigo.
Gastroscopy, or the examination of the gastric mucosa by electric
illumination, is not only of little value, but dangerous.
Gastro-diaphany, or transillumination of the stomach, has never come
into general use.
In spite of all the care that can be exercised, some cases of gastric
carcinoma will prove puzzling, to say the least. The gastric crises of
locomotor ataxy have been mistaken for the symptoms of pyloric
cancer, and operated upon to find no evidence of malignant disease or
pyloric obstruction. Gastric cancer has been mistaken for pernicious
anemia, and transfusion of blood resorted to. Simple fibroid contrac-
tion of the pylorus is often indistinguishable from scirrhus, except after
microscopic examination. Moreover, cancer of the stomach may occur
without any symptoms whatever, and be discovered after death from
other causes. Such being the status of our methods of research, we
have to resort to something more definite in search of evidence, and
complete the examination in these doubtful cases by making an ex-
ploratory incision. To quote the words of Loreta : " It may now be
accepted as a maxim in surgery that an exploratory abdominal incision
is to be recommended in cases of malignant disease of the stomach
where a diagnosis cannot be arrived at by other means."
Are there any conditions under which the diagnosis of cancer can
be positively made without exploratory incision ? Einhorn gives
the following as sufficient evidence to answer this question in the
affirmative :
If particles of tumor are found (in the wash-water or in the sound)
which under the microscope reveal the characteristic picture of a
malignant growth ;
The presence of a more or less large tumor with an uneven surface,
belonging to the stomach and associated with dyspeptic symptoms ;
The presence of a tumor associated with frequent hematemesis ;
Constant pains, frequent vomiting, ischochymia, emaciation, all these
symptoms being quite permanent, and not extending over too long a
period of time (six months to one year) ;
Tumor and ischochymia ;
Emaciation, ischochymia, presence of lactic acid.
Constant anorexia and pain, not yielding to treatment, accompanied
by frequent small hemorrhages (of coffee-ground color).
Treatment. — The surgical treatment of carcinoma of the stomach
may be curative or palliative in its aim.
228 SURGICAL DIAGNOSIS AND TREATMENT.
The simplest and most readily ai)plicable remedy is lavage. Ewald
calls it the sovereign remedy for dilatation. The ordinaiy stomach-
tube with funnel attached is all the apparatus required. Warm water
in large quantities should be alternately introduced and removed by
siphonage until turbidity ceases and all shreds, fragments of food, or
flakes of mucus cease to come away. This treatment is of course
but palliative. Obstruction at the cardiac orifice may prohibit the
employment of lavage and may call for more formidable measures.
Life may be prolonged by keeping the strictured portion patent by
dilating it with esophageal tubes. Through the tubes liquid and finely-
divided food may be introduced. In far-advanced stenosis a small
rubber tube or catheter may be introduced by one of the nasal
passages, retained in position, and through it liquids injected into the
stomach.
Failing in this, operative procedures may be resorted to. The
available surgical procedures resolve themselves into — i. pylorectomy;
2. gastro-enterostomy ; 3. combined pylorectomy and gastro-enter-
ostomy; 4. gastrotomy ; 5. jejunostomy; 6. curettage of the cancerous
portion of the stomach.
At the pylorus the disease is more accessible, and if diagnosed
at an early stage and operated upon before the glands becomes in-
volved or adhesions have formed, the operation of pylorectomy is
indicated.
The history, so far, has not been very encouraging. Bremer col-
lected 72 cases with a mortality of 76 per cent. Winslow found prac-
tically the same ratio in a smaller number of cases. Of 18 cases which
I have been able to collect in the past two years, 8 recovered and 10
died. The time may come when a remedy for cancer will be found,
but at present our hope for radical cure lies in early diagnosis and
complete removal. Could these two conditions be complied with, the
results following pylorectomy would be much more favorable than our
present figures show. Gastro-enterostomy is a palliative operation,
and shows better results than pylorectomy. The mortality is lower
and prolongation of life is from two months to a year or more, while in
pylorectomy the immediate dangers of the operation are much greater,
and in those who survive the disease proves fatal in a period varying
from four to eight months. In the early operations, according to Bill-
roth, the mortality was 50 per cent. Liicke of Strasburg reduced it to
31 per cent.
Gastro-enterostomy does not cure the disease, but it very often
brings about a very noticeable improvement in the local and general
conditions, showing what an important part the pyloric stenosis plays
in the production of many of the symptoms. The pain also disappears.
This is explained by the fact that the stomach-contents no longer come
in contact with the cancerous ulceration, but pass directly into the
small intestines along the new route opened up by the operation. This
is why in similar cases the employment of lavage is followed by so
much relief (Mathieu).
In the Annals of Surgery for December, 1887, Dr. Bernays of St.
Louis described an operation whereby, after making an incision in the
walls of the stomach, he removes by curette or other suitable instrument
INJURIES AND DISEASES OF THE DIGESTIVE SYSTEM. 229
cancerous growths bulging into the stomach-cavity. His method con-
sists in — first, an accurate examination of the outside of the stomach.
He then fixes a fold of the stomach to the parietal wound by numerous
sutures. The stomach is now opened and its lips carefully stitched to
the lips of the wound in the parietes. The stomach-cavity being com-
pletely shut off from the abdominal cavity, he proceeds with fingers
and curette to tear and scrape away masses of the growth. Bleeding
is free, but soon ceases. The results of the operation in several
cases have been fairly satisfactory, but a radical cure cannot be relied
upon.
Stricture of the Cardiac Orifice. — Stenosis of either orifice of
the stomach may be a result of carcinoma, or may be due to the
cicatricial contraction which follows the healing of an ulcer or a wound
caused by a foreign body.
The first symptom to attract attention to stenosis of the cardiac
orifice is a gradually increasing difficulty in swallowing solid food.
Liquids can pass through the narrowed opening, but with less rapidity
than in the normal condition ; solids are regurgitated. The epigastrium
is often retracted and the stomach collapsed, strongly contrasting with
the full epigastrium and dilated stomach which attend stenosis of the
pyloric orifice. The passage of olive-pointed bougies, as in the case of
esophageal stricture, will confirm the diagnosis. The question of
malignancy must be settled by the age of the patient and the history of
the case.
Stricture of the pylorus is in the vast majority of cases due to car-
cinoma. As the lumen of the pylorus becomes lessened, and there
is increasing obstruction to the passage of the gastric contents toward
the intestine, dilatation of the stomach results, and is a prominent-
symptom.
A case of pyloric stricture has a history of long-continued dyspepsia,
and every chronic dyspeptic should be carefully examined for this
condition.
It is not uncommon to find such a stomach rejecting food which has
remained in it for days or even weeks. If the stomach-tube be used,
the contents may be found to amount to several quarts, and the dis-
tended organ may reach considerably below the umbilicus. The pres-
ence of a tumor in the pyloric region must not be depended upon as a
diagnostic point, for, although the absence is indicative of cicatricial
stenosis, some of the worst cases of cancerous stricture afford no
evidence of a tumor.
Einhorn thus tabulates the differential diagnosis between benign and
malignant stenosis of the pylorus :
Differential Diagnostic Points.
Benign Stenosis of Malignant Stenosis of
Pylorus. Pylorus.
Tj ,- /• .,, r Long duration of illness (two to Short duration of illness (five
Duration of illness. < rf: . ^ ^, . j u ir \
t fifteen years). months to one and a half years).
(T • . 1 -lu . • No periods of perfect euphoria,
Long intervals without pain, or ,1 .. » j j 1
^ . J c r » u • but constant and gradual aggra-
penods of perfect euphoria. . r , " °^
r r r vation oi symptoms.
Tumor. As a rule, absent. Present in most cases.
230
SURGICAL DIAGNOSIS AND TREATMENT.
Free HCl.
Lactic acid.
Acidity.
Rennet.
Odor.
Condition of Gastric Contcttts.
Benign Stenosis of
Pylorus.
Malignant Stenosis of
Pylorus.
f Present in the great m.ijority of Nearly always absent.
\ cases.
( Absent in the great majority of As a rule, present.
\ cases.
Always increased. Fluctuates between 30 and 90.
Always present. Varies.
Unpleasant, disagreeable. Very frequently fetid.
Treatment. — Non-cancerous stricture of the cardiac orifice should be
treated by the introduction of bougies gradually increased in size until
the largest instruments can be passed. Nor should the treatment cease
at this stage. Full-sized bougies should be passed once or twice a week
to prevent recontraction. When this method of treatment fails, gas-
trostomy must be resorted to for the double purpose of supplying the
stomach with food and of dilating the stricture from below. The
manner of carrying out this procedure is described under Esophageal
Stricture.
At the pyloric orifice the measures to be adopted are forcible dilata-
tion through an opening in the stomach, the various plastic operations,
and gastro-enterostomy.
Forcible dilatation was first practised by Loreta in 1883. He made
an incision in the stomach a little nearer to the pylorus than to the
cardiac end. Through this opening he introduced the index finger of
the right hand and passed it through the stricture. The fore finger of
the other hand was then inserted, and by separating the fingers the
Fig. 105. Pyloroplasty: i, linear incision ; 2, the final result. The lower series of figures
show the transformation of the horizontal linear incision (3) into the oval (4), the sutures (5)
converting it finally into (6) a vertical linear incision (Heineke and Mikulicz).
stricture was forcibly stretched. The gastric opening was closed, as in
gastrotomy for other purposes. This operation is attended with con-
siderable danger, and has been largely replaced by the pyloro-plastic
operation of Heineke and Mikulicz.
The operation consists in making a longitudinal incision at the
INJURIES AND DISEASES OF THE DIGESTIVE SYSTEM. 23 1
pylorus, and then suturing it so that it becomes transverse. First
Step : After preparation of the patient by washing out the stomach
with boracic-acid solution or salicylated water, an incision is made in
the middle line from the ensiform cartilage to the umbilicus, the pylorus
brought to the opening and packed around with sponges. Second
Step : An incision is made into the pylorus and extended one inch
along the stomach and one inch along the duodenum (Fig. 105).
Third Step : Place a tenaculum at the middle of each side of the
pyloric incision and draw the edges apart. The line of incision will
thus become transverse to the axis of the stomach. In this position
two rows of sutures are applied — first at the angles, and lastly in the
central portion of the wound.
The results of this operation have been very encouraging. It is
attended with no more danger than a gastrostomy, and when properly
performed recurrence of the stenosis is impossible. For cancerous
stenosis it is of no value.
Gastro-enterostomy is the operation by which a communication is
established between the stomach and the upper part of the small intes-
tine. Wolfler was the first to propose and practise this operation. His
technique has been improved upon, and at the present time operators
resort to one of two methods — the approximation by Senn's decalcified
bone-plates or the anastomosis by Murphy's button. The junction
with the intestine should be made from twenty-four to thirty inches
below the pylorus. As this point is difficult to find, the following
directions may be useful : The first loop of intestine presenting itself
at the abdominal wound should be brought out and held by an assist-
ant. The operator then follows the intestine in one direction. If this
happens to be toward the pylorus, the intestine will be found to grow
paler and the walls thicker as the duodenum is approached. The
duodeno-jejunal fold is taken as a landmark, and a point twenty-four
to thirty inches from it is selected for the intestinal opening. Should
the operator find that the bowel becomes thinner and its color increas-
ing to a bright red, he may know that he is going away from the
pylorus, and must drop that part and start out in the opposite direc-
tion. The application of the bone-plates or button is the same as in
intestinal anastomosis, described already.
Dilatation of the Stomach. — This is a condition attended with
much more serious consequences than might at first thought appear.
A dilated stomach may be defined as one that cannot empty itself
(Mathieu). A distinction must be made between distention and dila-
tation. A distended stomach gradually disposes of its contents, and
at the end of the interval between meals, as in the early morning, the
organ is empty. A dilated stomach, on the other hand, has not the
power to empty itself, and in it may be found food which has remained
there for days or even weeks. This retention of food is followed by
fermentation and the production of toxic substances, so that the patient
is poisoned by the material formed in his own stomach. An extreme
dilatation of the stomach may be regarded as a fatal disease unless
relieved. It is as serious in its effects as cancer of the pylorus.
Causes of Gastrcctasia. — i. Mechanical dilatation due to obstruction
of the pylorus and to organic changes in the wall of the stomach. Of
232 SURGICAL DIAGNOSIS AXD TREATMENT.
this variety the great majority of cases occur in connection with can-
cer of the pylorus. Chronic gastritis leads to atrophy of the muscular
tissues, with loss of contractility and elasticity, and lastly to dilatation.
2. Hyperchlorhydria, or the excessive secretion of hydrochloric
acid, is a frequent cause of dilatation. Such cases often present
symptoms which closely resemble gastric cancer. The presence of
hydrochloric acid in large quantities readily settles the diagnosis.
Early treatment is of the utmost importance, for it not infrequently
happens that what would be only a temporary dilatation may become
permanent, even after the hyperchlorhydria has disappeared.
3. Atony of the Stomach. — In this variety the patients suffer from
dyspepsia of nervous character and the disease is purely medical.
Proper treatment resorted to at an early period can be relied upon to
prevent dilatation.
Symptoms of Dilatation. — When stricture of the pylorus is the
cause, there is usually a feeling of weight at the epigastrium or there
may be pain more or less severe. Acid eructations often prove trouble-
some, and there is a peculiar kind of vomiting which is pathognomonic.
It occurs at long intervals, two or three days, and is then very copious.
Pints or quarts of liquids are ejected containing particles of food but
little changed. This is particularly noticeable if a patient has eaten
Indian corn, peas, beans, or other vegetables. Sometimes the vomited
matter contains blood. If red in color, it is suggestive of gastric
ulcer; if black, it indicates cancer. If the stricture is in the duodenum
and below the entrance of the common bile-duct, large quantities of
bile will flow backward into the stomach and form an important con-
stituent of the vomited matter. The patient should be given a test
breakfast, and about an hour afterward the stomach-tube should be
passed. If a large amount of fluid is removed at this examination, the
diagnosis of dilatation may be safely arrived at, and especially if
unchanged food be observed or food that has lain in the stomach for
days. Having emptied the stomach, it can be distended with air before
the tube is removed. In many cases the form and size of the organ
can be seen by the bulging of the abdomen ; by percussion it can be
accurately mapped out. Roughly speaking, a stomach is dilated if it
comes below a line drawn between the umbilicus and the line of the
false ribs.
When dilatation attends hyperchlorhydria the pains in the stomach
are delayed, coming on three or five hours after a meal. Frequently
the patients are aroused from sleep by the pain, which persists until
vomiting occurs and affords relief.
Remote effects of gastric dilatation may be summed up as follows :
In the nervous system, neuralgia, headache, insomnia, melancholia,
nightmare, giddiness, and disorders of vision ; in the liver, congestion
and enlargement. The respiratory system is affected, as evidenced by
bronchitis, asthma, and pharyngitis. Albuminuria and peptonuria are
evidences of kidney-involvement.
Treatment. — In cases due to atonic dyspepsia regulation of the diet
and washing out of the stomach will greatly aid the medical treatment ;
it is seldom that the dilatation is so great as to necessitate operative
measures. When hyperchlorhydria is the cause the stomach-tube will
INJURIES AND DISEASES OF THE DIGESTIVE SYSTEM. 233
be found invaluable. Washing out the stomach before bedtime ensures
rest for the night and saves the mucous membrane from contact with
irritating gastric fluids. Mathieu advocates evacuation of the stag-
nating liquid once a day, actually washing out the viscus only two or
three times a week.
Dilatation due to stricture of the pylorus demands a surgical ope-
ration. When the stenosis is cicatricial, forcible dilatation or a pyloro-
plastic operation is indicated ; when the obstruction is cancerous, gastro-
enterostomy is the best. One of two operations may be resorted to —
gastro-enterostomy, which deals only with the obstruction, or a partial
gastrectomy, which removes the pylorus and a part of the stomach,
thus diminishing the size of the dilated organ. Out of 18 cases of gastro-
enterostomy collected by Lowenstein there were 6 deaths ; in 21 cases
of resection of the pylorus there were 7 deaths. In all cases of dilata-
tion particular attention should be paid to the following points : The
food should contain the greatest possible nutriment in the smallest
bulk ; it should be finely divided, so as to come speedily in contact
with the gastric juice and leave as little residuum as possible. Meat-
powder, milk, and the farinas are specially useful.
The diet should consist of articles which are least likely to undergo
fermentation. On this account sugar, alcohol, and vinegar should be
avoided. The muscular action of the stomach should be increased by
the use of strychnin, ipecacuanha, electricity, massage, etc.
Antisepsis of the stomach should be, as far as possible, secured by
the avoidance of fermentable food and by frequent washings of the
stomach. Patients soon learn to carry out this by themselves, and
what is at first a very disagreeable procedure becomes a source of
great comfort. In the words of Ewald, " Lavage is the sovereign
remedy for dilatation."
IV. DISEASES AND INJURIES OF THE INTESTINES.
Examination of the Intestines. — Inspection may give us
considerable information. A solid tumor, such as a carcinoma, causes
the abdominal wall to bulge outward. Obstruction of the lower por-
tion of the small intestine is often attended with tympanites and pain in
the umbilical region ; that is to say, in the normal position of the bulk
of the small intestine. Peristaltic action of the intestine in an ex-
aggerated degree may be seen through the abdominal wall when there
is obstruction and the intestine is making strong efforts to overcome
that obstruction. General distention of the abdomen and tympanites
form a very unwelcome sight after celiotomy, and stand out in strong
contrast to the flat abdomen which is the joy and pride of the ab-
dominal surgeon.
By palpation we ascertain the presence of tenderness. A dull
diffused pain is a common accompaniment of intestinal catarrh ; an
acute diffuse pain is an indication of general peritonitis. Tenderness in
the right iliac fossa is a characteristic of typhoid fever, appendicitis, and
intestinal tuberculosis. In the left iliac fossa it is a symptom of trouble
in the descending colon, and is commonly found in dysentery. When
tenderness is very acute and shifting about, it is strongly suggestive of
invagination of the small intestine.
234 SURGICAL DIAGNOSIS AND TKEATMENT.
Having settled the question of tenderness, we further use palpation
to search for tumors. By a rotary motion of the abdominal wall over
the subjacent structure the presence of tumors can be detected long
before they can be recognized by inspection. When a tumor of the
intestine is felt it must be placed in one of three classes: i. Fecal
masses or scybala, found in the large intestine : this is the only tumor
which retains an indentation. 2. Tumors of the intestine, carcinoma,
sarcoma, etc. : they are often lobulated and of firm consistence. In
the small intestine these tumors are apt to change their location,
while in the large intestine they are more fixed. 3. Invagination of
one portion of the small intestine into another or of the small into the
large intestine. Tumors of this character are round and smooth, the
pain is violent and comes in paroxysms. The other indications of
intussusception described under Acute Intestinal Obstruction are also
present.
Tumors at the junction of the transverse with the descending colon
are usually difficult to detect, for they lie deep and are liable to be
confounded with tumors of the kidney or spleen.
Percussion. — In health every part of the intestine gives forth a
tympanitic note, the pitch varying according to the amount of fluid or
gaseous contents. The size of the intestine cannot be accurately deter-
mined by percussion, nor can we always determine the boundary be-
tween colon and stomach or between the part of intestine above and
that below a constriction. Tumors of the intestine may grow to a
considerable size and yet not produce dulness on percussion. This
diagnostic measure is therefore not so reliable as palpation. Never-
theless, there are cases in which it proves very satisfactory. By noting
the difference in pitch between the stomach, colon, and small intestine
in the normal area occupied by each we can map out their relative
positions. Tumors which in light percussion elude us are often
detected when examined by " deep percussion " and when the over-
lying coils of intestine are pushed aside. Inflation of the colon with
air facilitates percussion. For this purpose carbonic-acid gas has
been considered preferable to air, for the reason that its irritating
character causes closure of the ilio-cecal valve, while air passes
through and distends the small intestine as well.
The phonendoscope is of great utility in examining the intestines.
The manner of using it has been described in Examination of the
Abdomen.
Diseases of the Intestines.
Cancer of the intestine is a disease of advanced life. Its onset is
obscure. Generally there is constipation, frequently diarrhea, always
emaciation. The first warning of anything of a serious nature may be
obstruction of the bowel. The growth may constitute a palpable
tumor. In examining for it the patient may with advantage be placed
upon his hands and knees, so that the intestines fall toward the pal-
pating hand instead of away from it. The tumor is very illusive. One
day it can be felt with the greatest ease, the next you may search for
it in vain. If connected with the small intestine, the neoplasm is freely
INJURIES AND DISEASES OF THE DIGESTIVE SYSTEM. 235
movable ; if in the colon, it is firmly fixed. It is always tender, and as
it increases in size the growth is in the direction of the axis of the intes-
tine. Its surface is lobulated or knotty, and it is incapable of receiving
an impression like a fecal tumor. You are liable to fall into the trap
of calling it sciatica if the growth is in the lower end of the colon, for
the sacral region is the part to which the patient refers his pain.
It may be difficult to diagnosticate the portion of the bowel which
is the seat of the disease. In the small intestine cancer, as a rule,
takes an annular form, and on this account the leading feature is sten-
osis. The symptoms of the stenosis will vary according to position.
In the duodenum we cannot always undertake to say which portion is
affected. The first portion is horizontal in direction, is almost sur-
rounded with peritoneum, is the most movable, and lies nearest to the
abdominal wall. It must be regarded clinically as a part of the stomach
and partaking of the diseases of the stomach. Hence cancer of this
portion cannot be distinguished from cancer of the pylorus.
A very important dividing-line is the ampulla of Vater. Stenosis
below this point is characterized by a permanent backward flow of bile
and pancreatic juice into the stomach. Cancer which involves the
ampulla has characteristics which partake of the symptoms found in
both the first and third portions.
In the other portions of the small intestine the presence of a movable
tumor in the long axis of the bowel will afford our strongest evidence.
In the sigmoid flexure and cecum the tumor is generally distinct. In
all cases blood is not infrequently passed by the bowels, and there even
may be masses of cancerous tissue.
The rectum is the portion of the intestinal tract in which the disease
can be detected with the greatest degree of certainty. One of the ear-
liest symptoms is pain in defecation. Whenever this is complained of
an examination of the rectum should be made as a matter of routine.
As the disease advances the pain increases and is more or less constant.
Blood and mucus are passed in the stools, and in many cases there is
morning diarrhea.
In making an examination of the rectum the patient should lie upon
the left side. The finger is vastly superior to any speculum. The sen-
sation conveyed to the finger by cancer is peculiar, and w^hen once
recognized cannot be mistaken for anything else. If the growth be
epithelioma, the mucous membrane will be found thickened, firm, and
freely movable, at least before the disease has reached an advanced
stage. If scirrhous cancer be present, hard nodules will be found
involving the submucous tissues, and later infiltrating the other tissues
and involving the glands, the liver, and other organs.
Two diseases are likely to be mistaken for cancer of the rectum —
simple ulceration with inflammatory thickening and syphilitic ulceration
with or without stricture. In simple ulceration there is usually a his-
tory of dysentery or of the presence of foreign bodies. The ulcer is
clean cut, and has the same kind of discharge as simple ulceration in
other parts of the body. There is no infiltration or gland-involvement,
and the growth does not show a disposition to break down.
Syphilitic deposit w^ith stricture must be carefully taken into con-
sideration in the diagnosis, as it is a common source of error. The
236 SURGICAL DIAGNOSIS AND 7'REATMENT.
history, the condition of the throat, the skin, the scalp, and the bones,
will usually clear up any doubt.
Treatment. — Carcinoma of the intestine only requires surgical inter-
ference when it is producing obstruction. In the duodenum gastro-
enterostomy is in many cases the best that can be done. In other por-
tions of the small intestine resection with circular enterorrhaj^hy is the
operation which is most radical and easiest of performance. Care must
be taken to remove the corresponding portion of mcsenteiy, lest the can-
cerous infiltration should spread through the mesenteric glands.
Cancer of the rectum must be treated according to the extent of
the disease. When the highest point of the cancerous mass can be
reached by the examining finger, and there is no involvement of the
glands or neighboring tissues, excision of the growth should be under-
taken. When the upper limit of the disease cannot be reached, or
when the vagina, the prostate, etc. are affected, excision of the rectum
should not be attempted. <
Operatioft. — For several days before the operation the intestines
should be well emptied by purgatives and the rectum washed out with
injections of boric-acid solution. The patient is placed in the lithotomy
position, and a final flushing given to the rectum, the bladder emptied,
and the buttocks elevated. If the growth is small and freely movable
and confined to the posterior wall of the rectum, it will be sufficient to
dilate the sphincter, draw down the rectum, excise the growth by a
transverse elliptical incision, and close the wound with catgut sutures
or pack it with iodoform gauze.
The great majority of cases, however, will require a more extensive
operation. An incision is made from the anus back to the coccyx in
the middle line or a little to the left. Crescentic incisions, one on each
side, are made to surround the anus. These incisions should be
through the skin when the sphincter ani is diseased, through the
mucous membrane when the sphincter is healthy. The bowel should
then be dissected up quickly behind, and bleeding arrested by pressure-
forceps. In front of the rectum the dissection must be slower, as there
is danger of getting into the prostate or vagina. When the bowel has
been separated well above the disease, cut it off with curved scissors. If
in this procedure the peritoneum has been opened into, it must be
closed with sutures. A large drainage-tube guarded with a chemisette
\z inserted and loosely packed with iodoform gauze. Drawing down
the divided gut and suturing it is no longer practised, as the tension is
too great and there is a risk of retaining secretions which interfere with
healing. The packing can be removed at the end of forty-eight hours.
Daily injections with boracic-acid solution should then be employed.
W' hen granulation is well advanced cicatricial stenosis must be guarded
against by passing a full-sized bougie daily, beginning about the end
of the second week.
Kraske's operation has several advantages over the method just
described, inasmuch as it allows more complete access to the bowel.
By it a greater extent of the rectum can be removed, and the external
wound need not be extensive. The incision is made from the anus to
the second bone of the sacrum in the middle line. The soft parts are
then separated from the bone on the left side until the edge of the
INJURIES AND DISEASES OF THE DIGESTIVE SYSTEM. 237
sacrum is freely exposed. The coccyx is removed, the sacro-sciatic
ligaments divided, and, if necessary, the left side of the sacrum partly
chiselled away. This gives complete access to the rectum. The pos-
terior part of the bowel is cut open down to the sphincter, and then,
by transverse incisions above and below the cancerous growth, the
diseased portion of the rectum is removed. The external wound is
packed with iodoform gauze, and the rectum irrigated twice a day, as
in other operations.
In far-advanced cases of cancer of the rectum, when the disease
goes high above the point which can be reached by the examining
finger and causes obstruction of the bowel, colostomy is the proper
treatment.
Intestinal Obstruction. — Intestinal obstruction may be con-
sidered under two heads :
(i) Acute obstruction, in which the symptoms come on suddenly
without any previous history of disease ; •
(2) Chronic obstruction, where there is previous intestinal disease
and a slow gradation from partial to complete occlusion.
Acute Intestinal Obstruction. — The almost uniform failure to cure
acute intestinal obstruction by medical treatment has led the profession
to look to surgery as the only hope of rescuing a class of cases other-
wise practically hopeless. The operation has a long but unfavorable
history. For centuries it has been approved and as strenuously con-
demned. Almost uniform disaster has attended its employment until
recent years, when the advancement along the whole line of abdominal
surgery has thrown new light upon its use and inspired its advocates
with new hope.
Acute intestinal obstruction practically exists under three conditions :
1. Intussusception;
2. Volvulus ;
3. Strangulation by bands or through apertures.
By intussusception or invagination of intestine is meant a prolapse
of a part of a bowel into the lumen of the adjoining part. One-third
of all the cases of obstruction are due to this cause. One portion of
bowel grasps — swallows, as it were — the portion immediately above it.
Grasping the bowel as if it were food, more and more is invaginated,
until, in extreme cases, several feet of bowel may be involved. The
name intussuscipicns is given to the receiving portion of intestine, while
the part invaginated is called the intussusccptuni.
This unnatural condition is followed by serious consequences : adhe-
sions form between the opposed surfaces of peritoneum, the walls be-
come swollen and inflamed, curving of the intestines by dragging of
the mesentery is produced, intense congestion results, followed by
discharge of blood from the rectum or gangrene, and finally complete
obstruction.
According to Senn, sloughing is caused by obstruction to the return
of venous blood by constriction at the neck of the intussusception.
Curiously enough, intussusception is very commonly found in the
post-mortem room, one body in four showing this condition. It is also
believed that many cases right themselves, and that a large proportion
of cases of acute colic belong to this class (Greig Smith).
238 SUKGICAl. DIAGXOSIS AND TREATMENT.
The most common situations arc — (i) in the small bowel, and gen-
erally the lower part of the jejunum. It occurs in the ileum in the
proportion of one case to four in the former class. (2) The colon may
be the seat of an intussusception at any part of its course, but it is by
no means common, and when it does occur only a small portion of
bowel is involved. (3) The most common of all situations is the ileo-
cecal region, and here it may be produced by the ileo-cecal valve form-
ing the apex of the intussusception, and, passing up the colon, followed
by the cecum and ileum, or the ileum may pass through the ileo-cecal
valve and be invaginated up the colon.
A rare and complicated variety is where a primary invagination of
the end of the ileum is either passed through the valve into the colon
or invaginated into the colon along with the cecum (Greig Smith).
By volvulus is meant an occlusion of bowel by torsion or rotation
round its axis of attachment. This may be caused by simple twisting
or two suitable coils may be intertwined.
The sigmoid flexure is the most common situation, constituting two-
thirds of all the cases. The tendency in this direction is increased by
the shape of the bowel, the length and loose attachment of the mesen-
tery, and the tendency of the bowel to become overloaded and dis-
placed by collections of feces. The bowel may be twisted once, twice,
or even three times around the axis.
Next in point of frequency is volvulus of the cecum or cecum and
colon adjoining. Here obstruction is easily brought about ; even an
acute flexure of the cecum is sufficient to block the passage; it may be
produced by intertwining of the small intestine. In the ascending colon
the disease is rare and is due to anatomical abnormality. In the cecum
it may be subacute or chronic.
The small intestine is rarely the seat of volvulus. An old hernia
with a long mesentery may be a predisposing cause.
Strangulation by tabids or through apertures is internally what an
ordinary hernia is externally. In either case a loop of bowel is con-
stricted by a tight, unyielding opening, obstructing its lumen and com-
pressing its vessels. In both cases strangulation results, producing
symptoms and calling for treatment almost exactly alike.
Bands of organized inflammatory material, the so-called " peritoneal
false ligaments," occur in an endless variety of forms. They are the
result of old attacks of peritonitis. They may pass from coil to coil
of the intestine, or from organ to organ, as the liver and uterus, or
from the intestine to the abdominal or pelvic wall. Tubercular glands
may form their starting-point, and the bands may stretch from gland to
gland in the mesentery, or, springing from one side of a gland, may
bend around the intestine and become attached to the opposite side of
the same gland. They may be round or flat, short or long, single or
multiple. The bowel may slip under a band when it is short, or it may
be caught in a loop or twisted when the band is long. The small intes-
tine, most commonly the lower part of the ileum, is likely to be the seat
of the strangulation.
The prog7iosis of acute intestinal obstruction is exceedingly un-
favorable. In ordinary strangulated hernia the chances for recovery
are almost nil, yet there is a bare chance, for gangrene of the bowel
INJURIES AND DISEASES OF THE DIGESTIVE SYSTEM. 239
may take place with the formation of a false anus. In strangulation
by bands there is not even a chance. If gangrene takes place, there is
but one termination — death. It is believed that spontaneous recovery
after volvulus is unknown.
Intussusception in a very small proportion of cases may right itself
and the patient recover, but such fortunate terminations are few and far
between.
The diagnosis of acute obstruction is of the utmost importance, and
in many cases exceedingly difficult. The symptoms are, roughly speak-
ing, those of strangulated hernia in an aggravated form. The abdom-
inal pain is agonizing. In some instances, however, it is not severe, and
frequently it is intermittent in character. The severity of the pain appears
to bear a direct ratio to the force of the peristaltic movements ; and this
explains the intermittent character of the suffering. When constric-
tion takes place, the bowel makes an effort to overcome it, and wave after
wave of peristaltic movement is directed against the obstruction. The
motions grow stronger and stronger, and the pain increases in seventy
till from exhaustion of the bowel-muscle the movement ceases and the
pain subsides. After a period of rest, the wall of the intestine, having
regained its tone, renews its fruitless attack, and with this new effort
the pain returns to its former intensity. It may be like severe colic, or
it may convey the sensation of a tight band around the abdomen. Be-
sides pain, the prominent symptoms are vomiting, constipation, collapse,
and tympanites.
Temperature is of little value as a symptom. It is usually sub-
normal, and even when peritonitis occurs it may remain subnormal to
the end.
Vomiting is one of the early and most important symptoms, and
we may set it down as a rule that the higher the obstruction the
more violent is the vomiting. At first the ordinary contents of the
stomach are voided, either in gushes without much effort or with
violent retching. Later the vomit is bile-stained, then of a dark,
grumous material, the so-called coffee-grounds. Finally, fecal mat-
ter is vomited more or less diluted. This requires that the constric-
tion should not be higher than the jejunum. Constipation is of the
most obstinate and insuperable nature. When once the intestine
below the seat of constriction is emptied, absolutely nothing passes
from the bowels, except in certain cases of intussusception, when
blood may escape.
Local meteorism is a symptom upon which von Wahl lays great
stress. The intestine above the seat of obstruction becomes distended,
and the enlargement gradually continues along the course of the con-
stricted bowel. The peristaltic action is also increased, and both the
contour of the bowel and its peristaltic movements may be seen
through the abdominal wall.
Rosenbach, Rosin, and others claim that in complete obstruction of
the ileum there is always indican in the urine. When the obstruction
is in the colon or high up in the small intestine, this reaction is not
produced. The simplest test is to boil a small quantity of the urine in
a test-tube and add nitric acid, drop by drop. The urine turns red, and
throws down a precipitate of a similar color. On shaking a violet-
240 SURGICAL DIAGNOSIS AND TREATMENT.
colored foam is produced. So long as this reaction can be detected in
the urine Rosenbach considers the case one of great gravity, and its
continuance after an operation proves that the obstruction has not been
relieved. It disappears within twenty-four hours after the relief of
obstruction. The fallacy in this symptom lies in the fact that it may
exist in a variety of morbid conditions.'
Diagnosis from Other Diseases. — Every case of abdominal pain,
and especially when the pain is attended with vomiting, should be
closely investigated for hernia. The ordinary hernial outlets should
one by one be examined, for strangulated hernia is the condition most
likely to be mistaken for acute obstruction.
Appendicitis probably comes next, but here there is the history of
localized indanmiation, fever rising to and not above ioi° or 102°, with
great tenderness over the position of the appendix, and possibly the
formation of a tumor.
Diagnosis of the Locality of the Obstruction. — For diagnostic pur-
poses it is convenient to divide the intestine into three portions :
1. TJie Duodenum and Jejunum. — When acute obstruction occurs
at the duodenum or upper portion of the jejunum the first indication is
sudden and intense pain at the epigastrium, followed by violent vomit-
ing. This vomiting is constant until the obstruction is relieved or the
patient dies. It never becomes stercoraceous, for it is too high up to
contain fecal matter. The parts above the constriction have a tendency
to become dilated, the parts below to become collapsed. Hence we
often find the stomach dilated and tympanitic, while the abdomen below
is flat and contracted. The bulk of the bowel being below the con-
striction, flatus and feces may pass naturally.
2. The Ileum, or Lower Part of the Jejunum. — The constriction
being much lower than in the preceding, accumulation of gas is a
marked symptom, and we consequently find the abdomen becoming
rapidly distended. Vomiting does not come on so suddenly, but it is
persistent and changes in its character — first normal stomach-contents,
next bile, and lastly fecal matter. The pain is colicky, paroxysmal at
the beginning, but soon becoming persistent.
3. Colon and Sigmoid Flexjire. — Here the symptoms come on more
slowly. The patient can often point out the seat of obstruction by the
localized pain. Tympanites is a very marked symptom after the first
few days. No fecal matter or flatus passes from the bowel and the
rectum is empty.
Is it possible to diagnose the variety of obstruction ? In certain
cases it is. An examination by the rectum will, in a small proportion
of cases, discover the bowel descending in intussusception. This form
occurs particularly in children. The pain comes in waves, gradually
gaining in intensity till a climax is reached, when it for a time subsides.
Vomiting in this form is not so characteristic a symptom as in the
other varieties. It may be a feature from the outset or it may not
appear till late ; it may be severe and copious or slight and almost pain-
less, or it may not exist at all. The abdominal wall is seldom dis-
tended ; indeed, it may even be retracted. There is one symptom,
however, which is valuable, and that is a discharge of blood from
1 American Year-Book of Medicine and Surgery, 1896.
INJURIES AND DISEASES OF THE DIGESTIVE SYSTEM. 24I
the rectum, which is often associated with tenesmus and diarrhea. If
besides these a tumor can be found by palpation through the parietes,
we have about all the evidence we can obtain that the case is one of
intussusception.
So rapid is the progress of the disease that death may take place
within twenty-four hours. In more favorable cases the fatal event is
postponed for several days ; in those still more favorable the condition
may become chronic and last for several weeks.
In volvulus of the large intestine there is usually a previous history
of constipation. It is commonly found in males above middle life. Its
usual situation is at the sigmoid flexure. The pain comes on suddenly,
is felt at the hypogastrium or in the back ; constipation is marked from
the first ; vomiting is a later development and is not necessarily severe.
Feculent vomiting occurs in about 1 5 per cent, of the cases. In later
stages of the disease there is tenderness on pressure.
Volvulus of the small intestine and strangulation by bands so closely
resemble each other in symptoms that it is probably impossible to
distinguish them. In both the pain is severe and continuous from the
outset, with frequent exacerbations, and is felt most commonly at the
umbilicus. There is no tenderness on pressure. The vomiting begins
early, is frequent, copious, and becomes stercoraceous about the fourth
day.
In the following table I have tried to place .side by side the diagnostic
differences in the three forms of obstruction :
Strangulation by Bands.
Volvulus.
Intussusception.
Young males.
Age.
Males above forty.
Young children.
At umbilicus ; severe from
the beginning.
Pain.
Hypogastrium or back ;
comes on at once, but not
so severe ;. intermits.
Prominent ; comes in waves.
Early, frequent, copious,
stercoraceous, fourth or
fifth day.
Vomiting.
Late or not at all ; never
very urgent ; 1 5 per cent,
of cases feculent.
Very variable symptoms.
Complete from first.
Not at first marked ; no
tumor.
Constipation.
From first.
Abdominal Distention.
Rapid accumulation of gas,
causing great distention ;
no tumor.
Blood from bowels, with
tenesmus.
Usually absent ; tumor felt
through parietes or in rec-
tum.
Die about the fifth day.
Duration.
Average six days.
Twenty-four hours to several
days or weeks.
Treatment. — Perhaps no condition requires more promptness, accu-
racy, and good judgment than intestinal obstruction. Temporizing in
the diagnosis may allow the only chance of saving the patient to slip
16
242 SURGICAL D/AGXOSIS AND TREATMENT.
away. Purgatives, althouf^li apparently demanded, may produce irre-
parable injury. If medical treatment be persisted in till the condition
becomes desperate, no amount of surgical skill can make amends for
an opportunity for ever lost. As regards medical treatment little need
be said. When we consider that the condition is analogous to stran-
gulated hernia, the question of drugs becomes a secondary matter. The
chief value in medical treatment is the rehef of the distressing symp-
toms that are ever present. Vomiting is one of these. Food by the
mouth is not only useless, but positively harmful. Alimentation must
be kept up by rectal enemata of beef-tea, brandy, and other easily-
assimilated nutriments. When the vomiting is feculent the stomach
should be washed out wath mild antiseptic solutions, such as salicylate
of soda. This greatly relieves the patient's discomfort and, according
to Jessett, arrests peristaltic action. For the relief of pain and the
lessening of peristalsis opium in small and repeated doses is valuable.
One serious objection to its use, however, is that it is apt to mask the
xsymptoms, and, by giving a feeling of false security, to prevent the sur-
geon from making an early diagnosis. Enemata or aperients are dan-
gerous, as they increase the peristaltic action of the bowels, aggravate
the vomiting, and hasten collapse.
Surgical Trcatnie7it. — Surgical procedures may be resorted to for
two objects — viz. (i) for diagnosis, and (2) for relief of the obstruction.
It is not discreet to advocate exploratory incisions as a routine prac-
tice, but when delay is attended with such disastrous consequences as
often happens in these conditions, if ever an exploration is advisable it
is here. When there is positive evidence of acute obstruction due to a
constriction, operation with the utmost promptness is demanded, for we
might just as reasonably treat a strangulated hernia by the expectant
method as to trust to medical treatment here. The diagnosis should
be made, if possible, and the operation resorted to, before fecal vomiting
and prostration have set in.
Various minor procedures have been employed for the relief of
obstruction. These will receive brief mention :
Evaaiation of the StomacJi. — This has been mentioned as a valuable
remedy for the relief of stercoraceous vomiting.
Distention of the Colon. — The injection of fluid into the colon is a
favorite remedy, and one almost instinctively resorted to. Many cases
of intussusception have been relieved by this method. To be of any
use it must be employed early, before adhesions have formed or obstruc-
tion to the circulation at the seat of the stricture has taken place. The
water employed should have a temperature of 105° to 108*^ F. and
should contain a small proportion (0.7 per cent.) of common salt. The
fountain syringe from which it flows should be held at a height of four
feet, which gives a pressure of about two pounds to the inch. The
fluid should be slowly injected, four ounces to the minute (Martin and
Hare). This treatment should not be persisted in beyond thirty or
forty minutes, and in case of failure abdominal section should be
resorted to without delay.
Distention with hydrogen gas or with filtered air is now regarded
with more favor than the injection of fluid. It is only to be thought
of in the early stage of intussusception or volvulus, and great care
INJURIES AND DISEASES OF THE DIGESTIVE SYSTEM. 243
must be taken lest too forcible distention produce ov^erstretching or
rupture of the bowel,
Maniial Exploration of the Rectum. — In children a digital examina-
tion may reveal an intussusception low down. The introduction of the
whole hand is a procedure to be discouraged, except under very special
circumstances. It is not warrantable, except when the patient is an adult
and the surgeon is possessed of a small and slender hand.
Puncture of the Intestine. — When there is great distention of the
intestine with gas, and the circumstances are such that no more suitable
operation can be resorted to, puncture of the bowel by a small aspi-
rating needle affords temporary relief It is needless to say that this
treatment is unscientific and not to be recommended.
Taxis and Massage of the Abdomen. — This method has had its
ablest advocate in Mr. Jonathan Hutchinson, who described the pro-
cedure in the following words : " The first point in abdominal taxis is
the full u.se of an anesthetic, so as to obliterate all muscular resistance.
Next (the bowels and bladder being supposed to be empty) the surgeon
will forcibly and repeatedly knead the abdomen, pressing the contents
vigorously upward, downward, and from side to side. The patient is
now to be turned on his abdomen, and in this position to be held up
by four strong men and shaken backward and forward. This done, the
trunk is to be held uppermost, and shaking again practised directly
upward and downward ; whilst in this position copious enemata are to
be given. The whole proceedings are to be carried out in a bond fide
and energetic manner. It is not to be merely the name of taxis, but
the reality, and patience and persistence are to be exercised. The
inversion of the body and succussion in this position are on no account
to be omitted, for they are possibly the most important of all. I do not
think that I ever spend less than a half or three-quarters of an hour in
the procedure."
It may well be questioned whether this energetic treatment is not
attended with as much danger as a carefully executed celiotomy, while
it only affords a haphazard means of righting an obstruction.
We have to deal with a disease that is invariably fatal in from
twenty-four hours to six days. Volvulus has never been known to
recover under medical treatment. Spontaneous recovery in cases of
strangulation by bands is beyond the bounds of possibility, and
recovery in cases of intussusception is a matter of the merest chance.
Looking at the matter in this light, the choice is left us either to stand
by with idle hands and see our patient die or to make the attempt to
save his life by timely operation.
The mortality may be fairly stated at 95 per cent, in cases treated
without operation.
The statistics of celiotomy for obstruction have been studied by
many writers, including Schramm in Germany, Delaporte in France,
Treves in England, and Whithall, Sands, and Ashhurst in America.
Of 346 cases collected by Ashhurst, the mortality was as follows :
Intussusception, 65 cases ; mortality, 75.4 per cent.
Volvulus, 29 " " 71.4 " "
Strangulation by bands, 1 19 " " 67.8 " "
244 SURGICAL DIAGNOSIS AND TREATMENT.
In the aererrecrate of \a6 cases from all causes the mortality after the
111 •/-
operation was 69.3 per cent. We thus see that the chances m favor of
operation are as 95 to 69.3, or a saving of nearly 25 per cent. In
Ashhurst's earlier statistics he found the mortality to be 67.6, and
argues that, contrary to the history of most operations, the gravity of
this one increases rather than diminishes as it is more often resorted to.
It must, however, be remembered that statistics of this character are
misleading. The difficulty of getting the results of unsuccessful cases
must always be great. The operation has hitherto been resorted to in
the most hopeless cases, and, as a rule, when every other means had
failed and death was imminent. With increasing confidence and dimin-
ished fear of operating it is likely that the operation will be resorted to at
an earlier period and the main danger wall be eliminated — the danger
of delay. An early resort to operation might confidently be expected
to bring about such good results as have followed the early use of
forceps as compared with ancient practice, or the success which fol-
lows early herniotomy. Given a competent operator, cases treated
before abdominal distention has come on, before the bowel has become
inflamed or gangrenous, before adhesions have formed, before the
patient's strength has become exhausted, would it be too much to say
that the mortality would be reduced to 1 5 per cent., as predicted by
Dr. Greig Smith ?
Operations. — Having decided that obstruction exists, the course to
pursue, as a rule, would be as follows : Distention with warm water
should be given a fair trial, provided w^e are satisfied that the obstruc-
tion is recent and there are no firm adhesions nor a gangrenous
bowel. Some prefer hydrogen gas or filtered air. The advantage
of using warm water is that in the event of failure to overcome
the obstruction it fulfils another indication which is a necessary
preliminary to operation — /. e. it washes out the lower portion of
the intestinal tract. One trial only of this method should be em-
ployed. If there is a tumor, showing the probable presence of
intussusception, success will be manifested by disappearance of the
tumor. In some cases the question can at once be settled, for the
tumor remains as large as before, occupying its original position. In
such an event we would better proceed to operate at once, without
letting the patient come out of the influence of the anesthetic. When
there is still doubt as to whether the distention has been successful or
not, the patient should be allowed to regain consciousness. The symp-
toms will soon decide the question beyond doubt.
EntC7'ostomy (iuzspov, the intestine, and azo/ia, a mouth) is the
formation of an artificial opening in the intestine by which the contents
can be discharged. The operation has by long usage gone under the
name of enterotomy (evrspov, the intestine, and to/jltj, an incision).
This term should be limited to the making of an incision into the
bowel as for the removal of a foreign body.
Enterotomy^ as it was improperly called, was first performed
by Nelaton on a patient of Trousseau's about the time the great
French clinical teacher was delivering those delightful lectures at the
Hotel Dieu. Nelaton advocated this operation in cases of intestinal
obstruction w^iich had lasted six or eight days, attended with fecal
INJURIES AND DISEASES OF THE DIGESTIVE SYSTEM. 245
vomiting and great abdominal distention. Resorted to under such
desperate circumstances and without the aid of modern technique, we
need not wonder that the operation was attended with such indifferent
success. It has no future, for it will be employed only in cases which
from neglect have been allowed to run on till profound collapse has left
the patient in such a condition that the only thing possible to save his
life is to draw up a loop of intestine, open and drain it. An artificial
opening of the bowel through the skin must always place the patient
in a pitiable condition. An artificial opening from one part of the intes-
tine to another is a different thing, and will take the place of the old
operation.
Enterostomy is a very simple operation. The abdominal wall is
divided by an incision one and a half to three inches in length parallel
to and a little above Poupart's ligament, between the anterior superior
spine of the ilium and the epigastric artery. Stitch the parietal peri-
toneum to the skin by a continuous suture. A loop of distended
bowel — which, as a rule, proves to be some part of the lower portion
of the ilium — is drawn out and attached by sutures to the abdominal
wound. If the case is not very urgent, the bowel need not be opened
for several hours. This greatly lessens the risk of infecting the peri-
toneal cavity, as it allows adhesions to form between the bowel and the
abdominal wound. If the bowel has to be opened at once, great care
should be observed in placing the sutures so as to shut off the ab-
dominal cavity. A portion of the surface of the bowel about the size
of a silver quarter-dollar can be secured to the edge of the wound by
fine silk sutures, either continuous or interrupted, and an opening made
by scissors or tenotomy-knife large enough to admit the finger. This
opening must be kept patent by placing a single stitch on each side to
connect the margin of the intestinal wound with that of the parietal
opening. Having established the artificial anus, we can utilize it in four
ways :
1. We can allow the patient to rally and regain strength, performing
a radical operation later.
2. In cases where the obstruction does not admit of removal, as in
cancer, the opening can be allowed to remain permanently.
3. Under fortunate but rare circumstances a cure has been effected
by enterostomy, the obstruction being removed by spontaneous correc-
tion of the mechanical conditions which produced it.
4. When the operation has been performed for fecal accumulation,
the fistula may be closed as soon as it shall have fulfilled its purpose.
Celiotomy for Acute Obstniction. — This is the operation which deals
radically with the obstruction and promises the best results. If possible,
a diagnosis should be made before the obstruction has lasted twenty-
four hours.
Preparation of the Patient. — When there is vomiting, and especially
if it be of a feculent character, the stomach should be washed out
with a 5 per cent, solution of salicylate of soda. The bowels also
should be emptied by a warm-water injection, and an enema of brandy
and beef-tea given just before the operation. The skin over the abdo-
men, having been washed with warm water and green soap, is next
cleansed with ether or turpentine, and lastly with corrosive-sublimate
246 SURGICAL DIAGNOSIS AND TREATMENT.
solution, I : 2(XX). Chloroform is the best anesthetic, as it is attended
with more placid breathing and there is less venous congestion than
when ether is administered. In some cases the patients are so deeply
collapsed that general anesthesia cannot be borne. The injection of
cocain along the line of incision is then the best means of making the
operation painless, and the most that can be accomplished is the forma-
tion of an artificial opening in the intestine, as already described under
Enterostomy.
The Iticision. — For most purposes a median incision midway between
the umbilicus and pubes will answer best. It should be long enough to
admit three fingers, and can be extended up or down as required by
dividing the parietes with strong scissors. It may be set down as a
rule that all parts of an intestine above a constriction are distended, all
parts below are collapsed. The fingers inserted into the wound should
first search for the cecum. Distention at this portion of the intestine
means that the colon, sigmoid flexure, or rectum is the seat of obstruc-
tion. Collapse here is an indication that the obstruction is in some part
of the small intestine, the ileo-cecal valve, or higher up (Jessett). The
abdominal incision should be extended as may be necessary ; coils of
intestine should be allowed to escape, care being taken to keep them
well protected by cloths or flat sponges wTung out of hot water. If
the search in the neighborhood of the cecum has been fruitless, the
sigmoid flexure should next be examined, for in nine cases out of ten
the obstruction will be found in the lower half of the abdomen and in
one or other inguinal region. Still failing to find the constriction, a
systematic search is to be made as follows : Pick up a loop and, draw-
ing it out so that it can be held by an assistant, examine it in one
direction ; observe whether distention and congestion increase as you
pass along its course. If so, you are getting nearer and nearer the
point sought for ; but if the bowel becomes more healthy, push the
loop back and continue your search in the opposite direction.
Once the cause is found, its removal may be attended with some
difficulty. Bands may be divided between ligatures, an opening may
be enlarged, as in the case of an ordinary hernia, a volvulus may be
untwisted, an intussusception drawn out. When the operation has
been resorted to before adhesions have formed or gangrene has com-
menced these methods of relief are possible ; but, unfortunately, com-
plications and difficulties must often be encountered, and these we shall
consider under the different forms of obstruction.
Intussusception. — Interference with circulation at the constriction sets
in at an early period, and consequently congestion and edema are
serious obstacles to reduction. An analogous condition is found in
paraphimosis. The swelling and edema must be removed before the
telescoped portion of bowel can be relieved. Three maneuvers may be
successively tried :
1. Apply steady pressure to the intussusception, and when the
swelling disappears draw gently down upon the neck of the intussus-
ceptum.
2. Pass a director around between the intussuscipiens and the
intussusceptum, and very gently break down any adhesions that may
have formed.
INJURIES AND DISEASES OF THE DIGESTIVE SYSTEM. 247
3. Failing in both of the above methods, the bowel may be inflated
per rectum with water or hydrogen gas, aided by traction and manipu-
lation.
When invagination has been relieved by one or other of these
methods the bowel must be carefully examined : slight rents in its peri-
toneal coat should be closed with Lembert sutures of fine silk ; abrasions
and gangrenous spots should be protected by omental grafts.
It often happens that adhesions have become so firm that they
cannot be separated, or the bowel has been so long strangulated that
it has become gangrenous. For the first of these complications we
resort to intestinal anastomosis, for the second to resection of the
gangrenous portion of bowel, intussusception and all.
Intestinal Anastomosis. — Where rapids occur in the St. Lawrence
River the obstacles to navigation have been overcome by connecting
the river above and below the rapids by means of a canal. In like
manner we get rid of intestinal obstruction by inosculating a loop of
intestine above to a loop below the stricture, and thus compelling the
intestinal contents to take a shorter course, by which they avoid the
portion of bowel which contains the obstruction. This idea was first
suggested by Maisonneuve. Billroth and Von Hacker also gave it
considerable study, but the operations were never attended with satis-
factory results until Senn designed and carried out the method of
forming anastomosis with decalcified bone-plates. As regards the
indications for the operation, Prof Senn has arrived at the following
conclusions: " i. If the external surface of the bowel presents evi-
dences of gangrene, disinvagination should not be attempted, and in
such cases resection is absolutely indicated. 2. The resection under
such circumstances should always include the whole intussusceptum,
but only so much of the intussuscipiens as is threatened by gangrene.
3. If the continuity of the bowel cannot be restored by circular sutur-
ing, either on account of the difference in size of the lumen of the
resected ends or of inflammatory softening, the same object is attained
in an equally satisfactory manner, and more safely, by lateral implanta-
tion or intestinal anastomosis. 4. If the invagination is not extensive,
but irreducible, and the bowel presents no sign of gangrene, the ob-
struction should be allowed to remain, and the continuity of the intes-
tinal canal restored by making an anastomotic opening between the
bowel above and below the invagination by the use of perforated
decalcified bone-plates. 5. If the invagination is extensive, irreducible,
and the bowel presents no indications of gangrene externally, the
intussusceptum should be made accessible through an incision below
the neck of the intussuscipiens, and resected after securing the stump
with an elastic ligature, after which the obstruction is permanently
excluded by an intestinal anastomosis. 6. In irreducible colico-rectal
invagination, or when this form of invagination has been caused by a
malignant tumor, the intussusceptum should be drawn downward and
removed by the operation devised by Mikulicz."
Manner of Using Bone-plates {¥\g. 106). — Having selected the two
loops which are to be united, (i) shut off the remainder of the bowel
from the part to be operated upon by clamps, rubber bands, or strips
of iodoform gauze, two for each loop. (2) Make in each loop a longi-
248
SURGICAL DIAGNOSIS AND TREATMENT.
tudinal incision on the convex side of the intestine at the part most dis-
tant from the mesentery. This incision should be two to two and a lialf
inches in length. Allow the contents of the loop to escape and wash
with sterilized warm water. (3)
Slip a bone-plate into each in-
cision. The lateral threads are
made to perforate all the coats
of the bowel ; the end threads
are left lying in the angles of
the wound (Fig. 107). (4) Tie
the threads and allow the knots
to lie between the serous sur-
faces. (5) Additional security is
gained by inserting Lembert su-
FlG. 106. — Senn's decalcified bone-
plate.
Fig. 107. — Ileo-colostomy with decalcified
bone-plates, showing plates in position, one in
the ileum, the other in the colon: a, a, a, lateral
or fixation-sutures passed through the margins of
the wound, a to be tied to a ; b, b, b', b', end- or ap-
position-sutures, to be tied b lo b and b' to b'; c, pos-
terior or sero-muscular sutures (Keen and White).
tures at intervals to unite the serous surfaces around the margins of the
plates (Fig. 108). Scratching the serous surfaces with the point of a
needle may hasten their union when brought into apposition. This,
however, is of doubtful value. Serous surfaces readily unite without
this, and the dangers of infection through even a slight scratch should
not be overlooked.
Abbe of New York objected to Senn's bone-plates on account of
the difficulty of getting plates of bone large enough for use in the
human subject, the trouble required for preparing them, and their
tendency to warp and bend, and has devised rings composed of several
strands of thick catgut around which are wound spirally other threads
of the same material.
Plates composed of raw turnip or potato have been used.
Murphy of Chicago has invented a very ingenious and easily
applied "button," which can be utilized with great rapidity and is
suitable for any operation to which bone-plates can be applied. The
INJURIES AND DISEASES OF THE DIGESTIVE SYSTEM. 249
»-'"^'
^
Fig. 108. — Showing the anterior continued sero-muscular suture as the final step in ileo-
colostomy (Keen and White).
Fig. 109. — Murphy's but-
ton (enlarged) : A, open ; B,
closed.
Closed. Open.
Fig. I id. — Oblong Murphy button.
Fig. III. — Method of applying purse-string suture in
using the Murphy button.
Fig. 112. — End-to-end approximation, button in position.
250 SURGICAL DIAGNOSIS AND TREATMENT.
following objections have been urged against it : The serous surfaces
brought into apposition are too limited in extent to afford safety ; the
button required for the small intestine is of so small a size that a con-
striction at the seat of operation is a common result, and the button is
not always passed in the alvine evacuations. Notwithstanding these
Fig. 113. — Showing incision into the intussuscipiens, the intussusceptum being seized by
volsellum forceps and cut across with scissors (first stage) (after Jessett).
Fig. 114. — Showing intussusceptum detached, and the divided end of intestine sutured
(second stage) (after Jessett).
Fig. 115. — Showing incision in the intussuscipiens closed, and the neck of the intussusceptum
united at end with sutures (final stage) (after Jessett).
criticisms most excellent results have been obtained by this method,
and the " button " is gaining in popularity. The method of using the
button is shown in Figs. 109-112. In each loop of intestine to be
united a purse-string suture is placed, as shown in Fig. in. The
intestine is then opened, and one half of the button is grasped in a
pair of hemostatic forceps inserted into the opening. The purse-
INJURIES AND DISEASES OF THE DIGESTIVE SYSTEM. 25 I
string suture is then tied, care being taken to include all the free
edges of the incision, so that they will come between the halves of
the button. The other loop of intestine is dealt with in a similar
manner, and the sections of the button are then clasped together.
The peritoneal surfaces unite, and by the constant pressure exerted
by the spring of the button the compressed parts slough, allowing
the button to pass per anmti in ten or twelve days. The operation
has a wide application, and can be used for lateral anastomosis, end-
to-end anastomosis, gastro-enterostomy, enterectomy, pylorectomy,
and cholecystenterostomy.
Jessett has devised an operation which may prove useful from its
simplicity. He makes a longitudinal opening into the intestine on the
side farthest from the mesentery, directly over the intussusception,
about one and a half inches long. Through this opening he exposes
the invaginated portion, and with scissors cuts it off close to its origin
(Figs. 113, 1 14, 1 15), and, seizing the distal part with volsellum forceps,
draws it out of the intussuscepiens, ligating any vessels that bleed.
The cut ends are next stitched together with a few interrupted sutures,
the stump dropped back into the intestine, and the opening through
which it was withdrawn closed with a double row of quilt sutures. The
advantages claimed for this operation are that it is much less dangerous
than resection or anastomosis, and that it is certainly preferable to an
artificial anus.
It may happen that the surgeon is so situated that he must operate
without any of the artificial aids just mentioned, and some surgeons
who are expert in the use of the needle prefer the old method. Abbe
has described a procedure by simple incision and suture which in the
hands of expert operators gives good results :
I. The two portions of bowel which are to be united are placed side
by side (Fig. 1 16).
Fig. 116. — Suturing intestines in apposition FiG. 117.— Showing the four-inch incision and
before incision (Abbe). the sewing of the edges (Abbe).
2. Two rows of continuous Lembert sutures a quarter of an inch
apart and an inch longer than the necessary incision are applied as
in Fig. 117, and each thread left with its needle at the end of the line
of suture.
3. The bowel is opened parallel to and at a distance of a quarter of
an inch from this line of sutures. The length of the incision is four
inches, and both rows of sutures are at one side of the incision.
Hemostatic forceps are applied to bleeding points and left there tem-
porarily. The opposite portion of the intestine is similarly opened.
252 SURGICAL DIAGNOSIS AND TREATMENT.
4. The two adjacent cut edges are united by an overhand continuous
suture, the mucous and serous coats being included. As this arrests
the hemorrhage, the forceps can be removed as they are reached. The
other free edges are similarly stitched.
5. The openings are now approximated and the two serous surfaces
brought toeethcr. The needles left at the end of the first double suture
are now used to apply a similar double line to the parts last approxi-
mated, and thus the whole circumference of the four-inch opening is
securely closed.
Besides intussusception, intestinal anastomosis is indicated in —
1. Volvulus ;
2. In inoperable carcinoma if the disease is located high enough
up in the colon to admit of an opening being made below it ;
3. Cicatricial stenosis of the intestine.
Resection of Intestine {Enterectomy). — This operation is indicated in
all cases w-here a portion of the bowel is gangrenous, or when the
intestine is the seat of a malignant tumor and it is possible to remove
the disease completely, or in the case of a benign tumor which cannot
be removed by enterotomy. Any length of bowel from a few inches to
three or four feet may be resected, but beyond this latter limit it is not
safe to go, for in case of recovery the patient is almost sure to suffer
from want of nutrition, and he gradually wastes away.
Operation. — i. Draw the loop of intestine to be resected well out of
the abdominal wound. At the upper and lower limits of the segment
perforate the mesentery close to the bowel, and pass a piece of rubber
tubing or strip of iodoform gauze through each opening, squeeze out
the contents of the segment, and tie the tubes or gauze sufficiently
tight to occlude the bowel. Place flat sponges or sterilized gauze
pads beneath the segment, so as to protect the remaining abdominal
contents.
2. Tie off the mesentery' in small sections with fine silk ligatures
close to the intestine, divide the bowel with scissors or knife, making
sure that you are cutting beyond diseased tissue. Wash out the lumen
of each divided portion with warm sterilized water.
3. The divided ends are approximated in either of the following
ways :
(a) By lateral anastomosis, the ends being turned in and sutured,
and the remaining steps as in Abbe's method.
{B) End-to-end anastomosis. One continuous suture through
mucous membrane only, and the serous coat stitched with Lembert's
suture.
For end-to-end anastomosis Murphy's button is very convenient
and quickly applied, and, if the part resected is a portion of the
colon and the large-sized button is employed, there cannot be any
of the objections which are urged against its employment else-
where.
4. The mesenter}' may be treated by excising a V-shaped portion or
by folding the redundant portion upon itself and stitching it at its free
edge.
The after-treatment of resection consists merely in feeding the
patient by rectal enemata for the first week. Nothing should be given
INJURIES AND DISEASES OF THE DIGESTIVE SYSTEM. 253
by the stomach except Hght liquid diet, and for the first twenty-four
hours small pieces of ice.
Volvulus. — The occurrence of a twist in the bowel is soon followed
by great distention, peritonitis, and firm adhesions. If we remember
that when the peritoneal surfaces are placed in close apposition there
is thrown out, even by the end of the first hour, a thick coating of
coagulable lymph, we can readily understand that adhesions soon
become so firm that separation of them is out of the question. The
bowel may be simply twisted upon itself or one coil may be intertwined
with another. Strangulation in such cases quickly comes on, and
gangrene is inevitable. Having exposed the volvulus, an attempt should
be made to straighten out the twisted portion ; if this cannot be done,
the distended bowel should be pulled out, opened above the con-
striction, and emptied. A second attempt should then be made at
reduction. If this fails, the safest procedure is to make an artificial
anus. Resection is not advisable, as the extent of the volvulus is
likely to include a considerable part of the intestine. The cases in
which only a small portion of the intestine is involved are usually
amenable to reduction.
Strangulation by Bands. — As a rule, it is a simple matter to get rid
of a band when once it is reached. A ligature should be placed at
each extremity of the band as close to its attachment as possible and
the band divided. One point should be guarded against, and that is
the possibility of a second band. It has happened more than once that
the successful removal of one band has not effected a cure, owing to
the existence of a second band, which, unnoticed at the time of opera-
tion, caused death by strangulation of the bowel at a later period.
Meckel's diverticulum, a common cause of strangulation, must be
dealt with in the same manner, care being taken not to mistake it for
bowel, and using care in disinfecting the pervious ends when divided.
When the diverticulum is pervious its mucous membrane should be
turned inward and its fibrous coat stitched on the outside.
After the obstruction has been relieved by any of the methods just
described the remaining steps of the operation are conducted on the
same principles as celiotomy for any purpose. The toilet of the peri-
toneum requires due attention. The abdominal wound should be care-
fully approximated, drainage employed when demanded, asepsis adhered
to throughout, and the patient kept in bed long enough to allow a firm
cicatrix, and thus guard against a subsequent ventral hernia.
Chronic Intestinal Obstruction. — In this variety the intestine
becomes gradually encroached upon and the lumen narrowed. At
any time the occlusion may become complete, and then the case is
practically one of acute obstruction. Chronic obstruction may be
produced by —
I. Stricture of the intestine, cicatricial or malignant. A cicatricial
stricture is, in the majority of cases, the result of the healing of an
ulcer in the wall of the intestine. Much depends upon the size of the
ulcer and upon its shape. If the ulcerative process extends along the
course of the gut, contraction is likely to be slight ; if, on the other
hand, the ulcer is annular, the lumen is greatly lessened and may
become entirely occluded. Strange as it may appear, the large bowel
254 SURGICAL DIAGNOSIS AND TREATMENT.
is affected six times as frequently as the small intestine (Treves).
When the small bowel is affected it is generally the middle and lower
end of the ileum.
Malignant stricture is almost always cancerous and of the cylindrical
epithelial variety (cylindroma). It has a tendency to encircle the gut,
and thus constriction is more readily produced. It rarely occurs in
the small intestine. Of 43 cases tabulated by Jessett, the small intes-
tine was the seat of the disease in only i instance, the rectum in 20,
the sigmoid flexure in 10, and other parts of the colon in 12. This
would indicate that the nearer the anus the greater the liability to
malignant stricture.
2. Benign growths affecting the wall of the intestine may cause
obstruction, but these are rare. They are such growths as adenomata,
fibromata, myomata, fatty and cystic tumors.
3. Foreign bodies obstructing the lumen of the bowel. Among
these are classed gall-stones, which may grow to sufficient size to
cause obstruction, bodies swallow^ed and becoming aggregated, small
polypi, and enteroliths.
4. Tumors outside of the intestine, but pressing upon the gut and
obstructing its lumen.
5. Fecal accumulations.
6. Paresis of the intestinal wall. This form is found in connection
with peritonitis following celiotomies. There is really no occlusion of
the bowel, but the peristaltic action is completely arrested and ga.ses
are retained, producing great abdominal distention and discomfort.
Sometimes paresis results from reflex action, as in cases reported by
Pitt and Jessett.
7. Adhesions following celiotomy or hysterectomy. One of the
most annoying distant results of operations on the abdominal or
pelvic organs is the occurrence of intestinal obstruction. If an
abraded surface on the bowel comes in contact with the parietal
wound or any serous surface, an adhesion is likely to take place at
that point, which gives trouble sooner or later. Experience goes to
show that this occurs more readily in suppurative cases. Two very^
practical points should therefore be borne in mind in abdominal opera-
tions — namely, to spread the omentum out carefully over the intestine
and to avert suppuration by the most scrupulous asepsis. These ob-
structions sometimes prove fatal directly, or they may necessitate the
opening of the abdominal cavity for their relief It is a statistical fact
that these secondary operations are followed by a large proportion of
fatal results.
Diagnosis of Chronic Obstruction. — The symptoms of chronic ob-
struction are the same as those of the acute form, only milder in
degree. The history of the case will reveal some chronic intestinal
disease, such as carcinoma, ulceration, or morbid growth. Repeated
occurrences of obstructive .symptoms will be followed by periods of relief,
but the tendency is for these attacks to return with increased frequency,
and finally wind up with complete occlusion, when the symptoms will
be intensified into the typical character of complete obstruction. Pain
is not so marked a symptom as in the acute variety, in many cases
coming on after eating. It occurs in paroxysms and has periods of
INJURIES AND DISEASES OF THE DIGESTIVE SYSTEM. 255
complete intermission. Vomiting appears later or not at all, and is
rarely feculent. Constipation is usually present, but may alternate
with attacks of diarrhea. Instead of the abdominal distention which
is so marked a character of acute obstruction, we may have only
attacks of flatulence, which, however distressing, may not cause
dyspnea except when death is approaching.
In the large intestine the most common form of obstruction is car-
cinoma of the rectum. Its diagnosis is not difficult, but obstruction
higher up may be obscure. The symptoms of obstruction in the large
intestine as distinguished from the smaller bowel may be summed up as
follows : Vomiting is less frequent, distention is more marked, and
there is tenesmus with discharge of blood or pus.
Diagnosis of Fecal Accumulations. — These occur in the large intes-
tine only, and for obvious reasons the cecum and the sigmoid flexure
of the colon are the two points at which obstruction most frequently
takes place. In a case reported by Jessett the hypochondriac and right
iliac regions were filled by a tumor which extended to the umbilicus,
and, having the shape of the liver, was diagnosticated as carcinoma of
that organ. The patients are for the most part women who have
passed the active period of life, and lunatics. The history of a case of
this kind is one of obstinate constipation, going on from bad to worse.
In some cases there is diarrhea, which, paradoxical as it may appear, is
often present when the bowel is obstructed by a mass of feces. The
tumor is not only plainly to be felt, but may be visible. Its consistency
is frequently an indication of its character. There is no other tumor in
which a permanent indentation remains after pressure by the fingers.
Treatment. — Purgatives are not only useless, but dangerous. If the
accumulation is low down in the sigmoid flexure and filling the rectum,
the masses can be broken up and removed with a scoop or the handle
of a tablespoon. Repeated enemata of sweet oil, followed by copious
injections of soap and water, give good results. Strychnin has a good
effect in restoring the muscular contractility of the bowel and increasing
peristalsis. To these measures may be added massage and the use of
the faradic current. It must be remembered that a person who has
once suffered from fecal accumulation is liable to a recurrence, hence
every care should be taken to maintain the bowels in a healthy state.
V. HERNIA.
The protrusion of a viscus from its natural cavity through a dis-
tended normal or an artificial opening is called a hernia. It includes
not only abdominal protrusions, but also those occurring in the thorax,
the cranial cavity, etc. In common parlance the term is applied to the
escape of abdominal contents through the parietes, either at one of the
natural openings, as the inguinal or femoral canals, or at weak points,
such as the umbilicus or the thin cicatrix left after abdominal section.
Clinically, we meet with hernia under various circumstances. One case
may be strangulated and threatening to prove fatal in a few hours
unless relieved ; another demands attention, owing to the inconvenience
and pain produced by an ever-increasing tumor which cannot be kept
within the abdomen. *' The life of a person afflicted with a hernia," says
256 SURGICAL DIAGNOSIS AiXD TREATMENT.
Championnicre, " is generally a sad and painful one. He has to carry
all his lifetime a truss more or less fitting, more or less adapted to his
needs. He is incapable of vigorous exertion, and the intestines, pass-
ing in and out of the hernial sac, give rise to colic more or less severe.
Sometimes the hernia is never reduced completely, and the patient is
always threatened with strangulation.
" Besides these inherent defects accompanying a hernia, it is demon-
strated that the sufferers are subject to a peculiar lack of vitality,
especially in those afflicted with hernial of large size or of long standing.
The majority of these cases are troubled with diabetes or albuminuria.
Hernia thus leads to an inevitable cachexia of which albuminuria and
diabetes are very grave results."
The diagnosis of hernia seldom presents great difficulty, but the
most serious consequences frequently arise from failure to recognize
this condition. A young physician is called to attend a man who is
suffering intense abdominal pain. He makes a hasty examination,
employs a hypodermic of morphia and hot fomentations, with assurance
that the disease is only colic and that the patient will be all right next
day. For three days the condition grows steadily worse ; vomiting sets
in and becomes feculent. Another physician is called, who, recognizing
a strangulated hernia, sends the man to a hospital. An operation is
performed at midnight, but the patient dies upon the operating-table.
There are few surgeons of large hospital experience who have not
seen cases with this unfortunate history. In severe abdominal pain or
vomiting an examination for strangulated hernia shoidd never be neglected.
The causes of hernia are predisposing and exciting. Certain parts
of the abdominal wall are naturally weaker than others, as the inguinal
ring, the femoral ring, and the umbilicus. Certain abnormalities tend
to hernia, as late descent of the testes, patulousness of the inguinal
canal, patency of the tunica vaginalis, lengthening of the mesentery,
and separation of the recti muscles. Among acquired defects may be
mentioned abdominal operations, in which the tissues have not been
brought into perfect apposition or where undue tension or suppuration
has prevented the formation of a firm cicatrix. Repeated pregnancies
and distention of the abdomen by ascites and sudden emaciation are
also predisposing causes. The immediate or exciting causes are chiefly
the action of the abdominal muscles. Consequently, those persons who
engage in laborious occupations and frequently make strong muscular
efforts are most liable to hernia, and especially if there is a predisposi-
tion. Violent efforts in coughing, straining at stool, and in urination
are also exciting causes.
A long mesentery favors the descent of a hernia in adult life. The
congenital variety occurs more frequently on the right side than on the
left, owing to the fact that the root of the mesentery lies lower on that
side. All perversions of function or diseases of the intestinal tract
which cause relaxation of the mesentery favor descent of a hernia.
Prolapse of the mesentery has been considered very important. It
occurs during late adult life, and is accompanied by a characteristic and
readily recognized bulging of the lower part of the abdomen. The
epigastric region is depressed, while below there is a bulging both at
the sides and in the median line, where the muscles are the weakest,
INJURIES AND DISEASES OF THE DIGESTIVE SYSTEM. 257
and a radical cure which is attempted for the purpose of rendering the
abdominal parietes more firm and resistant must of necessity fail, for
the reason that the root of the mesentery has been weakened from
some cause and has slipped down.
Certain hereditary conditions no doubt predispose to hernia. The
inguinal forms occur more frequently in men than in women, while the
femoral and umbilical are more common in the latter.
Varieties. — Hernia is classified according to the position which it
occupies — viz. inguinal, femoral or crural, umbilical, ventral, diaphrag-
matic, etc. Of these the inguinal is by far the most common, occur-
ring in 80 per cent, of all cases. Classified according to the manner in
which the sac is formed, herniae are divided into two classes — congenital
and acquired.
The contents of a hernial tumor are made up of — (i) a sac, which
is always the peritoneum, except in the very rare cases where a portion
of bowel uncovered by peritoneum escapes ; (2) a loop of intestine,
generally the ileum ; (3) omentum. The character of the contents is
expressed by using the Greek name of the viscus and the termination
cele {rqXrj, a tumor) ; thus we have enterocele when the tumor contains
intestine ; epiplocele when the oment?im occupies the sac ; entero-
epipiocele when the sac contains both intestine and omentum. In
addition to the foregoing, it is common to find in any hernial sac a
small quantity of serous fluid.
From a clinical standpoint every hernia falls into one of three
classes : Reducible, when the contents of the sac can be returned to
the abdominal cavity by simple manipulation ; irreducible, when,
owing to the formation of firm adhesions, reduction cannot be accom-
plished ; and strangulated, when constriction at the neck of the hernia
not only prevents the passage of the intestinal contents at that point,
but obstructs the circulation in the bowel-wall and speedily leads to
gangrene.
Symptoms. — Four-fifths of all cases of hernia occur in males. The
patient, as a rule, only consults a surgeon after he or his friends have
recognized the existence of a tumor in the groin, scrotum, or elsewhere.
There are many cases in which the patient is unaware of the nature of
his infirmity, and yet there are certain warnings which should arouse
the surgeon's suspicion. These are —
1. A feeling of weakness at a certain point, relieved by the support
of the hand or on assuming the recumbent posture.
2. Colicky pain and griping, supposed to be due to dragging on the
mesentery. This is more noticeable on exertion and after eating.
3. During sudden efforts, in which the abdominal muscles are
brought into violent contraction, the patient feels that something
has given way.
4. Mo.st important of all is the agonizing pain which is characteristic
of strangulation. It is generally felt at the umbilicus, and patients
describe it as twisting in character.
The Tumor. — Drawn to make a local examination by one or more of
these warnings, a tumor will be found, the character of which depends
upon its contents. If composed of intestine, the surface is smooth and
elastic, and if large enough for percussion it is resonant. Place your
17
258 SURGICAL DIAGNOSIS AND TREATMENT.
fingers upon it and ask the patient to cough— a distinct impulse is felt.
This impulse on coughing may be regarded as the pathognomonic sign
of hernia, and an examination without looking for it is no examination
at all. The patient should be examined while he is standing up, as well
as while he is lying down. If he stands upon a chair, it is still better,
as the hernia can be examined at the level of the surgeon's hand. This
is a very favorable position for the determination of multiple herniae
(Championniere). When omentum constitutes the bulk of the tumor
the impulse is not so expansile; the tumor is hard, doughy, and
uneven.
An enterocele slips back quickly when reduced, and there is a
peculiar gurgle which is a welcome sound to the surgeon's ear.
Epiplocele, on the other hand, goes back slowly, and, containing no
gas, there is of course no gurgle.
Having settled the point that the tumor is a hernia, the next ques-
tion is whether it is above or below Poupart's ligament. If above, it is
an inguinal hernia ; if below, it is a femoral hernia. The spine of the
pubis is an important landmark. An inguinal hernia always protrudes
at the external ring just at the spine, and lies above Poupart's ligament.
A femoral hernia is always below the spine.
Inguinal hernia occurs as a tumor near the center of Poupart's
ligament. There are two varieties — viz. oblique or external, direct or
internal. In the indirect hernia the bowel escapes from the abdominal
cavity at the internal abdominal ring, pushing the peritoneum before it,
and, following the inguinal canal, emerges at the external ring. Along
this same route the testicle, on the way to the scrotum, has been the
pioneer, and the intestine may follow it the entire distance. The epi-
gastric vessels lie to the inside of the neck of the tumor. In the direct
form the bowel does not enter the internal ring or traverse the inguinal
canal, but, pushing the fascia before it, escapes directly through the
external ring.
In examining the tumor these two forms can generally be differ-
entiated. The indirect form is by far the more common ; the tumor is
oval in shape or, when it has descended to the scrotum, it is pyriform.
The history of the case will show that the tumor began to appear at
the middle of Poupart's ligament and gradually extended toward the
pubes. The pulsation in the epigastric vessels is usually obscured.
The size of the tumor is sometimes immense, in some cases filling the
scrotum and causing it to drag downward until it comes almost to the
knee. The indirect hernia usually contains intestine. It is reduced by
pressure outward and backw^ard.
Direct inguinal hernia is rare. The tumor is small and globular,
usually making its appearance a little to the inside of the middle of
Poupart's ligament. It generally contains omentum, and the epigastric
vessels lie to the outer side. It is reduced by pressure directly back-
ward. The finger-tips can be pushed through the canal directly into
the abdominal cavity. On the inner side of the opening can be felt
the conjoined tendon and the posterior upper surface of the pubis ;
on the outer side is the epigastric artery. When a hernia is large and
of long standing, the differential diagnosis may be impossible, for the in-
ternal may be dragged downward until it is opposite to the external ring.
INJURIES AND DISEASES OF THE DIGESTIVE SYSTEM. 259
Femoral hernia is a female hernia ; that is to say, it is much more
frequently met with in women than in men. Its position is in the
crural canal, which has the following anatomical boundaries : In front,
Poupart's ligament, the deep crural arch, and the falciform edge of the
fascia lata ; on the outer side, the femoral vein ; on the inner side, Gim-
bernat's ligament ; and behind, the bone. The anatomical landmark
for this hernia is the spine of the pubes. A femoral hernia is always
below it and to the outer side.
In hernia of long standing and of considerable size it may be diffi-
cult to say whether the tumor is above or below Poupart's ligament,
for as it enlarges it turns upward and toward the abdomen, giving the
appearance of an inguinal hernia. What adds to the difficulty is the
existence in some women of a fold of the groin which extends across
the thigh lower down than Poupart's ligament, and may be mistaken
for it. When a femoral hernia remains in the crural arch it is said to be
incomplete ; when it protrudes at the saphenous opening it is called
complete.
Diagnosis between hernia and other swellings of the inguinal or
femoral region :
Bubo is generally associated with chancroids, gonorrhea, and
syphilis, and there are redness of the skin and tenderness. If the
swelling and subcutaneous infiltration are not too great, the outline of
the inflamed gland can be felt. Chronic inflammation of a gland in the
groin seldom leads to confusion, as the glands are distinct and movable.
Glands enlarged by malignant disease are hard and frequently occur in
chains.
Undescended testicle has the characteristic pain on pressure pecu-
liar to these organs, and, besides, there is absence of the testis in the
scrotum.
Varicocele is a swelling resembling a bunch of worms, commencing
in the lower portion of the cord and increasing upward. There is no
impulse on coughing. The swelling may disappear when the patient
lies down, as is sometimes the case in hernia. If the part be supported
and the patient stand up, the swelling will return in the case of varico-
cele, but not so if the case be one of hernia.
Hydrocele is translucent, and the swelling begins at the lowest part
of the scrotum, while in hernia this is the ultima thule. Hydrocele of
the cord is never very large, and has but a slight impulse on coughing.
The swelling moves with the cord.
Abscess in the neighborhood of Poupart's ligament may assume
the shape of a hernial tumor, but there are the characteristics symp-
toms of suppuration, pain, high temperature, etc. Psoas abscess has a
history of spinal or pelvic disease ; the tumor, if superficial, fluctuates
and gradually disappears under pressure.
Irreducible Hernia. — When, without impairment of the circula-
tion or the passage of feces, a hernia cannot be returned into the
abdomen, it is said to be irreducible. This may be brought about by
a variety of causes : the hernia may be composed of omentum, which
takes a mushroom shape, a small neck and an expanded body ; a large
quantity of fluid in the sac may interfere with direct manipulation of
the bowel ; or the great size of the tumor may in itself be an obstacle
260 SURGICAL DIAGNOSIS AND TREATMENT.
to reduction. The most frequent cause, however, is the existence of
adhesions, either between the sac and its contents or between the con-
tents themselves. Irreducible hernial are the cause of great discomfort.
More and more of the intestine slips down into the sac until the tumor
reaches an enormous size. Continual dragging pain, dyspepsia, colic,
and the ever-present danger of strangulation make the patient's lot
anything but pleasant.
Incarcerated or Obstructed Hernia. — When, without any inter-
ference with circulation, the loop of bowel contained in a hernia
becomes impacted with feces and gases, the hernia is said to be incar-
cerated or obstructed. This only happens when the colon goes to form
the hernia, as the contents of the small intestine are always liquid.
This condition is most frequently met with in umbilical hernia, especially
in that form which afflicts women who have borne many children. It is
easy of recognition. The tumor is hard and uneven, and in some cases
tympanitic. It hangs down from the umbilicus, and usually attains con-
siderable size, attended with colic, nausea, and total constipation after
the lower bowel has been emptied.
Strangulated Hernia. — A strangulated hernia is one in which
constriction at the neck is so complete as to arrest the circulation,
paralyze the nerves, and stop the flow of contents through the bowel.
Such a condition is naturally attended with the utmost danger, and its
progress is rapid — from strangulation to gangrene is a short step. It
is not essential that the hernia should contain intestine, for when the
sac contains omentum, or, in fact, any other structure, the course and
symptoms are the same. When the bowel is involved it may be con-
stricted at one side or in its whole circumference. In either case per-
foration is the usual consequence, the contents of the bowel escaping
in some instances into the peritoneal cavity, setting up general peri-
tonitis. In others they are poured out into the sac and followed by
suppuration.
Svviptoins. — If once the existence of hernia be recognized and the
symptoms of strangulation superadded, error in diagnosis is impossible,
The danger of making a false diagnosis lies in the fact that the con-
dition may be regarded as due to gastritis when vomiting is an early
and prominent symptom, or to peritonitis when pain and abdominal
tenderness are most marked. Two classes of symptoms must be
recognized — one due to obstniction of the bowel, the other to strangula-
tion. In every case of severe abdominal pain or persistent vomiting the
question of hernia should be considered, and every probable site of
hernia should be carefully examined.
Pain is usually an early and prominent symptom. It is generally
referred to one spot, the seat of the hernia, but frequently, and espe-
cially at a later stage, it is felt at the umbilicus, and described as if the
intestines were being violently twisted at that point. Tenderness is
most marked at the seat of hernia, but is commonly a marked symp-
tom over the whole abdomen. W^hen gangrene has become complete
pain ceases, and its sudden cessation may be regarded as a harbinger
of death. Too much reliance should not be placed upon pain as a
symptom. In some cases it is almost absent, and in others its onset
is delayed.
INJURIES AND DISEASES OF THE DIGESTIVE SYSTEM. 26 1
Vomiting may come on at the very commencement of strangulation,
or it may appear at a much later period. The higher the strangulation
in the bowel, the earlier, as a rule, will vomiting set in. At first the
food newly received into the stomach is ejected undigested and unal-
tered. After a time the gastric secretions, still later the chyle and bile,
are ejected, and lastly the vomit assumes all the characteristics of fecal
matter.
Obstruction is manifested by constipation, which is persistent and
complete. After the bowel below the strangulation has been emptied
nothing more, not even flatus, comes away. The abdomen gradually
becomes distended and tympanitic, but the area of liver-dulness remains
intact, thus showing that the gas is in the intestine and not in the peri-
toneal cavity. The part of the intestinal canal implicated may be
approximately determined. If, after the onset of the symptoms, a
considerable evacuation takes place from the bowels, it may be con-
cluded that the obstruction is in the small intestine. Distention also
comes on slowly if the lower intestine be the strangulated part.
The tcvipcraturc is seldom above normal, and in the late stages it
becomes subnormal.
The pulse is generally rapid, and becomes feeble and intermittent
toward the close.
Examination of the hernial tumor will reveal tenderness at the seat
of strangulation. There is absence of impulse on coughing. The
later history of a case of strangulation is the history of gangrene. If
we were restricted to the use of two words in describing the course of
a strangulated hernia, we would not be far astray if we used peritonitis
and gangrene. The first acute onset with its violent pain and other
signs of peritonitis passes into a stage in which the constitutional
symptoms play a more prominent part. More and more offensive
becomes the vomited matter, and it comes in great gushes without
any effort ; the pulse becomes feeble and intermittent ; hiccough is con-
stant and distressing ; the abdomen becomes more and more distended ;
the face is haggard ; the mind wanders ; the surface of the body becomes
cold and clammy ; and death by exhaustion ends the fearful scene.
In rare cases nature brings relief and prevents a fatal termination.
The tumor is swollen and edematous, and even tympanitic from the
putrefying gases ; the skin ulcerates and the contents escape, leaving
the patient his life, but with it the misery of an artificial anus.
When the hernia contains omentum only, or when only a part of
the circumference of the bowel is strangulated (Littre's hernia), the
symptoms are the same, only in a less marked degree.
Differential diagnosis of strangulated hernia must rest between
hernia and —
1. Acute peritonitis. The existence of a hernia previous to the
onset of symptoms and the presence of a tumor must be mainly
relied upon to exclude peritonitis.
2. Inflamed or obstructed irreducible hernia. The pain, constipa-
tion, and collapse are never so marked as in strangulation. The
vomiting is not fecal.
Treatment of Strangulated Hernia. — A condition so grave and
violent in its progress demands the most prompt and decisive treat-
262 SURGICAL DIAGNOSIS AND TREATMENT.
mcnt. Strangulation must be relieved or death will most certainly
result. Two measures are relied upon — taxis and operation. In
employing taxis or manipulation the first point demanding attention is
to secure complete relaxation of the parts. The head should be
lowered and the pelvis raised. If the hernia be inguinal, flex and
adduct the thigh ; if femoral, flex and rotate inward. Steady the neck
of the sac with the left hand while the right gently manipulates the
tumor with the view of emptying it of part of its contents. If intestine
slips back, a welcome gurgle announces the fact ; omentum goes back
more slowly, but with an equal sense of relief Should gentle efforts at
reduction fail, more complete relaxation of the parts must be secured by
putting the patient under chloroform. But before doing so every prep-
aration should be made for an operation in the event of taxis proving
a failure. This is required for two reasons — first, because the patient
should be subjected to anesthesia only once ; and second, because the
case, if unrelieved by taxis, will not admit of a moment's delay.
The operation for strangulated hernia or herniotomy consists in cut-
ting down upon the constriction, dividing it, and returning the bowel to
the abdominal cavity, or otherwise dealing with it as circumstances
demand. The pubes, scrotum, and neighboring parts having been
shaved and thoroughly disinfected, an incision is made in the long axis
of the tumor, the center of the incision corresponding with the position
of the neck of the sac. The next point is to find the sac, which, to an
inexperienced operator, may be a little difficult. It is recognized by
the fat which usually covers it ; grasped by the finger and thumb, its
surfaces can be made to slip over each other. Carefully dissecting
down through the tissues, we know that we have entered the sac by
the escape of a yellow or dark-brown fluid. Through the puncture in
the sac a groov^ed director is passed, and an opening made sufficient to
admit the finger, upon which the sac is divided to the full extent of
the tumor. The finger is now passed up to the constriction, palmar
surface upward, and the nail slipped into the opening. A long probe-
pointed bistoury is passed up, the flat surface of the instrument against
the palmar surface of the finger, until it slips between the sharp edge
of the constriction and the nail. The edge is now turned upward and
the ring sufficiently divided to relieve the strangulation.
The contents of the hernia should now be carefully examined, and
especially the bowel. Warm sterilized gauze is applied to the wound,
and allowed to remain for several minutes in the hope that circulation
may be re-established in the strangulated tissues. A strangulated
intestine varies in color from a pinkish gray to black ; if in the course
of five to fifteen minutes it changes to a healthy red, circulation is
restored and the bowel can be returned to the abdomen. The sac is
then treated in the same manner as in the radical operation for hernia,,
and the operation completed as described under the radical operation.
When omentum is contained in the sac, it should be separated if
adherent, tied in sections, and cut off
Should the intestine prove to be gangrenous, it may be dealt with by
one of three methods: i. The gangrenous portion is exsected ; the
healthy divided ends are brought together by end-to-end anastomosis
(enterectomy). 2. An artificial anus is formed by suturing the bowel
INJURIES AND DISEASES OF THE DIGESTIVE SYSTEM. 263
to the edge of the wound and opening into its lumen. 3. The bowel
is returned to the abdominal cavity, stitching it to the abdominal wall
inside the ring, and placing a drainage-tube in contact with it. This is
only applicable when the portion of gangrenous bowel is small.
The Radical Cure of Hernia.' — In the case of strangulated hernia
" the radical cure " is a term applied to a method of treating the sac
and closing the canal which prevents recurrence of the hernia. Its
usefulness is, however, by no means limited to strangulated hernia, for
it is almost universally adapted to those unfortunates who are doomed
to carry a truss through life, who are constantly threatened with the
dangers which are for ever hanging over the heads of the ruptured, or
who are shut out from many of the active walks of life by these
inflictions.
Long is the history which deals with the various attempts at the
radical treatment of hernia. Some were subcutaneous, as Wood's
and Spanton's, but the advance of aseptic surgery has proven that not
only greater accuracy, but equal safety, is gained by operations which
lay the parts open to view and deal with the separate structures as
their condition demands.
The operation is imperative in — (i) strangulated hernia; (2) in
herniae whose volume is gradually increasing.
The operation is indicated in (i) irreducible herniae ; (2) congenital
herniae with ectopic testicles ; (3) painful herniae ; (4) herniae in subjects
afflicted with diseases that form dangerous complications, as spasmodic
asthma, chronic cough, etc. ; (5) social necessities may demand the ope-
ration, as in those who have to perform manual labor, those who wish
to enter the military service, etc.
The operation is contraindicated in — (i) old men and very young
children (under six years of age) ; (2) persons who have albuminuria,
diabetes, or tuberculosis : those afflicted with emphysema are the most
dangerous of all ; (3) those predisposed to hernia.
If we bear in mind the conditions essential to the existence of a
hernia, the indications of treatment will be better understood.
1. In every hernia there is an enlarged foramen or canal in the
abdominal wall (Fig. 118).
2. Protruding through this opening is a serous sac which forms an
inclined plane, smooth and slippery, on which the viscera glide.
3. The viscera which form the hernia are generally the intestines and
the omentum. Everything tends to place the intestines upon this slip-
pery surface. Ordinarily the intestine is loose on this inclined plane,
but sometimes it forms adhesions with the omentum, which goes down
with it.
In view of the principles just laid down we have three indications
which must be fulfilled as much as possible :
I. The serous membrane must be modified or destroyed, for the
destruction of the slippery surface will remove the tendency of the
intestines to slide over it.
The opening of the sac, and then its removal at the highest possible
point, will destroy the slippery inclined plane. In order that this de-
1 For much that follows I am indebted to the excellent work of Champion niere, Ctire
radicale des Hernies, Rouff, Paris.
264
SURGICAL DIAGNOSIS AND TREATMENT.
struction be complete, the serous membrane away above the neck of the
sac must be removed with it and the oi)ening closed by a strong liga-
ture, so that no cul-de-sac or infundibulum be apparent, and that in the
Fig. 118. — Schema of the constituents of a
hernia; sac and slippery surface traversing the
wall (Championniere).
Fig. 119. — Schema of the radical cure,
restoration of the wall, closure of the serous
membrane : A, closure of the wall ; B, closure
of the skin (Championniere).
region which the hernia occupied we find only a smooth plane contin-
uous with the rest of the deep surface of the abdominal wall (Fig. 119).
2. We must build up at the opening in the abdominal wall a most
resisting cicatrix as a powerful barrier to prevent the forcing out of the
Fig. 120. — Serous sac of a hernia with
the points {A and B) at which the de-
struction of the serous sac must take
place (Championniere).
Fig. 121. — Sac drawn down by traction
and dissection ; the points A and B have
descended to A' and B' (Championniere).
viscera which have a tendency to come down. This point is gained
by the close approximation of a large operation-wound. The extensive
dissection of the serous membrane is an important preparatory step,
INJURIES AND DISEASES OF THE DIGESTIVE SYSTEM. 265
and it may be said that the larger the incision the more powerful will
be the cicatrix.
3. If intervention with the contents of the sac be possible, we must
destroy the parts not essential to the functions of the abdomen — e. g.
the omentum. The omental mass contained in the sac should not
only be removed, but all that can be drawn down by strong effort.
This is all cut off, thus creating in the abdomen a corresponding
vacuum (Figs. 120 and 121). In this way the omentum cannot play
its customary part in producing a recurrence of the hernia (Fig. 122).
Fig. 122. — Sac of the preceding, with the liga-
ture of the pedicle placed at the highest pos-
sible point. After resection the pedicle O, by
retraction of the peritoneum, ascends to O'
(Championniere).
Fig. 123. — Sac closed by chain ligatures
(Championniere).
Championniere' s Operatioji. — First Step : Removal of the Sac. — The
incision should be made where it best exposes the neck of the sac ; it
should not be too short, for the operator needs an abundance of room
to make a complete dissection of the sac ; it should be as far away as
possible from the scrotum and penis, and especially from the labia, to
guard against infection from the secretions of these parts. The sac, par-
ticularly if small, is often difficult to find; hence the advantage of mak-
ing the incision as high as possible in the direction of the inguinal canal.
No matter how thin the sac may be, an attempt should be made to
dissect it out /;/ toto. A pair of blunt-pointed scissors is the best instru-
ment. The sac must not be too strongly drawn upon, for it will either
be too firmly adherent to be separated from the other tissues, or it will
be too thin to stand the strain and will tear.
Whatever the hernia operated upon, the layers must be separated
one by one, and the serous membrane isolated as much as possible
from the neighboring parts, in order to carry dissection as far up as
possible. In an acquired hernia the adhesions may be just as firm as
those of a congenital hernia. In the latter variety the sac is generally
very thin. Having reached the highest point, a strong ligature is
applied and the sac cut off When the sac is large it should be tied
off with a chain ligature, as seen in Fig. 123.
Second Step : Treatment of the Orgaiis contained in the Hernia. — The
intestine, if healthy, is returned to the abdomen, and requires no further
266 SURGICAL DIAGNOSIS AND TREATMENT.
consideration. The omentum is a structure requirinj^f the most careful
manat^^ement. It is a dreaded agent in the formation, maintenance, and
recurrence of hernia, and should be reduced to the smallest possible
dimensions. Not only should the protruding omentum be removed,
but all that can be drawn out. And when none presents at the open-
ing, the finger should be passed up in search of it with a view of draw-
ing it down and resecting all that can be pulled out. The removal of
omentum has three advantages :
1. It empties the abdomen of part of its contents and makes room
for other viscera.
2. It suppresses an organ which is an active agency in the formation
of hernia.
3. This procedure allows us to discover adhesions at or above the
neck of the sac whenever they exist. These adhesions are often the
cause of the return of the hernia and the persistence of pain.
Having broken up adhesions and brought down the omentum, it
should be laid upon a sterilized towel and spread out until it is in a
single layer, with every vessel of any size plainly visible. De Garmo
urges the importance of numerous ligatures, instead of the older
method of tying off in one or two masses. He begins at one edge of
the fan-shaped omentum as it is spread out in a single layer, and places
a row of silk ligatures across to a corresponding point on the opposite
side. No piece of fat larger than a lead pencil is included within one
ligature, and every vessel that can be seen is tied separately. The liga-
tures are cut off close to the knots, except those at the edges, which
are clamped with forceps to control the stump. The omentum is then
cut away, the surface of the proximal portion is dusted with aristol, the
end ligatures are cut off, and the stump dropped back into the abdomen.^
TJiird Step: CIosui'c of the IVoiDid to Secure a Firm Cicatrix. — The
third fundamental condition of the radical cure is the formation of a
strong barrier extending along the whole hernial region. To secure
this the incision must be long and high up along the inguinal canal,
without sparing the lax muscular fibers stretched by the passage of the
viscera. One of the most potent factors in the formation of a strong
cicatrix is asepsis, for the cicatrices w^hich are really strong, truly
resisting, are those that heal by first intention.
For the deep suturing the best material is kangaroo tendon. It is
strong, easily tied, and is absorbed in about three months, the time
generally required for the completion of cicatrization. The soft parts
which formed the wall of the canal are first brought together, and
when the hernia has been large one side of the canal should be made
to overlap the other. This row of sutures should include the aponeu-
rosis and muscles. The next row can be of catgut, and it unites the
cellular tissue in front of the muscle and extends downward along the
cord. The last row is made with silkworm gut and closes the wound
in the skin. A drainage-tube is placed in the position farthest from
infection, an antiseptic dressing applied, and strong and steady pressure
maintained for three or four days.
Treatment of the Testicle. — The testicle may occupy any of the
following positions :
^ Annuls of Surgery, June, 1895.
INJURIES AND DISEASES OF THE DIGESTIVE SYSTEM. 267
First : It may be in the bottom of the sac, as in congenital hernia.
In this case it is normally located, and all we have to do is to provide
from the hernial sac a serous membrane to cover it. The membrane
may be sutured or it may be allowed to roll up around the testicle.
Second : The testicle may be in the vicinity of the inguinal canal or
in the canal itself This condition is more serious. If the patient is
not young" and the testicle painful, it may be sacrificed, but most
patients, even with atrophied testicles, object to this measure. The
testicle and epididymis may be so firmly adherent to the hernial sac that
it may be very difficult to separate them. The testicle held by fibrous
bands is drawn upward, and held there in spite of our efforts to bring
it down. If the bands be divdded, the testicle will remain down, but
there is no lodgement for it. Championniere is in the habit of making
a new bed for it by tearing through the cellular tissue of the scrotum
with his finger. When the vas deferens is shortened and atrophied, the
testicle should be sacrificed. In his 266 cases he has only been com-
pelled to perform castration 5 times.
Maceivcn's Operation. — The steps of Macewen's operation are as
follows :
(i) He forms a pad on the abdominal surface of the internal ring,
and (2) closes the inguinal canal.
(i) The formation of the pad. The bowel having been reduced in
the ordinary way, the sac is thoroughly freed in its whole extent from
the cord and from the walls of the
inguinal canal. Then strip the
peritoneum from the abdominal
wall for about two inches round
the internal ring and fix a stitch
securely in the distal (/. e. the ab-
dominal) extremity of the sac. This
stitch is passed several times through
the sac to its outer extremity, so
that when drawn tightly the sac is
Fig. 124. — Macewen's operation: the sac
transfi.xed and drawn into a fold.
Fig. 125. — The sac as a pad covering
the abdominal aspect of the internal ring in
Macewen's operation.
Fig. 126. — Macewen's operation : the threads
ready for tying.
folded up Hke a concertina (Figs. 124, 125). The free end of the
suture is then threaded on a hernia needle, passed along the inguinal
268 SURGICAL J) /A GNOSIS AND TREATMENT.
caiKil and through tlic structures of the abdominal wall, from within
outward, one inch above the ring. The skin is to be drawn up out of the
way while this suture is being passed. The end of the suture is then
fixed b\' introducing it several times through the external oblique muscle.
In this way the sac is not only obliterated, but forms a pad which
protects a weak point in the abdominal wall.
(2) The closure of the inguinal canal is accomplished in the follow-
ing manner (Fig. 126) : The conjoint tendon is penetrated in two places,
at its upper and lower ends, by a single thread of catgut, so that a loop
is made with its convexity on the abdominal aspect of the tendon.
The lower freed end of this thread is passed from within outward
through Poupart's ligament, and the upper end through the external
oblique and transversalis muscles, each stitch maintaining the level it
has at the conjoined tendon. The two free ends are then tied in a reef
knot. The cord should be examined before tightening each stitch to
avoid compression.
The pad is now considered an objectionable feature, and mainly on
this account Macewen's operation has been supplanted by the methods
of Bassini and Halsted.
BassinYs Operation. — First Step. — The incision extends from a
point on a level with the anterior superior spinous process obliquely
downward parallel to and about half an inch above Poupart's ligament,
and ends at the center of the external abdominal ring. The dissection
is continued until the aponeurosis of the external oblique is reached
and exposed for a distance of about three inches. A director is then
passed beneath the aponeurosis through the external ring, and the
aponeurosis divided to a point half an inch or a little more above the
internal ring. The edges of the aponeurosis are dissected backward
toward the middle line as far as the edge of the rectus, and outward
until the shelving portion of Poupart's ligament is fully exposed.
Second Step. — The sac and cord are isolated by the fingers and
blunt-pointed curved scissors. The cord and its vessel are separated
from the sac and the separation carried high up within the internal
ring.
Third Step. — Open the sac, and, having separated adhesions and
removed any thickened omentum that may be present, return the con-
tents of the sac to the abdominal cavity. Ligate the sac above the
internal ring and cut it off below the ligature.
Fourth Step. — The cord is held up by a hook and the edges of the
aponeurosis kept out of the way. Buried sutures are then placed so as
to close the abdominal wall beneath the cord. These sutures, three to
five in number, should include on the inner side the internal oblique
and transversalis muscles, the transversalis fascia, and in some cases
the edge of the rectus, on the outer side the shelving portion of Pou-
part's ligament. Replace the cord and close the aponeurosis over it by
a continuous suture. This suture should begin as near the pubes as
possible without constricting the cord. The wound in the skin is
closed by interrupted sutures. No drainage is necessary.
Halsted's Operation. — In Halsted's operation for the radical cure
of inguinal hernia an incision is made through the skin from a point 5
cm. above and external to the internal abdominal ring, as far as the
INJURIES AND DISEASES OF THE DIGESTIVE SYSTEM. 269
spine of the pubis. Then, the aponeurosis of the external obhque, the
internal oblique, transversalis muscles, and transversalis fascia having
been divided along a line extending from the external ring to a point 2
cm. above and external to the internal ring, the cord is isolated and
reduced in size by excising all the veins except one or two. The sac
of the hernia is next isolated and opened, and, its contents having been
replaced in the abdomen, the peritoneal cavity is closed by a few fine
silk mattress sutures, and the remainder of the sac cut off close to the
sutures. The isolated cord is now raised on a hook (Fig. 127), whilst
Fig. 127. — Inguinal canal laid open ; sac cut away after suture of the peritoneum ; elements
of cord isolated and lifted up ; deep mattress sutures introduced : A, aponeurosis of the exter-
nal oblique muscle ; D, vas deferens ; F, fascia transversalis ; P, peritoneum ; T, conjoined
tendon; V, vein; Kf^, stumps of excised veins (Halsted).
Fig. 128. — Deep sutures tied (Halsted).
the cut edges of the incision through the aponeurosis of the external
oblique, internal oblique, and transversalis muscles, and transversalis
fascia are again brought together by six or eight deep mattress sutures.
The cord passes between the two outermost sutures, and care must be
taken that the distance between them is such that the cord is embraced
without danger to its circulation. The cord will now lie on the surface
of the external oblique muscle under the skin (Fig. 128). The skin-
wound is closed by silver-wire sutures.
Halsted's operation is sometimes spoken of as a modification of
Bassini's, but this is not correct, as our famous American confrere
not only arrived at his conclusions independently of the distinguished
2/0 SURGICAL DIAGNOSIS AND TR BAILMENT.
Italian surgeon, but claims priority of publication. The two operations
differ in several important particulars. In Bassini's method the cord is
placed under the aponeurosis of the external oblique ; in Halsted's
operation the cord is placed outside the aponeurosis. Bassini's ope-
ration does not interfere with the veins of the cord ; Halsted removes
all superfluous veins, thus diminishing the size of the cord — a very im-
portant consideration. In Bassini's operation the obliquity of the
inguinal canal is not restored ; it is restored by Halsted's method.
The Radical Cure of Femoral Hernia. — The operation of Bassini of
Padua is probably the best. He makes an incision parallel to Poupart's
ligament and over the center of the tumor ; he ligates the sac high up
and removes it. He unites Poupart's ligament with the pectineal fascia
by three silk sutures which he inserts with a curved needle. The first
is placed near the spine of the pubes, the second half a centimeter ex-
ternally, and the third one centimeter from the femoral vein. These
sutures are not tied until four other sutures are passed through the
edges of the falciform fascia, and then the pectoneal fascia, the lower
suture entering just above the saphenous vein ; the upper sutures draw
Poupart's ligament backward to the pectoneal line and close the mouth
of the canal. The other sutures bring together the anterior and
posterior walls of the canal. The wound in the skin is then closed,
and no drainage is employed.
Palliative Treatment of Hernia. — As the radical operation comes
nearer and nearer to perfection fewer cases will require treatment of a
palliative kind. There are many persons whose natural abhorrence of
a cutting operation will lead them to go through life with the annoy-
ance of a hernia and the inconvenience of a truss. Besides, there are
certain cases already stated which are not amenable to the radical cure,
as old men and children below six years of age, persons suffering from
albuminuria, diabetes, etc., and those who are predisposed to hernia.
In young children a truss not only retains the hernia within the
abdomen, but in many cases effects a permanent cure. Hence in them
this treatment should always be adopted, with the radical cure held in
reserve to be brought into requisition if the hernia remains after the
child has reached the age of six years.
Persons who are the subjects of hernia should avoid violent exer-
cise, sudden strains, and should prevent constipation of the bowels.
For retaining a hernia in the abdominal cavity a truss is necessary, and
a great variety of appliances in this direction have been invented. For
slight or incomplete hernia, or in persons who are not obliged to
engage in laborious occupations, an elastic truss is sufficient, but in
others trusses having a steel spring. and a pad composed of hard wood
or rubber are essential. The wearing of a truss is attended with diffi-
culty in the case of fat people, in a hernia which contains a portion of
irreducible omentum, and in femoral hernia. In oblique inguinal hernia
the pad is made to fit over the internal inguinal ring ; in direct inguinal
hernia it fits over the external ring ; in femoral hernia over the femoral
ring at the level of Gimbernat's ligament.
Before applying a truss it is necessary to reduce the hernia. This
is done by placing the patient upon his back with the pelvis elevated.
The sac is first emptied as described in the employment of taxis. The
INJURIES AND DISEASES OF THE DIGESTIVE SYSTEM. 2/1
direction of pressure will vary according to the form of hernia. In
indirect inguinal hernia this will be upward and inward. For the
measurement of a truss a few points must be considered : the size of
the aperture, the circumference of the pelvis one inch below the crest
of the ilium, the circumference of the body below the level of the
aperture, the distance of the hernial opening from the anterior supe-
rior process, the direction in which pressure is to be applied, and
whether the hernia is single or double.
Umbilical Hernia. — This variety of hernia is found under three
conditions :
1. Cong-enital. — Both male and female infants are found at birth to
be the subjects of umbilical hernia, but female children are in the
majority. The hernia is due to imperfect closure of the abdominal
wall, the visceral plates failing to meet in the middle line. The cover-
ing is often exceedingly thin, consisting only of the peritoneum and
tissues of the cord, and allowing the contents of the sac to be plainly
seen. These herniae are often of immense size, and may even contain
all the abdominal organs. The cecum is a frequent constituent.
The trcatmoit consists in reducing the hernia as soon as possible
after birth, and retaining it by the use of strong strips of adhesive
plaster over which a broad bandage is applied. In small herniae a small
pad is useful under the strapping.
The radical operation in mild cases is seldom necessary, as with
proper care spontaneous cure is the rule.
2. Infantile umbilical hernia is the result of stretching of the
cicatrix shortly after birth. The tumor is easily reduced, and can be
kept in position by a pad about the size of a dollar and retained by an
easy-fitting belt. Tight bandaging and conical or button-shaped pads
which fill the opening are to be condemned. A piece of adhesive
plaster which is brought across the hernia in such a way as to fold the
skin up into a roll at each side of the umbilicus is often satisfactory.
The tendency of this form of rupture is to get well as the child
grows.
3. Umbilical hernia in adults is most frequently met with in
females who have borne numerous children. The covering is generally
peritoneum and skin, and the size of the tumor may be enormous. It
may at first escape observation, and one of its first indications may be
severe neuralgic pains radiating from the umbilicus. Two features
characterize these hernise : they increase rapidly, and they readily form
adhesions. In addition, the subjects are inclined to obesity and are
liable to emphysema of the lungs ; consequently the cough and diffi-
culty of respiration react upon the hernia, causing its more rapid
increase in size (Championniere).
Tj'catincnt. — Bandages here are of little value. The radical cure
affords the best prospect of a satisfactory result. The operation is to
be conducted on the general principles already laid down, consideration
being given to differences in anatomical structure and physiological
action. The incision may be straight or curved, the latter being chosen
when it is desirable to lay open a larger space. One end of the incision
must be over the hernial aperture. In view of the frequency of intes-
tinal adhesions the sac must be cautiously opened and care taken to
272
SL'KGICAl. DUGiVOS/S AND TREATMENT.
avoid perforating the bowel. \\\ dealing with the omentum the hernial
opening should be freely enlarged and a free portion of the omentum
found in the abdomen. From this point it must be traced down into
the sac and freed from its adhesions. The omentum is drawn gently
out, so that not onl)- the part which was adherent to the sac, but a por-
tion that lay above the hernia, is drawn down, spread out upon steril-
ized gauze, ligated off by chain ligatures, and removed (Championniere).
The sac is next dealt with. It is freed from all adhesions, laid open,
ligated by two, three, or more chain ligatures (as seen in Fig. 123), and
cut off In closing the abdominal wound interrupted sutures of kanga-
roo tendon are placed in the muscular wall. A continuous catgut
suture closes the cellular tissue and fascia, and lastly a row of super-
ficial and deep sutures, alternating, are employed to close the opening
in the skin. Drainage is useful when the abdominal wall is very much
thickened with fat, otherwise it is not indicated.
Ventral Hernia. — A hernia in the linea alba, above or below,
but not at, the umbilicus, in the linea semilunaris, or in any other
part of the abdominal wall which
is not a common position of rup-
ture, is spoken of as ventral
hernia. Many of the cases occur
after laparotomies (Fig. 129).
When of considerable size these
herni?e are readily diagnosticated,
and their treatment is practically
that of umbilical hernia. The
tumor may be very small and
escape observation, and yet pro-
duce very urgent symptoms. This
is especially the case when the
hernia contains omentum, which,
forming adhesions, is retained in
the sac. Sometimes the omen-
tum forms a narrow band be-
tween the stomach and the
hernia. In such cases the pain
and gastric disturbances are such
as to lead to a suspicion of can-
cer of the stomach. The band
usually goes to the great curva-
ture, and as a consequence intense
suffering results from movements
of the stomach or when the organ
is distended with food or gas.
The diagnosis must rest upon
the presence of a tumor, however
small, which may or may not be
attended with an impulse on coughing. Sometimes the presence of a
band may be determined by a drawing in of the abdominal wall at that
point. Violent attacks of gastric pain and vomiting are also common
consequences.
Fig. 129. — Large vt-ntrnl hernia forming in the
cicatrix made for removal of an ovarian cyst.
The patient bore two children, after which a
cyst formed in the remaining ovary, burst
through the cicatrix, and filled the hernia (from
a photograph in the collection of Dr. W. J.
Mayo, Rochester, Minn.).
INJURIES AND DISEASES OF THE DIGESTIVE SYSTEM. 273
The treatment consists in the radical operation for the hernia and
division of the omental band.
lylimbar Hernia. — A weak point in females who have rapidly lost
flesh is the triangle of Petit, formed by the lower margin of the external
oblique, the latissimus dorsi, and the crest of the ilium. Its floor is
formed by the internal oblique. The course of a hernia in this locality
is through the lumbar fascia, near the outer edge of the quadratus
lumborum muscle. Its interest from a diagnostic point of view lies in
the danger of mistaking the hernia for tumor or abscess — an error which
has more than once led to incision and disappointment. The history
of the case, the occurrence of a reducible tumor in an emaciated
female or its connection with a traumatism, the presence of an impulse
on coughing, and the absence of symptoms of suppuration should
make the diagnosis reasonably clear. The only treatment required, as
a rule, is a comfortably fitting elastic abdominal belt.
Other rare forms of hernia are the following :
Obturator hernia, a very rare form. The subjects are generally
above the age of fifty. It is seldom diagnosed during life unless it
becomes strangulated. The symptoms resemble femoral hernia. The
tumor is situated to the inner side of the femoral vessels in both forms.
The most characteristic symptoms are pain along the course of the
obturator nerve — that is to say, along the inner side of the thigh as
far as the knee — and the presence of a hard and tender swelling on the
inner side of the thigh, which in certain cases can be felt on vaginal
examination.
Treatment. — When there is strangulation, as is generally the case
before the hernia is recognized, attempts at reduction by taxis should
be made, which, if unsuccessful, should be followed by herniotomy.
The constriction is at the obturator foramen.
Perineal hernia is ver>^ rare, and is generally due to weakness of
the levator ani muscle. The tumor is formed in front of the rectum,
and in the case of females it may appear in the vagina or labium. The
tumor is always reducible, which distinguishes it from cysts or other
growths.
Diaphragmatic hernia is generally the result of a severe trau-
matism, as the passing of a cart-wheel over the abdomen or the
wound of a spear or saber. The symptoms are those of internal
strangulation, but in the majority of cases death occurs from the
severity of the traumatism and a diagnosis can seldom be made. If
under circumstances which would lead us to suspect rupture of the
diaphragm we find tympanitic resonance in the precordial region, with
interference with the heart's action, or over the pleura, with impaired
respiration, a diagnosis of diaphragmatic hernia will probably prove to
be correct.
VI. APPENDICITIS.
Arising from the lower and posterior part of the cecum is the
appendix vermiformis, a rudimentary form of the elongated cecum of
herbivorous animals. Its length varies from three to six inches, its
diameter is about half an inch. Dr. C. J. Ringnell in 200 autopsies found
the length to vary from two and a half to nine and three-quarter inches.
18
274 SURGICAL DIAGNOSIS AND TREATMENT.
By a nicscntcry of its own it is bound loosely to the back of the cecum,
in some cases to both cecum and ileum ; hence it is easily stretched or
twisted when these portions of the intestines are distended (White). It
is supplied by a sin<^le artery whose caliber is so small that stretching
or twisting readily produces occlusion.
The position of the appendix is not constant.
1. It is generally directed upward toward the termination of the
duodenum, and lies to the inner side of the cecum.
2. It is directed downward to the inner side of the cecum and into
the right iliac fossa.
3. It lies to the outside of the cecum, directed upward toward the
right kidney.
Much more rarely it is directed downward below the cecum, or it
enters the sac of a hernia, or runs directly inward to form an attach-
ment at the linea alba, as I once saw in the case of a young man who
had suffered many recurrences of appendicitis.
Inflammation in the appendix is a disease of common occurrence,
and of late years has received a great deal of attention. The terms
typhlitis, perityphlitis, paratyphlitis, and appendicular abscess have
almost become obsolete, since a constantly accumulating mass of
evidence goes to show that nearly all of the cases formerly classed
under these names are due to inflammation of the appendix with or
without suppuration. To say that there is no such thing as typhlitis
without appendicitis is to disregard clinical facts. Lanphear operated
on a case of supposed appendicitis, and found ulcer of the cecum with
perforation and perityphlitic abscess. The appendix was normal.^ It
would probably be correct to say that 98 per cent, of cases of peri-
typhlitis are due to inflammation of the appendix.
The appendix is composed of a serous peritoneal covering, a mus-
cular coat, and a mucous lining with a large proportion of lymphoid
tissue. To the presence of this lymphoid tissue is perhaps due the
clinical fact that so many cases of appendicitis occur in childhood and
youth.
The starting-point of appendicitis is from within, commencing as a
simple catarrh, and producing no local changes beyond a thickening
of the mucous membrane, and perhaps an accumulation of mucus.
From this point the disease may recede, pain, tenderness, and all other
symptoms disappearing. These are the mild cases which are often
pointed to as being successfully treated without operation. When the
inflammation results in suppuration, abscess, and peritonitis, we have
the disease presenting a variety of features, which will be spoken of
presently (see Fig. 130).
Causes. — I. The presence of a hard foreign body in the appendix,
such as a fecal concretion, the small seeds of fruit, fragments of bone,
etc. Although the presence of a foreign body is spoken of as the
most frequent cause, it is not a common thing to find such a body in
cases operated upon. Probably this cause has been over-estimated.
2. Catarrhal inflammation of the cecum and ascending colon. In
this class of cases the inflammation spreads by continuity of tissue.
As the mucous membrane becomes swollen the orifice becomes more
1 Ann. of Ufiiv. Med. Sciences, 1895, C. 35.
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INJURIES AND DISEASES OF THE DIGESTIVE SYSTEM. 275
and more obstructed, causing retention of the natural secretion of the
appendix.
3. As this secretion always contains putrefactive and pathogenic
organisms, the simple catarrhal inflammation readily becomes an
infective one (Barling).
Once suppuration begins, ulceration is a natural consequence.
Ulceration soon leads to perforation, and perforation to peritonitis.
Fortunately, against the effects of perforation Nature sets up her safe-
guards. As the infective inflammation reaches the outer coverings of
the appendix, adhesions begin to form, and the accumulating pus is
enclosed within strong walls, which prevent the bursting of an abscess
into the peritoneal cavity. Sometimes the adhesions occur so promptly
that the perforation is sealed, and a return to health takes place without
the formation of an abscess. In cases still more rare the inflammation
spreads so rapidly that no barriers can be raised, and the consequence
is a general peritonitis. Instead of ulceration of the appendix, the
inflammatory action may result in gangrene. Pressure of the exudates
on the v^essels from without and thrombosis from within can speedily
cut off the blood-supply to the whole or a part of this functionless
structure, which, at best, is endowed only with low vitality, and with
its blood-supply cut off quickly becomes gangrenous. As predisposing
causes typhoid fever and rheumatism have been mentioned. Age has
a decided influence, and about 50 per cent, of all cases occur between the
ages of ten and twenty-five. It is more common in males than females.
Symptoms. — The leading symptoms around which many others
group themselves are the following :
1. Severe localized abdominal pain, generally felt in the right iliac
fossa, sometimes over the whole abdomen.
2. Tenderness over the position of the appendix midway between
the umbilicus and the anterior superior spine of the ilium. We have
seen that the length and position of the appendix are subject to vari-
ations. It is only natural, therefore, that corresponding varieties should
be observed in the location of the symptoms. For instance, in 3 cases
reported by Fowler pain was more marked on the left side of the abdo-
men, especially at the outer border of the left rectus. At the operation
the appendix was found to the left of the rectus.' Too much reliance
must not be placed upon the presence or absence of tenderness at
McBurney's point, for there is no single point that can be definitely
named as the position of the appendix, or, for that matter, of the
cecum itself
3. A rise of temperature to 101° or 102° F. and a rapid pulse.
This temperature is reached in the first twenty-four hours and seldom
goes beyond. A temperature of 103° is very rare.
4. Nausea and vomiting.
These four symptoms we expect to find in ev^ery case of appen-
dicitis. Severe pain is present because there is inflammation in a
structure whose walls are dense and resisting. By reflex action this
pain is distributed widely over the abdomen through the sympathetic
plexuses. This widespread pain continues for from one to twelve hours,
after which it becomes localized in the right iliac fossa.
^ Ann. of Univ. Aled. Sd., c. 37, 1895.
2/6 SURGICAL DIAGNOSIS AND TREATMENT.
Now comes tenderness on pressure over the appendix. There are
the rapid pulse and high temperature peculiar to hectic fever, for
suppuration is going on. Vomiting is present in most cases. It may-
occur only once, and in any case it consists of the food last taken and
of bile. Persistent vomiting or persistent hiccough is a very unfavor-
able sign.
The patient generally lies in the dorsal position, with the lower
limbs extended, or the right may be drawn up to relieve tension in the
iliac fossa. Where there is general peritonitis both limbs are drawn up
and the abdominal walls are rigid.
5. Constipation is the rule, although diarrhea has been noted in a
few instances.
6. In about two-thirds of the cases a tumor is found in the right
iliac fossa. This does not necessarily prove the existence of an abscess.
In some cases it is the thickened appendix, the omentum, and intestine
matted together, or it may be the infiltration of the abdominal muscles
and fascia. Care must be taken not to mistake rigidity of the muscles
for a tumor. Anesthesia is a valuable aid in the examination, especially
in children, in nervous subjects, and in those whose abdominal walls
are thick.
It is customary to mention palpation by the rectum as a means of
detecting the presence of a tumor. I have never been able to derive
any information from this method, and have long ceased to employ it.
The cases in which such an examination proves of any service are prob-
ably those in which the appendix takes a direction downward into the
pelvis.
Neither can we expect much help from palpation of the appendix
itself, for, while it may be possible to detect it in the healthy subject,
the extreme tenderness and swelling which attend appendicitis will
render such a measure impossible during an acute attack. In relapsing
cases it has proved valuable when employed during the interval between
attacks ; and Ewald reports several cases in which palpitation enabled
him to settle the diagnosis. The pressure must be deep enough to
recognize the posterior abdominal wall and the brim of the pelvis
against which the appendix is felt. The beginning of the appendix is
found a little outside of a line drawn from the umbilicus to the middle
of Poupart's ligament.
7. Movements of the bladder may produce pain, as in the act of
micturition.
Differential Diagnosis. — Of the diseases from which appendicitis
must be distinguished I shall mention :
1. Pelvic inflammation in females. When a mistake is made, it is
because the surgeon has neglected the imperative duty of making a
vaginal examination. A diagnosis of appendicitis in a female should
never be entertained until pelvic inflammation, especially of the ovaries
and tubes, has been excluded. This, as a rule, is very simple : A fixed
uterus, hardness and infiltration of the pelvic floor, or enlargement of
tube or ovary leaves no room for doubt.
2. Intestinal obstruction. Appendicitis shows a rise of temperature
from the beginning ; intestinal obstruction of any kind has a normal
temperature until peritonitis has set in.
INJURIES AND DISEASES OF THE DIGESTIVE SYSTEM. 277
3. Typhlitis from accumulation of feces occurs in patients well
advanced in years ; there is a doughy, sausage-shaped tumor which
retains an indentation made by the finger. The local tenderness is not
so marked as in appendicitis.
4. Hepatic colic. The pain in hepatic colic is most intense at the
position of the gall-bladder, and radiates to the shoulder and the angle
of the scapula. In appendicitis the tenderness may at the outset be
widely diffused, but in a day or two it becomes localized in the right
iliac fossa. A history of repeated attacks, one or more of which have
been attended with jaundice, is strong evidence of hepatic colic. Vom-
iting is more persistent in the latter disease.
5. Renal calculus on the right side. Only when the examination
of the urine is negative and the pain is not localized, or when the pain
in appendicitis radiates toward the os pubis, scrotum, and testicles, with
tenesmus and dysuria, should there be room for doubt. In such cases
a little time will make the symptoms clearer, for the pain will become
localized in the right iliac fossa, proving appendicitis, or tenderness will
be manifested ov^er the kidney posteriorly, pointing to the kidney as the
seat of the affection. Fowler gives the following diagnostic points in a
tabular form :
Appendicitis.
Pain around the umbilicus and
in the epigastric region, not
radiating from these points ;
fixed painful point in the
iliac fossa.
Greatest tenderness in the
right iliac fossa, particu-
larly at McBurney's point.
Vomiting may be present, but
is usually not continuous.
The bladder and testicles are
very rarely symptomatically
tender or painful.
Hepatic Colic.
Pain in the epigastric region,
radiating to shoulder and
angle of scapula, arising
from the gall-bladder as
the fixed point.
Great tenderness below the
arch of the ribs ; slight ten-
derness over gall-bladder.
Vomiting frequent, and not to
be suppressed.
Bladder and testicles give no
symptoms.
Renal Colic.
Pain radiating to inguinal re-
gion and testicle, occasion-
ally to the rectum when at
stool ; also tenesmus.
Greatest tenderness behind,
over the pelvis of the kid-
ney; in front the maximum
point of tenderness is over
Poupart's ligament.
Vomiting is not a frequent nor
prominent symptom.
Bladder irritable ; dysuria and
tenesmus of the bladder ;
occasionally hematuria ;
testicle retracted.
All cases of appendicitis may be divided into four classes :
First class, mild appendicitis, in which neither abscess nor perforation
takes place. To this class probably belongs a majority of all cases.
They are not regarded as surgical cases, and form the basis of the
belief that appendicitis gets well without operation. The disease runs
a mild course ; the pain, local tenderness, vomiting, nausea, and fever
are not severe. The tumor, if present, is small, and all the .symptoms
abate in three or four days.
Second class, appendicitis attended with suppuration and the forma-
tion of an abscess. This class belongs to the surgeon, and affords him
support for the argument that the proper treatment for appendicitis
is an operation. The pain is severe, the local tenderness is marked,
there is fulness in the right lower quadrant of the abdomen, and sooner
or later a tumor appears at the point of tenderness.
There are special indications that suppuration is taking place. The
temperature goes up to 101° or 102° or 103° F. at night, and has a
278 SURGICAL DIAGNOSIS AND TREATMENT.
morning remission. In some cases there is a pronounced chill. If,
after continuing several days, the temperature should go still higher,
it is an indication that the septic infection is spreading to new localities.
The pulse gives still more valuable information. If at the end of three
or four days it continues to rise, reaching 110 or 120, the presump-
tion of abscess is very strong. The tumor becomes more prominent,
and, if allowed to take its course, redness of the skin, bogginess, and
fluctuation may appear, leaving no doubt that an abscess has formed.
Third class, perforating appendicitis presents some of the most per-
plexing problems which can confront the surgeon. Its symptoms are
often obscure, and, although operation is acknowledged to be the only
treatment of any avail, the decision to operate will often tax the judg-
ment of the most experienced. Much depends upon the position of
the appendix. If it happens to lie to the inner side of the cecum, per-
foration is speedily followed by symptoms that might be called explo-
sive in their character — sudden, unremitting pain, tenderness, and
tympanitic distention over the whole abdomen ; intense and persistent
vomiting with a pulse running up to no or 120, and a temperature
that suddenly bounds to 102° or 103°. When a case belonging to
another class assumes this character, we may strongly suspect that
perforation has taken place.
When the appendix, by good fortune, lies to the outside of or behind
the cecum or in a peritoneal pouch, adhesive inflammation plays an
important part. As soon as a drop or two of the contents of the ap-
pendix escape through a perforation the vicious fluid is fenced in by
adhesions, and the danger of general infection is greatly lessened.
Those who advocate operative treatment for every case of appendi-
citis find in this class their strongest argument. No matter how mild
a case may be at its outset, there always hangs over it three terrible
risks — perforation^ rupture, and relapse. In the hands of a good ope-
rator an incision which would reach the appendix is practically free
from danger. On the other hand, perforation or rupture is almost
certainly followed by death. Would it not be wisdom to anticipate
these risks and choose the course which affords the best prospect of
immediate cure and the only safeguard against recurrence ?
The operation in perforating appendicitis is practically the same as
in the suppurative form, except that when there is evidence of general
infection of the peritoneum an incision in the middle Hne will give a
better outlet. The fluid is often a milk-like serum rather than pus,
and here irrigation is not open to the same objection as in other
classes.
Fourth class, relapsing appendicitis. The appendix, even after a mild
attack, as well as the surrounding tissues, is more or less changed.
Adhesions take place, the tube may become narrow at one or more
places, or it may become kinked or twisted upon itself; all of which
may lead to retention of its secretions and render it liable to future out-
breaks of inflammation. The question of the most opportune time to
operate in relapsing cases is a difficult one. Generally the patient set-
tles the point by appealing to us only during an attack. This is
probably the best time, but operations during intervals are, on the
whole, satisfactory.
INJURIES AND DISEASES OF THE DIGESTIVE SYSTEM. 2'jg
Bull has collected 480 operations of this kind with 8 deaths, or a
mortality of 1.77 per cent. He estimates that 5 or 6 per cent, would
be more nearly correct.'
Appendicitis obliterans has been described by Prof Senn as forming
a class of cases in which the lumen of the appendix becomes gradually
obliterated by relapsing disease. This classification seems unnecessary.
In a functionless and rudimentary structure like the appendix oblitera-
tion would, a priori, be a natural process. This assumption is borne
out by the result of 400 autopsies made by Ribbert (death being due
to other causes than appendicitis) in which partial or complete oblitera-
tion was found in 25 per cent.
Prognosis. — In a total of 364 cases Wyeth calculates the mortality
of appendicitis at 18 per cent. The mortality from operations made in
the interval between attacks is probably 5 or 6 per cent. (Bull).
Treatment. — The treatment of the first class of cases is debatable
ground. Granted that the majority of all cases are of this kind, and
that they get well under medical care in three or four days, there is still
the question of recurrence. An appendix which has been the subject
of one attack is a perpetual menace.
According to the statistics of Sahli, Hollander, Fiirbringer, Leyden,
Reavers, Guttman, and Rotter, 90 to 91 per cent, of all cases of peri-
typhlitis get well without an operation. On the other hand, many
surgeons resort to operation as soon as they make a diagnosis, no
matter how early in the disease or how mild the symptoms. Between
these two extremes we must endeavor to find a golden mean.
The operation in the hands of a skilful operator has a low mortality;
but another consequence of surgical interference must be taken into
account, and that is the risk of hernia. On the other hand, every case
treated without operation has to run the risk of possible rupture during
the attack and of relapse after the patient recovers.
The third day, at the latest, should decide the question. If by that
time the symptoms are abating, do not operate, but watch the case
closely. If on the third day the case continues to grow worse or shows
no signs of improvement, operate. In spite of every care there are
cases in which grave doubts must exist as to the propriety of operation ;
but, as Helfrich tersely expresses it, " It is always better to say, ' The
patient might hav^e recovered without operation,' than to say, ' The
patient might have been saved by operation.' "
There are certain indications for operation which the most con-
servative physicians will admit : First. When there is perforation
followed by peritonitis. Many of these cases are the penalty of ultra-
conservatism. Second. When there is evidence of a collection of pus.
Third. When there are the current attacks increasing in frequency
and severity.
In the early stages of all classes of cases the first essential is perfect
rest in bed. The horizontal position should be persistently maintained,
the patient not being allowed to get up for micturition, defecation, or
for any other cause. The diet should be easil}^ digested fluids. The
practice of giving a purgative should be condemned. Fecal impac-
tion in the cecum is not so common as was formerly supposed ; hence
' Ann. of Univ. Med. Sciences, 1895.
28o SURGICAL DIAGNOSIS AND TREATMENT.
a purgative to remove impaction is unnecessary. The better course
is to relieve the bowel by enemata without causing much distention.
Warm fomentations locally afford great relief When, in spite of
these measures, pain is very severe, the indication is not to give opium,
but to operate.
In the second class of cases (those attended with suppuration and
abscess) the proper course is undoubtedly to operate. Wyeth states
that in his entire experience he has yet to see a death which could not
be properly ascribed to delay in timely and skilful surgical interference.
The diagnosis of pus may be confidently made when the tumor begins
to increase, the temperature showing morning remissions and the local
tenderness persistent. Fluctuation and edema should not be waited for.
The operation for appendicitis is performed as follows : An incision
is made in an oblique direction through the skin, crossing a line drawn
from the antero-iliac spine to the umbilicus, nearly at a right angle and
one inch from the iliac spine (McBurney). This is in the direction of
the fibers of the external oblique, which can be separated without cut-
ting. The wound is now held open by retractors, and divisions of the
internal oblique and transversalis effected in a similar manner along the
direction of their fibers. The advantage of this mode of dividing the
abdominal wall is that the action of the muscles tends to close rather
than retract the edges of the wound ; hence the chances of subsequent
hernia are greatly lessened. It is only suitable, however, in simple
cases without suppuration.
The position of the incision in suppurative cases must depend upon
circumstances. It should be oblique and over the most prominent part
of the tumor. Two inches in length is sufficient in most cases, though
others will require three or four inches. Pus wells up as soon as the
abscess is reached. The patient should be turned on to his right side,
and the abscess-cavity mopped out with gauze. Irrigation should not
be employed, le.st septic matter be carried into the general peritoneal
cavity. Having evacuated the pus, the finger is passed into the wound,
and search made for the appendix and for foreign bodies. The ana-
tomical guide to the appendix is the anterior longitudinal band of
muscle in the cecum which leads to the base of the appendix. When
the appendix is found, it should be ligated near the cecum and removed.
If it does not appear readily, no lengthened search should be made for
it, as drainage of the abscess-cavity will be sufficient to dispose of all
necrotic tissue, including the diseased appendix. The cavity should be
drained from the bottom, either by strips of iodoform gauze or by a
good-sized drainage-tube, around which gauze should be packed. The
wound can be materially reduced in size by inserting a few silkworm-
gut sutures, leaving sufficient room in the most convenient place for
drainage.
In the after-treatment of cases operated for appendicitis I would
draw attention to two points :
I. Fecal Fistula. — This is a complication which is likely to arise
when the operation has been delayed till a large abscess has formed or
when the drainage is not thorough. To the young or inexperienced ope-
rator the escape of intestinal gases from the wound or the appearance
of fecal matter therein is perfectly appalling. Experience, however,
INJURIES AND DISEASES OF THE DIGESTIVE SYSTEM. 28 1
has proved that such fistulae close of their own accord, and all that is
needed is a little patience on the part of the surgeon and the afflicted one.
2. Deficient Drainage. — It may happen that after the operation the
symptoms improve, and eveiything appears to point to a favorable
issue, but at the end of a day or two the temperature rises, the pulse
increases in frequenc}', pain returns, and the abdomen becomes tym-
panitic. These symptoms indicate either the retention of pus or the
formation of an abscess in a new location. The proper course to
follow under such circumstances is to pass the finger into the opening
and break up any adhesions that may have formed since the operation.
You will generally find one or more pus-cavities. In one case of
appendicitis I opened up the wound three times in this manner, and
saved the patient's life. Sometimes nature comes to the patient's relief
by allowing the concealed abscess-cav^ity to discharge into the bowel,
and thence per viavi naturalcin.
VII. DISEASES AND INJURIES OF THE PERITONEUM.
The peritoneum is a serous membrane almost equal to the skin in
its extent. While the skin is an organ which throws off waste material,
the peritoneum absorbs the fluids with which it comes in contact,
readily disposing of large quantities, and showing no discrimination
between poisonous and benign substances. Hence septic or poisonous
fluids are readily taken up and carried to the general circulation. The
free movements of the membrane have also an important clinical
bearing. It slides over the abdominal organs, and its own surfaces
ghde smoothly over one another, so that an infection which at first is
purely local is likely to become general in a short time. Another
important characteristic of the peritoneum is the readiness with which
it forms adhesions. Thanks to this power, septic foci are walled off
and the success of many surgical operations is assured.
So closely is the peritoneum associated with many of the abdominal
organs that disease of these viscera is almost certain to extend to the
serous membrane.
Examination of the peritoneum is very satisfactorily conducted by
inspection, palpation, and percussion.. In a systematic examination the
following questions should be settled :
I. Is the peritoneum distended?
Two conditions can produce distention of the peritoneum — viz.
escape of gas from the stomach or intestine and a collection of fluid —
ascites. Escape of gas into the peritoneal cavity, technically named
meteorismus peritonei, is always to be regarded as a very serious matter,
and always leads to peritonitis. The abdomen is distended and tym-
panitic, the pitch varying according to the degree of tension. This,
however, can be said of tympanites from gas within the intestine.
How, then, are we to decide the question as to whether the gas is con-
tained in the intestine or free in the peritoneal cavity ? By percussion
over the liver and spleen. If the gas be free in the peritoneal cavity, it
will come in front of these solid organs, and there will be no liver or
splenic dulness. If it is contained within the bowels, liver and splenic
dulness will be present. The liver may be displaced upward by the
282 SURGICAL DIAGNOSIS AND TREATMENT.
distended intestines, but it will nevertheless be recognized by dul-
ness.
When free fluid in the cavity is the cause of distention it gravitates
to the most dependent parts. At the beginning it is confined to the
peh-is (while the patient is standing), and gradually rises until it gives
a dull area and produces bulging in the lower part of the abdomen.
When the patient lies upon his back the fluid, gravitating to the most
dependent parts, causes the sides to bulge outward, while the intestines
and stomach float like air-balloons upon the water, and give a tym-
panitic note in the anterior portion of the abdomen. Ask the patient
to lie upon one side and then on the other, and in each case the fluid
will settle to the lowest part, and give a dull percussion-note, while the
intestines as promptly float and give a hollow sound.
Fluctuation or undulation is another important feature of ascites.
Place one hand flat upon the abdomen, and with the fingers of the
other hand gently tap the abdominal wall at a distant point, and the
waves of fluid can be felt and even seen. In people whose abdominal
walls and omentum are loaded with fat there is a tremulous movement
which may be mistaken for true fluctuation. When, owing to a large
amount of fluid, there is much distention, it may be impossible to elicit
fluctuation.
If fluid be present, it is either free or encysted. When free the ease
with which it gravitates to the dependent parts is very characteristic.
When encysted there is a feeling as if a ball were grasped within the
hand, or the tumor formed by the encysted fluid may have an elonga-
ted form ; tension is usually greater, and consequently fluctuation is
indistinct. Cystic ovaries, the pregnant uterus, and a distended bladder
all rise in front of the abdomen, pushing the intestines back, and when
the patient lies on the back the front yields a dull sound (Fagge).
2. Is the peritoneum inflamed ? Peritonitis, or inflammation of
the peritoneum, is generally described as primary and secondary, but
the opinion is gaining ground that most if not all cases are of secondary
origin. That is to say, there are no cases of idiopathic peritonitis,
there being an exciting cause in every instance, the recognition of
which is essential to a rational line of treatment. The disease is also
divided into acute and chronic varieties.
Surgically, we are deeply interested in peritonitis on account of its
frequency after many operations, such as celiotomy, lithotomy, lith-
otrity, and litholapaxy. We also meet with it as an extension of
disease or injury from the abdominal viscera. A perforation of the
stomach or intestines with escape of contents is with certainty followed
by general peritonitis. Septic infection can travel up the uterine canal
and by way of the Fallopian tubes gain access to the peritoneum. A
perforating appendicitis is responsible for many cases of peritonitis.
Plastic Peritonitis. — A very interesting feature about the peri-
toneum is its power to protect itself and other structures by throwing
out plastic material which acts as a barrier to advancing disease or
infection. This should not be classed as an inflammation, but rather as
a regenerative process. Should the peritoneum be wounded or bruised
or irritated by chemical substances, without the presence of septic
infection, the result is generally purely local. The action of the peri-
INJURIES AND DISEASES OF THE DIGESTIVE SYSTEM. 283
toneum is at once changed, so that, instead of absorbing, it secretes,
and its secretion is fibrinous material, which becomes organized and
forms adhesions between portions of the peritoneum itself or serves to
bind the membrane to neighboring organs. These adhesions may
afterward be absorbed or they may remain as permanent structures.
Examples of non-septic peritonitis are met with in aseptic wounds or
other traumae of the peritoneum, the application of chemical irritants,
the twisting of the pedicle of a tumor, the escape of aseptic contents of
an ovarian tumor, and the strangulation of a hernia.
This form of peritonitis being generally localized, the symptoms
which manifest its presence are localized pain and tenderness, rigidity
of the abdominal lua/l at that point, and the presence of more or less
fever. The rise of temperature is due to resorption, the fermentative
fever so commonly seen after operations, and in no way connected
with suppuration. The symptoms appear in from six to thirty-six
hours after the receipt of an injury. Collapse may at first mask the
symptoms of peritonitis, but they become apparent when reaction
sets in.
The treatment of non-septic peritonitis consists in perfect rest in the
recumbent posture, the use of hot fomentations and, if necessary,
opiates.
Septic Peritonitis. — Two things are necessary to produce septic
peritonitis : first, the entrance of bacteria, and second, the peritoneum
must have lost its absorptive power. The JiealtJiy peritoneum has a
marvellous power of absorbing and disposing of bacteria, so that con-
siderable numbers of germs can enter the peritoneal cavity without
producing septic inflammation ; but let the membrane once lose its
power of absorption, and infection readily takes place.
The bacteria which are generally found in such infections are the
pyogenic germs, but the common colon bacillus is so frequently present
in cases of intestinal origin that some have thought it of diagnostic
importance. Bacteria which produce peritonitis are sometimes spoken
of as specific and non-specific. Of the specific germs, the tubercle
bacillus occupies a most important position. The infection of syphilis
seldom figures as a cause of peritonitis. Of the non-specific organisms,
the pyogenic germs are most commonly found. Even they cannot
produce peritonitis except when the amount of fluid which they con-
tain is so great and the germs are produced so rapidly that the tissues
cannot deal with them (Grawitz). This comes back to the second
essential already stated, an inadequacy of the absorptive power of the
peritoneum. The bacteria reach the peritoneal cavity, either directly
through an opening in the abdominal wall, as in celiotomy, or from
parts which are covered by peritoneum and communicate with the
exterior of the body, as the intestinal canal and the genito-urinary
tract ; or they may find their way upward through the open mouths
of the Fallopian tubes, as is demonstrated in that terrible disease, puer-
peral peritonitis ; or it is possible that they may come from remote
points of the body, carried through one or more of the innumerable
blood- or lymph-channels.
The peritoneum may lose its power of absorption, and thus supply
the second essential — {a) by being bruised or wounded, {b) by being the
284 SURGICAL DIAGNOSIS AND TREATMENT.
seat of a pre-existing disease, or (r) by disease spreading from an organ
to the peritoneum which covers that organ. Both of the essentials are
well illustrated in perforation of the intestine ; numberless bacteria are
admitted to the peritoneal cavity, and the rupture which lacerates the
peritoneum deprives it of its absorptive power.
Sy)npto})is. — Pain is the most prominent of all the evidences of peri-
tonitis. In cases due to perforation of the stomach or intestine the
patient may declare that the pain set in with a tearing sensation. It is
nearly always sudden, and in most cases intense, cutting, or griping.
The slightest motion aggravates it, and the unhappy sufferer guards
against even such innocent movements as coughing or breathing, while
vomiting is perfect torture. To guard against the slight motion of the
abdominal muscles he draws his limbs up in bed, flexing the thighs
upon the abdomen. So tender is he to pressure that the weight of his
bed-clothes is unbearable, and the idea of examining his belly by
manipulation fills his soul with horror. The fixation of his abdominal
muscles causes him to resort entirely to thoracic respiration, and the
chest rises and falls while the abdomen is perfectly still. The diaphragm
cannot descend without producing pain ; consequently the breathing is
rapid and shallow, reaching as high as forty, fifty, or even sixty, instead
of eighteen or twenty, in the minute. It is scarcely necessary to press
upon the abdominal wall to look for tenderness. If you need to do so,
lay the hand gently upon the abdomen and watch the expression of the
patient's face, which will indicate pain before he can express his sensa-
tions in words. Sooner or later the abdomen begins to swell and
becomes tympanitic ; hiccough is not uncommon ; quantities of dark-
colored liquid are raised from the stomach without effort or, it may be,
expelled by distressing vomiting. Pinched and anxious from the first,
the face assumes a ghastly appearance ; the eyes become sunken ; the
pulse becomes more and more feeble, and may be imperceptible at the
wrist for twenty-four hours before the end. The condition of collapse
supervenes and death closes the scene, the mind in many cases remain-
ing clear until the last.
When the body is examined after death little change is seen in the
appearance of the peritoneum, and a small amount of serous fluid is all
that is found in the cavity. But this fluid is intensely poisonous. Shun
it as you would the venom of a rattlesnake. Such is the form of peri-
tonitis seen in that awful disorder puerperal fever, and also after some
abdominal operations.
When fully developed, septic peritonitis is almost absolutely certain to
prove fatal, and the most we can do is to palliate the patient's sufferings.
In the universal rush to the operating-table these cases have not been
made an exception, but, so far as my experience and observation have
gone, abdominal section and unlimited flushings have proved of little
avail. In the way of prevention, however, which is so much better
than cure, there is everything to be hoped for. As accoucheurs form
the habit of attending confinements with as strictly aseptic precautions
as they would conduct a major operation, as nurses abandon filthy
syringes and learn to hQ surgically clvau, septic peritonitis will gradually
but surely disappear.
After abdominal section it is not uncommon to find tympanites set-
INJURIES AND DISEASES OF THE DIGESTIVE SYSTEM. 285
ting in, which may possibly be the beginning of septic peritonitis.
Experience has shown that the best treatment in such a case is the
administration of a saHne cathartic, such as a Seidlitz powder or a one-
grain pill of calomel, every three hours till the bowels move. Such a
course is often rewarded by finding at the next visit a perfectly flat
abdomen and a happy patient.
Suppurative peritonitis is practically the same disease as septic
peritonitis, the only difference being that in the suppurative form the
process is less rapid, and pus has time to form either in localized
abscesses, walled off by adhesions, or in one large collection in the
general peritoneal cavity. Septic peritonitis is general, and results in
death before suppuration has time to declare itself Suppurative peri-
tonitis is more likely to be localized, and is therefore more amenable to
surgical treatment. Pain is very severe ; there is usually a chill to
usher in the disease; and the temperature rises to 102° or 104° F.
In perforative cases gases in large quantities collect in the cavity,
causing distention of the peritoneum, and are recognized by absence of
liver and splenic dulness, as already mentioned. When pus collects in
considerable quantity, its presence can be detected by dulness on per-
cussion in the most dependent portions, just as in the case of ascites.
Vomiting and constipation are the most characteristic symptoms, and
so pronounced are they that we often have to decide the question as
to whether the case is suppurative peritonitis or intestinal obstruction.
To do so we must remember that in obstruction a tumor may be felt,
the movements of the intestinal coils can be seen through the abdom-
inal walls, the temperature is not high from the beginning, and as time
goes on the vomiting becomes fecal in character. Temperature is not
an infallible guide, for while the rule is that in peritonitis it is high and
in obstruction not raised above normal (except there be complications),
some of the worst cases of peritonitis are free from a rise of tempera-
ture throughout their course.
Treatment. — To guard against suppurative peritonitis the greatest
care must be observed in the details of all abdominal operations.
Asepsis must be observed most scrupulously, the peritoneal toilet must
not be lost sight of, complete arrest of hemorrhage must be ensured,
and the cavity dried with aseptic sponges. Should there be infection
already established or a likelihood of a collection of serous or sanguin-
eous fluid, a drainage-tube must be employed. At the slightest indi-
cation of peritonitis a saline cathartic should be given, the action of
which is increased by the use of turpentine enemata. Opium in such
cases is to be avoided.
Perforative peritonitis requires a somewhat different line of treat-
ment. It would make matters worse were we to increase the peristaltic
action ; consequently, purgatives of every kind must be avoided and a
judicious use of opium resorted to. If a diagnosis of perforation be
made, the repair of the perforation by operative measures should be
attempted. With this object in view an incision is made in the linea
alba, unless the point of the disease can be located elsewhere. If the
opening in the intestine cannot be readily found, recourse should be
had to the hydrogen-gas test. The rent is to be closed by sutures, as
already described under Rupture of the Bowel, the abdominal cavity
286 SURGICAL DIAGNOSIS AND TREATMENT.
thorouglily flushed with Thiersch's solution, a drainage-tube inserted,
and the wound closed and dressed.
Fibro-plastic peritonitis is a variety characterized by a tendency to
numerous adhesions. The disease is probably identical with septic
peritonitis, except that there is not a general intoxication of the system
by ptomains, owing to a less violent character of the bacteria or a
greater resisting power of the system. It commonly terminates in
localized suppuration.
Tubercular Peritonitis. — Tuberculosis may attack the peritoneum
simultaneously with other structures, such as the lungs, the bones, or
the joints. These cases are not of surgical interest. It is also a fact
that the peritoneum may be attacked primarily, and remain the only
seat of the disease. In this form it is of the greatest interest to the
surgeon, since it has been found amenable to treatment in a very
satisfactory degree.
The disease is not limited to any particular period of life, but follows
pretty much the same law as tuberculosis of the lungs, the majority of
cases occurring between the ages of twenty and forty. In the diagnosis
of tubercular peritonitis we must not expect to find the disease follow^-
ing a uniform course in every case. Osier makes the following classifi-
cation :
1. Acute miliary tuberculosis, characterized by a sudden onset, a
rapid development, and a serous or sero-sanguineous exudation.
2. Chronic, caseous, and ulcerating tuberculosis, characterized by
larger tuberculous growths which tend to caseate and ulcerate, leading
often to perforation between the intestinal coils, and by a purulent or
sero-purulent exudation, often sacculated.
3. Chronic fibro-tuberculosis, which may be subacute from the out-
set, or it may be the termination of the miliary form. This variety is
attended with slight exudation if any. The tubercles are hard and pig-
mented. Although this classification is based on a correct pathology,
w^e have no means by which we can differentiate from a clinical stand-
point.
The diagnosis of tubercular peritonitis is not always easy. Bearing
in mind the manner in which tuberculosis acts elsewhere, we are pre-
pared to find it following a slow and chronic course. There are cases,
however, in which its development is rapid. We may reasonably look
for the leading symptoms by which we detect ordinary peritonitis — viz.
pain, tenderness, tympanites, fever, etc. — but these have not here the
significance which attaches to them in the other varieties of peritonitis.
They may be sudden in their onset, or they may come on so slowly
that distention of the abdomen is the first symptom to attract attention.
All the symptoms may be apparent at one time, and then subside.
This is just like tuberculosis, for do we not find in pulmonaiy phthisis
that a patient has his periods of improvement and decadence? Pain is
usually slight, but in exceptional cases very severe, and tenderness
to pressure is in direct proportion. The temperature is also variable.
As a rule, there is little elevation, and generally we find it in proportion
to the pain and tenderness. Enlargement of the abdomen may be due
to ascites or to meteorism or both. Should peritoneal adhesions take
place, collections of fluid may thus be encapsulated, giving the appear-
v\
INJURIES AND DISEASES OF THE DIGESTIVE SYSTEM. 287
ance of cystic tumors. Even when the distention is due to meteorism,
round elastic tumors can be felt, which do not change their position
when the patient is moved to one side or the other. These tumors are
formed in a variety of ways. Coils of intestine may become adherent
and form a mass resembling a solid abdominal tumor ; the omentum
may become thickened and curled upon itself; mesenteric glands,
especially in children, are liable to be the seat of tubercular enlarge-
ment and attain considerable size, and circumscribed collections of
fluid walled in by strong adhesions constitute the last class of these
deceptive tumors. The abdominal wall is frequently found to have
more than a normal resistance, due to a thickening of the peritoneum.
Vaginal or rectal examinations will also demonstrate a thickening of
the membrane.
A sign of great importance in the diagnosis of tubercular peritonitis
is an erythema which in some cases surrounds the umbilicus. This
is regarded by Dr. Henry ^ as pathognomonic, and is shown in Fig.
Many diseased conditions may be mistaken for tubercular peritonitis.
In fact, a large proportion of the cases which have been operated upon
have been incorrectly diagnosed. The errors have been fortunate ones,
for by them surgeons have stumbled on a treatment which is very suc-
cessful. In 1864, Spencer Wells, operating upon what he supposed to
. be an ovarian tumor, found on opening the abdomen that the fluid was
free in the peritoneum, while the membrane itself was studded with
miliary tuberculosis. The patient recovered, and was free from disease
twenty-six years afterward.
Against tubercular peritonitis the following must be carefully differ-
entiated :
1. Abdominal tumors. An ovarian cyst has many points in com-
mon. In it, however, there is generally a freedom from pain, tender-
ness, and fever until the tumor has attained to a larger growth.
Bimanual examination will also prove of value in the majority of
cases. Pyosalpinx or hydrosalpinx has its characteristic attacks
of localized pain, a history of disordered menstruation, and the cha-
racteristic tumor felt on examination. Pyonephrosis and hydronephro-
sis have their renal manifestations. An enlarged gall-bladder is con-
nected with the liver, and ascends and descends with respiration.
Malignant tumors in the abdominal cavity are usually more rapid
in their progress than tubercular peritonitis, and frequently are but
extensions of the disease from other parts.
2. Ascites of non-tubercular origin. This may be excluded by
taking into consideration the etiology of ascites. The condition of
the liver, the existence of jaundice, and a careful examination of the
urine will generally settle the point.
3. Typhoid fever. Acute tubercular peritonitis may closely simu-
late typhoid fever. The points which aid in differentiation are — the
absence of typhoid spots, the less constant diarrhea, the absence of
the typical remissions of temperature, and the non-limitation of the
point of tenderness to the cecal region.
In spite of every precaution the case may puzzle the most expe-
1 htternational Clinics, vol. iv. 5th series. •
288 SLKG/CAI. lUAGXOS/S AND TREATMENT.
riciiccd, and the real state of matters be only found after oi)eninic)it. — A child subject to prolapsus should be prevented from
straining at stool. He should have an attendant who will remove him
from the commode as soon as the bowels are evacuated. When the
bowel protrudes it should be wiped with a soft cloth wrung out of
cold water, gently pushed back, and retained by a T-bandage or by
broad strips of adhesive plaster applied so as to keep the buttocks
together. I have found great benefit from the use of astringent injections
given once a day. Alum, gallic acid, or hydrastis serves the purpose.
These children are usually debilitated, and require iron tonics and
cod-liver oil to build them up and improve their general health. Con-
stipation should be prevented by the judicious use of a mild laxative.
When the prolapsed bowel remains down in spite of the ordinary efforts
of the nurse or mother to return it, the aid of the physician is sought.
The best position for reduction is on the knees and elbows. The bowel,
having been washed with cold water, is anointed with vaselin. The
surgeon then inserts his finger into the rectum, and by taxis practised
around the finger the bowel easily slips back to its normal position
(Mathews).
Sometimes the bowel goes up more readily if the finger is covered
with a soft handkerchief or a piece of lint. Should these measures
fail, give an anesthetic, w'hich, by quieting the voluntary movements
and relaxing the sphincter, allows the bowel to go back without dif-
ficulty. To prevent a recurrence several operative procedures have
been recommended. The mucous membrane may be cauterized in
strips by solid nitrate of silver or nitric acid. The cautery has been a
favorite remedy with many surgeons, owing to the contraction which
follows its application. It should be applied in the long axis of the
bowel in four lines a quarter of an inch wide (Cripps). After the
cautery has been quickly passed over the surface in this manner a tube
is passed into the rectum a distance of five or six inches, and the space
around it packed with iodoform and absorbent cotton. The bowels are
kept quiet by opium for about ten days, and defecation allowed only
while lying on the side.
In aggravated cases a more radical operation may be called for, and
we have a choice of several procedures : {ci) One or more of the folds
of the mucous membrane may be removed by the clamp and cautery.
(^) A V-shaped piece may be removed from the sphincter and the
edges brought together by sutures, {c) A V-shaped portion is removed
from the posterior part of the sphincter and the entire thickness of the
rectum, having a common base below (Roberts). (^) The protruded
mucous membrane may be excised and the lower edge of the remainder
attached to the skin (Treves).
INJURIES AND DISEASES OF THE DIGESTIVE SYSTEM. 329
Pruritus Ani. — A complication of many diseases of the rectum
and anus is a very distressing itching. In some cases this disagreeable
sensation is constantly present. In others it is quiescent during the
day, but just as the patient is getting warm in bed and sleep begins to
steal over him an intolerable itching around the anus begins, and he
spends a wretched night. Scratching makes matters ten times worse.
After enduring this torture for an indefinite time, the patient consults
the physician for what he terms " itching piles." Examination shows
thickened, hardened, excoriated skin around the anus, often eczematous
from constant irritation, and the patient can scarcely keep his fingers
off, so urgent is the desire to scratch. Further investigation will lead
to the discovery of hemorrhoids, prolapsus, stricture, or other rectal
disorder. Sometimes the only apparent derangement is a mucous
secretion which keeps the parts moist. Many people suffer only during
periods of constipation or when the functions of the hver are being
imperfectly performed, and in others the affection is a pure neurosis.
Alcohol and highly seasoned foods have been known to act as exciting
causes, and women suffering from uterine diseases appear to form a
large class of cases.
The itching is most intense just inside the anus, and extends about
an inch up the rectum. The inferior hemorrhoidal nerve supplies this
area as well as the skin in the neighborhood of the anus, which
explains anatomically why the itching so uniformly extends over these
surfaces.
Treatment. — The treatment of pruritus is .very unsatisfactory and its
results uncertain. When it is possible to ascertain and remove the
cause this should be done. If thread-worms are present, injections of
the infusion of quassia should be employed. Whatever rectal diseases
coexist should receive prompt treatment. For the relief of the itching
I have found nothing so generally useful as calomel, either applied in
powder or made into an ointment with vaselin. Inasmuch as the most
trouble is experienced after the patient goes to bed, Mathews recom-
mends that the parts be bathed in water as hot as can be borne, then
wiped dry and the following lotion applied :
3^. Campho-phenique, 3j ;
Aquae dest., 3J. — M.
Morain paints the parts night and morning with a mixture con-
taining 60 grains of alum, 30 grains of calomel, and 300 grains of
glycerol.
To produce sleep 10 grains of sulphonal may be given.
Local applications, however, will produce no permanent benefit as
long as there is a thickened and scaly condition of the skin. To get
rid of this the tincture of iodin is applied and renewed in two or three
days, or a solution of nitrate of silver 20 or 30 grains to the ounce.
After the removal of the scarf skin local applications of a milder
nature can be used. Some of the preparations of tar have been very
popular, as the oil of cade or marine lint (which contains tar) placed
between the buttocks to prevent their apposition. A lotion containing a
mixture of menthol and cocain and an ointment of oxid of zinc and
330 SURGICAL DIAGNOSIS AND TREATMENT.
balsam of Peru arc favorite applications. Bulkley's ointment is the
following :
^. Ungt. picis, Siij ;
Untjt. belladonnae, Sij ;
Tinct. aconiti rad., 3ss ;
Zinci oxidi, 3j ;
Aquae rosae, 3iij.
After the disease has resisted every other treatment it may be cured
by dilatation of the sphincter or by the wearing of a bone plug which
keeps the anus slightly distended during the hours spent in bed.
Inflammatory Diseases of the Rectum. — Inflammation in and
about the rectum not only produces painful and troublesome conditions,
but leads to secondary affections. Thus proctitis, or inflammation of
the mucous membrane of the rectum, is likely to end in ulceration,
while periproctitis paves the way for fistula in ano.
Proctitis is a catarrhal inflammation of the mucous membrane of
the rectum, and is due to irritation or infection. Among the causes,
therefore, we find the abuse of purgatives, the presence of foreign
bodies or hardened feces in the rectum, gonorrhea, gout, and syphilis.
The disease may be acute or chronic. In the acute form the inflam-
mation does not go deeper than the mucous membrane, which is
congested and hyperemic. When the cause can be removed this
variety gets well in from eight to fourteen days. In very exceptional
cases, however, it may go on to gangrene of the bowel and end in
death. In the chronic form the submucous and muscular layers are
involved, the bowel-wall becomes thickened and infiltrated, and fre-
quently the disease goes on to ulceration.
Symptoms. — A sensation of burning and heaviness in the rectum is
a pretty constant symptom. Naturally, this burning is attended with a
frequent inclination to have a movement of the bowels ; the action is
painful, and attended with tenesmus. Neighboring organs sympathize ;
hence there is pain in the bladder, and frequent micturition, pain in the
uterus with leukorrhea, pain in the sacrum, in the loins, and along the
thighs. An examination of the parts will show that the anus is
inflamed, painful, excoriated, and contracted. The mucous membrane
of the rectum is intensely congested, and the temperature, even to the
examining finger, is greatly increased. The feces are streaked with
mucus, blood, and finally with pus. As a result of all this local dis-
turbance there are constitutional effects, as fever, nausea, and loss of
appetite. In chronic proctitis the symptoms are not so well marked.
Diarrhea may alternate with periods of constipation. The pain is not
so severe as in the acute variety. It is generally associated with stric-
ture of the rectum. Below the stricture the mucous membrane is con-
gested and covered w4th pus or bloody mucus, while above it is eroded
or destroyed (Kelsey).
Ulceration of the rectum is caused by the irritation of foreign
bodies or the passage of hard, scybalous masses, or it is a conse-
quence of chronic proctitis. Thrombosis and phlebitis are also causes.
The ulceration may be superficial, simply involving the epithelial lining.
INJURIES AND DISEASES OF THE DIGESTIVE SYSTEM. 33 1
or it may be so deep as to perforate all the coats of the bowel. This
is, of course, a serious matter, but much depends upon the position of
the perforation. If it is low down, it leads to abscess and fistula ; if it
is above the reflection of the peritoneum, a fatal peritonitis is a probable
termination.
Syphilitic, tubercular, and lupoid ulceration are not uncommon in
the rectum.
We know that ulceration of the bowel higher up, such as occurs in
typhoid fever, is attended with diarrhea. The same symptom attends
ulcer in the rectum. In the early and milder stage the patient has a
•call to stool as soon as he gets out of bed. He passes a small quantity
of liquid feces containing mucus like the white of an &%^. Once or
twice in the forenoon this is repeated. The rectum is now empty, and
the rest of the day is spent in comparative comfort. The condition is
apt to get worse ; diarrhea increases in frequency and is attended with
painful straining ; from mucus the motions change to a dark coffee-
ground material ; the skin about the anus is constantly moist, covered
with vegetations and excrescences, giving rise almost invariably to
itching. When you make a local examination you find that if the
ulcer is about the anus, it takes the form of a fissure, which is usually
exceedingly tender. If inside the sphincter, the ulcers lie deep between
the folds, and so sensitive are the parts that for an examination with
the speculum an anesthetic is required. The finger, however, is gen-
erally sufficient, and it should be introduced with the greatest gentle-
ness. The point of the finger will meet with a variety of conditions :
in one part are felt soft, smooth patches with ragged, overhanging
edges ; in another hard nodules project from the surface or dense
bands of cicatricial tissue traverse a part of the circumference of the
bowel, simulating stricture. When the finger is withdrawn it is usually
smeared with mucus and blood. An ulcer due to syphilis is found near
the verge of the anus, and makes its appearance during the first year
after the contraction of the initial lesion. Inherited syphilitic ulcer
appears three or four months after birth. The tertiary stage has also
its rectal ulcers which are due to the breaking down of gummata. The
tubercular ulcer may occur as a primary lesion or as a secondary mani-
festation of tuberculosis in other parts. It is oval in shape, its long axis
corresponding to that of the bowel ; its edges are ragged and under-
mined, and it often ends in fistula and abscess.
Treatment. — Removal of the cause and the securing of perfect rest
are the first requisites. Injections which will cleanse and soothe the
bowel are very useful. A solution of chlorate of potash, followed by
an enema of starch and a few drops of laudanum, gives great comfort
in the milder cases of proctitis. A dose of castor oil or small doses of
a saline aperient should be given to remove acrid contents of the bowel.
The diet should be light and easily digested, and such articles avoided
as tend to form bulky stools. Bread, meat, and vegetables are to be
avoided. Milk, soft-boiled eggs, and prepared foods are generally
satisfactory. In chronic cases astringent injections of alum, tannin,
nitrate of silver, and suppositories of iodoform are recommended.
Constitutional treatment must be directed to the existing conditions.
Syphilitic cases require iodid of potash. Cod-liver oil is valuable, as it
33^ SURGICAL DIAGNOSIS AND TREATMENT.
not only tends to replace the waste of flesh, but it keeps the motions
soft.
Operative interference may be required, but is not to be hastily
adopted. In obstinate cases benefit has been derived from stretching
or dividing the sphincter, and where every local remedy has been tried
in vain colotomy has been resorted to.
Periproctitis. — Inflammation around the rectum may occur in one
of three situations — close to the anus (marginal), in the ischio-rectal
fossa, or higher up about the insertion of the levator ani and the recto-
vesical fascia.
1. Margi)ial. — This is a superficial inflammation involving the skin
onh' of the margin of the anus. It is merely a collection of pus orig-
inating in one of the small glands of the part, and may be caused by
a traumatism or any irritation, such as the pressure of a rough seat,
the use of improper toilet-paper, or unhealthy discharges occurring in
menstruation, diarrhea, or dysentery. The swelling is seldom larger
than an almond ; it rapidly goes on to the formation of an abscess
and opens on the cutaneous surface. In phthisical persons it not infre-
quently ends in a fistula. Instead of appearing at the cutaneous sur-
face, this little abscess may form near the mucous membrane, and
usually it is the result of an inflamed internal hemorrhoid at, or just
inside, the sphincter. It varies in size from a grape to an almond, and
is excessively painful. This is the starting-point of nearly every blind
internal fistula. After a few days of suffering the abscess bursts into
the bowel, and the escape of pus from the anus accounts for the whole
trouble.
Treatment. — The important practical point in all inflammations about
the rectum is the danger of their resulting in fistula. In order to pre-
vent such a termination the abscess should be opened as early as pos-
sible and at right angles to the folds, so as to secure gaping of the
wound. The incision should be kept open and the cavity allowed to
heal from the bottom.
Another form of superficial abscess occurs in the subcutaneous
tissue ; hence it is more diffuse and more difficult to dispose of than
the preceding. The diagnosis needs no special mention, except that
fluctuation is best elicited by placing one finger in the rectum and the
other outside. Early and free incision is the only treatment.
2. Ischio-rectal Abscess. — Bounded above by the levator ani and
below by the skin, on the inside by the rectum, and on the outside by
the pelvis, is a space which is a favorite position for suppuration.
The most common cause for ischio-rectal inflammation is trauma-
tism. Generally the injury is from within the rectum. The rough use
of a syringe and the swallowing of fish-bones or other sharp objects
figure largely in the causation. External to the rectum the causes are
kicks and blows, the pressure of the fetal head during parturition, ex-
travasation of urine from ruptured urethra, and necrosis of the sacrum,
the coccyx, or the lumbar vertebrae.
Symptoms. — The disease may be obscure at its onset, the patient
complaining of a dull pain about the pelvis and loins, with general
malaise, or the symptoms may be acute chills, high temperature,
and severe pain. The first definite symptom will probably be pain in
INJURIES AND DISEASES OF THE DIGESTIVE SYSTEM. 333
defecation, which is often so severe as to amount to perfect torture.
Constitutional symptoms become more marked, such as high tempera-
ture, rapid pulse, and occasionally chills. On local examination a hard
brawny mass is felt on one or other side of the anus, which later
becomes red and fluctuating. Sometimes the tendency of the abscess
is to burrow upward to the prostate and urethra, in which case there
are retention of urine and other symptoms pointing to prostatic or
urethral complications.
Examination by the finger or speculum is generally so painful as to
be out of the question. If not opened early, this abscess is apt to
burst into the rectum, forming a fistula. A chronic form of the dis-
ease is met with in the feeble, debilitated, and phthisical.
3. Abscess above the Levator Ani Muscle. — The levator ani forms a
sling-like support for the lower part of the rectum. It arises on either
side from the posterior surface of the pubic bone below the symphysis,
from the curved white line indicating the separation of the obturator
and recto-vesical layers of the pelvic fascia, and from the inner surface
of the spine of the ischium (McClellan). Passing downward and
inward toward the middle line, the muscle is inserted around the
rectum between the internal and external sphincter ani muscles.
Inflammation and suppuration above this muscle is a very serious
matter. The abscess may assume enormous proportions, blending
laterally with the subperitoneal connectiv^e tissue of the iliac fossa,
and burrowing in almost any direction in the true pelvis (Kelsey).
The disease is generally an extension from some of the neighboring
viscera or the result of stricture in the rectum. It is not uncommon
after parturition or metritis, the disease in this case extending from
the uterus, thus causing stricture of the rectum to be much more
common in women than in men. In men the pus generally burrows
along the side of the bowel, making its way into the ischio-rectal
fossa, and finally through the skin of the perineum at some distance
from the anus. In females it not unfrequently burrows upward, reach-
ing the skin about the crest of the ileum or in the groin. Not unfre-
quently the abscess ruptures into the rectum. We then have a charac-
teristic symptom. Pus is discharged at each act of defecation. If the
opening is near the anus, the pus comes before the feces ; if it is above
the rectal pouch, it comes after the feces.
In very exceptional cases the abscess ruptures into the bladder, the
uterus, the peritoneum, or the vagina.
Treatvioit. — Early incision is here the only proper course. As soon
as diagnosis of the existence of pus is made, even before fluctuation is
detected, the patient should be anesthetized and the abscess freely and
deeply incised. All pockets should be explored, thoroughly evacuated,
and made to communicate freely with the main cavity. This should
then be well irrigated with a i : 2000 sublimate solution, dusted with
iodoform, and packed loosely with iodoform gauze. A drainage-tube
should be inserted and the cavity made to granulate from the bottom.
Fistula in Ano. — Any of the forms of abscess just mentioned may
heal to a certain point and then remain stationary, keeping up a con-
stant discharge of pus by an opening into the rectum or externally
through the skin, or in both directions. When the fistula has an open-
334
SURGICAL DIAGNOSIS AND TREATMENT.
ing through both skin and rectum, it is called complete; when the open-
ing is in only one direction, it is termed incomplete or blind. A fistula
whose only opening is into the rectum is a blind internal fistula, and
one opening only through the skin is a blind external fistula.
Fistuke may be divided into anal and rectal. In the first class the
opening is close to the anus, almost entirely subcutaneous or penetrat-
ing some of the lower fibers of the sphincter. They are generally the
sequelae of marginal abscesses. Rectal fistulae are deeper, traversing
the ischio-rectal fossa and passing into the bowel between the external
and internal sphincter or even above the internal. Sometimes there
are numerous fistulous channels running in different directions until
the perineum is fairly riddled by them (Fig. 144). Pus burrowing in
Fig. 144. — Horseshoe fistula with multiple openings (Gant).
the loose tissues of the perineum may travel far, and thus the external
opening is often found at a considerable distance from the anus. Some
cases have been recorded in which the opening was in the groin, others
in which pus burrowed beneath the gluteal muscles and opened in the
thigh and even the popliteal space. The walls of the fistula are gen-
erally thickened by increase of fibrous tissue, the result of chronic
inflammation ; the surface is covered w^ith granulations which secrete a
thin purulent fluid. The external opening is generally small, scarcely
admitting a probe, and sometimes surrounded by a mass of granula-
tions. The course of the channel may be direct from the skin to the
rectum, and the point in the rectum which is the seat of the opening
is about an inch from the anus or between the internal and external
sphincter. Sometimes the sinus runs partly around the rectum, giving
what is called a horseshoe fistula.
Symptoms. — The early histor}^ of a fistula is the history of the
abscess which produced it. Generally the patient seeks advice long
after the abscess has discharged. He expects the opening to heal, and,
as it gives no trouble beyond a daily discharge of pus and serum, he
bears the inconvenience until the opening closes temporarily and a
INJURIES AND DISEASES OF THE DIGESTIVE SYSTEM. 335
new collection of pus takes place. The skin at such a time becomes
red and tender, movement of the bowels causes great pain, and the
symptoms of abscess are repeated until discharge of pus takes place,
either by the old or through a new opening. In the ordinary condi-
tion of the fistula the skin about the part is always moist, sometimes
eczematous or covered with small boils. In the subcutaneous tissues
fistulous tracts can always be detected by their hard, resistant feel.
From the opening escapes a thin purulent fluid, always offensive in
smell ; when the opening is large enough, gas and even feces escape.
These are positive signs of fistula, but the variety of fistula must be
determined by further examination. Place the patient on the affected
side with the knees drawn up. The external opening is generally easily
found, but sometimes it is concealed between the folds of skin or it may
be temporarily closed. Even then its position can often be determined
by the induration and thickening of the tissues at that point. Having
found the external opening, a probe is inserted and gently pushed
toward the opening in the rectum. Here let me warn you against
two common errors : Do not look for the internal opening too high
up. It is generally between the internal and external sphincter. Do
not pass the finger into the rectum until you have pushed the probe as
far as it will go. The presence of the examining finger causes the
sphincter to contract violently, which changes the relation of the fistu-
lous track and prevents the probe passing through it. Insert the finger
after the probe has passed as far as it will go. If the course is moder-
ately straight, the examining finger will find the point of the probe in
the rectum. If the probe has not passed through the internal opening,
the finger must search for it. No matter how many external openings
exist, there is only one internal. The finger can generally detect it
even if the probe does not go through. In some cases the end of the
probe can be felt with only a thin portion of the mucous membrane
between it and the finger. This is sufficient. Push the probe through
this thin spot.
A valuable aid to diagnosis which I have never found to fail is the
injection of peroxid of hydrogen. A speculum is introduced, the per-
oxid injected by the external opening, and its appearance watched for
at the internal opening. If a fistula be present, the froth caused by
the peroxid will be seen to ooze through the internal opening, and in a
short time it almost fills the rectum.
A diagnosis of the fistula and the kind of fistula is not sufficient.
A very important practical point remains to be settled : Is there a
stricture of the rectum ? Sometimes stricture and fistula coexist, the
stricture being high up and the fistula near the anus. To operate on
the fistula and overlook the stricture would be a bungling piece of
work. Again, the abscess which led to the formation of the fistula
may have been due to necrosis of the sacrum, coccyx, or vertebrae.
An operation dealing only with the fistula would be worse than useless.
Blind internal fistulae have generally large openings, and it is
not uncommon to find that feces enter this cloaca viaxhna and keep
up irritation which prevents healing for an indefinite time. These
fistulae are generally painful, not only during defecation, but when
pressure is made externally near the anus. Diagnosis of this variety
336
SURGICAL DIAGNOSIS AND TREATMENT.
is made by fcelin<:;^ the internal opening and by passin<^ a bent probe
through the anus and into the fistula.
Treatment. — Palliative treatment is of little or no avail in fistula.
A free incision conv^erting the fistulous track into an open wound, which
is allowed to heal from the bottom, is the most satisfactory treatment.
An aperient is given the night before, and an enema of soap and water
on the morning of the operation. The patient is anesthetized, and
placed either in the lithotomy position or on his side with the limbs
well drawn up. A grooved director is passed by the external opening
through the fistula and out at the anus, and then a curved knife is
made to run along the groove (Fig. 145), dividing all the tissues, cut-
FlG. 145. — Typical case of fistula in ano, with operation for the same (Gant).
ting the fibers of the sphincter as nearly at right angles as possible.
The track of the fistula should then be scraped with a Volkmann's
spoon to remove all granulation-tissue. A packing of iodoform gauze
and a pad of sterilized gauze and absorbent cotton held in position
with a T-bandage complete the operation. The bowels should be kept
confined for two days and the wound repacked daily with great care.
In horseshoe fistula the incision on one side should be made in the
usual manner, while the opposite sinus should be freely dilated and
drained. To open up both fistulae would necessitate division of the
sphincter in two places. This will almost to a certainty be followed by
incontinence.
Goodsall recommends the following method of operating on horse-
shoe fistula : First pass a probe-pointed director through the internal
aperture, and on its point incise the skin in the middle line behind ;
then push the director through, and slit up. Second, slit up the lateral
sinuses on directors passed in at the external openings and brought out
at the external incision. When numerous external openings exist it
may be necessary to open up several of the sinuses and leave others
for a second operation. A tortuous fistula, instead of being cut through
at once, should be dissected up on a director from the external opening.
INJURIES AND DISEASES OF THE DIGESTIVE SYSTEM. 337
Sinuses which are offsets from the main fistula can be followed up in
the same manner. The walls of the sinus should be dissected out and
the wound packed with iodoform gauze. Closing the wound by su-
tures with the view of obtaining primary union is sometimes successful,
but I have known cases in which this plan was attempted with very
unsatisfactory results. The fistulous tracks retained suppurating mate-
rial and necessitated operations at a later period.
Fistula in phthisical subjects should be operated upon under certain
restrictions. A cough which is violent and frequent is a contra-
indication, as it prevents healing of the incision. In rapidly advancing
lung disease, in persistent diarrhea, or in an advanced stage of tuber-
culosis in any organ it is not advisable to operate. In ordinary cases
of phthisis complicated with fistula improvement may be expected after
treatment of the fistula, for, although the pulmonary disease may
render the condition of the patient hopeless, he is saved the misery
of a very exhausting complication.
Other methods of treating fistula have been advocated from time to
time. Injections of iodin and of nitrate of silver have been known to
cure, so also has dilatation of the mouth of the sinus, but the effect of
such remedies is so uncertain that they scarcely deserve mention. The
elastic ligature is employed in patients who are strongly opposed to
the use of the knife. It is also recommended in a fistula whose inter-
nal opening is high up in the rectum. In every other case it is far
inferior to incision. The ligature when employed should be of solid
rubber about one-tenth of an inch in diameter. It is passed through
the fistula and out the anus, then tightly secured by means of a lead
clamp.
Fissure of the Anus. — A fissure or small ulcer at the anal
orifice, attended with the most excruciating pain, and producing symp-
FlG. 146. — Painful ulcer (fissure) of the anus (Gant).
toms out of all proportion to the extent of diseased tissue, has been spe-
cialh' named anal fissure or irritable ulcer (Fig. 146). Its commonest
situation is on the posterior wall of the rectum about the junction of
the skin with the mucous membrane. It is not uncommon to find it
lying under a small hemorrhoid, presenting the appearance of a little
fissure lying between two folds of muco-cutaneous tissue. If, however,
22
338 SURGICAL DIAGNOSIS AND TREATMENT.
the folds be separated and the anus dilated, the shape changes to a
round or oval ulcer.
After all, there is nothing special about this form of ulcer, for it can
be caused by anything which causes an abrasion or laceration of the
tissue at the anal orifice. Its position gives it two characteristics which,
kept in mind, make it easy to understand the disease : It is exceedingly
painful, and therefore well named irritable ulcer. This is the first cha-
racteristic. The junction of skin and mucous membrane is always a
highly sensitive line. An ulcer of the mucous membrane alone, how-
ever slightly removed from this line, is not nearly as painful. The
extreme sensitiveness of the ulcer causes reflex contraction of the
sphincter ani muscle, which is the second characteristic.
Symptoms. — There is nothing that can compare with a severe case
of anal fissure. The patient at stool experiences a pain which he
believes is tearing his anus or burning the part as with a red-hot iron.
He is thrown into a state of collapse ; the pulse becomes feeble, the
surface of the body is damp and cold, and beads of perspiration break
out on the forehead. For hours this may continue, and the sufferer
naturally dreads to have a movement of the bowels, and they are
allowed to become constipated. This only increases the suffering by
hardening the feces and making defecation more painful than ever.
Blood to the extent of a drop or two is sometimes seen on the motions.
Retention of urine is common in men, and menstrual disorders in
women. The sphincter is rigidly contracted and feels hard to the
touch. Digital examination is out of the question without an anes-
thetic. An inspection shows a fissure, usually on the posterior wall,
and taking a round or oval form when the anus is dilated. The surface
is covered wdth red, inflamed granulations or a thin slough. In these
red granulations are the exposed nerve-filaments to which are due the
extreme sensibility. Hemorrhoids, blind internal fistula, and sphincter-
ismus might be mistaken for ulcer.
Treatment. — In mild cases healing of the ulcer may be secured by
astringent ointments, the application of weak solutions of nitrate of
silver or sulphate of zinc, and by keeping the bowels in a relaxed con-
dition. In more severe and obstinate cases the patient may be given an
anesthetic, and the ulcer then freely cauterized with nitrate of silver or
the acid nitrate of mercury'. The bowels are kept from acting for a
day or two, and the patient keeps his bed until the ulcer heals.
The most obstinate cases are those in which the sphincter is hyper-
trophied from constant contraction, and these require a more radical
method of treatment. To overcome the action of the muscle its
superficial fibers can be divided or it can be fully stretched. The
patient is placed under chloroform ; the sphincter is then stretched with
the thumbs, and the floor of the ulcer divided with a knife down to the
extent of a quarter of an inch, which is sufficient to sever the super-
ficial fibers of the sphincter. The base of the ulcer should be dissected
out and the wound packed with iodoform gauze. At the same time,
any small hemorrhoid, polypus, or tag of skin should be removed ; a
sinus, if present, should be opened up, the upper region of the rectum
examined, and in the case of females any retroversion of the uterus
corrected.
INJURIES AND DISEASES OF THE DIGESTIVE SYSTEM. 339
Spasm of the Sphincter (Sphincterismus). — This is an affec-
tion which is most commonly seen in fissure of the anus, but it also
exists in hysterical women, and in persons suffering from diseases of
neighboring organs, as the uterus or bladder. In some cases there is
an undiscoverable cause. When due to fissure this latter condition
should be attended to ; in hysterical women a suppository containing
two grains of the extract of belladonna is very efficient, and in obsti-
nate cases from any cause, stretching the sphincter is an almost certain
cure.
Tumors of the Rectum. — Of the benign growths the most
common in the rectum is polypus. The term polypus, however, is
applied to any growth projecting from the mucous membrane into the
cavity of the bowel. Sometimes it is an hypertrophy of the mucous
membrane, sometimes a fibroma or an adenoma (Fig. 147), sometimes
Fig. 147. — Fibrous (hard) polypus (Gant).
a villous growth. Polypi are generally single, occurring frequently in
children below nine years of age. They are usually attached to the
posterior surface of the rectum and not far from the anus. In size
they seldom reach the dimensions of a walnut, but they have been
found in such numbers as to block up the bowel and produce symptoms
of intestinal obstruction.
Symptoms. — When a child has hemorrhage from the rectum polypi
should always be suspected. Just as in uterine polypus, hemorrhage
is a pretty constant symptom. A digital examination of the rectum
should always be made in such cases, when, if a polypus be present,
it will be felt hanging from the rectal wall, usually the posterior sur-
face. When the pedicle is long, however, it may be directed upward,
so that the tumor is out of reach. On this account an enema of warm
water should be given before the examination. The expulsion of the
fluid brings down the polypus to the full length of its pedicle (Fig. 148).
The length of the pedicle varies greatly. In some cases it is so long
that the tumor escapes through the anus during defecation, and it not
infrequently happens that the sphincter, contracting firmly on the
pedicle, strangulates the growth and causes it to drop off, thus effecting
a spontaneous cure.
The diagnosis of polypus with a long pedicle is very simple. It is a
very different matter when the attachment of the tumor is broad and
340
SURGICAL DIAGNOSIS AND TREATMENT.
the pedicle absent. The question then arises as to whether the tumor
is benign or maUgnant. Diagnosis must rest upon the following points :
1. In children malignant disease is exceedingly rare, while polypi
are frequently met with.
2. Malignant tumors are not extruded and are not pedunculated, so
that the existence of even a very short pedicle is strong evidence of
polypi.
In adults an adenoid polypus which has ulcerated and which is not
pedunculated cannot always be distinguished from malignant disease,.
Fig. 148. — Adenoid (soft) polypus (Gant).
either by the microscope or the clinical history ; for the ulcerated and
bleeding tumor may cause a wasting and cachexia which strongly
resemble cancer (Kelsey).
Treatment. — The treatment of polypi is very simple when the tumor
is pedunculated. Hemorrhage is the only danger, and this can be
obviated by first throwing a ligature around the pedicle and then
dividing the tissue with scissors close to the point of ligation. Some-
times the pedicle is so long and slender that the tumor can be twisted
off by grasping it with forceps and making simple torsion. When
polypi have no pedicles, they must be removed in the same manner as
ordinary tumors, and the bleeding stopped by forceps and by packings
with gauze or sponges wrung out of hot water. Removal of polypi
by clamp and cautery is advocated by some authors.
Papillomata, Warts, or Vegetations. — These warty growths
occur about the anus in persons who are the subjects of warts in other
parts of their bodies. Their development is favored by the presence
of any irritating discharge, such as occurs in gonorrhea, leukorrhea,^
or any disease of the rectum. Formerly these growths were held in
very bad repute, being considered positive evidence not only of syphilis
but of sodomy. Molliere relates how in the time of Dionysius there
was a hospital in Rome for the treatment of these growths ; the sur-
geons, according to Dionysius, spared neither the iron nor the fire, and
were not moved to pity by the cries of the patients, inasmuch as this
disease was the result of unnatural intercourse between man and man
(Molliere, quoted by Kelsey). The ideas of surgeons have undergone
considerable change in recent years, the cause now being considered to
be a tendency to warts, plus a local irritation.
INJURIES AND DISEASES OF THE DIGESTIVE SYSTEM. 34 1
Symptojjis. — While papillomata occur at almost any age, they are
most frequently found in adults. The appearance will vary according
to the number of warts. When occurring singly the surface is dry ;
when existing in numbers they secrete a fluid of very disagreeable
odor. This secretion is irritating, and not only causes inflammation
in the warts themselves, but in the surrounding skin. When the
growth begins on one side of the intergluteal fold, the pressure of
their moistened surface against the opposite side produces a second
growth at that point. The patient suffers great discomfort from the
odor and irritation, and not infrequently defecation is attended with
considerable pain. Little difficulty is experienced in the diagnosis of
these growths ; the most common error arises by mistaking them for
syphilitic condylomata or for mucous patches. The surface of a flat
condyloma or mucous patch is smooth and different from the cauli-
flower-like growth of a papilloma. The papilloma, moreover, is found
to be attached to the skin by a number of small pedicles, so that if the
whole growth be cut off at the level of the skin, it does not leave a raw
surface, but a number of minute bleeding points.
Treatment. — Excision with knife or scissors is the best and most
rapid treatment. Applications of strong astringents, such as tannin or
alum or strong acetic acid, are sometimes sufficient to remove them.
Condylomata. — This is a term applied to several different growths
about the anus, as the raised mucous patches and the remains of exter-
nal hemorrhoids. There is a growth known as condyloma which is
non-syphilitic. It is attached by a broad base, is of a pink color, soft,
fleshy, moist, and flattened where two are pressed together. Condy-
lomata generally begin at a fold of the anus (Kelsey). They are due
to a localized chronic inflammation of the skin. They are most likely
to be confounded with syphilitic gummata.
Syphilitic condylomata begin as red spots with slight effusion
beneath the epidermis. The thin covering formed by the epidermis is
rubbed off, and a raw surface is left covered with a thin pellicle. Upon
this surface a new growth takes place, composed of papillae, connective
tissue, and blood-vessels. In this respect it closely resembles the papil-
lomata, and in fact their appearance is sometimes identical. Diagnosis
must rest, therefore, upon the history, the mode of development, and
the results of treatment.
Fibromata, lipomata, villous growths, enchondromata, and sarcomata
are so rare as to need no special mention.
(For cancer of the rectum see Cancer of the Intestines.)
Stricture of the Rectum. — Stricture of the rectum may be due
to changes in the bowel-wall which lessen its caliber, or to pressure
from without. Tumors in the pelvis by gradual encroachment on the
rectum may cause a diminution of its caliber, but this is generally an
obstruction rather than a stricture.
Two classes of stricture are recognized — simple and malignant.
The latter has been discussed in the section on Rectal Cancer. Simple
stricture is generally associated with inflammation, and, bearing this in
mind, its etiology is readily understood. Inflammation, and especially
the chronic form, tends to increase the connective tissue of the part
affected. The connective tissue of the rectum is arranged in a circular
342
SURGICAL DIAGNOSIS AND TREATMENT.
manner around the bowel, so that inflammation by increasing this
fibrous tissue causes a constriction. We have, therefore, the following
among the causes of simple stricture :
1. Traumatism, such as kicks, blows, the application of strong
acids, operations on the rectum, ulceration, and the presence of foreign
bodies. All of these produce stricture close to the orifice of the anus.
2. When the stricture is higher up the principal causes are — ope-
rations for internal hemorrhoids, tuberculosis, syphilis, dysentery,
parturition, pelvic cellulitis, and imperforate rectum, partial or complete.
Strictures arising from any of these causes may affect a small or a
large portion of the rectum, and two varieties are spoken of according
to the extent of the stricture. If it involves an inch or less, the stric-
ture is called anmtlar (Fig. 149); if more than an inch, it is tubular
(Fig. 150).
Fig. 149. — Diagrammatic drawing
of annular stricture (Gant).
Fig. 150. — Diagrammatic drawing of
tubular stricture (Gant).
Syviptoms. — Of seven patients suffering from stricture of the rectum,
six are women. Common sense tells us that the leading symptoms are
obstruction, due to narrowing of the bowel and irritation and inflam-
mation which produce the stricture. When high up obstruction may
be an early symptom, and may appear with very slight warning. In
stricture low down it does not appear until a late period. The first
symptom is generally a diarrhea coming on when the patient gets out
of bed and after each meal. The motions are either small like pellets,
or ribbon-shaped and covered with mucus. Later on, constipation
alternates with diarrhea. Pain becomes a prominent symptom, felt
especially in the perineum and radiating to the hips and down the
thighs. The sphincter loses its tonicity, becomes flabby, and, later on,
raw and excoriated. There is a constant offensive discharge about the
anus which keeps the parts moist and irritated. Later on, obstruction
becomes more apparent. In some cases the transverse and descending
colon can be felt distended with feces, dull on percussion, sensitive to
touch, and retaining indentations made by pressure of the fingers. The
bowels are never properly emptied ; abscesses, fistulae, and ulceration
INJURIES AND DISEASES OF THE DIGESTIVE SYSTEM. 343
are common ; and at last the patient dies either of peritonitis,
the result of complete obstruction, or wastes away from sheer ex-
haustion.
No diagnosis is complete without a local examination, which can be
digital or by bougies. The finger is preferable. A constriction, ring-
shaped or tubular, is felt, which at once settles the question. Should the
stricture be too tight to allow the finger to pass through, no attempt
should be made to force it. Death has occurred more than once
by rough examination. Having satisfied yourself that a stricture
exists, examine the condition of the rectum below the narrowing.
In females the vaginal examination may throw considerable light on
the subject.
No end of mistakes have been made by depending upon bougies.
Many supposed strictures have proved to be nothing more than the
arrest of the instrument by the promontory of the sacrum. When the
stricture appears to be beyond the reach of the finger, something can
be gained by having an assistant press the elbow of the examining arm,
thus pushing the perineum well up. Olive-pointed bougies or long
rectal tubes are sometimes useful.
Stricture high up in the rectum or in the sigmoid flexure is very
difficult of diagnosis. The symptoms complained of by the patient
are different from those already described. Chronic constipation and
dyspepsia are the most prominent. Pain is felt in the abdomen,
generally, but not always, in the left side ; sometimes in the loins
and down the thighs. An examination of the feces gives nothing
satisfactory. The motions, being formed in the rectum, have not the
ribbon or pellet-shape characteristic of a stricture low down. The
most significant appearance is the presence of blood or slime in
streaks in the feces. When the constriction is due to a morbid growth,
palpation, inspection, and percussion of the abdomen may afford valu-
able evidence.
In making a diagnosis of high stricture I would recommend the
following procedures :
1. Obtain a history of the subjective symptoms, such as constipation,
diarrhea, pain in the left side of the abdomen, loins, and thighs.
2. An examination of the feces for streaks of blood or slime.
3. Inspection, palpation, and percussion of the abdomen for tumor
or fecal impaction in the colon.
4. Examination with the finger under anesthesia, aided by an assist-
ant pushing against the examiner's elbow to raise the perineum.
5. The insertion of bougies. The best instrument is hollow, and to
its lower end should be fitted the tubes of a fountain syringe or irri-
gator containing warm sterilized Avater. The bougie must be inserted
with the greatest gentleness, and as soon as resistance is felt the water
should be allowed to flow and distend that portion of the bowel. This
will dispose of folds of mucous membrane which are so ready to obstruct
the tube. In order to pass the promontory of the sacrum the bougie
requires to be flexible.
6. Failing in making a diagnosis by any of the preceding, the hand
may be pressed into the rectum under the restrictions already men-
tioned.
344 SURGICAL DIAGNOSIS AND TREATMENT.
Differential Diagnosis of Benign and Malignant Strictnrc (Ball).
Benign. Malignant.
Generally a disease of adult life. Generally a disease of old age.
Essentially chronic, and not implicating the Progress comparatively rapid, and general
system for a long time. cachexia soon produced.
The orifice of the stricture feels as a hard Masses of new growth are to be felt, either as
ridge in the tissues of the bowel. Poly- flat plates between the mucous membrane
poid growths, if present, are felt to be and the muscular tunic, or as distinct
attached to the mucous membrane. tumors encroaching on the lumen of the
bowel.
Ulceration of tlic mucous membrane may be Ulceration, when present, is evidently the
present, but without any great induration result of the breaking down of the neo-
of the edges. plasm, and the edges are much thickened
and infiltrated.
The entire circumference of the bowel is con- Generally one portion of the circumference is
stricted unless the stricture is valvular. more obviously involved.
Pain, throughout the whole course, is in direct For the advanced stages pain is frequently
proportion to the fecal obstruction, and only referred to the sensory distribution of some
complained of during the effort of defeca- of the branches of the sacral ple.xus, due to
tion. direct imjilication of their trunks.
Glands not involved. The sacral lymphatic glands can sometimes
be felt through the rectum to be enlarged
and hard.
Treatment. — The diet of the patient requires careful attention. It
should be nutritious, containing such articles as leave a small residue.
The feces should be kept soft. When the stricture is due to syphilis
or tuberculosis the general treatment of these diseases must be
employed. The local treatment of stricture must depend upon the
variety. Many annular strictures can be completely cured, while tub-
ular strictures are frequently beyond the reach of local treatment.
The operative treatment may be considered under the following heads :
{a) Gradual Dilatation. — Bougies have been so much abused that
it is difficult to estimate their proper value. When they are employed
to overcome a stricture it should be clearly understood by both patient
and surgeon that a long course of treatment will be necessary. With-
out this understanding it is useless to begin. An annular stricture may
be compared to a rubber ring. The passage of a bougie will dilate the
ring, but it speedily returns to its original size. The use of the instru-
ment daily for weeks, and even months, will, however, in many cases
finally overcome the elasticity and cause the stricture to disappear.
This little operation is very simply done, and especially in stricture low
down the patient or a nurse with very little instruction can attend to
the treatment. Great care should be taken to make sure that the
instrument really passes through the stricture. Sometimes a pouch
forms below the stricture, and into this the nurse, or even the physician,
has been known to pass a bougie daily for weeks in the belief that he
was dilating the stricture.
Half an hour before using bougies it is best to give the patient an
enema of warm oil and water, which not only empties the bowel, but
quiets the irritability of the sphincter (Cripps). The patient lies on his
side with one knee drawn up. Beginning with a size which easily
passes through the stricture, larger instruments are employed as dilata-
tion advances. Great benefit is obtained by keeping the instrument in
position from a few minutes to several hours a day as the patient can
bear it.
INJURIES AND DISEASES OF THE DIGESTIVE SYSTEM. 345
{p) Forcible Dilatation. — This method is attended with too much
risk to warrant a recommendation. A stricture when forcibly dilated
gives way at its weakest point, and that is usually Douglas's cul-de-sac.
The consequence of such an accident is the pouring of the fecal con-
tents of the bowel into the peritoneal cavity, followed by general
peritonitis and death. So great is the risk of rupture that in no case
should an attempt be made to force the finger through a tight stricture
for the purpose of ascertaining the condition of the bowel higher up.
The only strictures of the rectum in which forcible dilatation can be at
all warranted are those within an inch of the anal margin.
(r) Litcrnal Division. — This is another dangerous operation. An
incision in the rectum is almost sure to result in suppuration, with
formation of abscess and burrowing of pus in various directions. The
cause of this is readily explained. The sphincter ani closes with more
or less accuracy the lower end of the rectum, and acts as a barrier to
the downward pressure of the bowel-contents. Before the resistance
of the sphincter can be overcome the rectum is distended, and with the
distention a stretching of the incision. This not only prevents heal-
ing but allows fecal matter to get into the incision and produce sup-
puration.
id') Posterior Division of the Stricture and External Parts. — The
great objection to internal division is the impossibility of free drainage.
That objection is overcome when a free division is made, not only of
the stricture, but of all the tissues between it and the surface.
Operation. — The bowels having been thoroughly evacuated by a
cathartic followed by an enema, the patient is placed in the lithotomy
position. The finger of the left hand is pressed through the stricture.
If this is impossible, a probe-pointed bistoury is passed through, and, its
edge being directed backward, the stricture is cut exactly in the middle
line sufficiently to allow the finger to pass through. A long curved,
sharp-pointed bistoury, guarded by the finger-nail or a director, is then
passed through the stricture ; the point is directed backward in the
middle line, and made to transfix the rectal wall behind, coming out at
the end or side of the coccyx. It is then made to cut its way out.
Bleeding points are ligated as far as possible. A drainage-tube is placed
in the rectum, its upper end reaching beyond the seat of the operation.
Around the tube the space is packed with iodoform gauze and a
T-bandage applied. The packing is removed daily, the parts irrigated,
and again packed. About the tenth day bougies are passed to prevent
recurrence of the stricture, and this is continued for six months.
During the healing a full-sized bougie should be kept in for several
hours a day.
{e) Colostomy. — When other measures are unavailing relief from
suffering and prolongation of life can be obtained by the formation of
an artificial opening in the colon (see Colostomy).
Congenital Malformations of the Rectum and Anus. — These
malformations are the result of arrested development in early fetal life.
The bowel and the sinus from which are later developed the genital
organs are not at first separate in the fetus. If the opening between
the two persists, malformation is the result, and the feces may pass by
the urethra (Fig. 151), or vagina, or the bladder (Fig. 152),
346
SURGICAL DIAGNOSIS AND TREATMENT.
If not wholly absent, the rectum and anus may be very narrow,.
though not entirely occluded.
Fig. 151. — Imperforate anus, the rectum terminating in the urethra (Gant).
Imperforate rectum and imperforate anus are the most common
deformities.
The bowel is developed from the hypoblast, except the lower por-
FlG. 152. — Imperforate anus, the rectum ter-
minating in the bladder (Gant).
Fig. 153. — Imperforate rectum, the anus
natural, but rectum separated from it by a
membranous partition (Gant).
tion, which, together with the anus, is an involution from the epiblast.
As the fetus develops the bowel pushes its length dow^nward, and the
THE GENITO-URINARY SYSTEM. 347
involution proceeds upward from the surface to meet it. Absorption
of intervening tissue takes place, and the two become one continuous
passage. If development is arrested at any point, imperforate rectum
or anus, or both, may occur. Should the involution at the surface not
begin at all, or cease after a mere depression has taken place, the con-
dition is known as imperforate anus. The involution, on the other
hand, may proceed to a normal exent, but, the bowel not descending
sufficiently, absorption of intervening tissue may not take place,
producing a condition known as imperforate rectum.
All degrees of malformation may exist — from that in which only a
thin membrane lies between the rectum and anus (Fig. 153) to those in
which, by absence or obliteration of the rectum, there is a space of
several inches between the anus and the bowel.
Symptoms. — The diagnosis of these conditions is made from the
fact that the child has had no motion from the bowels, or by the pres-
ence of a fistula connecting the bowel with the bladder or urethra or
vagina, through which the feces are passed. In addition, the abdomen
is distended, and there may be vomiting severe and persistent.
Treatment. — If only a membrane separate the rectum and anus
(Fig. 153), a simple incision affords an opening. During the process
of healing care must be taken to prevent contraction by daily insertion
of the finger.
If the rectal pouch is situated high up, but low enough, so that
bulging can be detected, an incision should be made in the median
line. All tissues are dissected away until the pouch is reached. It
should be opened, emptied, cleansed antiseptically, and its edges
sutured to the edges of the incision. It is then dressed antiseptically,
and bougies inserted daily to prevent contraction. If no pouch can
be detected, an incision is made in the left inguinal region, and search
made for the end of the bowel and inguinal colostomy performed.
When the opening is into the urethra or vagina this fistula should
be closed, and an outlet established at the anus if possible ; otherwise,
in the left inguinal region, as in high imperforate rectum.
CHAPTER VII.
THE GENITO=URINARY 5YSTEM.
I. INJURIES AND DISEASES OF THE KIDNEYS.
Surgical Anatomy. — The kidneys lie behind the peritoneum deep
in the lumbar region and imbedded in abundance of loose fatty tissue.
Each kidney lies upon the posterior portion of the diaphragm, the
transversalis aponeurosis, and the psoas muscle. The upper end of
the right kidney is in contact with the under surface of the liver. In
front the anterior surface is in relation with the duodenum and the right
flexure of the colon. The upper end of the left kidney is in contact
with the stomach ; its outer border for two-thirds of its length touches
348 SURGICAL DIAGNOSIS AND TREATMENT.
the spleen, and its lower end is crossed by the descending colon ; in
front toward the inside lies the pancreas. The upper end of the kidney
corresponds with the left intercostal space, and the lower end is on a
level with the middle of the third lumbar spine. The right is a little
lower than the left, owing to the pressure of the liver from above.
The left kidney may occupy a position above the spleen. It some-
times happens that there is only one kidney. In this case the organ is
large enough to compensate for the absent one. Sometimes both organs
are closely united at their extremities, forming the " horseshoe " kidney,
so called.
The kidneys are subject to great variations both in regard to the
size and the position of the organs. They may be placed as low down
as the brim of the pelvis or even in the pelvic cavity, and in either of
these situations they are likely to give considerable trouble during
menstruation or in the progress of parturition. The vessels may also
be abnormal. Thus the organ may receive its arterial supply from a
vessel rising from the aorta higher up or lower down than in the nor-
mal condition, or springing from the common iliac. The ureter is just
as variable. Sometimes it is double either at its origin or in its whole
course, or it may be tortuous, especially when encroached upon by
morbid growths. The ureters lie obliquely, and in such a position
that if their axes were prolonged upward they would meet on the
ninth dorsal vertebra, and if prolonged downward would pass over
the tips of the iliac crests. The inner border of each kidney is con-
cave, forming a longitudinal gap called the hilum, which contains three
very important structures — viz. the renal artery, the renal vein, and the
ureter. These constitute the pedicle in removal of the kidney.
The arteries arise from the aorta about the level of the first lumbar
vertebra, and pass almost horizontally to the kidneys. The right ves-
sel takes a slightly upward course to reach its organ ; it passes behind
the inferior vena cava, and is of course longer than its fellow, for the
aorta has the vena cava between it and the right kidney. The left
artery generally rises a little higher up than the right. Before reach-
ing the hilum each arter}' divides into three, four, or five branches
which go to supply the renal tissue. The position of the structures at
the hilum are, from above downward and backward, artery, vein, ureter.
The renal veins pass at right angles from the hilum of each kidney
to enter the vena cava inferior. The left vein is slightly higher and
longer than the right. The ureter is the membranous tube which con-
veys the urine from the kidney to the bladder. It is about fourteen
inches in length and its diameter is about one-eighth of an inch. It
begins at the lower border of the kidney, and expands into a funnel-
shaped sac called the pelvis ; then passes down behind the peritoneum
lying upon the psoas muscle, and crosses the bifurcation of the common
iliac artery to reach the base of the bladder.
Following the ureter from the pelvis into the substance of the kid-
ney, we find that it divides into two or three short trunks, and these
again subdivide to form the primary tubes or infundibula which receive
the papillae.
The kidney is held in position by a mass of fat which forms its bed.
In this it enjoys a slight degree of mobility, and when the fat is opened
THE GENITO-URINARY SYSTEM. 349
up the kidney may be seen to rise and fall with respiration. Sometimes
this fatty capsule is wanting, and the organ is held in place only by the
blood-vessels and ureter at its hilum, or, the fat being lost by sudden
emaciation of the patient, the movements of the kidney are greatly
increased. To this condition the name " movable kidney " is applied.
Sometimes the peritoneum invests the organ, forming a mesonephron,
and the kidney becomes displaced into the general peritoneal cavity,
moving freely in every direction as far as its vessels and ureter will
permit. To this abnormality the name of" floating kidney " is applied.
Injuries of the Kidney.
The kidneys are well out of harm's way, being protected in the rear
by the strong, thick muscles of the lumbar region, and in front by the
abdominal wall and the abdominal viscera. Injuries of the kidney are
on this account comparatively rare. They may be divided into three
classes :
I . Contusion without I/aceration of the External Tissues.
— This is one of the most frequent of renal injuries. It may be pro-
duced by blows or falls, especially when the body is in a sitting posi-
tion or forcibly bent forward at the time of striking the ground.
Another common cause of renal contusion is a squeezing or crushing
of the loins between carriage or machine wheels. Whatever the cause,
it may produce injury varying from little discomfort and few symptoms
up to complete rupture and even pulpification of the organ. Trauma-
tisms in the renal region, according to Kiister, cause either laceration
of renal tissue or mobility of the organ. As a rule, laceration occurs
in males, mobility in females. This is accounted for by the fact that in
the female the conformation of the body, the thickness of the adipose
tissue, and the protection afforded by the corset break the direct force
of a blow, and thus guard against lacerations.^
Synipt07iis. — The violence which produces the kidney lesion is likely
to cause so much pain in the loin as to mask the symptoms which point
more directly to the kidney. The pain shoots down the thigh and into
the testicle and loin. If the kidney is injured, we have in addition fre-
quent micturition and sometimes hematuria. Blood in the urine, how-
ever, is a symptom that must be carefully weighed. It may be present
when there is sudden congestion in any portion of the urinary tract, as
in violent strains. On the other hand, there may be extensive lacera-
tion and hemorrhage from the kidney, but, owing to the formation of
a clot in the ureter, no blood escapes with the urine.
The quantity of the blood that escapes is very variable. When it
is extravasated around the kidney it causes swelling in the loin, and as
the blood-stained serum passes downward along the vessels the skin
becomes discolored in the inguinal region, in the scrotum, and in the
thigh. When only the cortex of the kidney is torn the hemorrhage
is usually slight. If the laceration extends into the hilum or a vessel of
considerable size is torn, then a profuse flow of blood runs down the
ureter, filling the bladder, and perhaps coagulating therein. The symp-
^ An7i. of Univ. Med. Set., 1S96.
350 SURGICAL DIAGNOSIS AND TREATMENT.
toms of renal colic follow, and in some cases long worm-like clots are
expelled per urethram. There is intense pain about the pubes and at
the end of the penis. If the ureter becomes completely occluded by
a clot, hydronephrosis follows. Still more copious is the loss of blood
when the peritoneum is ruptured and the hemorrhage is poured out
into the abdominal cavity. The symptoms of profuse hemorrhage
rapidly come on and the patient may bleed to death in a short time.
Extravasation of Jiri/ic from the kidiuy is a symptom which is of
rare occurrence. It does not take place unless the pelvis or the hilum
is ruptured. Then the urine is poured out either into the peritoneal
cavity or into the areolar tissue around the kidney. Inflammation
follows, and often results in suppuration and sloughing, to which the
patient eventually succumbs.
Trcatinciit. — The patient should be kept in the recumbent posture
and fed on liquids. The loins should be supported by a broad strip of
adhesive plaster, as in the treatment of fractured ribs. Gallic acid,
ergot, acetate of lead, and opium are valuable in checking hematuria.
The bowels can be relieved by enemata, but purgatives are to be
avoided. When the bladder is filled with blood, as evidenced by
tenesmus and the passage of clots, every care must be taken to prevent
cystitis. A double-current catheter should be inserted and irrigation
carried out with some mild disinfecting fluid, as boric acid or Thiersch's
solution ; or one of the evacuating tubes and evacuators used in lithot-
rity can be employed to throw in and w^ithdraw quantities of water
from the bladder.
When the coagula are so large and firm as to resist these methods
perineal section is indicated. Severe cases w^iich are attended with
profound shock and a rapidly increasing tumor in the loin demand a
lumbar incision. After exposing the kidney the bleeding points are
sought for and ligated ; if the kidney is disorganized, it should be
removed.
2. Wound of the Kidney with I/aceration of the External
Parts. — The anterior surface of the kidney may be penetrated by an
instrument or missile entering the abdomen and passing through both
layers of peritoneum. The symptoms in this case are those of hemor-
rhage or extravasation of urine into the peritoneal cavity. When
the wound is received in the loin, the posterior surface of the kidney is
the part to suffer. If urine escapes, it is proof positive of renal lacera-
tion, but it must be remembered that the cortex may be incised with-
out flow^ of urine. Hematuria is also a sign, but the same uncertainty
attends it here as in the preceding class of injuries. Perinephric abscess
is a frequent sequel of renal wound. Extra-peritoneal wounds gen-
erally do well, but those which are intra-peritoneal have a very high
mortality.
Treatment. — Wounds of the kidney inflicted through the loin are
extra-peritoneal and require the same treatment as nephrotomy. A
drainage-tube is inserted down to the wound in the kidney, and the
surrounding space packed with strips of iodoform gauze. Should
further drainage be required, the external wound should be enlarged.
3. Intra-peritoneal wounds of the kidney demand celiotomy,
and in most instances nephrectomy.
THE GENITO- URINAR Y S YSTEM. 3 5 I
Diseases of the Kidney.
Bxamination of the Kidneys. — In the injuries which have just
been described our attention is naturally directed to the kidneys by the
position of the traumatism and the nature of the accident. In surgical
diseases of these organs we are led to the kidneys by the general
examination of the patient. When, for instance, we get a history of
violent attacks of pain in the loin shooting down toward the bladder,
the testicle, and the thigh, we suspect renal calculus, and the suspicion
grows upon us if we learn that during or after these attacks small
quantities of bright-red blood have come away with the urine. Again,
if the patient complains of periodical attacks of violent pain with
marked diminution of the quantity of urine, followed by a copious
flow and relief of all symptoms, we suspect hydronephrosis due to
movable kidney, and our suspicion is confirmed if he also tells us that
a tumor of a somewhat erratic character can be felt from time to time.
In the examination of the kidney our methods of investigation are
somewhat limited.
Inspection is only of value when the loin is greatly distended by a
solid or cystic tumor, in cases of hydronephrosis or pyonephrosis, in
enlargement of the kidney, and in cases of hemorrhage which is extra-
peritoneal.
Palpation is often of great value. The healthy kidney of normal
size and lying in its proper position is beyond the reach of palpation.
It is only when the organ is enlarged that it can be felt. To examine
it by palpation place the fingers of one hand just below the twelfth rib
and at the outer edge of the erector spinae muscle, or about two and a
half inches from the spinous processes ; the other hand is placed on
the abdominal wall in front. The enlarged kidney can be felt between
the two hands. Sometimes the finger and thumb of one hand are
sufficient, and in this way a good idea of the size of the kidney can be
obtained. In very lean persons with lax and thin abdominal walls the
lower third of the kidney may be felt ; with this exception, if you feel
the kidney at all, you may set it down as an enlargement of the organ.
As the kidney enlarges it extends in two directions, downward and
forward. The ribs and spinal column prevent its extension backward,
and its own weight tends to drag it downward. Hence the greater
the enlargement the more easily can the kidney be palpated.
Israel's method of palpation is as follows : A line parallel with the
middle line of the abdomen is drawn from the middle of Poupart's
ligament to the margin of the ribs. The finger-tips, placed two finger-
breadths below the margin of the ribs and upon this line, are directly
over the lower extremity of a kidney in place. In order to feel this
kidney we must avoid poking with eager hooked fingers, or the
abdominal muscles will contract in resentment. The tips of the
straight-extended fingers are placed upon the point indicated while the
patient lies supine, with flexed legs, upon a hard bed or table; The
other hand now lifts the loin gently toward the opposed fingers. At
each expiration which the patient makes the fingers upon the abdomen
are pressed a little farther toward the kidney ; the impress-fingers easily
recognize the object sought for. If the patient now takes a full breath.
352 SURGICAL DIAGNOSIS AND TREATMENT.
a wandering kidney will be forced far under the finger-tips (Israel, cited
by Fenwick).
Percussion. — The solid structures which surround the kidney
render its percussion impossible. On the right side the liver, on the
left the spleen, form its upper boundary ; behind is the spine, over it
the muscles, and surrounding it a mass of adipose tissue. There is
therefore nothing resonant about the kidney on any side. Only when
the organ is greatly enlarged can we gain anything from percussion,
and then it simply confirms what we have learned by palpation. Some-
times a resonant area traverses a greatly enlarged kidney ; tJiis is the
distended eolon.
Exploratory puncture is valuable, and, as it is extra-peritoneal, the
danger attending its employment is less than in abdominal explorations.
In hydronephrosis and pyonephrosis the needle is of great value, for,
having established the diagnosis, it can be used to evacuate the fluid
and thus produce relief, possibly a cure.
Movable Kidney. — Care should be taken to avoid the common
error of confusing the terms movable kidney and floating kidney.
Movable kidney is an acquired condition in which the organ remains
behind the peritoneum, but with more or less movement. It is simply
loosened up in its fatty bed. Floating kidney, on the other hand, is a
congenital abnormality in which the peritoneum surrounds the kidney
forming a renal mesentery. The kidney in this case has no fatty bed,
but floats about the abdominal cavity as far as its mesentery will
permit.
Movable kidney is more common on the right side than on the left,
and this has been accounted for by the downward pressure of the liver.
Women suffer more frequently than men, for the reason that repeated
childbearing, with its alternate distention and relaxation of the ab-
dominal wall and sudden loss of the fatty tissues of the body, is a
prominent cause of renal displacement.
Symptoms. — The sufferings of the patient depend to a great extent
upon the degree of mobility of the kidney. There may be only slight
discomfort or there may be the most agonizing pain. When there is
slight mobility, discomfort is usually felt after exercise, and especially
after long walks, or rides in which there is much jolting. The
menstrual period seems to have a powerful effect in bringing on pain.
There is a sense of dragging in the loin, and the pain shoots down the
groin and the thigh, as it always does when the kidney is the seat of
irritation. Very serious and alarming symptoms set in when the kidney
turns over in such a way as to twist its pedicle and cause obstruction in
the ureter and the renal vessels. The urine, no longer allowed to flow
away, distends the kidney, producing the condition known as hydro-
nephrosis. W'hen we stop to consider the disturbances which would
naturally be caused by a kidney distended almost to bursting by the
pent-up urine, we can readily understand the remaining symptoms.
The flow of urine from the bladder is diminished. Resorption of urea
takes place, and there are headache, stupor, foul tongue, vomiting, and
sometimes jaundice. In nearly all cases of movable kidney the
patients are nervous and hysterical. Dyspepsia, loss of appetite, and
general debility are always present. On palpation, with one hand at
THE GENITO-URINARY SYSTEM. 353
the outer border of the erector spinae muscle and the other in front,
the kidney may be felt. Sometimes it is difficult to find it, and the
patient should be placed upon his hands and knees, in which position
the kidney falls forward upon the palpating fingers. Some patients
have a way of assuming positions which bring the wandering organ
into prominence, and I am in the habit of giving them an opportunity
of doing so.
In favorable cases a tumor can be felt which is of the shape, size,
and consistency of a kidney. It is freely movable over a certain area,
but returns naturally to the normal position of the kidney in the loin.
Sometimes the organ can be grasped between the thumb and fingers
of one hand and made to slip from place to place. The mobility of
the kidney may give one loin a want of resistance in comparison with
the other. Pressure applied to the kidney causes a sickening pain very
similar to that felt in the testicle or ovary, and when this can be elicited
in a movable tumor it is strongly confirmator}^ of a wandering kidney.
The failure to find a movable tumor by palpation must not be taken as
settling the question. If the other symptoms are present and constant,
and if they are breaking down the patient's health, operative procedure
is indicated.
Diagnosis. — Many other tumors are liable to be mistaken for mov-
able kidney, but it is seldom that a movable kidney is mistaken for
anything else. The history of the case, the position of the tumor, its
tendency to return to the loin after it has been pushed to the length of
its tether, and a careful study of the symptoms must be our safeguard.
Floating kidney cannot be positively distinguished from movable kid-
ney by any symptom yet known. The length to which a mesonephron
permits the kidney to wander has been supposed to afford a criterion,
but when a movable kidney has become so loose that its movement is
only restricted by the renal vessels and the ureter, it has every charac-
teristic of a floating kidney.
Treatment. — Inasmuch as exercise and jolting of the body increase
the suffering, the patient should be kept as quiet as possible. In mild
cases patients may experience great relief by wearing an elastic belt with
an air-pad so constructed as to push the kidney well back into the loin.
When the cause of mobility is the loss of fat, as in women who have
undergone rapid emaciation, an attempt should be made to restore
normal conditions by keeping the patient in bed and on a diet which
will produce the greatest amount of fat. The most troublesome cases
are those in which renal colic occurs from twisting of the pedicle.
During an attack perfect quiet in the dorsal position must be enjoined,
with hot fomentations and sedatives to relieve pain. Such cases are
not infrequently attended with degenerative changes in the kidney
itself, and thus the condition is rendered more serious. When ordinary
means fail, relief must be sought by operation.
The operation by which a movable kidney is made to form attach-
ments in its original position is called nephrorrhaphy {yzippoz, a kidney ;
^«^7^, a suture). A better word would be nephropexy {yecpb:;, a kidney ;
-rjyuoixc, I fix). The mortality of the operation is probably not more
than 2 per cent., but the results are not always satisfactory. The
patient is placed on the sound side with a firm round sand-bag or
23
354 SURGICAL DIAGNOSIS AND IIUiATMENT.
pillow under the body to increase the costo-iliac space as much as pos-
sible. The incision is made in the loin, and is practically the same as
that eniplo\-ed in lumbar colotomy, only about an inch farther back.
Its bei^innini^ is at the lower border of the twelfth rib and at the outer
border of the erector spinas muscle. This point is generally about
two and a half inches from the spinous processes of the vertebrjE.
From this, as a starting-point, the incision is carried downward and
outward toward the crest of the ilium for three inches or more. The
skin and fat are divided and any bleeding points secured. The super-
ficial fascia is next laid open to the full extent of the wound, exposing
the outer edge of the latissimus dorsi and the posterior border of the
external oblique. Broad retractors in the hands of an assistant hold
the edges of the wound apart and afford working space. The edges
of these muscles are divided with scissors and the internal oblique and
transversalis come into view. These in their turn are severed as far as
the upper and lower limits of the skin-wound, and lastly the deep
layer of the lumbar aponeurosis. The peritoneal fat is now seen
bulging up into the wound, and it is an easy matter to tear it apart
with scissors and expose the kidney itself To bring the kidney up
to position an assistant with strength and endurance in his arm pushes
it from the front. In all operations on the kidney the organ gradually
comes up into the wound by internal abdominal pressure, so that,
although it may seem very far away when first exposed, it comes
nearer and nearer to the surface and can soon be conveniently handled.
Having exposed the kidney, two fingers are passed around the cap-
sule to ascertain the condition which is the cause of the mobility. By
tearing the fatty tissue and irritating the fibrous capsule, either by
manipulation or by scratching with the point of a needle, adhesive
inflammation will be induced, and upon this our chief reliance must
be placed. The renal capsule is opened and stripped off for a short
distance, so as to expose a raw surface of kidney. Sutures are then
passed through the lumbar aponeurosis, the capsule, and the border
of the kidney-substance. Some surgeons fasten the kidney to the
twelfth rib, and with a show of reason, for when the organ is hardened
ill situ it bears a deep groove, which is the impression of the twelfth
rib, and shows that in normal conditions the kidney lies in contact with
that bone. Chromicized catgut is a suitable material. Its service is
but temporary, for it only keeps the parts in apposition while adhesive
inflammation is taking place. Three or four sutures are sufficient. A
drainage-tube or strip of iodoform gauze is next placed in the wound
with its inner extremity touching the kidney. The wound is closed
with silkworm gut and a full dressing applied. The patient should lie
on the back as much as possible, in order that the kidney may not
gravitate from its position, and should keep his bed for six weeks.
Nephrectomy has been resorted to for the worst forms of movable
kidney. It is only when the organ is diseased as well as distressingly
movable that such a procedure is warrantable.
Renal Calculus. — Stones are formed in the kidney by the aggre-
gation and consolidation of certain constituents of the urine which
under normal conditions the kidneys eliminate. Of this class the most
common are uric acid and oxalate of lime. In unhealthy conditions
THE GENITO-URINARY SYSTEM. 355
of the urine, and especially when it undergoes decomposition, a pre-
cipitation takes place which may result in the formation of stone.
The constituents in this class of cases are most commonly phosphate
of lime and the ammonio-magnesium phosphate.
Renal calculi vary greatly in size, number, and shape. Frequently
they are round, and so small and smooth that they pass with ease
through the ureter and are voided in the urine. Others are rough and
pointed with crystals, so that on their passage they lacerate the deli-
cate lining of the urinary passages and cause it to bleed. Others are
so large that they cannot pass away from the kidney, but, continuing
to increase in size, produce one of the most distressing conditions
which a human being can be called upon to endure — exciting inflam-
mation, stopping the flow of urine, and bringing about the destruction
of the kidney itself
Symptoms. — The symptoms of renal calculus are practically those
of a foreign body in the kidney. Depending upon the position of the
stone and other circumstances, these symptoms are subject to consider-
able variation. They are not usually all present in any given case, but
the cardinal signs are not often wanting. These are pain and hematuria.
I. Pai)2. — Two kinds of pain are recognized, direct and reflex.
Direct pain may be constantly felt in the region of the kidney or it
may only be present when the patient is in active exercise. Movement
and jolting always aggravate it. When pressure is made over the kid-
ney or the organ grasped by the hands in the loin the tenderness is
very great.
It may be that no other symptoms are manifested, and yet a diag-
nosis of stone is warranted, and it may further be assumed that the
calculus is either in the cortical substance or in some part of the kidney
in which it cannot move.
Very different is the character of the suffering when the calculus
rolls about in the pelvis of the kidney, becomes blocked in the ureter,
or performs its painful journey to the bladder. Renal colic is the name
applied to these attacks when they appear in their worst form. The
local pain is intense, and the patient clutches the affected loin as if to
pluck some cruel dart from his tortured flesh. He rolls from side to
side bathed in perspiration ; rigors are frequent, and vomiting is often
severe and persistent. There are frequent calls to micturate, but the
quantity of urine is small. All this time the stone is working its way
down the slender ureter, rasping, scratching, and tearing the delicate
lining and causing more or less blood to flow. At last, after a couple
of hours or it may be several days, the calculus drops from the ureter
into the bladder. If it be true, as stated by some old philosopher,
that " the height of happiness is relief from pain," the patient expe-
riences real happiness, for the pain suddenly ceases and a great calm
follows the storm.
But a well-marked attack of renal colic may occur and no stone
pass into the bladder. The concretion may get into the very beginning
of the ureter, where the tube is larger than elsewhere ; it goes far
enough to produce occlusion ; the urine collects behind it, producing
hydronephrosis ; after a time the stone drops back into the renal pelvis
and the pain subsides.
356 SURGICAL DIAGNOSIS AND TREATMENT.
Reflex pain is felt at a distance from the seat of trouble. It runs to
the loin and the testicle, causing the latter to be drawn strongly
upward. It runs down the thigh along the inner side, and even
extends to the leg. Sometimes the patient traces a line along which he
says the pain is intensified, and this line corresponds with the course
of the ureter.
It must be carefully borne in mind that stone in one kidney may
cause pain in the opposite organ. Indeed, cases are on record in which
all the symptoms were on the side opposite to the disease.
2. Blood in the Jirinc is the second cardinal symptom. An attack
of renal colic followed by hematuria is almost pathognomonic of renal
calculus. The blood may appear in the form of small rounded clots or
it may be mixed with the urine less intimately than in other renal dis-
eases, but more freely than when the blood comes from the bladder or
prostate.
Hematuria may be absent from first to last. When the urine con-
tains blood, it of course gives the test for albumin. There are cases
in which albuminuria exists without the presence of blood.
Pus is frequently found in the urine of persons suffering from stone
in the kidney. It is a symptom of great gravity. It proves that
inflammation has gone on to suppuration, and that destruction of
kidney-tissue is taking place which may result in complete disorganiza-
tion. Mucus in the urine is also an important symptom. It is of
special significance in young persons, who are not likely to suffer from
enlarged prostate.
In the majority of cases the diagnosis of stone in the kidney is not
difficult. The most fruitful source of error is stone in the gall-bladder.
It is remarkable how silent the text-books are upon this point, and yet
there are cases in which a positive diagnosis is impossible. (See Diag-
nosis of Gall-stones.) The differentiation must rest upon two points :
I. A microscopical examination of the urine, which in the case of renal
calculi will almost surely contain blood- or pus-corpuscles. 2. Tender-
ness over the kidney. Another condition simulating in some degree
the passage of renal calculi is the discharge of tubercular abscess from
the kidney to the bladder by way of the ureter. Considerable pain
may be experienced and the symptoms closely resemble renal colic.
In gouty persons a discharge of large quantities of crystalline uric acid
may simulate calculus, but in either of the above the history will
generally remove all doubt.
The ;i--rays have been successfully employed in a number of cases.
In one case which came under my observation they proved misleading;
the skiagraph seemed to reveal a stone, but on operation nothing but a
healthy kidney was found.
Commencing tuberculosis in the kidney may lead us into error.
The symptoms already laid down and the examination of the urine for
the tubercle bacilli will generally settle the question.
The pathological condition and the size and position of the stone
may in many cases be diagnosticated. When pain and hematuria are
the only symptoms, we may assume that the kidney is Jicalthy and the
calculus large. When there are pus in the urine, a swelling or increased
resistance in the loin, and tenderness over the kidney, an abscess with
THE GENITO-URINARY SYSTEM. 357
small calculus may be diagnosed. Hydronephrosis, as evidenced by a
swelling in the loin, which is not tender to pressure and not very hard,
accompanied by alkaline urine, little pus, and repeated attacks of renal
colic, points to a stouc that is blocking the uj'ctcr.
Treatment. — During attacks of renal colic pain should be relieved
by hypodermic injections of morphin and the application of heat to the
loin. It is possible to aid the expulsion of a small stone by giving the
patient bland fluids in abundance to flush the urinary tract. These
measures, however, will in the great majority of cases be of little or no
avail, and considering the stone as a foreign body, the only hope of
permanent benefit lies in its removal.
Indicatitvis for Operation. — Not every renal calculus requires an
operation. If the stone is lying quietly in its bed, producing no pain
and causing no serious mischief, it should be let alone. When attacks
of renal colic follow closely upon each other, making the patient's life
a burden and preventing him from following his occupation, then an
operation is clearly indicated. Even if the diagnosis be shrouded in
more or less doubt, an incision for exploratory purposes should be
undertaken.
Operation. — For the operation of nephro-lithotomy the incision is
the same as that described under Nephrorrhaphy. When the kidney is
exposed the finger should be passed over its surface both before and
behind in search of inequalities which would indicate the presence of a
stone, a collection of fluid, a new growth, or abnormal mobility of the
organ. Failing to find evidence of a calculus by digital examination, a
fine aspirating needle can be used with the view of searching for stone
or of finding a cavity containing pus or other fluid. As a means for
finding stone I am convinced that punctures with a needle are of very
little value. In one case I passed a needle in about a dozen places
without feeling the least sensation of the instrument touching a stone,
and yet when I laid the kidney open forty small stones were removed.
Influenced by this and several similar experiences, I have come to the
conclusion that when digital examination fails to find a stone the next
step should be to lay the kidney open. By such an incision an abscess
can be evacuated or a stone in the pelvis of the kidney exposed. The
opening should be made on the convex surface of the kidney and large
enough to admit the fore finger. If no stone can be felt by the finger
in the pelvis of the kidney, a uterine probe bent so as to form a short-
beaked sound is employed to search the calyces. A flexible probe can
be passed down the ureter to the bladder. When a stone is found it is
removed by forceps. If the calculus be branched so as to fill a number
of the calyces, it may be necessary to break it into fragments before
removal. These cases are often exceedingly troublesome, and require
the utmost perseverance and ingenuity of the surgeon. Having gotten
rid of the stone, a drainage-tube is introduced down to the opening in
the kidney. Around the tube is placed a packing of iodoform gauze,
the wound in the loin is closed except at the point of exit of the tube,
and a dressing applied.
Nephrectomy (removal of the kidney) is indicated when the organ is
so disorganized by the presence of stones or from any other cause that
it cannot return to its normal condition. When calculi are found
358 SURGICAL DIAGNOSIS AND TREATMENT.
imbedded in abscess-cavities this question must be considered, for it is
better to remove a kidney that is riddled with abscesses than to let it
remain with the certainty of a second operation later on. To remove
a kidney is a serious consideration. The question of throwing the
whole of the work on one kidney is by no means the most serious
problem involved. If the remaining; or<^an be healthy, it is probably
already doing its own work and that of its fellow.
In a case of nephrectomy for chronic abscesses I found that the
patient was voiding thirty-one ounces of urine daily ; in the twenty-
four hours following the operation it amounted to twenty-nine ounces ;
and at the end of three or four days it was restored to the normal
quantity.
A much more serious question is the possibility of there being only
one kidney. In one out of every four thousand persons all the renal
substance is enclosed within one capsule, the removal of which would
leave no kidney at all. Another consideration is the possibility that
both kidneys are diseased. Assuming that one kidney is so seriously
diseased as to warrant its removal, the state of the other organ must
be systematically examined. A good routine method of investigation
is the following :
1. Examine the organ by inspection, palpation, and percussion.
2. By repeated examinations of the urine satisfy yourself that a
normal quantity and quality is being voided. The quantity of urea
should be carefully noted.
3. Examine the interior of the bladder with the cystoscope. The
pumping action of the ureters can in this way be brought under obser-
vation, and the appearance of the urine as it escapes from each ureter
can be studied.
4. In the female the ureters should be catheterized. (See Cystos-
copy.)
The operation of nephrectomy is thus performed : The incision is
the same as for nephrorrhaphy or nephro-lithotomy. After exposing
the kidney the finger is made to pass around it on every side to free
the organ from its fatty capsule. It is then very carefully drawn into
the wound as far as possible and handed to an assistant. The next step
in the operation is to find and secure the pedicle. In this case the
pedicle consists of the renal artery and veins and the ureter. The
fingers of the operator tease out the fat about the pelvis of the
kidney, exposing the vessels. The pulsation in the renal artery is a
guide of great value. Two ligatures are necessary — one for the vessels,
the other for the ureter. A pedicle-needle armed with a stout silk
thread is made to surround the vessels which form the upper part of
the pedicle. The ligature is then tied, care being taken that during the
tightening the assistant relaxes the traction on the kidney. The ureter
is then isolated and clamped with a pair of forceps as a temporary
measure. The kidney is now cut away. To be on the safe side
against cutting too closely to the ligature, a strong pair of forceps
may be placed upon the pedicle between the ligature and the kidney.
By cutting on the outside of the forceps ample space will be given
to prevent slipping of the ligature. We must relax tension on the
THE GENITO-URINARY SYSTEM. 359
pedicle while the ligature is applied ; we must be equally careful to do
the same thing while the pedicle is being divided, for an arter>^ put on
the stretch at this critical juncture might retract beyond the ligature
and produce fatal hemorrhage. The kidney disposed of, attention is
now turned to the ureter which was left secured by a clamp-forceps.
If there is no thickening of the walls of the duct, it can be secured by
a strong silk ligature and dropped into the cavity. If there is much
thickening or ulceration in its walls, it is best to attach it to the
parietal wound.
In the case of a large suppurating kidney there may be no room for
the application of a ligature between the aorta or vena cava and the
kidney. A temporary elastic ligature can then be thrown around the
base of the kidney and the diseased organ cut away with scissors.
This will do away with the risk of making too great traction on the
pedicle, and by cutting it away in pieces will allow a greatly enlarged
kidney to be delivered through the parietal wound. As soon as the
kidney is removed the pedicle is secured by ligatures, forceps, or actual
cautery and the elastic band removed.
If there is any apprehension of hemorrhage, strong forceps can be
applied to the pedicle and left in position for thirty-six hours. They
serve an excellent purpose in the way of drainage. The external
wound is stitched with silkworm gut and a full absorbent dressing
packed around the forceps.
When the forceps are not loft in the wound, a full-sized drainage-
tube is inserted and the opening closed and dressed as in the pre-
ceding operations.
Abdominal nephrectomy is rarely indicated. It has one advantage
over the lumbar operation, in that the operator can settle the question
of the presence and integrity of the opposite kidney. It is more
suitable than the lumbar operation for large movable, non-adherent
tumors and for a movable kidney which has become diseased and does
not admit of lumbar nephrectomy.
The incision is made in the linea alba or in the linea semilunaris.
The length should in no case be less than four inches, for it will be
necessary to admit the whole hand. For the removal of large tumors
the incision must be correspondingly extended. The middle of the
incision should be on a level with the umbilicus. Having entered the
abdominal cavity, the first point to settle is the condition of the other
kidney by direct palpation. Satisfied on this point, the peritoneum over
the diseased organ is scratched through. This opening must be in the
outer layer of the mesocolon. The fingers separate the front of the
kidney from its fatty capsule. The pedicle is exposed and one ligature
passed around the vessels, while strong forceps secures the ureter.
The kidney is then cut away at a safe distance from the ligature, and
all bleeding points carefully secured. The ureter is dealt with accord-
ing to circumstances. If healthy, it is washed, ligated, and allowed to
drop. If suppurating, it can be secured in the parietal wound or
brought through an opening in the loin. This will allow of its being
irrigated from time to time and will prevent the formation of an abscess.
The question of abdominal drainage here is settled by the rules which
govern it in other celiotomies. If pus or urine has escaped into the
360 SURGICAL DIAGNOSIS AND TREATMENT.
peritoneal cavity during the operation, a drainage-tube should be
inserted, otherwise it is not necessar\'.
Perinephritic and Nephritic Abscess. — Suppuration occurs
around the kidney as a result of direct violence, such as blows or kicks
upon the loin. It may be produced by the presence of a renal calculus
or it may spread from more distant organs, such as the liver, gall-
bladder, spleen, the intestine, or the vertebrae. Urinary fistula and
extravasation of urine are also causes. It not infrequently happens
that a perinephritic abscess is a metastasis from some distant organ, or
it may be a direct migration of septic infection from the urethra or
bladder.
Symptoms. — The local symptoms of a typical perinephritic abscess
are — tenderness in the loin with swelling more or less tense, the swell-
ing and tenderness being due to a collection of pus. We naturally
look for fluctuation, but, owing to thickness of the overlying tissues, it
is generally impossible to find it. To wait for the abscess to come near
enough to enable us to find fluctuation would be bad surgery. Much
better is it to make an exploratory puncture or incision and settle the
question. No harm can come from it, and neglect of this measure
may prove disastrous.
The general symptoms are those of suppurative inflammation, high
temperature, rapid pulse, chills, and general malaise.
In the course of time the pus has a tendency to burrow in one of
several directions and the symptoms are modified accordingly. It is a
rare event for the abscess to rupture into the peritoneal cavity. When
this happens the symptoms are those of general peritonitis. The most
common directions in which the pus is likely to burrow are the fol-
lowing :
1. It is confined by the fascia surrounding the neighboring muscles,
and eventually points in the loin. In this case we will have pain,
tenderness, swelling, edema, and, at a late stage, fluctuation in the loin.
2. The pus gets into the sheath of the psoas, and, following the
course of that muscle, points in the inguinal region after the manner
of a psoas abscess. The psoas being involved, we naturally find the
muscle contracted. Hence the hip is flexed and the patient is unable
to extend the thigh. Pain is felt in the thigh and may run down the
obturator nerve to the knee. Reflected pain is felt in the testicle or
vulva.
3. The pus burrows upward through the diaphragm, and, pene-
trating the lung, is got rid of by expectoration. Here we must be on
our guard lest the pleuritic and pulmonary symptoms divert our atten-
tion entirely from the kidney. In a case which came under my care in
1 884 a fistulous opening in the fifth interspace on the left side was sup-
posed to be due to empyema. On passing a flexible catheter through
the opening it took a direction directly downward and was arrested in
the loin. Cutting down upon the end of the catheter, the sinus was
traced directly to the kidney. Free dilatation and drainage stopped the
suppuration. When pus takes this upward course we expect to find
pleuritic friction, effusion and empyema, dyspnea and expectoration of
pus. On the right side the liver is liable to be involved, hence jaun-
dice is a common symptom ; the stomach sympathizes, and there is
THE GEAVTO-CNnVARY SYSTEM.
361
vomiting ; pressure interferes with the venous circulation, and there is
ascites. In rare cases perinephritic abscesses have burst into the colon,
the duodenum, and the bladder.
Trcatvioit. — Hot fomentations give temporary relief, but valuable
time should not be wasted
in employing such reme-
dies. The proper treat-
ment is to make an incis-
ion, wash out the pus, and
drain the cavity.
The term nephritic ab-
scess is to be restricted to
a collection of pus in a
kidney otherwise healthy.
Abscesses of this charac-
ter seldom contain more
than half an ounce of pus.
The tendency is for the
pus to find its way into
the pelvis of the kidney,
thence being expelled with
the urine, recovery taking
place. The symptoms are
usually severe at the out-
set of acute cases, while in
chronic cases there may
be little or no fever. Pain
is usually felt in the loin
and is intense ; rigors oc-
cur at frequent intervals,
and the temperature is
high. There is a feeling
of increased resistance in
the loin, and sometimes
there are redness and ede-
ma of the skin. The urine
should be carefully exam-
ined for pus ; if it occur in
considerable quantity and
is followed by diminution
of a tumor in the loin, a
diagnosis of renal abscess
can be made with certainty.
Treatment. — I n c i s i o n
is the proper treatment.
Fig. 154. — Suppuration in right kidney, ureters, blad-
der, and prostate from stone in the bladder. The left
ureter, filled with water, measured J-i in. in diameter.
The capacity of the bladder was only 9 drams. The blad-
der contained a calculus i^ in. in diameter (from a photo-
graph in the collection of Dr. Jepson, Sioux City, Iowa).
Sometimes the pus lies
beneath the capsule of
the kidney, and a simple incision of the membrane is sufficient. When
it lies deeper in the substance of the organ the kidney must be incised
and drained.
Surgical Kidney. — This is an unfortunate choice of a name, and
362 SURGICAL DIAGNOSIS AXD 71-:EATiMENT.
means iiothini:^. It is used to designate a general suppuration in the
kidne\' which is secondary to sujjpuration of the urinary tract lower
down, as, for instance, in the bladder or urethra (Figs. 154, 155). It
was observed to frequently follow surgical operations on these parts,
and hence the name " surgical kidney." In reality, it is more fre-
FlG. 155. — Left kidney of same case as Fig. 154. It is laid open to illustrate to what extent
the secreting structure was absorbed. It is simply a large pus-sac ; the walls in some places
are no thicker than brown wrapping-paper (from a photograph in the collection of Dr. Jepson,
Sioux City, Iowa).
quently the result of the lack of surgical procedures, and is to be
traced to infection spreading unchecked up the ureters to the pelvis
and lastly to the renal cortex. The disease frequently affects both
kidneys simultaneously, both being equally exposed to infection.
Symptoms. — The patient is usually a sufferer from some chronic
urinary disorder, as stricture or enlarged prostate, requiring the fre-
quent use of a catheter. The extension of sepsis to the kidney is
observed after the employment of catheters or other instruments, but
it may be entirely independent of them. At first the symptoms are
of a typhoid character. The patient becomes feverish, has a furred
tongue, dry skin, foul breath, and is restless and sleepless. Rigors
are frequent, sweating profuse, and emaciation becomes marked. The
urine generally contains pus and is ammoniacal. Death by exhaustion
THE GENITO-URINARY SYSTEM. 363
is the rule, but in some cases suppression of urine, followed by uremia,
brings about a painless dissolution.
Treatment. — Prevention is better than cure. In every case requiring
the use of a catheter or the simplest operative procedure on the ure-
thra or bladder the greatest care should be taken to disinfect the seat
of operation and the instrument employed. When, after the use of a
catheter, symptoms of urethral fever set in, the urine should be dis-
infected by the administration of salol or quinin, and the patient kept
on nutritious and easily digested food. Should there be evidence of
cystitis or an unhealthy condition of the urine, a soft-rubber catheter
should be introduced with the least possible irritation and the bladder
washed out with boracic-acid solution. When there is suppurative
cystitis the bladder should be washed out, and injected with an ounce
of water containing three grains of nitrate of silver, after which the
bladder should be again irrigated with sterilized water. The question
of nephrotomy for surgical kidney is advisable in certain cases. If
there be evidence of renal abscess and the condition of the patient
will justify it, an exploratory incision should be made over one kidney
in the hope of giving exit to an abscess or of checking the septic process
by incision and drainage.
Hydronephrosis. — The kidney may be compared to a lake among
the hills, drawing its water from numberless springs and rills, and hav-
ing as its outlet a mountain-stream which bears the surplus water to
the sea. If from any cause the outlet becomes obstructed, the lake
must overflow. So it is with the kidney when its outlet, the ureter,
becomes impervious. The numberless tubules like tiny mountain-rills
continue to pour urine into the renal pelvis, from which there is no
escape ; the pelvis and calyces expand, eventually forming a tumor in
the loin attended with most disagreeable symptoms. It is a serious
matter when one kidney is thus affected ; it is disastrous when hydro-
nephrosis occurs simultaneously in both.
The obstruction which produces this serious condition is congenital
in about one-third of the cases. A stone impacted in the ureter is
responsible for about 40 per cent, of acute cases, and is one of the
serious results of renal calculus. Sometimes the pedicle of a movable
kidney becomes twisted and obstruction in the ureter is complete.
Growths in the bladder, tumors pressing upon the ureter, enlarged
prostate, and pregnancy are also entitled to places on the list of
causes. It is a curious fact that frequent micturition of itself is a
sufficient cause of hydronephrosis. This is how it happens : Every
time the bladder contracts the ends of the ureters which pass obliquely
into the bladder are compressed and the flow of urine is obstructed.
Stone in the bladder causes oft-repeated contractions and is a common
cause of hydronephrosis.
SvJnptoins. — There are two leading symptoms of hydronephrosis :
I. The formation of a tumor in the loin or abdomen, increasing rapidly
and fluctuating. 2. An excessive flow of urine, followed by subsidence
of the tumor. This is pathognomonic. It is seldom, however, that
these two .symptoms are found together. The tumor, when it is appa-
rent, varies greatly in size. In one case examined post-mortem by
Glass the right kidney formed a tumor which so distended the abdo-
364 SURGICAL DIAGNOSIS AND TREATMENT.
men that it measured six feet four inches in circumference, and from
the ensiform cartilage to the pubis it measured four feet and half an
inch. The fluid contained in the cystic kidney measured thirty gallons
and was of a light coffee-color. The tumor is sometimes irregular or
lobulated, and fluctuation may be felt. Without a tumor there are no
s\-mptonis which are distinctive of hydronephrosis. Sometimes hydro-
nephrosis is intermittent, the tumor at one time being tense and at
another soft and easily compressed, and if care be taken to measure
the urine, the amount voided will be found to be increased with each
subsidence of the tumor.
The character of the urine is of no value in diagnosis when only
one kidney is involved, for the healthy kidney is capable of keeping up
the normal character of the excretion. The fluid in the affected kidney
is a very dilute urine, having a specific gravity of about 1002, and
containing the natural constituents in small amounts.
When both kidneys are affected the condition is serious and may
lead to uremic poisoning. The diagnosis in the case of a tumor
forming in both loins can be settled by aspirating one or other kidney.
The danger of hydronephrosis is destruction of the affected kidney,
the constant pressure producing absorption of the excreting part of the
renal substance, and eventually converting the whole organ into a
fibrous sac containing fluid. When only one organ is affected, the
opposite one often proves equal to the requirements of both, and the
full amount of urine is excreted.
The diagnosis must be made between hydronephrosis on the one
hand and ovarian cyst, ascites, and hydatids on the other. On palpa-
tion and percussion a dilated kidney has the colon in front of the swell-
ing, and there is dulness in the lumbar region. -An ovarian cyst can be
palpated by the vagina, and has its dulness in the middle line, gradually
growing from the pelvis. In ascites the patient is like a rubber water-
bag, the level of the fluid varying with change of position. Hydatids
cause a painless, slowly-growing tumor, in rare instances having the
hydatid fremitus, and definitely determined by the presence of vesicles
in the urine.
Treatment. — WHien there is evidence of obstruction of the ureter
either by a calculus or other foreign body an attempt may be made to
facilitate its passage toward the bladder by massage of the loin. The
injection of water into the bladder to fully distend it has occasionally
proved of assistance in favoring the release of a calculus down the
ureter (Reghiald Harrison). Failing in these measures, the next effort
should be to relieve the symptoms by aspirating the tumor. In some
cases this has not only given immediate relief, but effected a permanent
cure. If repeated aspirations prove unavailing, the next question to
take into consideration is the opening and drainage of the kidney. The
operation consists in a lumbar incision with an opening into the kidney,
and the establishment of drainage until the sac consolidates or becomes
a harmless sinus. This is preferable to nephrectomy, which has also
been resorted to by some surgeons as a remedy for hydronephrosis.
Pyonephrosis. — Just as water in the pleural cavity may be changed
to pus, so a hydronephrosis may become a collection of purulent matter ;
or if, during the course of a pyelitis, obstruction of the ureter takes
THE GENITO-URINARY SYSTEM. 365
place, the secretion of pus gradually distends the kidney till it reaches
the dimensions and character described under Hydronephrosis. The
symptoms are practically the same. When a diminution in the size of
the tumor takes place the excreted fluid is found to be pus.
Tuberculosis of the Kidney. — Tuberculosis of the kidney is to
be suspected when chronic renal symptoms exist, combined with a
family history of tubercular disease. Males form a large majority of
the patients, and the most susceptible period of life is during early
adolescence and while the sexual functions are most active. One
reason of this distinction is the important part which gonorrhea plays
in the causation. The female when the subject of gonorrhea is more
readily cured, and is not so liable to complications as the male, and
when the tubercle bacillus attacks women it shows a decided preference
for the lungs. In males a gonorrheal orchitis is almost a constant fore-
runner of renal tuberculosis, and while it occasionally happens that the
tubercular process begins in the kidney and makes its way downward,
the opposite direction from testicle to kidney is the rule.
Symptovis. — The patient is generally a male below middle age,
having a family history of tuberculosis and frequently the subject of a
chronic orchitis. With these data to start from, the symptoms of tuber-
culosis in the kidney bear a close analogy to those manifested by the
disease in the lung. There are hematuria, corresponding to hemopty-
sis ; irritation in the urinary tract, causing frequent micturition, corre-
sponding to cough ; and increase in the quantity and change in the
character of the mucus, corresponding to expectoration in phthisis.
Although hematuria can occur in the early stage of the disease, it is
after ulceration has been established that it appears in its most marked
form. Frequent micturition in children leads to a suspicion of stone in
the bladder, and this source of error must be guarded against. As
the disease advances the excess of mucus undergoes a change, and
the urine is found to contain considerable quantities of pus.
The thermometer is valuable here as in the diagnosis of pulmonary
tuberculosis, a persistently high temperature in the latter part of the
day being very characteristic. The demonstration of the bacilli in the
urine settles the diagnosis beyond question.
Treatmetit. — The general treatment as regards diet, climate, and
hygiene are the same as indicated in pulmonary tuberculosis. The
local treatment involves some serious considerations. When the tes-
ticle is tuberculous, the gland should be treated as any other tuber-
culous gland. If there be no evidence of the disease in any other part
of the body, the cheesy masses should be removed or the testicle
completely excised. The bladder requires close attention, especially
when the urine is offensive. Injections of a weak solution of nitrate
of silver, preceded and followed by irrigation, is one of the best
methods of disinfection. Reginald Harrison recommends Iodoform
suspended in mucilage in the proportion of five grains to the ounce.
Nephrotomy or nephrectomy cannot be recommended, for the disease is
seldom confined to one kidney or to any one portion of the urinary
tract.
Hydatid Cysts. — The kidney is much less frequently affected by
hydatids than the lungs or the liver. In the majority of cases the left
366 SURGICAL DIAGNOSIS AND TREATMENT.
kidney is the seat of the parasites, and males suffer more frequently
than females. The cyst begins, as a rule, in the secreting substance,
but occasionally in the cellular tissue beneath the capsule or surround-
ing the pelvis. Small portions of the contents frequently escape
through the ureter, and it is probably on this account that hydatid
cysts of the kidney seldom attain to large size. Rupture is not
uncommon, and the discharge may take place into the intestine or
lung, but never externally through the loin. Sometimes the cyst
undergoes inflammatory or absorptive changes, as happens in hydatids
of other organs.
Syviptonis. — When the tumor is small a hydatid cyst of the kidney
may present no symptoms, and in the favorable cases in which it dis-
charges through the ureter the disease may undergo a spontaneous
cure without recognition. In many cases (52 out of 63, according to
Roberts) vesicles are passed in the urine and afford the first clue to the
nature of the affection. In their journey down the ureter these
vesicles produce well-marked attacks of renal colic, and occasionally
hydronephrosis. The tumor in the loin is smooth, but seldom is
fluctuation elicited. When the vesicles get into the bladder they
may produce irritation and tenesmus ; in the urethra they may
cause retention of urine. In any case inflammation and suppuration
may supervene, while blood and pus escape with the urine. The
hydatid fremitus so constantly mentioned as a diagnostic sign is really
of little value, owing to the extreme rarity with which it can be
detected. To settle positively the diagnosis, exploratory puncture is a
proper measure, the demonstration of the booklets under the micro-
scope leaving no possible room for doubt. It must, however, be
borne in mind that exploratory puncture is not devoid of danger.
When it is necessary to resort to it the surgeon should be prepared to
operate the moment the diagnosis is settled.
Treatment. — The surgical treatment is the same as that indicated for
hydatids of the liver. An incision as for nephrorrhaphy is made in the
loin, the cyst freely opened, its edges stitched to the external wound,
and the ca\'ity cleaned out and drained.
Simple Cysts. — Serous cysts springing from the renal cortex are
recognized on palpation as thin-walled globular tumors. Their con-
tents vary from a thick jelly-like substance to a thin, straw-colored
fluid containing albumin, cholesterin, and sometimes blood.
There are few symptoms to aid the examiner except a painless,
smooth tumor in the loin, growing slowly and producing neither dis-
turbance of the general health nor derangement of the urinary organs.
The diagnosis must rest upon the exclusion of other tumors of the
kidney of a cystic nature.
Solid Tumors. — Before five years of age and after thirty solid
tumors of the kidney are not uncommon. No matter how fine the
distinctions made by the pathologists, or how exhaustiv^e the classi-
fication adopted by the clinician, tumors will always fall under one of
two great classes — benign and malignant. In the kidney benign solid
tumors are almost never found. When you make a diagnosis of solid
tumor it is equivalent to saying that the growth is either a sarcoma or
a carcinoma. For the sake of being systematic we adopt a classifica-
THE GENITO-URINARY SYSTEM.
367
tion of renal tumors, and that of Paul seems to be the simplest and is
sufficiently comprehensive :
Of congenital origin : Sarcoma, hydronephrosis, cavernous tumors,
dermoid tumors.
Of adult origin : Cystic disease, cavernous tumors, sarcoma, adenoma,
carcinoma.
Syuiptoms of Solid Tumors. — In examining a tumor in the lumbar
region the following points require attention : A kidney as it enlarges
takes a direction forward, while an abscess or other lesion which can
simulate an enlarged kidney causes bulging posteriorly. A kidney is
always round, and can thus be distinguished from the liver, which has
a sharp edge, and from the spleen, which has a characteristic notch.
Fig. 156. — Carcinoma of the kidney from a patient aged eighty. Patient made a good
recovery from the operation, but died two months later of persistent vomiting and dilated
stomach (from a photograph in the collection of Dr. Andrews, Mankato).
The kidney does not rise and fall with the respiratory movements as
freely as does the liver. A tumor of the kidney has usually a resonant
zone in front of it, which is the ascending or descending colon. This
may be absent, owing to congenital malposition of the colon. When
the intestine fails to give resonance on percussion, the bowel can some-
times be felt as a cord-like structure between the tumor and the skin.
Briefly stated, the distinctive symptoms of cancer of the kidney are a
tumor in the lumbar region and hematuria (Fig. 156). The tumor
grows in the direction of least resistance, which is forward, and over-
lying it is the colon recognized by a zone of resonance. From tumors
of the liver a renal growth is distinguished by the following points :
368 SCKGICAL DIAGXOSIS A .YD TREATMENT.
1. The liver rises and falls with respiration.
2. Hepatic tumors have no bowel-resonance in front.
3. The sharp edge of the liver can frc(]iu;ntl\' be felt; kidney tumors
are always round.
4. Between a renal tumor and the edge of the ribs is a space into
which the fingers can be pushed.
Between a splenic and a renal tumor the differences are —
1. A splenic tumor has no bowel in front.
2. It has usually a well-defined edge, and sometimes a notch can
be felt.
Hematuria is found in about half the cases. It may occur at any
stage of the disease, and is generally intermittent. When the amount
of blood is large it may form clots in the ureter or bladder, and then
renal colic or vesical tenesmus becomes a prominent symptom. In the
intervals between attacks of hematuria the urine is normal or it may
contain pus- or tube-casts.
Pressure-symptoms are sometimes prominent. One or both legs
may be edematous, and large veins may course over the abdominal
wall ; the bladder may be irritable and the bowels constipated.
Pain is not a constant symptom, but in a majority of cases it is pro-
nounced. It is most prominent in the loin and abdomen, but is reflected
down the thigh and around the back and shoulders.
Treatment. — All congenital solid tumors of the kidney must be con-
sidered malignant, and therefore the treatment is by no means hopeful.
Internal remedies, such as iodid of potassium and Chian turpentine,
have given some encouragement. When improvement appeared to
take place it was only temporary. The toxins of er>'sipelas and
bacillus prodigiosus enjoyed a reputation for a time, and several cases
of sarcoma were reported as cured by their use. A most patient trial
in three cases of my own ended in utter disappointment.
The question of removal of the growth, including the kidney, is a
most serious one. Of 35 operations reported by Mr. Sutton for renal
sarcoma in children under six years of age, 15 recovered, but all died
within a year from recurrence of the growth. If recognized at an early
period of the disease, extirpation would give a chance of future im-
munity, and several cases are recorded in which the patients remained
free from recurrence at the end of two or three years. In adults, when
urgent symptoms such as profuse hematuria or intense pain call loudly
for relief, operation may afford the only prospect, but the possibility of
cure is so remote that the brightest side that can be claimed for the
operation is that it is likely to end the patient's suffering by an easy
death.
II. INJURIES AND DISEASES OF THE URETER.
Surgical Anatomy. — The ureter is a muscular canal which carries
the urine from the pelvis of the kidney to the bladder. Its average
diameter is one-eighth to one-sixth of an inch, and its length from
ten to thirteen inches. Its walls consist of three coats. The outer
is composed of connective tissue with elastic fibers ; the middle coat is
muscular, the fibers being; both longitudinal and circular; the inner
THE GENITO-URINARY SYSTEM. 369
coat is composed of mucous membrane. The ureter lies behind the
peritoneum, but bound to that membrane by fibrous bands, so that
when the peritoneum is stripped from the parts behind the ureter
always follows it. On this account the ureter is difficult to find in the
bottom of a deep lumbar wound, especially in fat subjects.
Its course is downward from the kidney, at first lying on the psoas
muscle, and then crossing the bifurcation of the common iliac arteries.
Although nearly straight, the tube really takes two curves — the first
from the kidney to the brim of the pelvis, its convexity toward the middle
line ; the second or pelvic curve has its convexity directed toward the
outer wall of the pelvis. The ureters enter the neck of the bladder
about two inches apart, running obliquely between the muscular and
mucous coats for a distance of a half or three-quarters of an inch. In
the male this opening is external to the vas deferens ; in the female the
ureter penetrates the plexus of veins beneath the broad ligament.
The canal is not absolutely uniform in caliber throughout its entire
course ; Halle and Tanguery have shown that in normal subjects it is
narrowed in three places — viz. {a) At a point between one and a half
and two and a half inches from the pelvis of the kidney ; {d) at the
junction of the pelvis and vesical portions ; and (r) at the place where
it crosses the iliac artery. These are the localities where small stones
from the kidney have been found to be arrested (Fenger).
In palpating the ureter the following landmarks from Tourneur are
of importance: At the junction of the internal with the middle third
of Poupart's ligament erect a vertical line. This line corresponds with
the course of the abdominal portion of the ureter. It crosses the brim
of the pelvis four and a half centimeters from the middle line. This
point is found by drawing a horizontal line from one anterior superior
iliac spine to the other, and intersecting this by a vertical line through
the pubic spine. At the point of intersection gentle steady pressure can
be made by the fingers until the brim of the pelvis is reached. Tender-
ness or dilatation of the ureter at this point can thus be detected. The
vesical portion of the ureter can be palpated through the rectum in the
male. When a stone is lodged in the ureter, even at a point high up,
exquisite sensitiveness is experienced in this examination (Guyon, cited
by Fenger). In females the ureter can be palpated through the vagina
for a distance of two or three inches as it runs in the broad ligament
close to the upper wall of the vagina (Cabot).
Rupture of the Ureter. — It would seem almost impossible that
the ureter should suffer injury, protected as it is by strong masses of
muscle and fat and guarded by promontories of bone. When rupture
does occur, it is by the application of very great violence to the trunk
or abdominal region. The kick of a horse, the passage over the body
of a heavily-laden wagon, a blow from the handle of a wheelbarrow,
violent over-stretching, and other traumatisms have been reported as
causes.
Symptoms. — The symptoms are generally obscure, and often they
are long delayed. When the bladder or the kidney is ruptured, the
symptoms are prompt in making their appearance. Not so with the
ureter, for at the beginning there are no grave symptoms unless some
other important organs are injured.
24
370 SURGICAL DIAGNOSIS AND TREATMENT.
When there is an external wound through which urine is found to
escape the diagnosis is positive. In the absence of this sign the evi-
dence must rest hirgely on the nature and severity of the injury. In
some cases the urine is bloodstained. A swelling in the loins and a
collection of fluid, which when drawn off by the aspirator is found to
resemble urine, are very suggestive of rupture. This swelling does not
occur until some time after the receipt of the injury. The time varies
from seven days to seven wrecks. The swelling is round, oblong, or
sausage-shaped, following the course of the canal, and is paljiable from
the abdomen (Fcnger).
The fluid which produces the swelling just mentioned is not pure
urine, nor is the rupture of a ureter followed by extravasation of urine,
as we would naturally infer. The clinical fact remains that in cases of
ruptured ureter a fluid is poured out at the seat of rupture which is not
productive of the disastrous consequences which follow extravasation
of urine in other parts. When extravasation of urine takes place in
the scrotum or perineum from ruptured urethra, inflammatory symp-
toms soon appear and rapidly proceed to gangrene of the parts
involved. In rupture of the ureter a swelling forms and continues for
days or weeks without any inflammation or gangrene. In explanation
of this singular condition Reginald Harrison suggests that the rupture
of the ureter is followed by the formation of clots, not only in the
ureter, but in the corresponding kidney ; that these ante-mortem clots
are a provision for the substitution of a kind of urine which is incapable
of proving destructive to the tissues with which it may come in con-
tact. In a case of his own he was able to examine this kind of urine,
and found that there w^as almost a complete absence of 'urea. There
being no urea to decompose, there is no source for the production of
the ammonia by which the destruction of tissues is eflected when nor-
mal urine is extravasated. The absence of urea renders the urine
chemically harmless to the tissues with which it comes in contact.
One of the consequences of ruptured ureter is the formation of
dense and unyielding strictures. As a consequence of stricture the
kidney may suffer from hydronephrosis and undergo atrophy.
Treatment. — If an early diagnosis can be made (and this is only
possible when there is a wound through which urine is trickling), the
proper treatment of ruptured ureter would be to enlarge the incision,
find the divided ends of the tube, and unite them in the manner which
will be presently described. So far, this has not been attempted. In
the majority of cases the diagnosis is arrived at after the formation of
a swelling due to a collection of modified urine above described. The
treatment in vogue for this condition is puncture or incision, and drain-
age either through the abdominal cavity or by a lumbar incision.
Nephrectomy has been resorted to in a number of these cases and in
accidental division of the ureter during celiotomies.
Nephrectomy is too radical an operation to be thought of before
every other expedient has been tried to restore the function of a rup-
tured or severed ureter. Instead of proceeding deliberately to remove
the kidney, an exploratory incision would be the proper course. Search
should be made for the ends of the ureter, and if found an attempt
should be made to unite them. Access to the ureter can be had by
THE GENITO-URTNARY SYSTEM. 37 1
the abdominal or by the lumbar incision. An incision in the middle
line or a little to one side exposes the whole length of the ureter with
little difficulty, but the operation is intra-peritoneal, and unless the urine
is aseptic the danger of peritonitis is great. The lumbar incision ren-
ders it more difficult to reach the ureter, owing to the depth of the
wound, but when it is practicable it should be chosen as much the
safer operation. The incision begins at the lower border of the twelfth
rib, at the edge of the erector spinae muscle, and extends along a line
one inch anterior to the ilium, and thence along Ponpart's ligament to
about its middle. Only the upper two-thirds of the ureter can be ex-
posed by this procedure.
Van Hook's method of suturing the divided ureter (uretero-ureter-
ostomy) is as follows: i. " Ligate the lower portion of the tube one-
eighth or one-fourth of an inch from the free end. Silk or catgut
may be used. Make with fine sharp-pointed scissors a longitudinal
incision twice as long as the diameter of the ureter in the wall of the
lower end one-fourth of an inch below the ligature.
2. " Make an incision with the scissors in the upper portion of the
ureter, beginning at the open end of the duct and carrying it up one-
fourth of an inch. This incision ensures the patency of the tube.
3. " Pass two very small cambric sewing-needles, armed with one
thread of sterilized catgut, through the wall of the upper end of the
ureter one-eighth of an inch from the extremity, from within outward,
the needles being from one-sixteenth to one-eighth of an inch apart
and equidistant from the end of the duct. It will be seen that the
loop of catgut between the needles firmly grasps the upper end of
the ureter.
4. " These needles are now carried through the slit in the side of the
lower end of the ureter into and down the tube for half an inch, where
they are passed through the wall of the duct side by side.
5. "It will now be seen that the traction upon the catgut loop passing
through the wall of the ureter will draw the upper fragment of the duct
into the lower portion. This being done, the ends of the loop are tied
together securely, and, as the catgut will be absorbed in a few days,
calculi do not form to obstruct the passage of the urine.
6. " The ureter is now enveloped carefully with peritoneum, as
already described in other operations, provided an intra-peritoneal
operation has been done."
As an additional security against leakage Bloodgood recommends the
application of two sutures through the external coats (Figs. 1 57-161).
Another method of dealing with a divided ureter is b)' ituplantatioii.
When there is loss of substance or when from any cause the ends of
the tube cannot be approximated, the following expedients have been
resorted to :
1. Implantation of the proximal end of the ureter into a loop of
intestine. This is objectionable on account of the risk of septic
infection of the kidney by the gases escaping from the bowel.
2. Implantation into the bladder. When the proximal end of the
ureter is long enough to reach the bladder, this procedure is better
than any other, as it re-establishes the natural course of the urine and
is free from danger of septic infection.
372
SURGICAL DIAGNOSIS AND TREATMENT.
Fl>.. 1-,/. — L itifio-urfterectomy (Van Hook's method). The needles have been introduced
into the wall of the renal portion of the ureter. The end of the vesical portion of the tube has
been ligated and a slit made in its wall.
Fig. 158. — The needles carrying the traction suture attached to the renal portion of the
ureter have been passed into the slit in the wall of the vesical portion, carried down a short
distance, and pushed out through the wall.
Fig. 159. — By means of the traction suture the renal portion of the ureter has been implanted
into the vesical portion. The ends of the traction suture have been tied together.
Fig. 160. — Ureter anastomosed
traction sutures tied ; and two fi.xation sutures in place ready
to be tied.
Fig. 161. — Longitudinal section of ureter, showing new lumen and diverticulum.
3. Implantation into the pelvis of the kidney. This is applicable to
cases in which the division is at the upper portion of the ureter.
4. Implantation through the skin. When the ureter is divided in
THE GENITO-URINARY SYSTEM. 373
the pelvis and cannot be connected with the bladder and vagina, it has
been suggested by Van Hook to attach the proximal end by sutures
to an opening in the skin.
Ureteral Calculus. — A stone in the ureter is likely to be arrested
at one or other of three portions of the tubes which are naturally nar-
rowed — that is to say, at a point between one and a half and two and
a half inches from the pelvis of the kidney, at the junction of the pelvic
and vesical portions, and at the point where the ureter crosses the iliac
artery. Of these three portions, the upper is most frequently the
lodging-place of a calculus, while stone is found in about equal
frequency in the two lower portions.
Diagnosis. — The diagnosis of stone in the ureter is only possible in
that portion of the duct which can be palpated from the rectum or
vagina. Even when thus favorably located errors in diagnosis are apt
to occur. A calculus palpated from the vagina is likely to be mistaken
for a diseased ovary, as happened in Collingworth's case. The symp-
toms of stone in the upper portion of the ureter are those of stone in
the kidney, and a differential diagnosis is impossible.
Removal of stones from the ureter is effected by different methods
according to their location :
1. Longitudinal Ureterotomy. — When the calculus is lodged in the
upper part of the ureter an attempt should be made to push it back into
the renal pelvis, whence it can be withdrawn through an incision in the
renal tissue. Failing in this, an incision should be made in the long
axis of the ureter over the stone. The wound in the ureter is care-
fully closed with sutures if the operation is intra-peritoneal. When
extra-peritoneal no sutures are required, as the urine can be drained
until the wound closes by granulation.
The consequences of obstruction with calculi of one or both ureters
are serious. When one tube only is obstructed, absorption and dis-
integration of the corresponding kidney take place. When both tubes
are occluded, speedy death results from mechanical suppression of
urine.
2. Ureterotomy through the Vagina. — When by palpation a stone
can be felt in the lower end of the ureter, its removal by way of the
vagina may be accomplished without great difficulty. The usual posi-
tion of the calculus is in the broad ligament close to the cervix uteri.
The incision is best made with scissors, and the wound can be closed
with interrupted sutures.
3. Removal through the Rectum.
4. Removal through the Bladder. — The stone may be so near the
lower end of the ureter as to give a click when examined with a sound.
In this case the urethra is dilated, and also the orifice of the ureter if
necessary, and the stone withdrawn. Whitehead removed eleven
calculi in this manner. Sometimes the mucous membrane has to be
divided before the stone can be set free.
Ureteritis. — Inflammation of the ureter is probably a quite com-
mon condition, but masked by renal and vesical diseases. According
to Mann, ureteritis has seven causes: (i) injuries during childbirth;
(2) previous disease of the bladder ; (3) gonorrhea ; (4) suppuration
of the pelvis of the kidney ; (5) pelvic inflammations and tumors ; (6)
0/4
SURGICAL DIAGNOSIS AND TREATMENT.
abnormal conditions of the urine; (7) tuberculosis. The pathological
changes produced by inflammation are in some cases a slight swelling
of the tubes and desquamation of the epithelial lining ; in others a
purulent condition indicating ulceration of the lining membrane ; in
still another class the tube is thickened, increasing the caliber of the
ureter to the size of a lead-pencil or larger.
Symptoms. — The most constant symptoms are frequent or almost
continuous micturition and a boring pain along the course of one or
both ureters. The left suffers more frequently than the right. The
disease is usually chronic in its course, and great depression of spirits
is not uncommon.
Treatment. — The general treatment consists in securing the best
hygienic surroundings, avoiding alcoholic and other irritating bever-
ages, and paying careful attention to diet. The bowels should be kept
relaxed and alkalies should be given continuously. For improving the
condition of the urine copaiba, oil of sandalwood, and benzoic acid are
recommended.
Local applications of nitrate of silver or boracic acid may be made
to the ureters after first dilating the urethra in the manner recommended
by Simon, Pawlik, and Kelly.
Stricture of the Ureter. — The healing of a wound of the ureter
>-yr-yO
k:^
<^
Fig. 162. — Fenger's plan of operating for ureteral stricture on extra-peritoneal surface of
ureter: (^) ureter stricture and line of incision ; (i5) opening through the stricture extending
into the proximal and distal portion of the ureter, the extreme ends of the incision a and a' to
be united; (C) ureter after suturing; a, the bend at the site of the stricture.
is likely to be attended with the formation of cicatricial tissue, which by
its contraction narrows the tube in the same manner as occurs so fre-
quently in the male urethra. There is a question whether stricture can
THE GENITO-URINARY SYSTEM. • IJ^
be caused by gonorrheal infection spreading from the urethra to the
bladder and thence to the ureter. Tumors in the pelvis and abdomen
are common causes of obstruction of the ureters.
In many of the cases stricture results from the healing of ulceration
caused by the temporary obstruction of a calculus or by the healing
of a tubercular abrasion.
Operations for the Relief of Stricture of the Ureter. — i. Fenger's
method consists in making a longitudinal incision at the seat of stric-
ture and converting it by sutures into a transverse incision. The ureter
is opened above or below the stricture and the incision carried through
the constricted portion, as seen in Fig. 162. The upper and lower ends
of the longitudinal wound are then brought together by folding the
ureter upon itself The remainder of the wound is approximated by
sutures which catch the outer and middle coats, thus converting the
longitudinal into a transverse wound (Fig. 162).
2. Dilatation by bougies has been successfully practised by Alsbe'rg
in a case of stricture near the pelvis of the kidney attended by hydro-
nephrosis.
3. Resection of the ureter and implantation of the distal end into
the pelvis of the kidney.
III. INJURIES AND DISEASES OF THE BLADDER.
In the general examination of a patient our attention is usually
drawn to the bladder by one or more of the following symptoms — viz,
pain, frequent micturition, and hematuria. The significance of these
symptoms we shall now consider.
Pain. — This is not necessarily felt at the seat of the disease, but, like
the pain in hip-disease, may be felt at a distance. Stone in the bladder
produces pain on the under surface of the penis a little behind the
meatus. When the kidney is the seat of the disease, pain is felt in the
groin, in the testicle, and down the thigh. Disease in the testicle pro-
duces pain along the inguinal line. These are reflected pains, and are
felt at the termination of the nerve and not at the spot where the nerve
is irritated.
Direct pain, however, is not uncommon. When the bladder becomes
over-distended the pain is felt over the viscus itself Urethritis causes
pain at the seat of the inflammation, which is always accentuated by
external pressure at that point. In inflammation of the prostate the
pain is most marked in the perineum and rectum, and is greatly in-
creased by digital pressure by way of the rectum. Combined with
these direct we may also have indirect pains running along the course
of the urethra, and leading us to suspect the presence of stone in the
bladder.
A valuable aid to diagnosis is a consideration of the time at which
pain is felt. If it is felt during micturition, we naturally suspect inflam-
mation in the urethra, the prostate, or the bladder. A patient with
stone in the bladder complains of pain at the end of micturition, and
well he may, for the viscus, after expelling all the urine, violently con-
tracts upon the calculus in a vain but painful effort to get rid of the
foreign body. Pain that is felt before the act of micturition, and which
376 SURGICAL DIAGNOSIS AND TREATMENT.
ceases after tlie act, is due to cystitis or to retention of urine. Pain
durinL^ micturition, <^reatly aggravated by the act of defecation, is an
indication of inflammation in the prostate.
Frcijucnt Micturition. — The expulsion of urine from the bladder is a
reflex act. In the normal condition the urine trickling down the ureters
gradually expands the bladder till a certain degree of irritation is applied
to the terminal branches of the sensitive nerves which supply the viscus.
This stimulus runs up the sensory nerves to the spinal cord, and thence
to the motor nerves which supply the muscles of the bladder and ure-
thra. These muscles contract and empty the bladder. Any stimulus
applied to the terminal branches of the sensitive nerves will produce
the same result ; consequently, frequency of micturition is a symptom
of cystitis, urethritis, or prostatitis. It also occurs when the capacity
of the bladder is lessened, when the urine undergoes certain changes,
when there is phimosis, contracted meatus, stricture, or calculus. Taken
by itself, frequent micturition is a symptom of very indefinite signif-
icance. When it is met with, the question should be decided as to
whether it is increased by exercise or by rest. A stone or a tumor in
the bladder may be suspected when movement increases the frequency ;
atony of the bladder and disease of the prostate are to be suspected
wl^en the frequency of urination is increased by rest. The size and
force of the stream should be carefully noted. A small stream is
caused by stricture, by a contracted meatus, or by inflammatory
swelling in some part of the urethra. If the time spent in the act of
micturition is lengthened and the force of the current is slow, obstruc-
tion may be suspected, the most common causes of which are stricture,
prostatic disease, and muscular atony.
Hematuria. — Bleeding may occur from any part of the urinary tract,
and by close observation we can generally locate its origin. When it
comes from the kidneys it is well mixed with the urine, giving the fluid
a smoky appearance. In addition there is a history of renal disease, as
indicated by albuminuria, the presence of granular or hyaline casts,
degeneration of the retina, etc. The color alone should not be relied
upon, for smoky or beef-tea-colored urine may be produced when
blood in small quantities escapes from the bladder-wall and has time
to mix freely with the urine before being expelled. Black or coffee-
colored blood is produced by profuse hemorrhage from the bladder
accompanied with retention from clotting. Blood from the ureter is an
accompaniment of renal colic, and is usually due to the passage of a
calculus on its way from the kidney to the bladder. The quantity of
blood is seldom large, but the terrible pain up the back and loin, in the
testicle, and down the thigh leaves little doubt as to its origin. Hemor-
rhage from the prostate comes away in clots, and is usually a concom-
itant of chronic disease of the gland, such as tuberculosis or carcinoma.
The prostate is generally enlarged. When the urethra is the seat of
hemorrhage it is generally due to the use of instruments. The blood
comes before the urine and is clotted. The bladder is frequently the
seat of hemorrhage, owing to the presence of calculi and morbid
growths, especially papillomata. We recognize this source of bleed-
ing by excluding the other localities and by the history of the case.
As a rule, the blood comes with severe straining at the end of urina-
THE GENITO-URINARY SYSTEM. ^yj
tion. An ingenious test for ascertaining the existence of a wound or
abrasion of the bladder is the so-called absorption test of Ultzmann.
A solution of iodid of potassium is injected into the bladder. If there
is a breach in the continuity of the mucous membrane, the iodid is
absorbed and can be detected in the saliva. The absence of iodin in
the saliva would indicate an uninjured mucous membrane. The follow-
ing axioms from E. Hurry Fenwick may be taken as in the main
correct :
1. " The brighter and more arterial the color of the urine, the nearer
the source of the bleeding is to the meatus urinarius.
2. " Long dark clots like earth-worms or quill-barrels indicate bleed-
ing from the renal pelvis, for they are clots or moulds of the ureter.
3. " Large irregular-edged scarlet clots are derived from a bladder
source if traumatism of the kidney and renal tumor are excluded.
4. " Blood appearing toward or at the finish of clear urination
denotes a vesical or a prostatic origin.
5. " Blood issuing from the meatus independently of micturition is
from an urethral source."
In cases of doubt the microscope may throw some light upon the
source of the hemorrhage. Blood-casts indicate the renal tissue as the
seat of hemorrhage, and the same is true of granular casts. When
the bladder is the seat of a morbid growth small portions of the neo-
plasm are likely to be voided with the urine, and may be subjected to
the microscope.
The voided blood may be further examined by allowing it to subside
in a conical glass. Of this test Von Jaksch says : '* When blood-cells
are intimately mixed with the urine in such a way that, though present
in large quantity and deeply tingeing the fluid, they do not form a sedi-
ment after many hours' standing, it may be inferred that the hemor-
rhage took place in the substance of the kidney or in the renal pelvas or
ureters. If, under these circumstances, they are seen with the micro-
scope to be profoundly altered, having lost their coloring matter and
presenting the appearance of pale yellow rings, the further conclusion
results that the blood has been effused from the kidney itself, and the
symptoms point to acute nephritis or to a fresh exacerbation in the
course of chronic nephritis."
Having completed the examination of the urine, the next step in the
investigation of the seat of hematuria is a physical examination of the
various parts of the urinary tract as follows :
I. The Kidneys. — The method of palpating the kidney has been
already described. By palpation we ascertain the presence or absence
of tenderness of the kidney. Tenderness can be elicited on deep
pressure in the following conditions : viz. pyelitis, chronic abscess,
inflamed cyst, and acute suppurative nephritis. A stabbing pain
elicited by pressure over the front of the kidney is very suggestive of
renal calculus, but too great stress should not be laid upon the absence
of this sign. Enlargement of the kidney may be due to the following
conditions : {a) It may be a simple hypertrophy of the organ to com-
pensate for atrophy of its fellow, [b) It may be due to the presence of
a large calculus and to the inflammatory changes which such foreign
bodies produce, (e) Tuberculosis is a common cause of enlargement:
378 SCRG/C.IL DIAG.VOSIS AND TREATMENT.
this condition appears after the age of twenty and the patients show a
history of tuberciihir disease in other organs. (<■/) Hydronephrosis is
suggestive of obstruction by calcuH or the twisting of the renal vessels
and ureter, [c) Perinephritis with abscess in its early stages produces
adhesions and subsequent contraction which draw the kidney upward
beneath the ribs. (/") Tumors of the kidney, which in the vast
majority of cases prove to be sarcomata or carcinomata.
3. The Ureters. — Deep pressure along the course of the ureters may
elicit tenderness in the whole course of the tubes, and is suggestive of
ureteritis. If the tenderness is only found in spots, calculi are probably
the cause. The examination of the lower portions of the ureters per
rectum in males and per vaginam in females must not be neglected.
3. Tlic Bladder. — By rectal or vaginal examination the base of the
bladder can be felt and any thickening or induration readily determined.
After the age of forty-five the most common cause of thickening is
carcinoma, and, as the infiltration begins near the opening of one or
other ureter, the thickening occurs to the right or left of the middle
line. Care should be taken in this examination, for rough palpation is
frequently followed by profuse hemorrhage. Hardness and thickening
are also felt when the bladder contains a calculus, and particularly if
the stone is sacculated.
Injuries of the Bladder.
Rupture. — The bladder is liable to rupture by direct violence
applied to the lower portion of the abdomen, and it may be laid down
as an axiom that the more the bladder is distended the greater is the
risk of this injury. Bullets and other missiles are causes of rupture
which attack the bladder from without. The viscus may be ruptured
from within, and the most frequent cause is the laceration of its wall by
a fragment of bone occurring in severe fractures of the pelvis. Injuries
to the rectum or vagina not infrequently involve the bladder.
The bladder has sometimes ruptured by over-distention, as when
filled preparatory to the operation of cystotomy. It is only when its
walls are weakened or sacculated from previous disease that this is
likely to occur. In any severe injury of the pelvis or hypogastrium, if
the patient be unconscious or has not the power to micturate, a catheter
should be passed into the bladder and the effect carefully noted.
Rupture of the bladder is of two kinds — intra-peritoneal and extra-
peritoneal. When the organ is ruptured and its contents escape into
the peritoneal cavity, the most serious consequences follow : the shock
is profound, and unless prompt treatment is resorted to the patient dies
in from three to seven days. In such a case the catheter will be found
to draw off only a small quantity of blood-stained urine. If the instru-
ment happens to enter the laceration, it will pass freely up beyond the
natural limit of the bladder. The catheter, however, may impinge
against an unbroken portion of the bladder, in which event the con-
traction of the viscus prevents the instrument from passing its normal
distance, and it appears to have gone in a wrong direction. To settle
the point pass a finger into the rectum, when it will be found that the
catheter is in the proper position, but firmly grasped by the bladder.
THE GENITO - URINA RY SYS TEM. 379
Should the surgeon still be in doubt as to the existence of intra-
peritoneal rupture, he may next proceed to measure the capacity of the
bladder. A rubber catheter is inserted, and Peterson's rubber bag
passed into the rectum and distended with warm water. The bladder is
then slowly filled by allowing a measured quantity of some mild anti-
septic solution to flow through the catheter. If free from rupture, it
can be felt to rise out of the pelvis and its limits can be defined by per-
cussion. After the injection of six or eight ounces the fluid is allowed
to flow out by the catheter, after which it is carefully measured and
compared with the quantity injected. If the amount withdrawn is
equal to the amount injected, the bladder is not ruptured. Another
means of diagnosis is the injection into the bladder of filtered air
through a Davidson's syringe over the outer end of which cotton has
been tied. If there be an intra-peritoneal rupture, the air will inflate
the whole abdomen ; if the bladder be intact, it alone will be distended.
Should this injection produce emphysema of the cellular tissue, it
proves that an extra-peritoneal rupture of the bladder has taken place.
Treatment. — Several cases are on record in which careful drainasfe
by a catheter, retained just inside the neck of the bladder, has been
followed by recovery. This method, however, is not to be relied upon.
As soon as possible after a satisfactory diagnosis has been made the
abdominal cavity should be opened by an incision in the middle line
just above the pubes. The rent in the bladder having been found, it is
closed by a double row of carbolized silk sutures. There has been
considerable discussion ov^er the question of retaining a catheter in the
bladder after this operation. The weight of opinion seems to be in
favor of dispensing with the catheter. If the rent in the bladder be
closely secured so as to prevent leakage, a moderate degree of disten-
tion is less likely to do harm than the retention of the catheter in the
bladder for several days.
In extra-peritoneal rupture of the bladder the urine is extravasated
in the prevesical connective tissue or into the vesico-rectal or vesico-
uterine space. Its diagnosis is arrived at by exclusion of the intra-
peritoneal variety, by the production of cellular emphysema when the
bladder is distended with filtered air, and by the presence of urinary
infiltration. When there is an injury which from its position evidently
implicates the parts concerned in micturition, and when, after examina-
tion of the rectum or vagina, and the use of the catheter as already
described, there is still doubt, a perineal incision should be made into
the membranous portion of the urethra for the purpose of digital ex-
ploration of the neck of the bladder. On this point Reginald Harrison
observes : " Many patients in cases of this kind have undoubtedly been
lost for the want of that knowledge which can only be thus obtained.
Where the suspicion is grave the possibility of not finding such a lesion
by exploring should not be allowed to weigh against making the at-
tempt. If a pelvic fracture with rupture of the viscus or rupture alone
is discovered, a drainage-tube should be inserted into the bladder. If
the prevesical space is also opened, an additional aperture above the
pubes will be required in order that thorough drainage may be pro-
vided. Procedures of this kind are safe and slight compared with the
risk connected with extravasation of urine imperceptibly going on in
380 SURGICAL DIAGNOSIS AND TREATMENT.
a part where otherwise drainage is impossible and subsequent absorp-
tion uncertain."
The danger of this form of rupture is in the pent-up extravasated
urine, which if allowed to remain in the tissues speedily produces cellu-
litis and sloughing, ending in many cases in septicemia. The treatment,
therefore, must consist in free incision to allow the extravasated urine
to escape, and, w^hen necessary, in free drainage by the perineal or
suprapubic route, or both.
Incised wounds in the hyj^ogastric region are liable to be compli-
cated with wound of the bladder ; the methods of diagnosis are the
same as for rupture. When a wound of the bladder is suspected, the
urine should be drained off through the external wound or by a cath-
eter in the urethra. Wounds of the anterior bladder-wall heal readily
by granulation, and in view of the slight trouble which such wounds
give when intentionally made in the operation of cystotomy, they
should be dealt with on the principles which govern that operation.
Retention of Urine. — In its expulsion from the bladder the urine
has to pass through a long tube having a small caliber and tortuous
course — the urethra. Retention or inability to expel the urine is due
to two classes of causes — viz. those which produce obstruction in the
urethra, and those which result in a want of expulsive power. Of
obstructive causes, by far the most common is stricture of the urethra,
which may be organic or spasmodic. Other causes are enlarged pros-
tate, inflammation or abscess of the prostate, impacted calculus, tumors
of the bladder or urethra, pressure of the gravid uterus, and atresia of
the urethra or meatus urinarius. The expulsive power may be wanting
from any of the following causes : paralysis, atony of the bladder,
reflex influences such as occur after the ligature of hemorrhoids.
Retention is common in shock and in the great muscular exhaustion
which attends fevers. Certain drugs, as opium, belladonna, cantharides,
and alcohol, by their toxic influence produce want of expulsive power.
Diagnosis. — The symptoms of retention are very plain. Besides the
inability to micturate, the patient complains of pain in the region of the
bladder and the kidneys. There is a constant desire to empty the
bladder, and the patient makes violent straining efforts, which some-
times expel the contents of the lower bowel. In many cases a few
drops come aw^ay and lead to the erroneous belief that the bladder is
being emptied. After a time the symptoms of uremic poisoning super-
vene — viz. rigors, fever, failing circulation, and death. In less acute
cases the backward pressure of the urine produces destructive changes
in the kidneys. On palpation the round distended bladder can be felt
in the hypogastrium, sometimes extending to or even beyond the
umbilicus. On percussion this tumor is dull, while the flanks on
either side are resonant. In thin persons the tumor can be distinctly
seen through the parietes, and is more prominent when the patient is in
the erect position.
Treatment. — This must depend upon the cause of the retention. In
the majority of cases the catheter is indicated, and should be resorted
to wathout delay. In some cases it is impossible to pass a catheter, and
aspiration of the bladder then becoms imperative. This can be done
by three different routes :
THE GENITO-URINARY SYSTEM. 38 1
1. Suprapubic. — The operation is very simple and free from danger.
The pubis having been shaved and thoroughly disinfected, the aspi-
rating needle is inserted in the middle line just above the symphysis
pubis, and the bladder emptied. The puncture is then sealed with
iodoformized collodion. This route should be chosen in preference to
either of the two following.
2. Rectal. — Tapping the bladder by way of the rectum was formerly
much in vogue. A large curved trocar was passed into the rectum and
made to pierce the bladder just behind the base of the prostate.
3. Perineal. — This route is recommended when there is enlargement
of the prostate, but in every other condition it is inferior to the supra-
pubic route.
Atony of the Bladder. — Atony of the bladder is a condition
which is almost analogous to dilatation of the stomach. Its most
important feature is that the viscus cannot e.xpel the whole of its con-
tents. At the end of micturition there is still a quantity of urine left
in the bladder, to which the name " residual urine " is applied. The
causes of atony are numerous. Every male who has passed the period
of middle life has less expulsive power than he had in youth, and this
debility increases as age advances. This, however, cannot be regarded
as a morbid condition. The term " atony " is more correctly applied
to a paresis of the muscular coats of the bladder. Coincident with this
are certain changes in the vesical walls. They may undergo fatty
degeneration and become atrophied, thinned, and distended. An
almost opposite condition is sometimes observed, wherein the walls
are changed by the formation of fibroid tissue, leading to contraction
of the viscus and reduction of its capacity. Among the causes of
atony may be mentioned stricture of the urethra, enlargement of the
prostate, tumors in the vicinity of the neck of the bladder, and neglect
to empty the bladder at proper intervals. All of these causes act in
one direction — they produce ov^er-distention. A single failure to relieve
the bladder at the proper time is sufficient to produce atony.
Symptoms. — Atony of the bladder is to be taken into consideration
when there is any cause of over-distention, as stricture, enlarged pros-
tate, etc. After the patient has micturated and emptied the bladder to
the extent of his ability, a catheter should immediately be passed. If it
be found that an ounce, two ounces, even a larger quantity, of residual
urine flows through the catheter, the case is one of either atony or
sacculation of the bladder. It may be impossible to make a differential
diagnosis between the two. In sacculation a soft catheter may empty
the general cavity of the bladder, and after all the urine has ceased to
flow a change in the position of the instrument may be followed by the
flow of a quantity of residual urine. In atony the residual urine comes
away with any form of catheter.
Treatment. — The most serious feature of atony is the retention of
the residual urine and the chain of evils which are apt to follow — viz.
decomposition of urine, cystitis, retention, and degenerative changes in
the kidney. To guard against these the regular and persistent use of
the catheter is necessary, and the patient should be taught to use the
instrument for himself The frequency of its employment must depend
upon the amount of residual urine. When after the act of micturition
382 SURGICAL DIAGNOSIS AND TREATMENT.
the bladder still retains four ounces, the catheter should be used night
and morning ; when six ounces are retained, the instrument is indicated
three times a day ; and if there be eight ounce of residual urine, it will
need to be withdrawn every six hours. Use the catheter once a day for
cverv tzc'o ounces of residual urine. The patient should be taught not
only the use of the catheter, but the manner of disinfecting it and
keeping it surgically clean.
The medicines of any value in giving more healthy tone to the walls
of the bladder are strychnin, iron, tincture of cantharides, and ergot,
but too much must not be expected from their employment.
Electricity is of great value in mild recent cases, and is a help to
other measures when the condition is long continued and severe. It is
employed as follows : an insulated electrode is passed into the bladder,
while the other electrode is applied to the hypogastric region or passed
into the rectum. A mild current is employed, and gradually increased
till the patient complains of discomfort.
When cystitis complicates atony, special treatment must be directed
to the inflammator)' condition.
Sacculation and Pouching of the Bladder. — Two other con-
ditions closely allied to atony are sacculation and pouching of the
bladder. These terms are frequently used as synonymous. Sacculation
may be defined as a hernia of the vesical mucous membrane through a
weakened part of the muscular coat of the bladder ; hence this portion
of the bladder has no power to empty itself and becomes a receptacle
for residual urine and for calculi. It is usually the result of over-
distention, and may occur at any age and at any portion of the organ.
Of the causes which lead to sacculation obstruction to the flow of urine
plays the most important part. Intra-uterine pressure is also a not
infrequent cause, while a third class of cases are of traumatic origin.
The diagnosis of sacculation is not always easy. A soft or flexible
catheter passed into the bladder is found to draw off a certain quantity
of urine ; the position of the instrument is changed and the flow^
recommences. This is ver)^ suggestive of sacculation, and if the cha-
racter of the urine drawn off from the two compartments is found to be
materially different, the evidence is conclusive. Guthrie demonstrated
the presence of sacculation by injecting the bladder with twelve ounces
of warm water, and finding that only ten ounces could be withdrawn.
Sometimes when digital examination is made by rectum or vagina
the sacculation can be felt as a tumor in the proximity to bladder.
Should the examiner meet with a tumor of this character, an effort
should be made to pass a catheter into it ; if he succeed, the tumor
will quickly disappear.
One of the most serious results of sacculation is that it affords a
hiding-place for calculi. Stones thus imbedded cannot be dealt with by
the lithotrite, and even if they could the detritus would be sure to
collect in the pouch and renew the trouble. The best way to deal
with a stone thus sacculated is to make a suprapubic cystotomy, remove
the stone, and treat the sacculation by drainage (Reginald Harrison).
Pouching differs from sacculation in that the whole thickness of the
bladder is involved. It is also confined to the most dependent part of
the bladder, and is in nearly all cases met with in persons well advanced
THE GENITO-URINARY SYSTEM. 383
in years. A good-sized stone has a tendency to cause the floor of the
bladder to form a pouch, and when this occurs the removal of the
calculus can only be accomplished by a cutting operation.
Treatment. — Drainage of the bladder is the best method of dealing
with sacculation or pouching. The effect of a sea-voyage is often
remarkable ; on this point Mr. Harrison observes : "I have known
thick, cystitic urine, due to the pollution of the general cavity of the
bladder by the contents of a stagnant sac, entirely recover itself when
placed under these conditions. The constant movement of the ship
both by day and night and in whatever position the body may occupy
renders stasis of any of the fluids of the body impossible, and thus one
element necessary for decomposition is removed. The immunity of
seamen from stone and certain bladder affections may in some measure
be due to this. In one instance at present under my observation, where
there is very little doubt the patient has a sacculated bladder, the urine
is invariably clear and normal when he is at sea, and turbid and offen-
sive when he is on shore for any length of time. Yet in other respects,
as far as I can judge, the conditions are the same."
Cystitis, or Inflammation of the Bladder. — It is customary to
divide cystitis into two varieties, acute and chronic. The symptoms are
almost identical in both, and, as every degree of chronicity is met with,
it is sometimes difficult to draw a dividing-line.
Acute cystitis may arise from a great variety of causes — for exam-
ple, direct injury to the bladder-walls by the unskilful use of sounds or
other instruments ; the presence of foreign bodies, either pushed into
the bladder by way of the urethra or arising from within in the shape
of calculi or fragments thereof; the use of cantharides ; the extension
of inflammation from the urethra, as in stricture or simple urethritis ;
the infection of micro-organisms, as the gonococcus or tubercle bacillus,
and the presence of new growths, as carcinoma.
One of the chief dangers of cystitis is the liability of the inflamma-
tion to spread by way of the ureters to the kidney, causing a pyelitis, a
pyelo-nephritis, disorganization of the kidney, and frequently death.
The changes which take place in the bladder-walls are congestion,
thickening of the mucous membrane, desquamation of the epithelial
lining, and the formation of raw surfaces. In advanced stages of the
disease the tissues become infiltrated with pus, and ulceration and
sloughing are not uncommon. In some instances the inflammation is
attended with the formation of a false membrane, which may be voided
in pieces or in casts of considerable portions of the bladder. This may
be a true diphtheritic membrane, the disease attacking the bladder
simultaneously with other regions of the body.
Symptoms. — The first symptom to usher in an attack of acute
cystitis is generally frequent viicturition. This increases ; the patient
is obliged to empty his bladder more and more frequently, till at last
he is kept constantly getting in and out of bed. Vesical tenesmus is
also a prominent feature ; the sufferer strains, trembles, and perspires,
but can only expel a few drops of urine at a time. A feeling of weight
in the perineum is not uncommon, attended with a sensation as if some
foreign body were there which ought to be expelled.
A few hours after the onset of the symptoms just mentioned pain
384 SURGICAL DIAGNOSIS AND TREATMENT.
becomes a prominent feature. It is usually deep-seated, and felt above
the pubes, down the ^roin and thighs, and at the end of the urethra.
Pressure over the bladder elicits tenderness.
CJiangcs in the urine can be observed at an early period of the dis-
ease. It is high colored, and at the end of each effort to empty the
bladder a few drops of blood are expelled. More or less mucus
gives the urine a thickened appearance ; lithatcs appear in abundance,
and later the fluid becomes ammoniacal.
The coiistitutio)ial symptoms do not follow a definite course. Rigors
or chills are sometimes met with, and a high temperature and rapid
pulse may exist throughout the attack.
Treatment. — Whatever the form in which cystitis presents itself, the
first indication is to ascertain and remove the cause. Fragments of
stone, retained unhealthy urine, gonorrheal secretions, or any other
excitants should be sought for and either removed or their influence
counteracted. The pain will call most loudly for prompt action. Injec-
tions of warm water into the rectum often afford great relief, but, as a
rule, opiates will be required. Half a grain of morphin dissolved in
half a pint of water and at a temperature of about 110° F., injected
into the rectum, will be followed by an exquisite sense of relief, putting
a speedy stop to pain, tenesmus, and constant micturition. Supposi-
tories will produce the same effect, but their action is not so prompt.
The patient should keep his bed, be restricted to a light diet, and par-
take freely of diluent drinks. Hot fomentations and hip-baths are
favorite remedies, and the internal administration of hyoscyamus has
long enjoyed the reputation of being the most useful single remedy in
inflammatory affections of the bladder.
Chronic cystitis is frequently a continuation of the acute form. It
is often a result of enlarged prostate, of calculus, atony, stricture, and
new growths. Its origin is often traceable to the kidney, to defective
digestion, or to gout. The symptoms in general are those of the acute
form, but not so pronounced. There may be little pain ; tenesmus may
be slight or absent. Micturition is usually less frequent, and the
majority of patients are able to move about, but they suffer incon-
venience which makes their lives more or less of a burden. The urine
seldom contains blood, but to offset this it is thick, filled with ropy
mucus or pus, and often ammoniacal and foul-smelling. Catarrh of the
bladder is a popular name for this disease.
Treatment. — Removal of the cause must claim the closest attention.
Many a patient who has suffered from chronic cystitis for years has
been restored to health after he had fallen into the hands of a surgeon
who took the pains to search for, find, and remove a calculus which had
never been suspected by previous advisers. TJie treatment of ehrojiic
cystitis should never be begun until a most thorough ond searching ex-
amination has been made for the cause. The prostate is responsible for
a large proportion of all cases. A digital examination by the rectum
will speedily settle the question as to whether the gland is enlarged. A
vesical calculus will manifest its presence by the symptoms peculiar to
stone, and the bladder should be searched for stone.
Urethral stricture is another cause which should receive careful
attention. It is readily recognized by the diminished or forked stream
THE GENITO-URINARY SYSTEM.
385
of urine, difficulty in micturition, and by examination with the urethral
sound or catheter.
The general treatment may be summed up under the following
heads :
1. Remedies administered internally or by the rectum. The drugs
which have found most favor in the treatment of chronic cystitis are
buchu, pareira brava, oil of sandalwood, balsam of copaiba and cubebs,
uva ursi, etc. Quinin, salol, and boric acid are valuable on account
of their power to disinfect the urine and prevent the growth of micro-
organisms.
2. Irrigation. Washing- the bladder with warm sterilized water or
boric-acid solution is very important, after which the organ is ready to
receive an injection of one or other of the solutions mentioned in the
following paragraph.
3. Injections. Of all the remedies used for injecting the bladder,
nitrate of silver must take the first place. Nothing will act more
Fig. 163. — Keyes' irrigator for bladder.
promptly in destroying the bacteria, and its action upon a chronically
inflamed mucous membrane is superior to anything else. The bladder
is first washed out with sterilized water. Two ounces of water holding
five grains of nitrate of silver are then allowed to flow into the bladder
and out again, after which the bladder is again washed out with steril-
ized water. Other solutions which are recommended for irrigation are
the following : boric acid of a strength of 5 to 10 per cent. ; bichlorid
of mercury, i : 10,000; permanganate of potash, 3 per cent. ; carbolic
acid, I : 500. The method of irrigating the bladder is shown in Fig. 163.
It consists of a rubber bottle {A) which holds about a pint and can be
suspended at a height of three or four feet above the level of the
patient's bladder ; a rubber tube (i>) five feet in length, ending in a
25
386 SURGICAL DIAGNOSIS AND TREATMENT.
Stop-cock ({T), which directs the fluid into the catheter {D) or the
outlct-jMpc (A). The apparatus is used as follows : Fill the reservoir
and hang it up ; open the stop-cock to allow the fluid to expel the air
from the tubing; then pass the catheter. Turn the stop-cock (6^) to
allow the fluid to enter the bladder, and when the viscus is full reverse
the tap and allow the fluid to escape from bladder and run into the
receptacle (4). By alternating this action the bladder is repeatedly
filled and emptied.
A simpler contrivance is a glass funnel connected with a catheter by
means of a rubber tube two feet in length. The funnel is elevated and
the fluid poured into it, which by gravitation reaches the bladder. By
lowering the funnel below the level of the patient's pelvis the fluid
escapes. The objection to this method is that it allows air to enter the
bladder.
Drainage. — In spite of the most persevering efforts in the use of
these remedies some cases will show no improvement. Another
resource is still open to the patient, which gives not only a fair prospect
of relief from pain and constant urination and tenesmus, but a possi-
bility of perfect cure. This is perineal cystotomy. By means of it the
bladder can be thoroughly drained, and the irrigations and injections
given a better opportunity to exert their full benefit upon the inflamed
surface.
Stone in the Bladder. — In its normal condition urine contains
about 90 per cent, of water in which are dissolved 10 per cent, of
organic and inorganic materials. The organic substances are urea and
uric acid. Of these, uric acid plays an important part in the formation
of calculi, for, although it exists in the proportion of only i to looo
in the urine, it enters into the formation of a great majority of
vesical calculi. The inorganic constituents are sodium, potassium, and
magnesium, bases with which uric acid unites. These bases also unite
-with sulphuric and phosphoric acids to form corresponding salts. Nor-
mal urine also contains chlorids, mucus, and epithelium.
While these substances are held in solution all is well. When they
form deposits and their particles aggregate around a nucleus, stone is
the result. In the majority of cases uric-acid crystals form the nucleus,
the crystals being held together by the renal or vesical mucus. A drop
of dried blood or a foreign body in the bladder, as a piece of catheter or
a fragment of bone, is sometimes the nucleus. Nuclei composed of
uric acid or of oxalate of lime are found in the kidney, and increase in
size as they lie in the renal pelvis or the bladder. When composed of
the triple phosphates the calculi begin to form in the bladder and owe
their origin to ammoniacal urine.
The examination of a patient for urinar}^ calculus may be considered
under the following heads :
History. — A large proportion of cases of bladder-stone will be
found to have had their origin in the kidney. The passage of the
stone thence to the bladder is marked by an attack of renal colic, and
the patient will probably give a. graphic description of a terrible attack
of pain which occurred weeks or months previously, and which was
followed by freedom from suffering until the bladder began to give
trouble. Chronic cystitis should excite suspicion of stone, for it may
THE GENITO-URINARY SYSTEM. 387
either be the result or the cause of a calculus. The irritation set up
by a stone invariably produces cystitis. The existence of cystitis, on
the other hand, is attended with copious secretion of mucus or muco-
pus, affording the colloid material which binds together the particles
that form the nucleus of a stone. Enlargement of the prostate is
another powerful predisposing cause, owing to the changes which take
place in the urine and in the bladder as a result of obstruction to the
flow of urine and the consequences of that obstruction — viz. atony and
retention. For similar reasons inflammation or catarrh of any part of
the urinary tract is a predisposing cause of stone. Persons who have
been sufferers from gout or rheumatism are liable to stone, and a history
of one or other of these diseases should arouse our suspicion.
As regards age, childhood and advanced life afford the largest num-
ber of cases. Children suffer from uric-acid, old men from phosphatic,
calculi. Females on account of the shortness of the urethra and the
freedom from causes of obstruction rarely suffer from stone in the
bladder.
Symptoms Indicating the Presence of Stone. — Frequent micturi-
tion is generally the first symptom to draw the patient's attention to the
fact that something is going wrong. At first he may be called to urinate
once in three or four hours, the frequency gradually increasing until he
is compelled to empty his bladder every few minutes. This symptom is
more marked in children than in those advanced in years. It is in-
creased by exercise, by walking or running, by riding on horseback or
in a jolting vehicle. As might be expected, the patient is much better
during the hours which he spends in bed. A small stone moves freely
in the bladder with every change in the position of the patient's body,
while a large stone may form for itself a bed in the floor of the bladder
and be subject to very little movement. This explains the clinical fact
that not only frequent micturition, but pain, is often more marked when
the calculi are small.
Sudden arrest of the floiv of 2irine is a symptom of great value. It
is most marked when the stone is small, and during micturition rolls
into the mouth of the urethra or the neck of the bladder, forming a
ball valve and obstructing the flow. Many patients by painful expe-
rience learn to alleviate this by assuming an attitude which keeps the
stone well away from the urethral opening.
Pain. — It is possible for a good-sized stone to exist without causing
much pain, but this is very exceptional. If the stone is firmly imbedded
in a vesical pouch or coated with a colloid material which covers up its
rough points and gives it a smooth, soft surface, it may produce little
irritation. As an almost invariable rule stone in the bladder is attended
with intense suffering. The pain has two characteristics : {a) It is felt
at the under surface of the penis near the meatus. This is why little
boys with stone in the bladder keep up a constant pulling of the pre-
puce till it becomes greatly elongated and inflamed, {li) The period of
greatest intensity is at the end of micturition. The bladder contracts
upon the stone, and woe betide the poor sufferer if the surface of the
calculus is rough, hard, and nodular, as is generally the case when it
is composed of oxalate of lime ! Firmly closing upon the stone, the
bladder may hold its grip until the slowly collecting urine comes be-
388 SURGICAL DIAGNOSIS AND TREATMENT.
tween it and the stone and affords a brief respite. Distal pains of reflex
character are not uncommon. The rectum and perineum are most
liable to suffer, but parts more remote are sometimes affected, as the
lungs, the stomach, the extremities, the back, and the thighs.
Hematuria is a symptom frequently observed, and is a natural con-
sequence of the rough treatment to which the mucous membrane is
subjected by the presence of a stone. It is most marked when the
patient takes exercise or is subjected to jolting, as in travelling. The
character of the urine is worthy of attention. It is generally loaded
with muco-pus, but, as this simply indicates cystitis, it is not of much
value from a diagnostic standpoint. The passage of small calculi, the
so-called " gravel," is much more significant.
The symptoms just mentioned are not sufficient to base a diagnosis
upon. Their presence in whole or in part simply warrants us to proceed
to the third part of the investigation — viz. :
Sounding the Bladder. — We cannot introduce the finger into the
bladder, so we use a long, slender metallic finger called a sound. This
instrument should have a straight shaft, a flat handle, and a short curve.
It should be of the size of a No. 8 English or 13 French bougie. Two
sizes are convenient — one having a slight curve (Fig. 164), the other
Fig. 164. — Harrison's searcher.
having a short, abrupt curve for the purpose of searching the part just
behind the prostate, and which is likely to be the hiding-place of a
stone.
The indications for resorting to the use of bladder-sounds are thus
laid down by Reginald Harrison :
1. "In children suffering from vesical irritability, incontinence of
urine, sudden interruption to micturition, retention of urine, blood in
the urine, penile irritation inducing the pulling of the foreskin, and
prolapse of the bow^el.
2. " In the vesical irritability of adults after attacks of renal colic,
where there are reasons for believing a calculus may be retained in the
bladder; in cases of hematuria of a doubtful nature, or of chronic
muco-purulent or ammoniacal urine, or where the urine contains on
standing an excess of cloudy mucus.
3. " In pain after micturition referred to the end of the penis.
4. " In the enlarged prostate of elderly persons, with persisting^
symptoms of vesical irritability.
5. " Where calculi or portions of them have been spontaneously
passed and symptoms of irritation continue.
6. " In cases of acute vesical spasm terminating the act of micturi-
tion, or where, though the bladder contains but little urine, there is
frequently a sudden and uncontrollable desire to micturate.
" Though the indications of stone may be numerous, it will be seen
that they all have reference to either a persisting source of irritation
THE GENITO-URINARY SYSTEM. 389
within the bladder or a mechanical interference with the act of mic-
turition."
The operation of sounding for stone is not to be lightly undertaken,
and, when employed, the patient should be as carefully prepared as for
a major cutting operation. If he has just completed a long journey
by rail or carriage, time should be given him to rest and to allow the
bladder to recover from the irritation consequent to the jolting move-
ment inseparable from such a journey. The history and present con-
dition of the patient should be thoroughly gone into, and a specimen
of his urine taken for chemical and microscopic examination. The
bowels should be emptied, and just before the passage of the instru-
ment the urethra should be washed out with a mild antiseptic solution.
None but a slovenly or antiquated practitioner would use an instrument
without having first boiled or otherwise disinfected it, and the operator's
hands should be as carefully scrubbed as if about to begin a laparotomy.
The patient should lie on a table ; his knees should be drawn up to flex
the thighs upon the abdomen, and the limbs should be slightly sepa-
rated. The bladder should be moderately filled, either by injecting it
with warm boric-acid solution or by having the patient retain his urine
for several hours previous to the examination.
Passing the Soiuid. — The instrument, having been disinfected by
boiling, is dipped in sterilized olive oil, and while still warm is passed
into the bladder in the following manner : Stand at the patient's left
side ; hold the sound in the right hand and take the penis between the
thumb and fore finger of the left. Put the organ gently on the stretch
in such a position that the dorsum faces the abdominal wall, with the
urethra free from kinks or twists. Insert the end of the sound into the
urethra, keeping the instrument parallel to Poupart's ligament. The
handle is held low and the penis gently stretched while the instrument
is passed in to about the membranous portion of the urethra. Sweep
the handle round to the middle line of the body, still keeping close to
the abdomen ; then press the instrument gently downward toward the
feet and make slight traction upon the penis. The instrument should
glide a few inches farther in this direction ; when it stops raise the
handle, keeping it exactly in the middle line, and, passing the perpen-
dicular, depress it between the thighs. During the time that the right
hand is describing this arc of a circle the fingers of the left hand are
shifted to the perineum beneath the scrotum, where they aid in direct-
ing the sound through the membranous and prostatic portions of the
urethra into the bladder. Sometimes it will be found better to take the
instrument in the left hand just after it has passed the perpendicular,
and to use the index and middle fingers of the right hand, placed on
each side of the root of the penis, to make downward pressure.
Searching for Stone. — Having now inserted the sound, a careful
search must be made, not by pushing the instrument about on a
happy-go-lucky chance of striking against a stone, but in a systematic
manner. We know that the sound is in the bladder by the freedom
with which we can move the tip of the instrument when we rotate the
handle, and by the instrument remaining in the middle line and point-
ing away from the pubis when the hand is removed. The middle line
should first be explored by slightly withdrawing and replacing the
39°
SURGICAL DIAGNOSIS AND TREATMENT.
sound, raising and depressing the handle. It should then be rotated
so as to make the tip of the instrument turn to one side, and as it is
slowly and gently pushed in and out the curve is made to feel the floor
of the ca\ity to both right and left of the middle line. It may be that
in all these maneuvers no stone is felt, and yet the sound repeatedly
passes over it. This is because the calculus is lying in a pouch on the
bladder-floor just behind the prostate, and the instrument with a slight
curve fails to touch it. This possibility should always be taken into
account, and, failing to find a stone with the first sound, a second instru-
ment with a short, abrupt curve should be employed and the search
renewed. It is not advisable to state positively that the patient has no
stone in the bladder on the data obtained from one examination. A
second examination a few days later will perhaps yield different results,
as many surgeons have found by experience.
The presence of a stone is recognized by the sensation com-
municated to the hand when the sound strikes a hard body, and by the
Fig. 165. — Diagnosis of calculus (Fenwick).
peculiar chck which can generally be distinctly heard. To magnify
this " click " a stethoscope can be placed over the hypogastrium, or one
end of a rubber tube can be attached to the bladder-sound and the
other end applied to the examiner's ear. As aids to the examination
the following procedures may be mentioned : The anterior wall of the
bladder can be brought within reach of the sound by the surgeon
pressing upon the abdominal wall. A finger in the rectum can be
used with advantage to raise the bas-fond of the bladder and bring it
in contact with the sound. In cases of enlarged prostate a stone is apt
to lie hidden behind the gland and thus elude the searcher ; raising the
hips or placing the patient in the Trendelenburg position will cause the
stone to roll back toward the fundus. In the case of very small stones
a hollow sound is useful. By means of it a portion of the bladder-
contents can be removed while the patient is standing upright, and, if
the sound be slowly withdrawn and turned from side to side until it
comes to the neck of the bladder, the calculi, however small they may
THE GENITO- URINARY SYSTEM.
391
be, are sure to come in contact with the instrument. Bigelow's
evacuator and wash-bottle sometimes succeed in finding and removing
a small stone which cannot be felt with a sound.
For the detection of stones lying in a deep post-prostatic pouch E.
Hurry Fenwick recommends plunging a long trocar and cannula into
the suprabubic region and directly backward to the stone (Fig. 165).
Examination by the Cystoscopc. — In doubtful cases the use of the
cystoscope in skilful hands is of great value. Leiter's cystoscope (Fig.
166) is of the shape and size of a No. 21 F. sound. At the extremity
Fig. i66. — Leiter's cystoscope.
it carries an Edison incandescent lamp enclosed in a cup having a small
aperture fitted with a plate of rock cystal. Two conductors passing
within the shaft connect with the little sockets for the lamp and com-
plete the circuit. The bend of the instrument contains a prism. To
make use of the cystoscope the patient should be placed in the dorsal
or the lithotomy position. The bladder ought to contain six to eight
ounces of clear urine. Should the urine be turbid, wash out the blad-
der and inject boric-acid solution ; if the urine is tinged with blood,
irrigate the bladder with equal parts of extract of hamamelis and hot
water. Anesthesia may be local or general or may be dispensed with.
Should cocain be employed, it must be kept in mind that fatal results
have followed its use, although Fenwick says that he has injected a
dram or more of a 20 per cent, solution and never saw any evil effects.
Having tested the lamp to ensure its being in working order, the instru-
ment is introduced and carefully moved about, to be sure that the beak
is not in contact with the bladder-wall. First the beak is directed up-
ward, and then turned from side to side till all parts of the bladder
come into view except the trigone. The handle is then lowered and
the position of the beak reversed, bringing within the field of vision
the trigone and the orifices of the ureters.
In its normal condition the mucous membrane of the bladder is of
392
SURGICAL DIAGNOSIS AND TREATMENT.
a yellowish or reddish-yellow color. Its blood-vessels are tortuous
and ^ " • ■ • 30 to 32
3^ " 32 to 34
4 " 34 to 36
This table, however, must not be looked upon a.s strictly accurate :
the circumference of the penis is subject to considerable change, and
a too rigid adherence to the theory would result in the passage of a
sentence of stricture on almost every urethra. If the meatus is ab-
normally small, it must be incised by means of a probe-pointed knife.
The instrument first selected should be of moderate size, .say 15 to
16 Fr. ; if this can be passed without resistance, No. 20 or 21 may be
tried. If you succeed in passing this without resistance, you may
reasonably infer that there is no stricture.
A source of error must be guarded against in this examination, for
it frequently happens that as soon as the bulb of the instrument passes
the fossa navicularis it is grasped by spasmodic action of the urethra
and firmly held ; in a minute or two the muscular fibers become
fatigued and the bulb can be passed onward without resistance. This
spasm may occur at any part of the urethra, and is most apt to take
place in patients who are examined for the first time, or in those of
nervous temperament, or in those who are the subjects of uric-acid
diathesis.
If the bulb meet with sudden resistance (which is not due to spasm
Fig. 186. — Weir's urethrometer.
of the urethra) and cannot be passed farther, it should be withdrawn,
and smaller sizes introduced until one is found which will pass the
stricture with only slight resistance. The position of the stricture is
now carefully noted.
2. The length of the stricture. By passing the bulb beyond the
stricture, and then withdrawing it, the base of the cone can be felt to
catch against the limit of the stricture farthest from the meatus. The
nearest point has already been ascertained, and the distance between
the two will represent the length of the stricture. In many cases the
resistance of the stricture can be felt during its whole length as the
instrument is withdrawn.
3. The degree of contraction or size of the stricture. This can be
estimated by the size of the bulb which can be passed with a slight
resistance, but more accurately by the urethrometer of Otis, Weir (Fig.
186), or Gross.
4. The number of strictures. This may be difficult to determine by
the aid of bougies, but the urethrometer, being adjustable to the caliber
of each contraction, is the proper instrument by which to solve the
question.
THE GENITO-URINARY SYSTEM. 437
5. The condition of the urethra behind the stricture. As the bougie
is withdrawn it carries with it the urethral secretion which collects
against the shoulder of the bulb, an examination of which will afford
some idea of the state of the urethra.
Classification of Organic Strictures. — For convenience in selecting a
mode of treatment strictures are divided according to the degree of
contraction into —
1. Those of lage caliber. No. 15 French is taken as the limit; any
stricture which admits a larger bougie is said to be of large caliber.
2. Those of small caliber (less than No. 15 French).
3. Strictures permeable only to filiform bougies.
4. Impassable strictures.
In reference to the situation, the following classes are convenient :
1. At the meatus or fossa navicularis.
2. In the pendulous portion of the urethra.
3. In front of the bulbo-membranous junction.
4. At or behind the bulbo-membranous junction.
Treatment. — Before considering the surgical procedures which have
been devised for relief of stricture attention should be paid to some points
in the general treatment which have much to do with the success of
operative procedures. The patient who is the subject of a stricture
should pay the closest attention to sexual and genito-urinary hygiene.
Exposure to cold should be avoided, as well as everything approaching
excess in eating and drinking. When cystitis is present, as is frequently
the case, this condition must be treated and remedies used w^iich will
prevent decomposition of the urine. Quinin, salol, salicylate of soda,
naphthalin, boracic acid, and creasote are all useful drugs for this pur-
pose. When retention of urine occurs it is usually due to spasm of
the urethra and can be overcome by a hot bath.
Operative Treatment. — Many modes of treatment have been devised
and practised for the relief of stricture, a large proportion of which
have been abandoned as barbarous, useless, and unscientific. The
methods now in use and meeting with more or less general approval
are — i. Gradual dilatation; 2. Continuous dilatation ; 3. Urethrotomy
and dilatation combined; 4. Internal urethrotomy; 5. External
urethrotomy with a guide; 6. External urethrotomy without a guide;
7. Electrolysis ; 8. Excision ; 9. Subcutaneous section.
Let us now consider the operative treatment suitable for the various
forms of organic stricture :
1. Stricture of the MeatJis. — The meatus may be abnormally con-
tracted as a congenital malformation or it may be the result of disease.
In either case the treatment consists in making an incision with a
probe-pointed knife, the blade being directed downward and care being
taken to divide the fibrous bands which are the cause of constriction.
Bougies should be passed every second day after the operation to keep
the orifice dilated until healing shall have taken place.
2. Stricture of the Pendulous Portion. — Gradual dilatation should be
given a fair trial. Internal urethrotomy is with some authors the favor-
ite operation for strictures in this portion of the canal. The opera-
tion is almost free from the dangers which attend its use in the deep
urethra, and if carried out under aseptic precautions these dangers may
438 SURGICAL DIAGNOSIS AND TREATMENT.
practically be disregarded. And yet discretion is necessary in a choice
of method even here. If the stricture be recent and soft, gradual
dilatation may give good results, and should first be tried. If there be
gleet or the stricture be unyielding, urethrotomy should be chosen,
owing to its freedom from danger and the probability of its effecting
a permanent cure.
Internal urethrotomy combined with dilatation is a very satisfactory
method of treatment, and can be well carried out by the aid of Otis's
urethrotome. Whatever instrument is employed, the preparations for
the operation should be aseptic in every detail. The urethra should be
irrigated with a bichlorid solution of a strength of i : 10,000. The
hands of the operator and the instrument should be as carefully dis-
infected as in a major operation. It is not always necessary to employ
general anesthesia, as a solution of cocain (4 per cent.) is sufficient.
The incision is made in the roof of the urethra, and it is essential that
all the strictured tissue be divided, from the normal urethra behind to
the normal parts in front. In very small strictures a preliminary incision
may be necessary. A filiform bougie is passed through the stricture to
serve as a guide; over this a Maisonneuve urethrotome (Fig. 187) is
\
Fig. 187. — Filiform whalebone bougies.
passed through the stricture, and an incision made which allows the
passage of a dilating urethrotome and division of the stricture from
behind forward.
About the third day the passage of sounds should be commenced
to prevent recontraction during the healing of the wound. This
should be repeated once or twice a week for six weeks or longer.
Strictures at or behind the Bulbo-mcinhranous Jtinctioii. — These are
the most difficult of all strictures to treat, for it may be laid down as an
axiom that the seriousness of stricture increases with its distance from
the meatus. When of large caliber, simple, and soft, gradual dilatation
is indicated. Great care is necessary in the use of steel instruments, as
the urethral mucous membrane is soft and easily lacerated. In treat-
ment of strictures of small caliber the choice lies between dilatation and
urethrotomy. Good results are obtained by using continuous dilata-
tion for twenty-four or forty-eight hours, and gradual dilatation every
second day thereafter. Traumatic strictures in this situation demand ex-
ternal urethrotomy as a rule. Sometimes the stricture is so contracted as
to render it impossible to pass a steel sound of any size. Filiform bougies
are employed in such cases wath good effect. The opening may not be
in the center of the stricture, but at some part of its circumference. If
the filiform bougie cannot be passed, withdraw it and bend the point of
it over the thumb-nail to an angle of 45°, as seen in Fig. 188. By
persevering efforts the instrument can usually be made to enter the
stricture, and when once passed it should be left there for twenty-four
hours, when it will be found that others can be inserted by its side.
THE GENITO-URINARY SYSTEM. 439
Having succeeded in passing a filiform bougie, the proceeding will
vary according to circumstances. First, an attempt should be made to
pass a tunnelled catheter or grooved staff over the filiform into the
bladder, after which gradual dilatation can be employed. Or the fili-
form can be used as a guide to a Maisonneuve urethrotome, and inter-
nal urethrotomy performed, followed by gradual dilatation. In most
cases, however, the best course is to use the grooved staff as a guide
and perform external urethrotomy.
In spite of the most persevering efforts it is sometimes impossible to
pass ev^en a filiform bougie. A stricture of this kind is called impassable.
The condition is attended with serious consequences. Retention of
urine is complete, and in powerful efforts to force it through the stricture
the urethra may give way and extravasation follow. The only remedy
is perineal section or external urethrotomy without a guide. Extrav-
asation of urine presents symptoms which depend upon the part of the
urethra which has suffered the urine to escape through its walls. In
the penile urethra the swelling will be found to extend from the meatus
to the scrotum, and will be most marked at the seat of rupture. Rup-
FlG. 188. — Maisonneuve's urethrotome.
ture between the attachment of the scrotum and the anterior part of
the bulb is late in showing itself by swelling ; the urine, being restricted
by the deep layer of the superficial fascia, first appears in the scrotum,
whence it escapes between the pubic spine and symphysis and reaches
the abdomen. If the rupture lies between the two layers of the tri-
angular ligament, the urine will be imprisoned until suppuration and
sloughing allow it to break through and appear in some part of the
perineum. In the prostatic urethra extravasation finds its way along
the rectum to the perineum near the anus, or, passing through the
pelvic fascia, it may spread through the subperitoneal connective tissue.
Another result of extravasation is urethral fistula. The urine may
escape drop by drop through a break in the urethral wall, and set up
suppuration, resulting in an abscess which opens externally. Accord-
ing to its location a fistula of this character is spoken of as urethro-
penile, uretJiro-perineal, and itrethro-rectal. There is little or no dif-
ficulty in the diagnosis, as the escape of urine through a fistulous
opening is sufficient evidence. To corroborate this sign pass a steel
sound into the bladder and probe the fistula from its external opening.
In the vast majority of cases urethral fistulae are caused by strictures.
The treatment consists in curing the stricture, after which the fistulous
tract is laid open or curetted. During the healing process the urine is
drawn off at regular intervals or a catheter is retained in the bladder.
440
SURGICAL DIAGNOSIS AND TREATMENT.
External Urcthrotoiiy. — The operation of incising the urethra from
without is indicated in complete retention due to stricture, in extravasa-
tion of urine, and in several forms of stricture as already described.
The terms external urethrotomy with a guide and external urethrotomy
without a guide are self-explanatory. The term perineal section is best
reserved for those cases which are impermeable to all instruments.
Operation ivith a Guide. — To the late Prof Syme is due the credit
of reviving this operation, and its performance has been greatly facil-
itated by the staff which he invented as a guide (Fig. 189). It consists
— Syme's staff.
of a sound having two parts of different diameters ; for the last two
and a half inches it is of the size corresponding to No. 2 English, and
this portion is grooved on its convexity. The rest of the staff is equal
in size to No. 10 English. At the junction of the two parts there is a
shoulder which is intended to rest on the face of the stricture. The
instrument is passed carefully along the urethra and the slender por-
tion through the stricture, the finger meanwhile inserted into the rec-
tum to guard against the making of a false passage. The staff is then
given to an assistant, who holds it steadily and during the incision
presses the convexity of the instrument downward against the peri-
neum. The patient is placed in the lithotomy position. The operator
inserts his left fore finger into the rectum, and, cutting exactly in the
middle line, makes an incision about an inch in front of the anus and
cuts down upon the groove in the staff. Having found this, he uses it
as a guide and freely divides the stricture. Through the perineal wound
a grooved director or gorget is passed into the bladder and the staff
removed. The next step is to pass a full-sized catheter by the urethra
into the bladder, the grooved director or gorget (Fig. 190) serving as a
Fig. 190. — Teale's probe-gorget.
guide. If the bladder will tolerate it, the catheter can be retained, but
this is not necessary. At the end of a week a full-sized bougie a boule
should be passed, keeping close to the roof of the urethra. This is
rendered painless by the injection of a 4 per cent, solution of cocain.
THE GENITO-URINARY SYSTEM. 44 1
and should be repeated every second day for the first week, after which
the intervals may be gradually lengthened.
Operation witJiout a Guide. — When a stricture is impermeable even
to a filiform bougie, the operation of external urethrotomy without a
guide is indicated. The operation of Wheelhouse of Leeds is the best.
A special staff is employed which has a groove throughout its entire
length except the last half inch (Fig. 191). The operation is thus
described in the eminent surgeon's own words : " The patient is placed
in the lithotomy position, with the pelvis a little elevated, so as to let
the light fall well upon it and into the wound to be made. The staff
is to be introduced with the groove looking toward the surface, and
brought gently into contact with the stricture for fear of tearing the
tissues of the urethra and causing it to leave the canal, which would
mar the whole after-proceedings, which depend upon the urethra being
opened a quarter of an inch infron{ of the stricture. Whilst an assist-
ant holds the staff in this position an incision is made into the perineum,
extending from opposite the point of reflection of the superficial peri-
neal fascia to the outer edge of the sphincter ani. The tissues of the
perineum are to be steadily divided until the urethra is reached. This
is now to be opened in the groove of the staff, not upon the point, so
as certainly to secure a quarter of an inch of healthy tube immediately in
front of the stricture. As soon as the urethra is opened and the groove
in the staff fully exposed, the edges of the healthy urethra are to be
Fig. 191. — Wheelhouse's staff.
seized on each side by the straight-bladed nibbed forceps and held
apart. The staff is then gently withdrawn until the button point appears
in the wound. It is then to be turned around so that the groove may
look to the pubes, and the button may be hooked into the upper angle
of the opened urethra, which is thus held stretched open at three points
— at two by the forceps, and at the third by the hook of the staff.
The operator looks into it immediately in front of the stricture, inserts
the director into the urethra, and, if he cannot see the opening of the
stricture, which is often possible, generally succeeds in very quickly
finding it, and passes the point onward through the stricture toward
the bladder. The stricture is sometimes hidden among a crop of
granulations or warty growths, in the midst of which the probe point
easily finds the true passage. The director having been passed on into
the bladder (its entrance into which is clearly demonstrated by the
freedom of its movements), its groove is turned downward ; the whole
length of the stricture is carefully and deliberately divided on its under
surface, and the passage is then cleared. The director is still held in
the same position, and the straight probe-pointed bistoury is run along
the groove to ensure complete division of all bands or other obstruc-
tions. These being thoroughly cleared, the old difficulty of directing
the point of a catheter through the divided stricture is to be overcome.
To effect this the point of the probe-gorget is introduced into the
groove of the director, and, guided by it, is passed onward into the
442 SURGICAL DIAGNOSIS AND TREATMENT.
bladder, dilating the divided stricture and forming a metallic floor along
which the point of the catheter cannot fail to pass securely into the
bladder. The short catheter is now passed from the meatus down into
the wound ; is made to pass once or twice through the divided urethra,
where it can be seen in the wound, to render certain that no obstructing
bands have been left undivided, and is then, guided by the probe-
dilator, passed easily and certainly along the posterior part of the
urethra into the bladder. The gorget is now withdrawn, the catheter
fastened in the urethra and allowed to remain three or four days, the
elastic tube conveying the urine to a vessel under or by the side of the
bed. After three or four days the catheter is removed, and is then
passed daily or every second or third day according to circumstances
until the wound in the perineum is healed, and after the parts have be-
come consolidated it requires to be passed still from time to time to
prevent recontraction."
Great difficulty is sometimes experienced in finding the proximal
end of the urethra, especially in traumatic strictures. If the bladder
contain considerable urine and pressure be made over it, a jet of the
liquid may reveal the opening of the urethra. The same result may
be obtained by bimanual palpation, with the fingers of one hand over
the bladder and those of the other hand in the rectum. Failing in this,
the parts should be douched with hot water, when the urethra will
become prominent by its being paler than the other tissues. Every
effort to find the urethra having proved futile, the best way out of the
difficulty is to perform a suprapubic cystotomy and make retrograde
dilatation.
CJioicc of Operation. — Gradual dilatation is the simplest and safest
operation, and is generally successful. It may fail in tight strictures
close to the meatus, and then internal urethrotomy should be resorted
to. Tight strictures of the bulbo-membranous region may resist all
efforts at gradual dilatation ; external urethrotomy is then to be
chosen, especially if the stricture is of traumatic origin. Impassable
strictures leave no choice, and must be treated by external urethrotomy.
Urinary Pouches. — A stricture or the presence in the urethra of
a calculus sometimes causes a pouching or rupture of the urethra
behind the obstruction, and the formation of a reservoir which holds a
quantity of urine that is not expelled in micturition. This condition
may be mistaken for urethral abscess, the preliminary to urethral fistula
already mentioned.
Symptoms. — Urinary pouches appear as round or ovoid tumors
along the course of the urethra. There is absence of pain and redness,
but there is fluctuation. The swelling becomes more tense and promi-
nent during the act of micturition, after which it is more relaxed, but
does not disappear. The patient, having learned by experience that
the tumor can be prev^ented from filling, makes pressure with the
fingers of his right hand while he holds the penis in the left during
urination. The urine which remains in the pouch in spite of this or
other precautions dribbles away later on, soiling the clothing of the
patient and causing great annoyance. In some cases the urethra is
merely dilated, and then the urine contained in the pouch is always
normal ; in another class of cases there is a breach of continuity in
THE GENITO-URINARY SYSTEM. 443
the urethral wall ; a pouch forms in the same manner, but the urine is
likely to contain pus or blood, and frequently ends in urinary fistula.
Treatment. — When the urethra is simply dilated the whole treatment
must be directed against the obstruction which is the cause of the
pouch. A calculus if present must be removed or a stricture remedied.
When there is perforation of the urethra it is sometimes sufficient to
retain a catheter and use mild compression externally. When there is
an abscess it should be opened, and a catheter kept in the urethra to
prevent the formation of a fistula.
VI. INJURIES AND DISEASES OF THE MALE GENERATIVE ORGANS.
Diseases and Malformations of the Penis.
The meatus, instead of opening in its normal position, in very rare
cases is found to open at the side or in the dorsum of the penis. In
absence of the bladder the ureters have been found to empty into the
urethra, and the rectum has in very rare instances been known to have
a similar outlet.
These malformations are of little practical value, but there are
two others which require more extensive notice — viz. hypospadias and
epispadias.
Hypospadias is a malformation the distinctive feature of which is an
absence of the lower wall of the urethra, so that the canal opens on the
under surface of the penis. The opening may be in the glans or in the
spongy portion, or the urine may be expelled at the scroto-perineal
junction. When the hypospadic opening is at the scroto-perineal
junction there is a fissure in the scrotum, giving it the appearance of
the external genitalia of the female ; the penis is bound down to the
fissure and may be very much atrophied. In the penile variety the
opening maybe at any point on the floor of the pendulous urethra, and
an almost constant complication is a downward curvature of the penis.
An opening within an inch of the normal position of the meatus may
be attended with little inconvenience, and requires, as a rule,- no treat-
ment, but a penile, scrotal, or perineal hypospadia is one of the most
distressing of abnormalities and requires operative interference.
Of the diagnosis there is little to be said, as the condition is self-
evident.
Treatment. — Several operations have been devised, but the method
of Duplay is the only one that has met with success. It consists of
three stages :
1. Straightening the Penis. — This is done by making a transverse
incision of the ridge which unites the hypospadic opening to the glans,
the incision being carried to a depth which will secure complete
straightening of the penis (Fig. 192, A). In this incision it may be
necessary to go deeply into the corpora cavernosa, but this can be done
without risk. When the organ is straight or but slightly curved this
step of the operation is not necessary.
2. TJie Formation of a Nezv Canal from the Meatus to the Hypospadic
Opening. — The first point to demand attention is the formation of a
meatus. The position of this opening is indicated by a depression in the
444
SURGICAL DIAGNOSIS AND TREATMENT.
glans penis. The two lips of this depression are vivified as in F'ig. 192,
B. Between them is placed the tip of a catheter, and over this the
edges of the freshened surfaces are secured by several catgut sutures.
If the depression is too shallow, more room can be gained by making
A B
Fig. 192. — Duplay's operation for hypospadias (Duplay and Reclus).
two small lateral incisions, a, a', or a single median incision in the sub-
stance of the glans. Next comes the formation of the new canal.
Along the lower surface of the penis on each side of the middle line
two incisions are made from the corona glandis to within a quarter of
an inch of the hypospadic opening (Fig. 193). The internal lip at a d
is dissected up and turned inward over the
catheter, but not entirely covering it. The ex-
ternal lip, r, d, c', d' , is freely dissected so as to
separate the skin from the subjacent tissues,
and so as to allow the skin of the sides of the
penis to be drawn toward the middle line. The
cutaneous surface of the lips at a' b' are turned
toward the cavity of the canal, and their raw
surfaces toward the outside and covered by the
raw surfaces of the outer flaps. The edges of
the flaps are united in the middle line by quilled
sutures of silver wire, silkworm gut, or silk, and
fastened with perforated shot.
3. Jimctiojiof tlic Tivo Portions of the Canal. — This consists in closing
the fistulous opening which still remains at the hypospadic orifice by
freshening the edges and bringing them together by quilled sutures
over the catheter. A retained catheter is employed to carry off the
Fig. 193. — Transverse
section of the penis after
operation : S, the new ure-
thra (Duplay and Reclus).
THE GENITO-URINARY SYSTEM. 445
urine during the healing process. The whole process of the cure of
hypospadia is long and tedious. Three, four, or five operations may be
necessary, and the treatment may extend over six or eight months.
Hpispadias is a much rarer abnormality, and consists in a de-
ficiency of the upper wall of the urethra. The operation for its cure is
similar to that just described.
Phimosis is characterized by an unnaturally elongated condition
of the prepuce, with so small an opening that it is impossible to uncover
the glans. The condition may be congenital or acquired. The acquired
form has already been described as a complication of balanitis and
balano-posthitis. The congenital variety is important on account of the
continual irritation kept up by it, leading in extreme cases to chorea,
•epilepsy, and other nervous affections. The glans is often adherent to
the prepuce in whole or in part ; the preputial orifice is usually small,
sometimes little larger than a pinhole, and during micturition the pre-
puce become distended with urine. The secretion collects inside, and
the danger of infection is greatly increased should the patient be
exposed to venereal diseases.
Treatment. — When a corona glandis cannot be completely exposed
without difficulty circumcision should be performed. The parts having
been carefully disinfected, the prepuce is drawn well forward and grasped
by a pair of forceps in front of the anterior extremity of the glans. The
blades of the forceps should be an inch and a half in length, so as to
grasp the whole width of the prepuce. With ordinary care there is no
risk of wounding the glans, although this has happened in the hands
of incompetent operators. With a sharp knife the foreskin in front of
the forceps is removed. The prepuce is now allowed to retract, when
it will be found that while the skin recedes to the corona or behind it
the mucous membrane forms a hood over the glans. This membrane
is slit in the middle line up to the corona, and then cut off all around
at a distance of one-sixteenth of an inch from the point of reflection.
This will be found to follow the line of the corona. The frenum should
be spared unless there is marked hypertrophy at that point. The edges
of the skin and mucous membrane should be approximated by inter-
rupted catgut sutures. The most convenient dressing is a thin layer of
absorbent cotton covering the incision and sealed over with iodoform-
ized collodion. The end of the penis can be protected from irritation
by absorbent cotton and a T-bandage.
Paraphimosis. — Should the glans be forced through a prepuce
too narrow to admit it, constriction is sure to follow. The glans
becomes swollen, congested, and edematous ; the orifice of the pre-
puce forms a constricting ring, while the part of the prepuce behind
falls forward like an edematous collar. Unless relieved, this condition
ends in ulceration and sloughing. The glans should be pushed back
in the manner described under Phimosis due to Gonorrhea. Failing in
this, a director should be passed beneath the constricting ring and the
constriction divided.
Carcinoma of the Penis. — Epithelioma of the squamous variety
is the only form found upon this organ. It begins as a warty growth
upon the glans or the inner surface of the prepuce, and it is said that
phimosis is a predisposing cause. The wart soon breaks down and forms
446 SURGICAL DIAGNOSIS AND TREATMENT.
ail ulcer with very hard margins. The disease rapidly spreads by infil-
tration of the surrounding parts, and sooner or later the corpora caver-
nosa, the glans, and, secondarily, the lymphatics of the groin, become
involved. The only disease with which it is liable to be confounded is
syphilis. The ulceration of epithelioma is recognized by attention to
the following points :
1. It is a chronic ulcer, with an irregular hard base and a foul,
watery, or bloody discharge.
2. The growth infiltrates the tissues of the penis, and at the same
time grows from its surface.
3. Antisyphilitic treatment has no effect upon the disease.
4. The inguinal glands become involved sooner or later,
5. Microscopic examination shows cancerous elements.
TrcatDioit. — The only remedy is amputation, and in view of the
rapidity of the growth this treatment should be resorted to at an early
period. The operation was formerly done by a simple sweep of the
knife, or at most by the formation of a flap of the skin to cover
the surface of the wound. This method was followed by stricture
of the orifice of the urethra and frequently by recurrence of the
disease.
The best results are obtained by amputation of the entire penis, and
the operation of Pearce Gould is now generally adopted. The method
of its performance is thus described by Treves :
Operation. — " The patient having been placed in the lithotomy posi-
tion, the skin of the scrotum is incised along the whole length of the
raphe. With the finger and the handle of the scalpel the two halves
of the scrotum are then separated quite down to the corpus spongiosum.
A full-sized metal catheter is now passed as far as the triangular ligament^
and the knife is inserted transversely between the corpora cavernosa and
the corpus spongiosum.
" The catheter having been withdrawn, the urethra is cut across.
The deep end of the urethra is then detached from the penis quite back
to the triangular ligament. An incision is next made around the root
of the penis continuous with that in the median line ; the suspensory
ligament is divided and the penis separated, except at the attachment
of the crura. The knife is now laid aside, and with a stout periosteal
elevator each crus is detached from the pubic arch. This step of the
operation involves some time, on account of the very firm union of the
parts to be severed. Four arteries — the two arteries of the corpora
cavernosa and the two dorsal arteries — require ligature.
" The corpus spongiosum is slit up for about half an inch, and the
edges of the cut stitched to the back part of the incision in the
scrotum.
" The scrotal incision is closed by sutures, and a drainage-tube is so
placed in the deep part of the wound that its ends can be brought out
in front and behind. No catheter is retained in the urethra.
" In Gould's case — the operation was performed for epithelioma in
a man aged seventy-three — there was no complaint of pain after the
operation. The temperature reached the normal line on the fourth
day, and on the sixth day the patient had regained complete control
over the bladder. The skin-wound healed by first intention, the deeper
THE GENITO-URINARY SYSTEM. 447
wound by granulation. The parts were completely healed in forty-six
days."
Diseases of the Scrotum.
Bdema and Inflammation. — Owing to the looseness of the
tissues which form the scrotum, swelling may occur rapidly and attain
an enormous size. Edema is recognized by its doughy feel, by its
pitting on pressure, by the disappearance of the normal scrotal folds,
and by the glossy character of the skin. It is commonly the result of
dropsy in the lower extremities due to cardiac or kidney disease, but it
may follow any acute inflammation of the part. Inflammation of the
scrotum is common, but, like inflammation in other loose tissues, such
as the eyelid, the swelling is out of proportion to the other symptoms,
and need give no great uneasiness, as it is likely to disappear as rapidly
as it came on. The most serious form of scrotal inflammation is that
due to extravasation of urine. This is about the only form which is
really dangerous, and it demands the most prompt and vigorous treat-
ment of the extravasation. Eczema and the irritation of dribbling urine
are also common causes of mild forms of inflammation.
Kpithelioma of the scrotum differs little from this form of carci-
noma in other situations. In the scrotum, however, it is almost invari-
ably due to a definite cause — the irritation of soot, hence the name
" chimney sweep's cancer." It appears as a wart with hard edges
raised above the surrounding skin and irregular in shape. It spreads
from the margin and ulcerates in the center. In the early stages it is
confined to the skin and is freely movable, but later it becomes attached
to the deeper tissues, spreads to the glands of the groin, and involves
the penis. Removal of the growth by operation is very satisfactory if
resorted to in time. It would be wisdom to remove any warty growth
with hard edges and showing a disposition to spread. Even after the
disease has invaded the glands removal is followed by a good percentage
of recoveries.
Elephantiasis of the scrotum is common in some Eastern coun-
tries as elephantiasis Arabian. It is characterized by enormous hyper-
trophy of the skin and subcutaneous cellular tissue. It is often
associated with repeated attacks of inflammation, such as attend
urinary fistula, or it may depend upon lymphatic destruction and
inflammation. From the scrotum it may extend to the penis, but
never to the testicles.
Swellings of the Scrotum. — There is no part of the body in
which so great a variety of swellings is met with as in the scrotum.
In most of the cases presenting themselves for examination the patients
consult the surgeon for the purpose of ascertaining the nature of some
enlargement of these parts. A systematic examination should cover
the following ground :
A. The swelling is confined to the scrotum. It is either edema, ele-
phantiasis, epithelioma, or other tumor. Edema is associated with
dropsy of the lower extremities, but it may be a result of extravasation
of urine. Elephantiasis is a tropical disease, or it may be the result of
repeated attacks of inflammation. Tumors found in connection with
the scrotum are lipoma and epithelioma ; other growths are rare.
448 SURGICAL DIAGNOSIS AND TREATMENT.
B. The swelling is connected with the testicles or their coverings.
It must be one of the following : orchitis, malignant disease, benign
tumor, hydrocele, hematocele.
C. The swelling is connected with the spermatic cord. It is either
an inflammation, a hydrocele of the cord, a varicocele, or a tumor.
Orchitis, or Inflammation of the Testicle. — This is easily rec-
ognized by pain, tenderness to touch, and its association with trau-
matism, gonorrhea, tuberculosis, or syphilis. It is convenient to divide
orchitis into two varieties, acute and chronic. Acute orchitis is gen-
erally the result of traumatism, but may also be an extension of the
inHammatory process from the epididymis or it may be metastatic, as
in mumps. The pain is acute and the organ is very sensitive to the
slightest touch. Swelling comes on rapidly, and the skin over the
affected gland is red and glistening. Suppuration is not an uncom-
mon result, especially in patients of low vitality.
Treatment. — The pain is kept up and greatly aggravated by the
weight of the testicle ; hence the first point in treatment is to support
the scrotum and its contents by the use of a suspensory bandage or by
a small pillow placed beneath the parts while the patient lies on his
back. A brisk purgative often produces an immediate effect upon an
acute orchitis, and should come in as a part of the routine treatment.
In the early stages of the inflammatory process cold applications afford
relief, especially in the form of lead-and-opium lotion ; later the same
application as warm as can be conveniently borne will be more suc-
cessful. When there is great tension and the case resists the above
remedies, an incision should be made into the tunica vaginalis.
Chronic orchitis is generally a complication of syphilis, and espe-
cially if confined to the body of the testicle. In gonorrhea and tuber-
culosis the swelling is likely to be confined to the epididymis. There
is one character w'hich distinguishes the syphilitic testicle, and that is
its weight. It is remarkably heavy as compared with the normal
organ or with the weight of the organ under any other diseased condi-
tion. Chronic orchitis of any kind is likely to produce atrophy of the
testicle, or if suppuration begins the organ soon becomes riddled with
sinuses and is finally destroyed. The diagnosis of chronic orchitis is
very plain, but the variety of the inflammation — that is to say, whether
it is syphilitic, tubercular, gouty, or malignant — is very necessary to
determine.
Syphilitic testicle has an even, smooth surface when the deposit is
distributed through the whole of the fibrous tissue of the gland. The
organ retains its normal shape, but it is enlarged, hard, and heavy.
When the condition is due to a single gumma or several separate gum-
mata the swelling is uneven and nodular. It comes on slowly, is free
from pain, and generally attacks both testicles simultaneously. A his-
tory of other manifestations of syphilis and the readiness with which
the enlargement responds to antisyphilitic treatment need leave no
doubt in the minds of the examiners. The form of testicular enlarge-
ment with which it is most likely to be confounded is the gouty, but
the previous history will usually be clear enough to differentiate them.
Treatment. — lodid of potassium acts speedily upon the swelling up
to a certain point, when improvement ceases and a hard mass remains
THE GENITO-URINARY SYSTEM. 449
as a permanent deposit. Mercury cannot be applied to the scrotum,
but has a very good effect when rubbed into the skin of the inside of the
thigh. It can be given internally in the form of the bichlorid. When
every other form of treatment has failed and the testicle is disorganized,
it should be removed by castration.
Tubercular Orchitis. — In many cases tuberculosis in the testicle is
a manifestation of constitutional disease. The enlargement begins usu-
ally as a hard nodule at the back of the testicle or in the epididymis.
Like syphilitic orchitis, it is frequently bilateral. In the advanced
stages caseous degeneration causes a breaking down of the tissues, and
should the infection of suppuration be superadded the whole organ may
become riddled with abscesses.
Treatment. — The treatment must be carried out on the principles
which govern the treatment of tuberculosis elsewhere. Residence at
the seaside or a long sea-voyage is especially to be recommended.
When the disease is confined to one testicle and has advanced to the
destructive stage, the organ being riddled with sinuses, castration is
advisable, care being taken to divide the vas deferens as high up as
possible.
Gouty orchitis is exceedingly rare, and closely resembles the
syphilitic form. It is not always easy to trace its connection with the
gouty diathesis. The enlargement is confined to the testicle itself, the
epididymis remaining unaffected. Like other manifestations of gout,
this form of orchitis is painful, and in some cases the inflammation is
severe.
Malignant Disease of the Testicle. — Carcinoma of the testicle
appears as the encephaloid or soft variety. A peculiarity of cancer
in this situation is that it attacks men comparatively young, the major-
ity of cases being between twenty and forty. It is usually confined
to one testicle, and appears as one or more small hard nodules in the
body of the testis, the epididymis becoming involved later. At first the
surface of the tumor is smooth and even, but as the growth increases
and breaks through the tunica albuginea it becomes uneven, with hard
and soft areas alternating. The progress of the disease is characterized
by the horrible features which are inseparable from cancer. The
growth is steady and may attain an enormous size ; large veins
traverse its surface ; the skin becomes adherent, just as it does in cancer
of the female breast ; it ulcerates, and a fungous mass breaks forth
covered with unhealthy granulations, foul smelling, and throwing off
sloughs of connective tissue and even parts of the gland itself This
fungous mass is very vascular, bleeding on the slightest irritation, and
sometimes threatening life by profuse hemorrhage. The epididymis has
suffered early, the cord falls a victim later on, and the destroyer passes
on to the glands and to distant organs till the life of the patient goes
out in exhaustion.
Sarcoma may occur at any age, not even the unborn infant being
exempt. The most of the cases are below ten or between thirty and
forty. Following a law of sarcoma, the round-celled variety is the
most malignant, and sometimes it is an impossibility to distinguish it
from soft cancer ; but practically it matters little, for both are terribly
malignant, the same treatment is demanded, and, unfortunately, the
29
450 SURGICAL DIAGNOSIS AXD TREATMENT.
resources of our art arc set at defiance by one as well as by the
other.
In the other forms of sarcoma, the spindle-celled and the t^iant-
celled, cysts are frequently met with, and sometimes cartilaginous
formations. Sir Astley Cooper called these cysts " hydrated testicles."
They must be distinguished from hydrocele and hematocele, and gen-
erally this can be done without difficulty, for the cystic testicle is
heavier than a hydrocele and is opaque. Hematocele is more apt to
cause confusion, but if a trocar be inserted the hematocele will be
found to contain blood more or less altered, while the cystic growth
produces little or no blood. Cartilaginous growths must always be
looked upon with suspicion ; theoretically they are benign, clinically
they are almost sure to be associated with sarcoma. The features that
distinguish sarcomatous from other enlargements of the testicle, accord-
ing to Jacobson, are — i. Continuously progressive solid enlargement
without inflammation ; 2. Unequal resistance of the swelling at differ-
ent parts ; 3. Entire absence of translucency ; 4. Tendency to become
adherent; 5. Increasing aches or painfulness ; 6. Enlargement of the
cord and, a fortiori, of the lumbar glands.
Treatment. — No hope can be held out to a patient suffering either
from carcinoma or sarcoma of the testicle, except by early removal of
the gland. Even then the prospect of permanent cure is not bright.
The operation, however, is attended with but slight danger, and, as it
is almost sure to prolong life and lessen suffering, its performance
should not be delayed.
Operatio}i. — Castration is performed as follows : The parts having
been shaved and disinfected, the skin is steadied by the thumb and
fingers of the left hand, and an incision made from the external abdom-
inal ring along the course of the cord and down to the lower end of
the scrotum. This incision, however, is not advisable when the skin
is adherent to the adjacent parts. An eliptical incision meeting above
and below the adherent portion is the best under such circumstances.
Layer by layer is divided ; all are freely movable until the tunica vagi-
nalis is reached, when it will be found to be immovable. The first
layer, then, which is immovable is the tunica vaginalis. This should
be opened for diagnostic reasons, and if necessary to reduce the size
of the tumor. The cord having been separated from surrounding tis-
sues and the tumor shelled out by the finger, aided here and there by
touches of the knife, moderate traction is made upon the cord, and it
is then tied off This can be done in several ways: i. The cord is
grasped with a clamp, divided below the instrument, and the vessels
tied separately. This is the safest and best method. 2. The whole
cord may be tied eii masse by a stout chromicized catgut or silk liga-
ture, the ends cut off short and allowed to slip up into the canal. 3.
A double ligature may be passed through the substance of the cord
and the two halves tied separately (Jacobson). Some operators place
a rubber drainage-tube in the inguinal canal in contact with the stump
of the retracted cord, but this is unnecessary. The utmost care should
be taken to ensure complete hemostasis before losing sight of the cord
or closing the wound, for even the oozing of a small vessel may cause
troublesome hemorrhage for days after the operation. In closing the
THE GENITO-URINARY SYSTEM.
451
wound a blunt hook placed in each angle should be made to stretch
the edges of the skin and prevent their turning inward by the action
of the dartos.
Benign Tumors. — These may be cystic or solid. Hydatid and
dermoid cysts are difficult to diagnosticate except by removal and
examination of their contained fluids. Cystic adenomata grow slowly,
are free from pain, and rarely appear before puberty. The solid tumors
are fibromata and enchondromata. While cysts present a nodular
appearance, these solid growths are smooth. The testicle is hard and
heavy% thus simulating the syphilitic testicle.
Abnormalities of the Testicles. — The testicle sometimes fails to
reach the scrotum, and remains at some point in the inguinal canal, in
the abdominal cavity, or just outside the external abdominal ring. This
abnormality is known as retained testicle. Its chief inconvenience con-
sists in the liability of the organ to inflammator}' attacks. It sometimes,
when complicated with hernia, prevents the wearing of a truss, and is
probably a predisposing cause of malignant disease.
Treatment. — Unless the retained organ gives trouble it is best to let
it alone, no operation for placing it in its proper position havang so far
proved satisfactory. When it is producing trouble and the other organ
is normal, castration is the proper course.
Absence of both testes is rare, but it is not very uncommon to find
an individual who only possesses a single gland.
Hydrocele is a term applied to any collection of fluid about the
Fig. 194. — Hydrocele (Keen and White).
testicle or spermatic cord, but, as a rule, this fluid is confined in the
tunica vaginalis. It occurs at any age, and may vary in size from a
barely perceptible enlargement of the scrotum to a tumor of enormous
dimensions. Traumatism, violent muscular effort, and relaxation of the
scrotum by residence in tropical climates have been assigned as causes.
In the congenital form of the disease the peritoneal cavity commu-
nicates with the tunica vaginalis, thus allowing the abdominal serum to
trickle down along the cord to the testicles.
The diagnosis of hydrocele is generally easy. The swelling is first
observed at the lower end of the scrotum ; it is smooth, tense, fluctu-
452 SURGICAL DIAGNOSIS AND TREATMENT.
ating, and increases slowly. It is free from pain and other inflamma-
tory symptoms. All these symptoms are not sufficient to differentiate
hydrocele from other enlargements in the scrotum, but there is one
sign which is pathognomonic, and that is the translucency of the
tumor. If the patient be examined in a darkened room and the
scrotal swelling held between the surgeon's eye and a lighted candle,
the tumor will allow the light to pass through it ; all other scrotal
swellings are opaque. This test, however, is interfered with if the
tunic is greatly thickened, as is sometimes the case, or if the serous
fluid is mixed with blood. The aspirating needle should be employed
in cases of doubt.
Inexperienced examiners are liable to mistake hernia for hydrocele,
and vice versa, and the writer has more than once been consulted
because a truss for inguinal hernia could not be made to fit over a
hydrocele. With ordinary care and a study of the symptoms this
error need not occur. Except when strangulated a hernia has an
impulse on coughing, and the swelling can be traced up to and into
the inguinal canal. Both hernia and hydrocele may be present, but
even then an impulse can be felt when the hernial portion of the
swelling is grasped between the thumb and finger.
Hydrocele of the cord is recognized by its sausage shape and by its
being connected with the cord.
Treatment. — Congenital hydrocele may be cured by a truss, which
prevents the flow of serum from the abdominal cavity into the tunica
vaginalis ; failing in this, the neck of the sac should be ligated.
The treatment of other forms is palliative or radical. Palliative
treatment consists in tapping the tunic as often as it becomes over-dis-
tended. The radical operation aims to obliterate the sac by the injec-
tion of iodin or carbolic acid or by incision. Tapping is thus performed :
The position of the testicle having been ascertained, the skin and trocar
disinfected, the left hand grasps the tumor so as to render the skin tense.
The trocar is grasped by the thumb and finger of the right hand so as
to form a guard which will prevent the instrument being thrust in too
far, and is then by a quick movement made to perforate the scrotum.
If the object is simply palliative, the trocar is withdrawn and the fluid
allowed to escape through the cannula. In the radical operation the
fluid is withdrawn, and then the cavity is injected with five or six drams
of the undiluted tincture of iodin, which should be caused to permeate
every part of the sac by shaking up the scrotum or gently kneading it.
The opening made by the trocar is closed by iodoformized collodion.
Instead of tincture of iodin, some surgeons use from five to ten drops
of pure carbolic acid in sufficient water to keep it in a liquid state. It
produces less irritation than iodin.
For the first two days after injection the swelling may return to its
former size and the parts become violently inflamed, but this soon
subsides and a cure may be expected at the end of three or four weeks.
Incision is an effectual method of dealing with hydrocele. It con-
sists in laying open the tunica vaginalis for a distance of about an inch
and a half and stitching the edges of the tunic to the skin. A drainage-
tube is inserted or the cavity packed with iodoform gauze and allowed
to heal by the open method.
THE GENITO-URINARY SYSTEM. 453
Hematocele is a condition in which the tunica vaginahs is distended
with blood. It sometimes occurs after tapping a hydrocele or it may
follow a traumatism or inflammation of the tunic. The tumor is ovoid
in shape, but broader at its most dependent part. It does not fluctuate,
but is hard, opaque, and heavy. Difficulty may arise in distinguishing
it from an old hydrocele with thickened walls, and from tumor of the
testicle. In some cases this point can only be decided by exploration
or incision.
Traumatic hematocele is easily recognized by the rapidity with which
the symptoms develop, a tumor of considerable size forming in a few
minutes or a few hours at most.
Treatment. — In acute traumatic cases the patient should lie in bed
with the scrotum supported on pillows, while cold and moderate pres-
sure are employed to check the extravasation of blood. Failing to get
rid of the hematocele in this manner, and especially if the case is of long
standing, the proper course is to lay the part open by an incision, turn
out the clots and fibrinous deposits, examine the testicle, and remove it
if diseased or disorganized, pack the cavity with iodoformized gauze, and
allow it to heal by granulation.
Inflammation of the spermatic cord very rarely occurs as a pri-
mary affection, but as a sequel of gonorrheal or syphilitic orchitis it is
not uncommon. The cord is hard, tender to the touch, and painful,
especially when the weight of the testicle drags upon it. The consti-
tutional symptoms are often well marked, but it is seldom that the dis-
ease proceeds to suppuration. The treatment is that of other local
inflammations, with attention to the specific disease which may be
acting as a cause.
Hydrocele of the Cord. — Two varieties are recognized — diffused
and encysted, the latter being the more common.
Diffused Hydrocele. — This variety arises as follows :
In its descent to the scrotum the testicle carries with it a double
layer of peritoneum, which goes to form the serous sac lining the
inguinal canal : one layer is in contact with the spermatic cord and the
tunica albuginea, the other with the inner surface of the cremaster
muscle and the scrotum. Between these two layers, as they surround
the testicle, is the space known as the tunica vaginalis. In normal
development the space between the two layers becomes obliterated at
the lower end of the inguinal canal, so that the two become blended
into one as they invest the spermatic cord. Sometimes, however, this
blending does not take place, and the layers remain separate in the
inguinal canal. If serum accumulates in this space, it forms a tumor
resembling a sausage and extending from the internal abdominal
ring almost to the testicle. It is readily recognized by fluctuation
and by its shape. When the patient stands up, the fluid, gravitating
to the lower end of the canal, gives the tumor a pyriform appearance.
The same effect can be produced by pressure downward along the
course of the cord. The similarity of this tumor to omental hernia is
likely to mislead the unwary, especially when it has an impulse on
coughing, as is sometimes the case. Care should be taken to note the
change in shape brought about by the position of the patient, the fluc-
tuation at the lower end of the tumor, and its bulging when pressure is
4S4
SURGICAL DIAGNOSIS AND TREATMENT.
made downward aloni:^ tlic course of the cord. It must also be remem-
bered that both h\-drocele and omental hernia ma)' coexist.
Trcatiiioit. — The tumor can be aspirated and injected with iodin as
an ordinary h}'drocele.
Encysted Hydrocele. — When the two layers of the covering of the
cord are blended in several places, the intervening spaces remaining
sejiarated, and when these spaces become distended with serum, the
condition is known as encysted h)'drocele (Fig. 195). While the patient
stands erect the symptoms resemble those of the
diffuse form of hydrocele, but on assuming the
recumbent posture the tumor disappears slowly.
This distinguishes it from hernia, for the latter
goes up quickly and has its peculiar gurgle.
Treatment. — This form can usually be cured
by wearing a truss. In infants simple puncture
is often sufficient. Failing in this, a silk thread
should be passed through the tumor, loosely
knotted, and left to act as a seton for forty-eight
hours. This operation should be carried out with
aseptic care and the part covered with an aseptic
dressing. A sufficient amount of inflammation
is thus established to cause obliteration of the
sac.
Varicocele. — The term varicocele is applied
to a dilated and tortuous condition of the veins
of the spermatic cord. Two groups of veins
exist in the cord — the anterior, accompanying the
spermatic artery and forming the pampiniform
plexus ; it is this group which is most commonly
involved in varicocele. The posterior group attends the spermatic
artery and surrounds the vas deferens. Occasionally this group also
becomes varicose. Varicocele occurs almost universally on the left
side, and for this clinical fact the following reasons have been assigned :
I. The left vein as it enters the renal vein has no valve. 2. It is longer
than the corresponding vein on the right side. 3. It enters the renal
vein at a right angle to the current of the blood. 4. It passes behind
the sigmoid flexure and is subject to occasional pressure.
Symptoms. — No great skill is required for the diagnosis of varicocele.
The scrotum contains a soft mass resembling a bunch of worms.
There is usually no acute pain, but a dull aching is commonly present.
The scrotum hangs down loosely and is of a purplish color, and the
tortuosities of the veins can be seen through the skin. Perspiration on
that side of the scrotum is usually present. The testicle is generally
soft and sometimes atrophied. Like many other disorders of the
sexual system, varicocele is apt to produce a form of melancholia,
and many patients erroneously get the idea that they are impotent.
Treatment. — Palliative treatment consists in wearing a suspensory
bandage, and nearly every patient who consults a surgeon for varico-
cele comes clothed in this regalia. For mild cases attended with no
pain or inconvenience this is satisfactory, but when pain and constant
aching are present, when the testicle is gradually wasting away or the
Fig. 195. — Encysted hy
drocele.
INJURIES AND DISEASES OF THE HEAD. 455
patient's mental condition threatening to prove serious, something of a
more radical nature is demanded. Two operations are in common use,
either of which can be recommended.
I shall mention first the operation of incision of the veins, with
shortening of that side of the scrotum, as it is the most thorough and
satisfactory when properly performed.
In any operation upon the cord the vas deferens must be located
and kept out of harm's way. It lies at the posterior and inner aspect
of the cord, and is recognized by its tough, leathery feel. It has a per-
sistent way of slipping out of the grasp of the thumb and finger.
Operation. — The parts having been shaved and thoroughly disin-
fected, an assistant locates the vas deferens and keeps it out of the way,
while at the same time he makes tense the skin of the scrotum. The
operator then makes an incision for about two inches over the most
prominent part of the varicocele. The group of veins is exposed, but
not separated from one another, and at the lower end of the incision an
aneurysmal needle is passed beneath the group, carrying a short catgut
ligature. This is securely tied and one end cut short. A ligature is
applied in a similar manner at the upper angle, and one end cut short
as before. The portion of the plexus lying between the ligatures is
then removed by scissors. The two long ends of the ligatures are
next tied together, thus shortening the cord and raising up that side
of the scrotum. The incision in the skin is closed with a continuous
catgut suture and a proper dressing applied.
The second operation is that of Keyes. The vas deferens being
kept well in the background, a needle armed with stout aseptic silk
is passed through the scrotum between the vas and the group of veins,
and left in position ; a second needle, threaded with the free end of the
same thread, is entered beside the first needle, and, after passing through
the skin and dartos, is carefully made to surround the veins and emerge
beside the first needle at the opposite side of the scrotum. Both
needles are now drawn through, thus placing a loop around the veins.
The silk is securely tied in a single square knot and the ends cut short.
The two layers of scrotal skin are now separated, and the knot slips
within the dartos, where it becomes encapsulated. The small openings
made by the needles can be sealed with iodoformized collodion : the
patient should remain in bed one day and keep in-doors for four or five
days longer.
CHAPTER VIII.
INJURIES AND DISEASES OF THE HEAD.
I. CEREBRAL TOPOGRAPHY.
Injuries of the scalp and of the bones of the cranium would have
no special importance were it not for the danger of brain-complications,
which danger is ever present in such traumatisms. A wound of the
scalp heals as readily as a wound of the soft parts in any other portion
456 SURGICAL DIAGNOSIS AND TREATMENT.
of the body, but unless the greatest care be taken in its treatment such
a wound may become infected, and the infection may thence be carried
to the brain or its membranes. A fracture of the skull, as far as the
bone itself is concerned, is unimportant, for union readily takes place,
and there is not so much thickening at the point of union as is usually
found in repair of other bones. But fractures of the skull are exceed-
ingly grave injuries, from the fact that the fragments almost invariably
cause direct compression of the brain or produce hemorrhage, which is
a source of danger no less grave. Before proceeding to the injuries of
the head the brain itself must claim our attention.
An organ so essential to the economy, so highly developed, so
exquisitely delicate and sensitive, must of necessity be well protected.
The skull is the strong casket which contains this precious jewel, and
to this end it is admirably adapted. It is formed of strong bones, with
additional strength where most exposed to violence, presenting a con-
vex surface from which blows glance and missiles are deflected. Within
the cranium cushions of cerebro-spinal fluid support the brain and break
the force of shocks and jars to which it would otherwise be exposed.
The strong and unyielding skull, however, is, under certain condi-
tions, a source of danger to the brain. When inflammation attacks the
organ or its membranes, when pus accumulates or blood is extrav-
asated, there is no room for expansion ; brain-pressure soon follows,
showing its presence by paralysis or by other manifestations of func-
tions impaired or entirely destroyed. Dangers from this source are
not only immediate, but remote, assuming at more or less distant
periods the form of epilepsy or insanity.
Although the functions of the various regions of the brain are still
imperfectly understood, a wonderful amount of light has been thrown
upon this subject in recent years. For our knowledge in this interest-
ing field of study we are indebted to Broca in France, Fritsch, Goltz,
and Hitzig in Germany, and Ferrier and Horsley in England. Their
investigations have demonstrated the fact that different parts of the
brain preside over different motions of the body. The functions of
certain areas are pretty definitely understood, while other parts are
still a terra incognita.
There are five areas whose functions have been demonstrated ; they
are — i. The sensori-motor area; 2. The area which presides over
speech; 3. The area of vision; 4. The area of hearing; 5. The area
of sensations of smell and taste.
I. The Sensori-motor Area. — To comprehend the limits of
these areas let us examine the outer surface of the left hemisphere
of the brain (Fig. 196).
The cerebrum is divided into two hemispheres, the right and the
left. The gray covering or cortex of each hemisphere presents three
surfaces — the lateral, the median, and the basal. The most interesting
to surgeons is the lateral surface, in the study of which we recognize
certain fissures, lobes, and convolutions. It has four lobes — the frontal,
parietal, occipital, and temporal. Each lobe is furrowed by certain
fissures or sulci, and between these lie the convolutions or gyri.
The frontal lobe (F) contains two sulci, the superior and inferior
(/i and f). It also contains the following convolutions : the superior.
INJURIES AND DISEASES OF THE HEAD.
457
median, and inferior frontal {F^, F^, F^), and the ascending frontal or
anterior central convolutions (A).
The Parietal Lobe. — Between the frontal and the parietal lobe is the
fissure of Rolando (<:-). This lobe contains the posterior central con-
volution {B) and the superior and inferior parietal lobules {P^, P.^. The
inferior parietal lobule is subdivided into the supramarginal convolution
at the posterior limit of the fissure of Sylvius, and the angular gyrus
bending round the posterior limit of the temporo-sphenoidal fissure {P^}.
The temporal lobe lies between the fissure of Sylvius and the cere-
bellum. It contains the first and second temporal fissures and the first,
Fig. 196.— Outer surface of the left hemisphere (Ecker) : A, anterior central or ascending
frontal convolution ; B, posterior central or ascending parietal convolution ; c, sulcus centralis
or fissure of Rolando ; cw, termination of the calloso-marginal fissure : F, frontal lobe ; F\,
superior, F-i, middle, and Fz. inferior frontal convolutions ; /i, superior, and f-i, inferior frontal
sulcus ;/3, sulcus praecentralis ; ip, sulcus intraparietalis ; O, occipital lobe ; 0\, first, 02, second,
O3, third occipital convolutions; t^i, sulcus occipitalis transversus ; (12, sulcus occipitalis longi-
tudinalis inferior; P, parietal lobe; po, parieto-occipital fissure; P\, superior parietal or pos-
tero-parietal lobule; P-i, inferior parietal lobule— viz. Pu gyrus supramarginalis ; P-i , gyrus
angularis; 6', fissure of Sylvius; S , horizontal, S" , ascending ramus of the same; T, temporo-
sphenoidal lobe; T\, first, Ti, second, Ts, third temporo-sphenoidal convolutions; /i, first, h,
second temporo-sphenoidal fissures.
second, and third temporal convolutions, or the superior, middle, and
inferior convolutions, as they are sometimes called.
At first thought one might expect to find that the boundaries of
these areas would follow the lines of the lobes and convolutions, but
such is not the case. It is interesting to note that the relative positions
of the motor centers correspond with the relative positions of the parts
over which they preside. Instead of inscribing the names of the parts
controlled, I have had drawn upon the brain itself the figure of the
body (see Fig. 197), showing at a glance the whole field of cerebral
localization and adding new interest to this absorbing study. It looks
as if the Almighty had traced his own image upon the masterpiece of
his handiwork, and recorded the crowning triumph of creation in a
language which we are just beginning to learn, and in characters
which we hope soon to decipher.
The first landmark to which we must direct our attention is the
458
SURGICAL DIAGNOSIS AND TREATMENT.
fissure of Rolando (r). It may be compared to a ravine, one bank of
which is formed by the anterior central convolution, the other by the
posterior central convolution. In the cortex of this area and in the
adjacent cortex in front and behind is located the sensori-motor area.
The left hemisphere of the brain presides over the right side of the
body, and the right hemisphere over the left side. Roughly speaking,
the upper one-third of the sensori-motor area controls motions of the
lower extremity of the opposite side, the middle third controls the
upper extremity of the opposite side, and the lower third presides over
the movements of the face (see Fig. 197).
To be more precise : let us first examine the upper third or the area
of the leg. The fissure has in front of it the anterior central convolu-
FlG. 197. — Cerebral localization.
tion, and posterior to it is the posterior central convolution. Proceed-
ing from before backward, we find that the anterior central convolution
controls motions of the thigh, and the posterior central convolution con-
trols movements of the leg, foot, and toes. In front of the thigh district
is supposed to be the region which controls movements of the trunk
(Fig. 197).
In the middle third of the fissure of Rolando and in the convolutions
on each side of it is the arm center. Well forward in the posterior
part of the second frontal convolution is the area which governs the
movements of the head and eyes. Proceeding backward, we find the
area for the shoulder and elbow in the anterior central convolution,
and, crossing over the fissure, we come upon the district of the wrist,
fingers, and thumb in the posterior central convolution.
In the lower third of the fissure and the anterior and posterior cen-
tral convolutions is the area which governs the face, tongue, pharynx,
and larjaix. The upper and anterior portion of this area controls the
eyebrows and cheeks, the lower and forward part the tongue and
INJURIES AND DISEASES OF THE HEAD. 459
larynx, and the posterior part the mouth, pharynx, and platysma
myoides.
When we say that a given area controls a certain motion or a
certain part of a Hmb, we must not assume that the area in question
ends abruptly. This is in accordance with Nature's laws. The colors
of the rainbow are not sharply defined, but beautifully blended. The
light of day does not suddenly cease and the darkness of night begin,
but the atmosphere catches the departing rays, and, refracting them to
the earth, changes day into night through the mellow light of the
gloaming. So it is with the brain : each motion or each part of a
limb has a special point which controls it in a pronounced manner, but
shading off from this point the neighboring cortex controls it also, the
power lessening as we go away from the special focus. If, for instance,
the portion of the brain which controls the motion of the thumb be
removed, paralysis of the digit will not follow, for the thumb is repre-
sented, although in a less degree, in the neighboring areas. It is
interesting to note that the coarser movements, such as motion of the
head, the shoulders, the trunk, and the thighs, have their centers in the
anterior portions of the motor area, and as we proceed backward the
movements which are represented are of a more and more delicate
character. Thus the delicate movements of the face, the lips, the
fingers, and the toes have their centers in the posterior part of the
motor area. Proceeding backward, the centers of sensation probably
occupy the region next in order (Fig. 197), and lastly, the most
delicate of all, the seat of vision.
2. The Area of Speech. — Speech has a wide representation and
occupies four areas in four different locations — vdz. :
{a) Motor spcccJi, or the movements required in the production of
speech, is represented in the posterior part of the third frontal convo-
lution, on the left side in right-handed persons and on the right side in
those who are left-handed. Just behind the coronal suture and running
parallel to it is the precentral or vertical sulcus (/g, Fig. 196). It is
the anterior boundary of the motor area. It lies in front of the fissure
of Rolando, and is separated from it by the width of the anterior cen-
tral convolution. Around the lower end of this sulcus the anterior
central convolution makes a bend, and lies in the hollow formed by the
limbs of the fissure of Sylvius. This area is called the operculum, and
in it is Broca's center for speech. The symptoms produced by disease
in this area are loss of the use of language and the power of speech.
The loss of power to convey our thoughts by writing is called agraphia.
The center representing this power is not definitely settled, some cases
going to show that it is in Broca's center, others that it is near the
area of the hand and wrist.
{B) The Auditory Speech-area. — In the first and second temporal
convolutions is the area which receives the sounds of words and retains
the memories of these sounds. Disease in this region causes the per-
son to lose the memory of words, to be unable to recollect the names
of the most familiar objects, and to fail to understand language when
he hears it.
{c) The Area of Visual Speech. — A person may be able to see the
words of printed language, but may not understand them, and is
460 SURGICAL DIAGNOSIS AND TREATMENT.
thereby unable to read. Such symptoms would indicate disease in the
inferior parietal rei^non.
3. The Area of Vision. — 'rins centre is situated in the cuneus
and the occipital lobe of the brain. Disease here causes blindness in
half of both retinae, and to this condition the name hemianopsia has
been applied. From the right half of each retina impressions are con-
veyed to the left side of the brain, and from the left half of each
retina to the right cerebral hemisphere. Disease of the visual area
therefore causes blindness of the right or left half of each retina ac-
cording as the left or right side of the brain is affected.
4. The area of hearing is located in the first and second temporal
convolutions. Disease of this area, if confined to one side of the brain,
does not produce deafness, for the reason that each ear has a connection
with both hemispheres. If both sides of the brain are diseased, deaf-
ness is complete.
5. Smell and taste are represented at the tip of the temporal
lobe (Fig. 196), but the clinical value of changes in these senses is not
very great. In the first place, both are easily blunted or modified from
trifling causes, and, in the second place, each is represented on both
sides of the brain.
The surgeon, in order to deal with injuries and diseased conditions
of the brain, must be able to locate the various areas on the outer sur-
face of the skull. For finding the fissures certain rules have been laid
down, which we shall now consider :
1 . The fissure of Bichat, which lies between the cerebrum and cere-
bellum, is readily located by drawing a line from the external auditory
meatus to the external occipital protuberance. This line, continued
around the occiput to the opposite meatus, corresponds to the lateral
sinus.
2. The fissure of Rolando is the most important of all the fissures
from a surgical standpoint, for on each side of it lies the sensori-motor
area. The upper limit of the fissure is thus located : Measure the dis-
tance from the glabella to the external occipital protuberance ; at a
point which represents 55.7 per cent, of this distance is the beginning
of the fissure. For all practical purposes
a point a half-inch behind the middle of this
line is sufficiently accurate. The fissure
runs downward and forward at an angle of
67° ; the next point, therefore, is to find
that angle, and for this purpose several ex-
pedients have been adopted. The simplest
and readiest is that of Mr. Chiene of Edin-
burgh. A square piece of paper (Fig. 198)
is so folded as to bisect one of its an-
gles, BAD. The result is an angle of
45°, BAG. The angle D A C is again
o ^v . .u J r c bisected by folding the paper on the line A
198. — Chiene s method of fix- _^ ,-' ,9 i <- in ■~^^
position of Roiandic fissure. F, and the result IS an angle of 22^^". 1 he
angle BAG (45°), plus the angle G A E
(22^°), makes an angle of 67-^°, which is near enough for all practical
purposes. The side A B is then applied to the middle line of the scalp.
INJURIES AND DISEASES OF THE HEAD.
461
SO that the point A is half an inch posterior to the middle of the line
between the glabella and the external occipital protuberance.
The line A E will represent the position of the fissure of Rolando.
I .-^1 . . .61 , I .s| . I .■»! . , »| . I ?| . ^ .«! . , o|
\^sM.,.\^...\y..V..A
Fig. 199. — Horsley's cyrtometer (as modified by Dr. Morris J. Lewis).
The length of the fissure is 3f inches. The upper third of this line
will indicate the position of the leg area, the middle the arm area, and
the lower the face.
Another method of finding the angle of the fissure of Rolando is
that recommended by Horsley. He has devised a cyrtometer consisting
of two strips of metal or parchment-paper,
as represented in Fig. 199, the long arm of
which is 14 inches in length ; to this a lat-
eral arm is attached at an angle of 67 '^.
The long arm is graduated each way from
a zero point half an inch in front of the
short arm. The long arm is applied to the
middle line in such a way that the glabella
and the external occipital protuberance will
each mark the same distance from the zero
point. The short arm, being half an inch
behind this point, will correspond with the
fissure of Rolando, and the figures 3I on
the scale will represent the length of the
fissure.
3. The fissure of Sylvius is found as fol-
lows : First draw a base line from the lower
margin of the orbit to the auditory meatus ;
draw a line parallel to this from the external
angular process running backward one inch
and a quarter and then upward one quarter
of an inch. This point represents the be-
ginning of the fissure of Sylvius. From it
to the parietal eminence draw another line,
and it will represent the course of the fis-
sure, which is four inches in length. The
anterior limb of the fissure is two inches
behind the external angular process. An-
other method of finding the fissure of Sylvius is as follows : From the
external angular process (Fig. 200), E A P, to the external occipital
Fig. 200. — Head, skull, and
cerebral fissures (adapted from
Marshall by Hare) : B corre-
sponds to Broca's convolution ;
EAP, external angular process ;
FR, fissure of Rolando ; IF, in-
ferior frontal sulcus ; IPF, intra-
parietal sulcus ; MMA, middle
meningeal artery ; OPr, occipital
protuberance ; PE, parietal emi-
nence ; POF, parieto-occipital
fissure ; SF, Sylvian fissure ; A,
its ascending limb ; TS, tip of
temporo-sphenoidal lobe. The
pterion (to the left of B) is the
region where three sutures meet —
viz. those bounding the great
wing of the sphenoid where it
joins the frontal, parietal, and
temporal bones.
462 SURGICAL DIAGNOSIS AND TREATMENT.
protuberance draw a line passing about half an inch above the auditory
meatus. At a point upon this line one and one-eighth inches from the
external angular process draw another line to the parietal eminence,
P E ; this corresponds with the main branch of the fissure of Sylvius.
The anterior ascending branch follows the squamoso-sphenoidal suture
for its entire length and ascends about half an inch higher.
II. INJURIES AND DISEASES OF THE SCALP.
Contusions. — Bruises of the scalp are frequently met with, and
claim special attention owing to one peculiarity — namely, the resem-
blance of their symptoms to those of fracture of the skull. When a
blow is received upon the head, swelling begins almost at once, and is
due to extravasated blood and effused serum. The swelling is soft in
the center, and is sharply defined at the circumference, instead of blend-
ing with the surrouncling parts. These features give the appearance
of a depressed fracture, and should there chance to be a small ruptured
vessel in the center, pulsation of the brain is very closely simulated.
The diagnosis between this and depressed fracture is made by press-
ing firmly with the finger at the bottom of the depressed area. If it
is a simple contusion, the surface can be still further indented and the
smooth bone can be felt beneath. The surrounding swelling " pits " on
pressure. This i.snot the case in fracture. When the bone is depressed
there is also compression of the brain, as a rule, while this is absent in
contusion, unless there is at the same time rupture of a vessel within
the skull which is forming a clot of blood on the cerebral surface.
Compression caused in the last-mentioned manner does not come on
immediately after the receipt of the injury.
The treatment of contusions consists in moderate pressure and the
application of lead-and-opium lotion.
For the relief of swelling and pain massage acts most satisfactorily.
If a slight abrasion of the skin is made by the blow, suppuration may
follow and an abscess form beneath the scalp, which must be promptly
evacuated.
The most important part of the treatment consists in guarding
against complications ; for symptoms of inflammation of the brain may
set in or inflammation may extend over the whole scalp, or a traumatic
aneur>'sm may form beneath the scalp, any of which must be met with
its appropriate treatment.
Cephalhematoma, or caput succedaneum, is readily recognized
as a soft tumor seen on new-born infants, and generally at the parieto-
occipital region. It is the effect of prolonged pressure during labor.
In most cases no treatment is required, the swelling disappearing at the
end of two or three days. Should it prove unusually obstinate, as I
have seen in two cases, the fluid may be aspirated and pressure applied.
Wounds of the scalp would not need special mention were it not
that they are liable to be followed by serious consequences which do not
threaten wounds of other parts. Patients suffering from scalp-wounds
are usually taken to the nearest drug-store, where an artistic dressing
of strips of sticking plaster is arranged in a stellate or a tessellated
pattern. Of all dressings, probably sticking plaster is the worst ; it is
INJURIES AND DISEASES OF THE HEAD.
463
not aseptic, and it confines the pus which is sure to form in a wound so
treated. From the scalp the pyogenic germs may find their way along
the vessels which perforate the skull, and thus reach the brain itself.
In dressing a wound of the scalp the greatest care should be taken
to cleanse the injured part. The hair should be shaved for some dis-
tance around the incision ; all impurities should be got rid of by wash-
ing with sterilized water and then with sublimate solution. In lacerated
wounds an attempt should be made to save even flaps of skin which
are only attached by narrow pedicles, for the blood-supply of the scalp
is so abundant that the vitality of these pieces is likely to be maintained.
The edges should be brought together and held by stitches of catgut
or silkworm gut, and an antiseptic dressing applied. For small wounds
here or elsewhere iodoformized collodion forms a simple and easily
applied dressing.
Tumors of the Scalp. — The most common by far of scalp-tumors
are sebaceous timiors, or iveiis (Fig. 201). They are readily recognized
Fig. 201. — Sebaceous cysts of scalp (from a photograph in the collection of Dr. Lincoln).
by their rounded, even shape and their being painless. They cause
inconvenience simply by their awkward position, the patients complain-
ing that the tumors annoy them when combing their hair or interfere
with the headgear. They are usually single, but frequently multiple,
and their growth is slow.
The treatment is extirpation. After disinfecting the scalp the hair
can be parted over the tumor and an incision made through the skin
down to the cyst, which can generally be dissected out without evac-
uating the contents. Or the whole tumor maybe transfixed with a
scalpel and the cyst-wall grasped with forceps and pulled out. In any
case the cyst-wall must be totally removed. The skin is brought
together with sutures and a dressing applied.
Fatty tumors are sometimes seen on the scalp, and they may be
confounded with wens. They are, however, flatter and more deeply
seated. An error in diagnosis is of no consequence, as the treatment
of both is extirpation.
464 SURGICAL DIAGNOSIS AND TREATMENT.
Horns and warts arc easily diagnosed. Horns should be removed
by an incision including their base. Warts, if showing a tendency to
rapid growth, are probably malignant, and should be extirpated.
Pneumatocele, or a tumor containing air, has been found on the
scalp in ioca.ses reported by Treves. The tumor is recognized by its
being painless, smooth, elastic, and tympanitic. It is produced by
erosion of the osseous tissue, allowing escape of air from the mastoid
cells into the subcutaneous tissue.
The treatment is pressure after evacuation of the air by a hypoder-
mic needle.
III. INJURIES OF THE SKULL.
Contusions. — In other parts of the body a contusion of bone is
liable to be followed by osteo-myelitis, and such is the case in bones of
the skull ; but the mischief does not end here, for a chain of symptoms
may follow such an injury, showing that the inflammatory process has
spread from the bone to deeper structures. The blow which causes
contusion of bone may produce hemorrhage between the pericranium
and the skull. The effusion of blood and the inflammation which fol-
low strip the periosteum from the bone and necrosis is the result ; or
the blow may crush the cancellous tissue or rupture the veins of the
diploe, or the vessels which run between the dura mater and the inner
surface of the skull may be ruptured, and hemorrhage occur in that
situation. The effects of a contusion of the skull may be summed up
as follows :
1. Osteo-myelitis with separation of the pericranium. The symp-
toms here are local pain and tenderness, inflammation, and perhaps the
formation of an abscess. There is dull headache, but the constitutional
symptoms are slight. The osteitis may be acute or may continue for
years. A ver>' characteristic symptom of osteo-myelitis of the skull is
the so-called "puffy tumor" of Pott. It is a flattened, circumscribed
swelling over a spot w^hich is very tender on pressure.
2. The inflammation may extend to the dura mater. If blood has
been poured out at the time of the injury, so as to separate the dura
mater from the bone, the condition is thereby rendered more serious.
The symptoms are still local. Inflammator>' products or a collection
of pus may produce pressure-symptoms, but, as a rule, it is only when
the third step is reached that these signs appear.
3. The inflammation extends to the arachnoid. Up to this point the
inflamed area is localized, but now it extends over the surface of the
membrane. From this membrane the extension to the pia mater and
the brain itself is unimpeded. The symptoms change accordingly.
The patient complains of malaise, headache, stiffness of the muscles of
the neck, giddiness, chilliness, nausea, and vomiting. The temperature
rises, and the senses of sight and hearing become abnormally acute.
The location of the disease and its gradual advance can, in some cases,
be followed by noting the effects upon the motor areas. Thus a loss
of motion of the arm, followed by a similar loss in the leg, would indi-
cate a spread of the inflammation upward along the sensori-motor area,
and would also be an indication to trephine the skull over the part of
the brain suffering pressure. If the disease advances, stupor, drowsi-
INJURIES AND DISEASES OF THE HEAD. 465
ness, paralysis, and coma supervene, and the patient dies. After a blow
upon the head we should watch carefully for cerebral symptoms, not
feeling that the patient is safe until three weeks shall have passed with-
out appearance of this complication. The second week is probably the
most critical period.
Treatment. — The smallest breach of skin upon the head should be
dressed with great care, lest septic germs should gain an entrance to
the contused bone and its coverings. The treatment must aim at pre-
venting osteo-myelitis, meningitis, and inflammation of the brain itself.
Perfect quiet should be maintained and the simplest diet enjoined. The
bowels should be kept freely open by calomel or other purgatives. Cold
applications to the head are required when there is the slightest indica-
tion that the inflammation is taking a direction inward. Sedatives are
necessary to relieve headache, and for this purpose the bromids are the
best. When symptoms of pressure appear in the form of localized
paralysis, such as of the arm, leg, or face, the part of the motor area
of the brain indicated should be exposed by a large trephine opening
with the view of getting rid of pus.
Fractures of the Skull. — As far as the bones themselves are
concerned, there is nothing remarkable about fractures of the skull.
Union takes place as readily here as in other parts of the bony frame-
work, and, as a rule, the repair is such as to leave little if any thicken-
ing or deformity. The traumatism, however, which is severe enough
to break the skull is almost sure to injure the brain, or the displaced
fragments may be driven in upon the brain and its meninges, leading to
the most serious consequences.
Fractures of the skull are divided into those of the vault and those
of the base.
Fractures of the Vault. — If a force applied to a limited area of the
skull is sufficient to make the bone yield, the effect will be {a) a fissure
or crack in the skull, and it may extend for a considerable distance
from the point to which the force has been applied. It is not uncom-
mon to find a fissure which has run across sutures from one bone to
another or has even extended so as to involve the base itself. (/;) The
bone may be comminuted at the point of contact, (r) The fracture may
be opposite to the point of contact, the so-called fracture by contrc-
coup or counter-stroke, {d^ To the above I shall add a fourth class, in
which the force may cause fracture at a part of the skull which is dis-
tant from the point of contact, but not opposite to it. This is well seen
in Fig. 202. The wounds of entrance and exit of a bullet are seen at
opposite sides of the calvarium, while between them is a fissure
extending nearly the whole length of the vault from the frontal to
the occipital bones.
Symptoms. — In examining the skull for fracture pass the fingers
gently over the vault to ascertain the existence of any depression or
sharp edges of bone. In many cases the fracture is compound, and
the examination is made at the bottom of the scalp-wound. The
wound itself should be carefully examined for splinters of bone or
portions of brain-tissue. The finger, carefully disinfected, can now
explore the wound, searching for depressions, fragments, or fissures.
Next the edges of the wound are held apart, so that the tissues may
466 SURGICAL DIAGNOSIS AND TREATMENT.
be seen. The fractured edge of bone has a dark-red color. A fissure
may in some cases be detected by its holding in its grasp one or more
hairs. A very old and infallible sign of fracture is the nature of the
clot which is found in the wound : if there is no fracture, this clot can
be wiped away; in the case of fracture no amount of washing or wiping
can dispose of the clot.
Simple fracture must be determined by the depression which is felt
through the scalp. Care must be taken to distinguish this depression
from the effusion of blood which takes place after a bruise of the scalp,
the diagnostic importance of which has already been dwelt upon.
Another symptom which can sometimes be elicited is the " cracked-
pot " sound heard on auscultatory percussion. In some cases it is so
distinct as to be heard without the aid of a stethoscope, and even by
Fig. 202. — Fracture of the vault (from a photograph in the collection of Dr. C. H. Hunter).
the bystanders. Rarely, it happens that the dura mater is wounded,
and cerebro-spinal fluid escapes through the fractured skull and forms
a translucent tumor beneath the skin. This tumor is recognized by its
becoming tense with such movements as sneezing or coughing, and is
positive proof of fracture.
The outer table of bone may alone be broken. In such a case the
depression is but slight and the cerebral symptoms are not marked.
The inner table may also be broken alone. The symptoms are not
sufficient for a positive diagnosis, and the fracture can only be suspected
when, after a force applied to the head, evidence of cerebral inflamma-
tion and pressure supervene.
Treatment. — The question of treatment must be influenced by the
amount of injury which the brain has suffered. The bone is of minor
importance.
INJURIES AND DISEASES OF THE HEAD. 467
In simple fracture, without evidence of compression of the brain, or if
compression is passing off, perfect quiet and good nursing constitute all
the treatment required. The patient should be kept in a darkened room,
the diet should be light, the bowels should be freely moved by a dose
of calomel. The head should be shaved, ice-bags applied, and the
patient kept in bed for at least three weeks. When there is marked
depression it is evident that the brain has been injured, and, although
there may be no immediate evidence of compression or other injury to
the brain, the proper course is to trephine with the view of preventing
these complications. A depression of the skull is a perpetual source
of danger, for if there be no immediate effects there may be developed
at even a remote period insanity or epilepsy.
In compound fracture of the vault the wound requires most care-
ful attention. The whole scalp should be shaved, instead of a small
portion around the wound, as is too generally the custom. After
washing and disinfecting with corrosive-sublimate solution (i : 2000),
and having arrested all hemorrhage and dried the parts, the surgeon
next directs his attention to the condition of the bone. If the fracture
is a simple fissure without depression, and no hairs or other foreign
substances arr: caught in the fissure, the wound may be closed with
catgut sutures and a copious dressing applied. If the fissure holds in
its grasp dirt, hairs, or any other foreign material, the edges of the
fissure should be chiselled away, removing the outer table of bone and
leaving a V-shaped groove. Rubber drainage-tubes or strands of cat-
gut should be placed in position and the wound closed and dressed.
When there is depression the bone must be elevated to its proper level
and loose pieces removed. It is true that the brain can endure a con-
siderable degree of pressure, and that many patients recover in whose
brains foreign bodies have existed for years, but the danger is always
great. In skilful hands the operation of trephining is not of itself dan-
gerous, but it should be resorted to as a preventive measure, and not
as a last resort when the patient is dying of brain-disease. It may be
sufficient to raise the bone by using an elevator, care being taken to
bring the displaced portion up to its former level. When the bones are
locked together, as is frequently the case, it is necessary to remove a
portion of bone with the trephine. The pericranium, if healthy and
uninjured, should be carefully preserved, and under favorable circum-
stances the button of bone removed by the trephine may be replaced.
After dealing with the fracture the wound is closed and dressed in the
ordinary manner.
Punctured wounds of the brain always demand the use of the
trephine.
Fractures of the Base of the Skull. — Fractures of the base may
occur in one of the following ways : {a) A fissure of the vault may run
downward and involve the base. It is convenient to divide fractures of
the base according as they involve the anterior, the middle, or the
posterior fossa. Fractures extending from the vault are apt to run into
the middle fossa and through the petrous portion of the temporal bone.
{p) The fracture may be caused by indirect violence, as when a person
falls from a height, landing in a sitting posture, and communicating the
force through the spinal column to the base of the skull, {c) The
468 SURGICAL DIAGXOSIS AND TREATMENT.
lower jaw may be driven backward with such force as to fracture the
base, {(i) Punctiu'ed fractures can occur through the cavities of the
orbit, the mouth, and the nose.
Syniptojiis. — There is one leading symptom which is proof of frac-
ture of the base, and that is escape of blood and cerebro-spinal fluid
from the ear. This sign, however, only exists when the fracture is in
the middle fossa and involves the petrous portion of the temporal bone.
And not even then must it follow that blood and fluid escape, for the
membrana tympani must first be ruptured. Care must also be taken to
distinguish between this kind of hemorrhage and bleeding from an
ordinary wound in the ear. If it be a simple wound, the hemorrhage
will soon cease ; if serum escapes, it is only the serous oozing which is
common in every wound.
When there is fracture the bleeding and escape of cerebro-spinal
fluid arc very characteristic. The hemorrhage continues for a long
time, and it may be both mixed with, and followed by, the watery dis-
charge. This watery fluid escapes more profusely when the patient
increases the intra-cranial tension by forced expiration, coughing,
sneezing, or blowing the nose, and the flow is also influenced by the
position of the body. The fluid should be collected and examined
chemically. It contains chlorids in large amount, a trace of albumin,
and sometimes sugar.
There are other positions in which hemorrhage can be taken as an
indication of fracture of the base — viz. the nose, the pharynx, beneath
the deep muscles of the occiput, and the tip of the mastoid process.
In any of these positions the bleeding is characterized by its long con-
tinuance, lasting from twenty-four to forty-eight hours. When there is
fracture of the orbital plate of the frontal bone, blood will appear at the
end of one or two days as an ecchymotic swelling beneath the con-
junctiva of the eyeball and, later, in the lids. An ordinary " black
eye " produces ecchymosis of the eyelid first. Hemorrhage at the tip
of the mastoid process, spreading upward and backward with a cres-
centic margin, is an indication of fracture of the posterior fossa — a
dangerous fracture. Escape of brain-matter is always proof of fracture.
It is usually found in the nose or pharynx.
Paralysis of the cranial nerves is an evidence of fracture of the base.
Deafness and facial paralysis frequently go together, and afford evidence
of fracture of the petrous portion of the temporal bone. Optic neuritis
is evidence of fracture of the posterior fossa (Battle).
In many cases the diagnosis of fracture of the base can only be
suspected. If a fracture of the vault is extensive and takes a direction
downward, we may infer that it reaches the base. A piece of wood
entering the orbit must fracture the skull if it pierces the tissues to a
greater depth than the orbital cavity extends, and an umbrella rib
entering the floor of the mouth must perforate the brain unless the
wound is very shallow.
The term compound fracture has a wider significance here than in
other parts of the body. A fracture of the base may communicate
w'ith the external air through the ear or the nose or the mastoid cells,
and is on that account compound, although deep within the cranium.
It is important to keep this in mind in considering treatment.
INJURIES AND DISEASES OF THE HEAD. 469
Treatment. — It is seldom that retentive apparatus is required to
steady the fractured bones. When the traumatism is so great as to
render this necessary, the head should be shaved, covered with a thin
layer of absorbent cotton, and enclosed in a plaster-of-Paris cast.
In the majority of cases treatment will consist in keeping the patient
perfectly quiet and preventing sepsis in the injured part. The portals
of entrance for septic germs are the ear, the nose, the eye, and the
mouth. The ear must be thoroughly cleansed from blood, dirt, and
wax, irrigated with warm corrosive-sublimate solution, packed with
iodoform gauze, and covered with sublimate dressing. The mouth is
kept as nearly disinfected as may be by the frequent use of antiseptic
washes, such as boracic acid or a solution of Seiler'5 antiseptic tablets.
The nose is thoroughly cleansed by peroxid of hydrogen and douches
of boracic acid, and packed with sublimate gauze or borated cotton.
The orbit requires particular attention when the fracture has occurred
by that route. Drainage is the first consideration, and, if this cannot
be otherwise secured, the roof of the orbit should be sufficiently cut
away by gouge or chisel to giv^e free exit to pus and other products ;
a drainage-tube can be placed in the wound, and after thorough disin-
fection an antiseptic dressing can be applied. The middle fossa is best
drained by a trephine opening above and behind the auditory meatus.
The anterior fossa is reached through the nose by breaking through
the cribriform plate of the ethmoid bone and inserting a drainage-tube.
IV. INJURIES OF THE BRAIN AND ITS MEMBRANES.
Concussion. — In the writings of the older authors the term con-
cussion was used to imply a suspension or sudden arrest of the func-
tions of the brain, the result of a force transmitted through the
cerebro-spinal fluid to more or less distant portions of the brain,
mainly the fourth ventricle. Authorities of to-day are pretty well
agreed that the condition known as concussion is the result of actual
injury to the brain, a laceration of its substance, the result of force
applied directly or indirectly. Concussion and laceration may be used
almost as synonymous terms. In this connection the experiments of
Felizet are interesting. He filled a skull with paraffin and let it fall
from a height which was not sufficient to fracture the skull. On exam-
ination it was found that the bone was unbroken, but at the point of
contact the paraffin was flattened, proving that when the force was
applied the bone was driv^en in, and then by its resiliency bounded
back to its place. No doubt the same resiliency exists in the living
skull ; the bone rebounds, but the brain is bruised or lacerated and a
small amount of hemorrhage takes place. In post-mortem examina-
tion of cases of concussion it is common to find extravasation of blood
into the meshes of the pia mater and beneath the arachnoid. Accord-
ing to Duret, these are due to the waves communicated to the sub-
arachnoid fluid, the force of which may have its greatest intensity
opposite the point at which the blow is received.
Symptoms. — In mild cases the injured person turns pale, becomes
giddy, loses his balance, and falls. He may lie unconscious or semi-
conscious, and after a time get up of his own accord or with slight
470 SURGICAL DIAGNOSIS AND TREATMENT.
assistance. His mind is confused and he suffers from nausea, and per-
haps vomits. In severe cases the symptoms are much more serious.
The person falls suddenly, and lies perfectly still, totally unconscious
or capable of being only partially roused. The heart is weak and the
pulse fluttering. The pupils generally respond to light, but they may
be unevenly contracted. Vomiting is the first indication of returning
consciousness. After the patient has regained consciousness he suffers
from headache, vertigo, and lassitude, and this may continue for several
weeks. In the worst cases the injury to the brain is so great that the
unconsciousness deepens into coma, or the symptoms of meningitis,
cerebritis, or abscess are developed. Remote consequences of such
injuries are epilepsy and insanity.
Trcatiiicjit. — The treatment is the same as for contusions of the
skull — perfect quiet and the closest watchfulness for brain-compli-
cations. Among the laity it is a common practice to give alcoholic
stimulants ; this is to be condemned, as their effects upon the brain
may prove serious. Aromatic spirit of ammonia is free from this
objection, and should headache prove troublesome a dose of bromid
of potassium is proper. Every case of concussion should be looked
upon as a serious injury, and no amount of remonstrance on the part
of the patient should influence you in relaxing the rigidity of your
management.
Compression of the Brain. — An organ so delicate as the brain
is intolerant of pressure, and refuses to perform its functions when en-
croached upon by foreign bodies. The causes of compression are —
hemorrhage above or below the dura mater or in the center of the
brain, collections of pus, hyperemia, depressed fractures, and tumors.
The time at which evidences of compression appear varies with the
nature of the compression. Rapid extravasation of blood produces
immediate compression ; inflammation does not produce it until the
hyperemia or the inflammatory products have had time to develop ;
tumors do not cause compression until an advanced stage of their
growth, except when they are attended with hemorrhage ; in meningitis
or osteo-myelitis of the skull this symptom does not appear until the
second week, while an abscess in the cerebral substance may not
reveal its presence until weeks or months after the accident which
caused it.
Symptoms. — The symptoms of compression are in many respects
entirely different from those of concussion, and yet there are cases in
which the diagnosis is difficult, as one condition runs into the other.
There are degrees of compression too, for in one case the whole brain
may suffer, in another the pressure may be local. Sudden compression
may begin with convulsions.
Total Compression. — The patient is completely unconscious and lies
in a state of coma. One leading symptom is very pronounced, and can
be heard the moment you enter the patient's room — stertorous breath-
ing. If you watch the cheeks, you will see that they expand, and the
lips are passively blown outward at each expiration. This is because
they are paralyzed. In concussion we saw that the patient could be
roused to semi-consciousness : not so in compression, for voluntary
and reflex movements are in abeyance. The skin is cold, and usually
INJURIES A.\D DISEASES OF THE HEAD. 47 1
it is covered with perspiration. The pulse is slow and strong. The
pupils are fixed, generally dilated, and do not respond to light. The
bladder has lost its power to contract, and becomes over-distended ;
the feces are passed involuntarily.
When the cause of compression acts slowly the following sequence
of symptoms may be observed : The patient becomes restless and irri-
table, and complains of nausea and other digestive disturbances ; there
is severe headache ; the pupils are contracted ; the face is flushed ; the
pulse is full and rapid, and the beating of the carotids is apparent to
the eye. Impairment of speech, vomiting, and sometimes convulsions
precede the period of stupor, which lasts as long as compression ex-
ists. A rise in temperature is a symptom of great importance, and
has a prognostic as well as a diagnostic value. It comes on early and
is persistent. A subnormal followed by a high temperature demands
a bad prognosis.
Local Couiprcssio)i. — The patient does not lose consciousness, and
the symptoms will depend upon the part of the brain which suffers
compression. The anterior lobes show the least response, and it is not
uncommon to find a considerable area of cerebral tissue destroyed
without having shown symptoms during life. When the anterior por-
tion of the brain is compressed no paralysis is produced, unless the
posterior part of the inferior left frontal convolution becomes involved,
in which case there is motor aphasia. Pressure in the motor area will
be recognized by paralysis of the limbs or impairment of the movements
over which the several districts preside, as follows :
Paralysis of the lower limb indicates the upper third of the fissure
of Rolando on the opposite side and the corresponding parts of the
ascending frontal and ascending parietal convolutions (Fig. 197).
Paralysis of the upper extremity indicates pressure upon the middle
third of the Rolandic fissure and the corresponding parts of the con-
volutions.
Motor aphasia indicates pressure upon Broca's area in front of the
lower third of the fissure of Rolando. Mind-blindness may be caused
by pressure of the angular gyrus, as shown by a case of Macewen's in
which a spiculum of bone from the inner table was driven in upon the
anterior portion of the convolution. Word-blindness (apraxia) would
point to the temporo-sphenoidal lobe ; hemianopsia, to the cuneus and
its neighborhood. Pressure upon the pons Varolii or the medulla
oblongata speedily endangers life by destroying the nerve-centers
themselves or arresting the nerve-currents as they pass from the skull.
In the diagnosis of compression of the brain the following must be
excluded : alcoholic intoxication, opium-poisoning, apoplexy, and
uremia. A drunken person, unless carrying a very heavy "jag," is not
unconscious ; he probably has the appearance of habitual indulgence
and the smell of alcohol taints his breath. Doubt may arise, however,
from various sources : the drunken man may have fallen and caused an
injury to his head, which injury may divert the attention of the examiner
from the real condition. On the other hand, an injured person is almost
sure to have stimulants poured down his throat by those who come to
his rescue. The pupils of a drunken man are usually contracted, but
they dilate w^hen he is aroused. The temperature is subnormal. The
472 SURGICAL DIAGNOSIS AND TREATMENT.
effects of alcohol pass oft" in a few hours, when all doubt is removed
if not before.
Opium-poisoning is attended with the drowsiness and the deep sleep
which characterize the effects of opiates ; the pupil is contracted to a
pin-point and remains so, and there are no evidences of an injury to
the head.
Apopelxy is due in nearly all cases to hemorrhage of the lenticulo-
striate artery, which Charcot has designated " the artery of cerebral
hemorrhage." In this lesion unconsciousness comes on immediately or
after a very short interval ; the breathing is stertorous, unconsciousness
is complete, and there is cither hemiplegia or total paralysis.
Uremia is recognized by a history of albuminuria, edema of the legs,
and the absence of paralysis and stertorous breathing.
Treatment. — Compression is only a symptom, and its treatment must
depend upon the lesion which is acting as the cause.
Intra-cranial Hemorrhage. — Hemorrhage within the skull, as a
rule, arises from one of three arteries: i. The lenticulo-striate causes
the hemorrhage of apoplexy, and comes under the consideration of the
physician. 2. The middle meningeal produces those cases in which the
bleeding is outside the dura mater. 3. The middle cerebral gives rise
to hemorrhage beneath the dura mater — subdural hemorrhage. Other
sources of intra-cranial hemorrhage are the sinuses, the small vessels
of the membranes, and, in exceptional cases, the internal carotid artery.
The cases of cerebral hemorrhage which fall under the care of the
surgeon are nearly all of traumatic origin. They may be classed under
three heads : {a) extradural hemorrhages, or those which occur between
the dura mater and the skull ; (Jj) subdural, or those which take place
between the dura and the brain ; and {c) cerebral, or those which take
place into the tissue of the brain itself
Extradural Hemorrhage. — The source of this form of hemorrhage
is nearly always the middle meningeal artery, and the exciting cause is
a blow or a depressed fracture. The artery is a branch of the internal
maxillary and enters the skull throngh the foramen spinosum ; it then
divides into an anterior and a posterior branch. The anterior follows
the groove in the great wing of the sphenoid, and, reaching the ante-
rior inferior angle of the parietal bone, turns upward toward the middle
line of the head. The posterior branch passes over the squamous
portion of the temporal bone, and thence to the posterior margin of
the parietal bone. One or other of these branches is usually the seat
of extradural hemorrhage — the anterior more frequently than the
posterior.
Symptoms. — There is one symptom of intra-cranial hemorrhage
which is worth all the rest combined. // is a period of consciousness
after the first shock of the injury, folloived by paralysis or unconscious-
ness. Thus, a person receives a blow upon the head, and, falling to the
ground, remains for a time unconscious, owing to concussion of the
brain. From this he soon recovers, but at the end of several hours,
or it may be one or two days, symptoms of compression appear,
manifested by paralysis of a limb or gradually increasing stupor. At
the time he received the blow a branch of the artery was ruptured, and
the blood began to collect and form a clot upon the surface of the
INJURIES AND DISEASES OF THE HEAD. A.'Jl
brain. At first the brain could tolerate the moderate pressure thus
produced, but when the clot became larger the symptoms of compres-
sion began to be apparent. When paralysis appears it is upon the side
of the body opposite to the brain-lesion, and may involve a single move-
ment or limb or take the form of hemiplegia. In some cases we can
trace the course of the growing clot by the paralytic symptoms. Palsy
of the muscles of the face, motor aphasia, paralysis of the arm, and
later of the leg, would indicate that the clot began to form low down
near the base and gradually ascended to the middle line. The patient
becomes drowsy, and the drowsiness may deepen into coma. The pulse
is frequent, and in contrast to it the respiration is slow and stertorous.
If the clot tends to increase toward the base of the brain instead of
upward, the pupil on the same side will at first be contracted, and
afterward dilated and insensible to light. It occasionally happens that
the hemorrhage takes place on the side opposite to the injury. In that
case the injury and the paralysis will be upon the same side.
Subdural hemorrhage cannot always be distinguished from the
preceding variety. The pressure is not so great as in the extradural
form ; hence the pressure-symptoms are not so clearly marked. The
blood comes from the middle cerebral artery, from the vessels of the
pia mater or cortex, or from the veins of the surface of the brain.
When the motor area is the seat of subdural hemorrhage the para-
lytic symptoms are the same as those observed in extradural bleeding,
but less marked and indefinite. When the frontal lobes are involved
the mental condition of the patient becomes changed, as shown by
irritability of temper, loss of self-control, and sometimes insanity.
Subarachnoid hemorrhage is not recognized by any symptoms
which distinguish it from other forms of intra-cranial hemorrhage.
The blood usually comes from the cortex itself, and, if it does not
burst through the arachnoid, it spreads over the surface, filling the
sulci and gravitating toward the subarachnoid space at the base of the
brain. This form may be suspected if after a severe contusion the
symptoms are local at first and rapidly become general, attended with
convulsions and paralysis.
Cerebral hemorrhage, or hemorrhage into the substance of the
brain, probably occurs, in a slight degree, in most cases of concussion,
but produces no definite symptoms. When a vessel of considerable
size is ruptured, the blood is poured out into the ventricles and the
case is one of apoplexy.
Treatment of Intra-cranial Hemorrhage. — When signs of com-
pression appear within a few hours after an injury hemorrhage may
be almost positively diagnosticated. The treatment must be deter-
mined by the question of localization. If the compression is general
and no e.xact point can be fixed upon as the situation of a clot, we
must be content with helping the flow of venous blood from the brain
by keeping the head and shoulders slightly raised and by lessening the
amount of cerebro-spinal fluid through the influence of purgatives.
Formerly, venesection was resorted to, but its value is now considered
doubtful.
When the position of the clot can be accurately determined by local
symptoms, it is an imperative duty to trephine the skull, remove the
474
SURGICAL JU A GNOSIS AND TREATMENT.
clot, and litj^atc, if possible, the bleeding vessel. When the middle
menintjeal artcr}' is the bleeding vessel, which is the case in the
majority of injuries, the prognosis is not necessarily bad, and espe-
cially if it is the anterior branch of the vessel which is injured. If
there is a fissure of the skull along the line of this artery, it is more
than likely that the bleeding point is just beneath the fissure, and the
trephine should be applied accordingly. It must never be forgotten
that the blow may be on one side of the head and the hemorrhage on
the opposite side ; the paralytic symptoms in that case would be on the
same side as the accident. In operating, therefore, the point for tre-
phining must be chosen not from the position of the original injury,
but by the localizing symptoms. Thanks to the observations of
Kronlein, there is one point at which we are almost sure to find the
clot, and that is one and a quarter inches behind the external angular
process and on a level with the upper margin of the orbit (P1g. 203).
Fig. 203. — Site of trephine opening to reach clot in hemorrhage from middle meningeal
artery (Kronlein) : a,b, horizontal line through the meatus; c, d, on a line with the eyebrows;
e,f, vertical line 3 to 4 cm. behind the ext. ang. process; g, h, at the posterior border of the
mastoid process. A, the point to reach the anterior, and B, the posterior branch.
This reaches the anterior branch of the middle meningeal. If there are
dilatation of the pupil and other evidences that the clot is increasing
downward, this opening must be made half an inch lower. Should we
be disappointed by this exploration, we must immediately look for the
clot at the position of the posterior branch of the artery. This is
reached by trephining farther back — viz. on the same level as the
former opening and just below the parietal eminence.
When the clot is reached it presents the appearance of a dense,
almost black coagulum bulging into the opening. This must be care-
fully scooped out, and if the trephine opening does not give sufficient
room, the bone must be further removed by Keen's or Hoffman's cut-
ting forceps. Having got rid of the clot, the next and most difficult
task is to find the bleeding point. If the blood keep welling up as fast
as it can be sponged away, the carotid artery should be compressed,
and sterilized water at a temperature of 110° should be applied to the
INJURIES AND DISEASES OF THE HEAD. 475
wound. When the bleeding point is found, a catgut ligature should be
passed around the vessel by means of a full-curved Hagedorn needle,
the point of the needle being made to enter the dura mater at one side
of the artery, and, passing under the vessel, emerge at the other side.
The ligature is then tied so gently as not to rupture the vessel. Another
difficulty in stopping the bleeding point is that the part of the brain
occupied by the clot does not rise to the opening when the clot is
removed, but remains depressed. This may require a further enlarge-
ment of the trephine opening. Having found and secured the bleeding
vessel, the wound is well cleansed and ample drainage provided for.
The Operation of Trephining. — As this operation is a preliminary
to nearly all the operations which can be performed on the brain and
involves the technique of all cerebral operations, let us consider it in
detail. It is indicated for the removal of a depressed bone in fracture
of the skull, for intra-cranial hemorrhage, for the evacuation of cerebral
abscess, for the relief of epilepsy or insanity, and for the removal of
tumors.
Preparation of the Patient. — The patient's head should be shaved as
the very first proceeding, since his examination cannot be conducted
satisfactorily without it. It is remarkable how scars, prominences, and
depressions are revealed after removal of the hair. The nature of the
lesion having been arrived at, not by a " snap " diagnosis, but after
careful study of every feature of the case, the fissures or other land-
marks are marked by an anilin pencil or by a stick of nitrate of silver.
The head is protected by a suitable cap or silk handkerchief The day
before the operation the scalp should be again shaven, thoroughly dis-
infected, and wrapped in sublimate gauze. When the patient is taken
to the operating-room a final washing and sterilizing is carried out.
AncstJicsia. — The semi-recumbent posture is believed to lessen the
amount of hemorrhage during the operation. Chloroform is un-
doubtedly the best anesthetic.
Raising the Flap. — Having mapped out the location of the fissures
upon the scalp, it is very important that corresponding points should
be marked upon the bone. The sharp point of a trocar or the center
pin of a spare trephine is pushed through the scalp, and by rotary
movement or a sharp stroke of a hammer is made to mark the bone.
In any case the point to which the trephine is to be applied should be
marked, and if the operation is to be over the fissure of Rolando, the
upper and lower end of the fissure should also be marked.
If there is already a wound in the scalp, this can be utilized and
enlarged as required. In the uninjured scalp a suitable flap must be
raised and the bone exposed. Formerly this was done by a crucial
incision, but it had several disadvantages : four triangular flaps were
constantly in the way and had to be held aside ; the application of
sutures to close the wound was troublesome, and a weak point was left
which was sure to come over the center of the opening, where the
greatest support was required.
A horseshoe flap is the shape which best fills all requirements. It
should have its base below when practicable, as this secures better
blood-supply. The incision goes through the pericranium, and the flap
is raised by separating the pericranium from the bone. The scalp is
476 SURGICAL DIAGXOSIS AND TREATMENT.
likely to bleed freely, but this is readily controlled by grasping its
edges in hemostatic forceps. The operation can be made almost blood-
less by apph'ing a stout rubber band around the scalp, just above the
eyebrows and ears, but the advantage thus gained is more than lost by
the copious hemorrhage that follows removal of the tourniquet. For
holding the flap out of the way a stout silk thread can be passed
through its margin and tied to form a loop.
Trcphiiiino the Bone. — The skull is now exposed to view and is
examined. If there is fracture with depression, it may be possible to
introduce an elevator beneath the depressed portion and restore it to its
proper place. If the bones are so interlocked as to make this impos-
sible, the trephine must be used to get rid of the necessary extent of
bone.
When the object of the operation is to deal with an intra-cranial
lesion a good-sized trephine is applied over the spot indicated by the
mark which has previously been made on the bone. The point of the
center pin hav'ing become well engaged, the trephine begins to cut
through the bone by light rapid movements from right to left and from
left to right. Care must be taken to keep the instrument at right
angles to the bone, in order that it may cut through evenly, and as soon
as the center pin has ceased to be necessary it is retracted and fixed
with its thumb-screw. The bone-dust is at first dry, but becomes moist
and blood-stained as soon as the outer table is cut through. The chan-
nel made by the saw must be kept clear by occasionally using a
sterilized toothpick or needle, and the instrument itself freed from
debris by washing it in carbolic-acid solution. When the diminishing
resistance gives warning that the bone has been cut through, the tre-
phine is laid aside and the button of bone removed by gently elevating
it. An improv^ement on the time-honored trephine has been devised
by Leonard (Fig. 204). It has a fixed handle in which a shaft revolves,
Fig. 204. — Leonard's improved aseptic trephine.
and to which the force is applied through a double raised spiral by
means of a sliding handle. By each upward movement of the sliding
handle the shaft and trephine are caused to make three complete revo-
lutions. The friction is less and the cutting more easy than in the
ordinary treatment.
A trephine opening to be of any utility should be not less than an
inch and a half in diameter. Should this be found insufficient, the
opening can be enlarged by rongeur forceps (Fig. 205). Before enlarg-
ing, however, the dura mater is to be separated from the bone, for
which purpose Poirier's (Fig. 206) or Horsley's dural separator (Fig.
207) can be employed, or a stout probe bent to a proper angle.
INJURIES AND DISEASES OF THE HEAD. 477
Examination of the Brain. — The dura mater is now exposed, and
the rule is to open it, for without this step a satisfactory examination
of the brain cannot be made ; but it must be borne in mind that unless
Fig. 205. — Hopkins's rongeur forceps.
the most thorough asepsis is carried out the risk is greatly increased.
The cicatrix which follows an incision of the dura may prove trouble-
some, and should be taken into account. The membrane is divided
Fig. 206. — Poirier's dural separator.
Fig. 207. — Horsley's dural separator.
with curved scissors a quarter of an inch from the edge of the bone, so
as to form a flap, which at the end of the operation is replaced and
stitched to the quarter-inch margin. The brain now lies in full view,
and we must observe the following points :
{a) The Degree of Tension. — Does the brain bulge into the trephine
opening ? If so, there is an increase of intra-cranial pressure due to a
tumor, an abscess, or excess of fluid in the ventricles.
ib) The Color of the Brain. — Lividity or a yellowish tinge indicates
a probable tumor beneath the cortex. An old laceration has a dirty
yellowish-brown appearance. A dark purple substance, seen before
opening the dura, forced up into the trephine opening and without pul-
sation, would indicate subdural hemorrhage.
{c) Pulsation. — With a moderate degree of compression strong pul-
sation can be felt and the resistance is increased ; when the pressure is
due to a large underlying tumor or abscess, pulsation is absent.
{d) Faradization. — It is not advisable to spend much time in testing
the motor-centers by faradization, but should it be deemed necessary
478 SURGICAL DIAGNOSIS AND TREATMENT.
to follow this line of investigation, an ordinary faradic battery with a
weak current is sufficient. A very convenient electrode is that devised
by Keen (Fig. 2o8).
Fig. 208. — Double brain-electrode (Keen)
Operations on the Brain. — If the aim of the operation is the arrest
of hemorrhage, the bleeding vessel can be secured by passing a full-
curved Hagedorn needle through the brain-tissue and beneath the
vessel, and tying the ligature with only sufficient tension to sto]3 the
bleeding. A ligature drawn too tightly is sure to tear through the
delicate tissues. If it is necessar>^ to remove a diseased portion of the
brain-substance, the lines of incision should be made antero-poste-
riorly, as in that direction they do not cut across motor areas, and are
therefore less likely to produce paralysis. If a tumor is to be removed,
the necessary incision through the cortex should be made at right angles
to the surface of the brain.
Closing the Wotmd. — When the removed portion of bone is in a
healthy condition, it is proper to replace it. With this object in view
the greatest care is necessary that the bone should be properly looked
after. One assistant should have this matter as his sole charge. As
soon as the bone is removed he should place it in a bowl containing a
I : 2000 sublimate solution, and keep the bowl floating in water at a
temperature of ioo° to 105° F. All bleeding having been arrested
and the wound carefully dried, the flap of dura mater is replaced and
stitched with a fine catgut continuous suture. The bone, if healthy, is
cut into several pieces with rongeur forceps and laid upon the dura.
The skin-flap is laid in position and stitched with catgut or silkworm
gut. If the case is one of abscess, hemorrhage, or gunshot wound, a
rubber drainage-tube should be placed in the position which will be
most dependent when the patient lies in bed. The outer dressing is the
same as for any other wound.
Wounds of the Brain. — The brain, although admirably protected
from ordinary violence, may yet be wounded by instruments or foreign
bodies penetrating the orbit, roof of the mouth, or the cribriform plate
of the ethmoid by way of the nose. Instruments, as sabers, bullets,
knives, or bayonets, applied with great force, may even penetrate the
skull and wound the brain. The wound of the brain in all these in-
stances is a complication of the attending compound fracture of the
skull. The symptoms are usually overshadowed by the fracture or
they may be remarkably slight or slow in making their appearance.
Such wounds are nearly always septic ; consequently there is evidence
sooner or later of inflammation ; the patient complains of headache,
and this is followed by the group of symptoms which attends cerebritis
and ends in death. The cortex is, as a rule, the part that suffers, except
when the wound is receiv^ed by the mouth, and then it is the base of the
brain. In many cases the penetrating body, as a knife-blade or a piece
of wood, is broken off and left within the cranium. Such a case came
INJURIES AND DISEASES OF THE HEAD.
479
under my observation in which a splinter of wood about half an inch
square and six inches in length was driven into the orbit ; the wood was
immediately withdrawn, but a portion three inches in length remained
in the brain, and was not discovered till three weeks afterward, when
evidences of an abscess led the surgeon to operate. Sometimes the
localizing symptoms, as paralysis of the face, the arm, or the leg, hemi-
anopsia, aphasia, etc., may lead to a diagnosis of the position of the
foreign body.
Treatment. — The wound is to be thoroughly cleansed (the head
having been shaved), all pieces of bone and foreign bodies removed,
and every effort made to secure asepsis ; the dura mater, if practicable,
should be united by sutures, a drainage-tube placed at the most depend-
ent part of the wound, the scalp closed by sutures, and a full antiseptic
dressing applied. Suppuration may follow in spite of all these pre-
cautions ; abscesses should be watched for and promptly drained.
V. INJURIES OF CRANIAL NERVES.
The symptoms that indicate injury of the cranial nerves are due
either to a lesion of the part of the brain which gives origin to the
nerves or to injury along the course of the nerv^es themselves.
The Olfactory Nerve. — The olfactory nerve begins at the tuber
olfactorium in front of the anterior perforating space (Fig. 209). From
Fig. 209. — Anterior and middle portions of the base of the brain (after Hirt) : F, frontal
lobe; 7", temporal .lobe ; b.ol., olfactory bulb ; /r. (?/., olfactory tract; t.ol., tuber (trigonum)
olfactorium; s.m., middle; j. /., lateral root; /., infundibulum (cut off); cm., corpora albi-
cantia ; /./. a., anterior perforated space ; s.p. p., posterior perforated space.
this point the nerve runs forward and slightly toward the middle line,
ending in the olfactory bulb {b. ol). The bulb lies upon the cribriform
plate of the ethmoid bone, and through the minute openings of this
bone two sets of "fibers pass to be distributed over the mucous mem-
brane of the nose. The deep origin of the nerve is not positively
known, but authorities are generally agreed that there are three roots.
The brain-center of the sense of smell is also a disputed point. It has
480 SURGICAL DIAGNOSIS AND TREATMENT.
been placed in the )'.i VI
^^
-
—
rj
,
5 102
cc .
UJ 101
LU 100
39°
98°
97°
E=^-^
^
^.
-J
g.
!-A.
&:^.
TT-^ r
t—
.1 .. ,:
':^;^^^
-.=.^
..i,
^
■ :::-;-=
Fig. 212.
-Abscess of the brain : temperature-chart of a typical uncomplicated case
(Macewen).
is blunted because there is encephalitis, and the pain is really less on
account of increased pressure and reduction of mental perception.
Two very characteristic symptoms mark this stage : one is pain on
pressure over the mastoid process and the squamous portion of the
temporal bone on the affected side. The other symptom is delayed
cerebration. When asked a question the patient stares vacantly and
makes no immediate reply. The answer comes, however, after a brief
interval, and is given in a slow, concise, dignified manner, and generally
correct. Following this, or coincident with it, is a condition veiy
similar to that which is produced by opium in large doses. The
patient is unable to sustain his attention. In giving an answer which
requires a number of sentences he gets lost in the middle, and is either
asleep or has forgotten what he was talking about before his answer is
finished. If he asks for something, he forgets all about it before his
request is granted. Another characteristic of the mental condition is
inability to apply the strength. He may be quite able to perform an act,
but the will-power is wanting — a condition very familiar to those who
have frequently taken opiates.
490
SUKG/C.iL DIAGNOSIS AND TREATMENT.
Fig. 213. — Chart of infective thrombosis of cavernous sinus, for comparison with that of
cerebral abscess (Macewen).
The temperature in the second stage is normal or subnormal ; its
average range may be set down at 97° to 99° F.
Figs. 212, 213, 214 illustrate the difference in temperature between
Fig. 214. — Chart of infective purulent cerebro-spinal leptomeningitis (Macewen),
INJURIES AND DISEASES OE THE HEAD. 49 1
cerebral abscess, infective thrombosis, and cerebro-spinal leptomenin-
gitis.
The pulse also falls below normal, and may beat sixty, forty, or even
thirty times in the minute. A slow pulse with a high temperature
indicates intra-cranial disease ; when pulse and temperature are both
high, it points to systemic disease. A slow pulse is produced by pres-
sure on the brain. It is found in abscess, in extradural blood-clots and
intra-cranial tumors. The respirations are diminished in frequency, and
may assume the Cheyne-Stokes character. This is especially the case
when the abscess is in the cerebellum. Other symptoms more or less
constant in this stage of cerebral abscess are constipation, vomiting,
convulsions, rigors, and optic neuritis.
Third Stage. — If allowed to take its course, cerebral abscess usually
ends in death. The patient may pass into a stage of profound stupor
and die of coma. The abscess may rupture either upon the surface of
the brain, and its contents spread over the convexity of the cerebrum,
or it may burst into the ventricles, in either of which events a train of
symptoms is produced whose universal termination is death. Spread-
ing over the brain-surface, acute leptomeningitis is produced, and we
recognize this new departure by the onset of rapid pulse and high tem-
perature, vomiting, restlessness, squinting, flushing of the face, and
spasmodic contractions of the muscles. When the abscess ruptures
into the ventricles, a sudden and alarming change takes place in the
patient's condition. The pupils dilate widely, the face becomes livid,
and the breathing hurried, shallow, or stertorous. The temperature
rises rapidly to 103°, 104°, or 105°, and the pulse comes up with a
bound from 40 or 50 to 120. Convulsions are common, and the end
may be expected in six to twelve hours from the time of rupture.
Besides the general symptoms just described, the situation of a
cerebral abscess may be definitely determined by localizing symptoms.
Arising from suppurative ear-disease, the abscess is usually in the tem-
poro-sphenoidal lobe or the cerebellum, which are both remote from
the motor area, but even then large abscesses may exert pressure upon
the motor centers. When the abscess is in the frontal or temporo-
sphenoidal lobe, the pupil on the same side may show any of the
following conditions : i. Contracted and stable: this indicates a slight
degree of compression and a small abscess ; 2. Dilated and stable :
indicating a greater degree of pressure and a large abscess.
When there is sufficient pressure upon the third nerve to cause par-
alysis there are ptosis, external strabismus, and a fixed, dilated pupil of
the same side.
Hemiplegia of the opposite side is observed in large abscesses.
Aphasia is sometimes produced. Motor aphasia suggests pressure on
Broca's convolution ; sensory aphasia or word-deafness, the posterior
half of the first temporal convolution.
Abscess of the occipital lobes is a rare affection and is generally
pyemic.
Abscess of the cerebelhun is attended with great prostration, feeble
pulse and respiration, and low temperature. Certain muscular phe-
nomena are sometimes observed ; these are retraction of the head
and neck and rigidity of the masseters, causing firm closure of the
492 SURGICAL DIAGNOSIS AND TREATMENT.
mouth, ^^'^\vnin<,f is coniiiion, and speech when attempted is slow and
jerk\-.
Differential Diagnosis. — In the earl)- staf,^e it is impossible to dif-
ferentiate cerebral abscess from meningitis or acute encephalitis. In fact,
at this stage the diseases are coincident, the abscess being surrounded
by an inllamed zone of brain-tissue. Rigors occurring in the course
of encephalitis should cause suspicion of abscess. Time is an import-
ant factor in diagnosis. Meningitis develops within three or four days,
while abscess seldom appears before the end of a week! The onset of
meningitis is also more abrupt, and is attended with delirium, high
temperature, photophobia, and contractions of both pupils simul-
taneously ; in abscess only one pupil is affected, and that on the
side in which the abscess is situated.
Thrombosis of tJic Lateral Simts. — In this condition the temperature
is high, and the jugular vein is felt to be hard and knotted, for the
thrombus which occludes the lateral sinus also extends into the inter-
nal jugular. Respirations arc quickened and vomiting occurs when the
patient is in the upright position. Pyemic symptoms develop at a later
period, and w^hen abscesses appear in the lungs and joints there can be
no room for doubt.
Tumor of the brain is distinguished from abscess by the slow
development of the symptoms. Febrile symptoms are wanting, nor
is there a history of an injury or a suppuration which could be the
source of infection. The localizing symptoms in the case of tumors
are more definite than in abscess, and optic neuritis is more constant
and pronounced.
An error to be carefully guarded against is the mistaking of a
cerebral abscess, spreading from the middle ear through the tegmen,
for disease in the mastoid cells. It has repeatedly happened that the
surgeon has opened the mastoid cells without benefit, the disease going
on to a fatal termination, and a post-mortem examination showing that
the suppuration had spread through the tegmen, causing meningitis or
abscess (Crafts).
Treatment. — Prophylactic. — There are few diseases in which so
much can be done in the way of prevention as in abscess of the brain.
A wound of the scalp, be it ever so small, should be treated with the
utmo.st aseptic care. Too often such cases are rushed to the nearest
drug-store, the blood washed off with an unclean sea-sponge and germ-
laden water, a few locks of hair cut away with scissors, and an artistic
stellate patch of sticking-plaster applied to the wound. Suppuration is
inevitable, and the risk of septic infection ever present. In scalp-wounds
and, a fortiori, in compound fractures, the scalp should be shaved for
a considerable distance around the seat of injury ; dirt should be washed
off with soap and water, and, if a flap of the scalp is so impregnated
that the dirt cannot be washed away, it should be removed with a
sharp knife, so as to leave a freshened surface. Ether, alcohol, or tur-
pentine should next be used, and afterward a solution of corrosive sub-
limate, I : 2000. If a fissured fracture of the vault holds in its grasp
hair or other sources of infection, a V-shaped channel should be chis-
elled out, removing the lips of the outer and leaving the inner table of
the skull. If the surface of the bone, without being fractured, has dirt
INJURIES AND DISEASES OF THE HEAD. 493
ground into it which cannot be washed out, the surface should be chis-
elled off.
When the dura mater or the brain has been infected in compound
fractures, the dura should be freely incised and carefully disinfected.
Fractures of the base or punctured fractures made by way of the orbit,
the nose, or the mouth should be kept from infection by constant dis-
infection of the cavities, as also the cavity of the ear. Chronic suppura-
tion of the middle ear should be looked upon as a constant source of
danger and treated accordingly.
Abscess of the brain is almost invariably fatal unless means be
taken to evacuate the pus and drain the abscess-cavity. The recent
advances in brain-surgery have placed the operation of trephining for
abscess on a sound basis, and many successful cases have been re-
ported. The localizing symptoms must be mainly relied upon to
determine the position for the opening in the skull. If a scar is pres-
ent and the local symptoms indicate that the abscess is beneath the
scar, the trephine should be applied there. If, on the other hand, the
localizing symptoms point to some other part of the brain as the seat
of abscess, the position of the scar should be disregarded.
The preparation of the patient and the mode of opening the skull
have already been described. Macewen suggests that the exposed
osseous surface made by the trephine be rubbed over with iodoform
and boracic-acid powder to protect the bone from contamination by the
pus about to be withdrawn.
On opening the dura mater the brain-substance will bulge up into
the wound, and if the pressure be great the normal pulsations will be
wanting. The best instrument for exploring the brain is an ordinary
grooved director. It is pushed gently into the cerebral substance at
right angles to the surface and in the direction in which the collection
of pus is supposed to lie. When the cavity is reached, the operator is
warned of the fact by a sense of lessened resistance and by the appear-
ance of pus in the groove of the instrument. Should the first attempt
fail, the director is to be withdrawn and passed in another direction,
nothing being done which will change the puncture to a laceration of
the brain-substance. When pus is found a fine straight knife is passed
along the director, and an opening made sufficient to admit a pair of
hemostatic forceps. The latter instrument is then passed into the
abscess, moderately opened and withdrawn, so as to dilate the incision
made by the knife. The granulation-tissue lining the cavity is next
carefully and gently scraped away with a spoon and the cavity washed
out with boric-acid solution. A rubber drainage-tube is passed down
to the bottom of the cavity and made to emerge through an opening in
the scalp, to which it is attached by a stitch. The bone is not replaced.
A moist dressing is applied. At the end of forty-eight hours the tube
is shortened from day to day until it is no longer required. It must be
borne in mind that suppuration is apt to recur, and this may be months
and even years after apparent healing. On this account the drainage-
tube should not be removed too early. It must be remembered, too,
that drainage-tubes do not act so effectually here as elsewhere ; an
abscess once evacuated, the walls of the cavity rapidly come into con-
tact with each other as a result of pressure in the neighboring areas.
494 SURGICAL DIAGNOSIS AND TREATMENT.
In this way it is easy for septic germs to be retained instead of coming
away with the drainage, and such germs, remaining latent for a time,
may result in abscess at a remote period.
Abscess of the cerebellum is best reached by a trephine opening
made just below the position of the lateral sinus — that is to say, below
a line leading from the external auditory meatus to the external oc-
cipital protuberance. The proper point on this line is one midway
between the tip of the mastoid process and the inion. Abscess in the
frontal lobes is reached either from the temporal region or from the
front of the brow according to the position of the abscess. If the pus
is contained in the posterior part of the lobe, it is best reached from the
temple, but at the same time there is a danger that after going through
the temporal muscle suppuration may take place beneath it, the part
being infected from the abscess. By the frontal route the danger is that
the frontal sinus may be opened into. In cases which involve the sinus
itself this opening is a necessity. To expose the cribriform plate of the
ethmoid a small opening may be made a quarter of an inch above the
glabella, " remembering that the frontal lobes dip at this point to the
level of the nasion " (Macewen).
When the cerebral abscess is a result of disease in the middle ear
the first procedure in an operative way is the opening of the mastoid
process and its thorough cleansing. A vertical incision two inches in
length is made a quarter of an inch behind the external auditory
meatus, beginning at the posterior root of the zygoma and ending a
third of an inch from the tip of the mastoid process. The incision is
made down to the bone, and the periosteum and soft parts are separated
forward so as to expose fully the external auditory meatus. This flap,
including the auricle, is held forward by a sharp retractor, and bleeding
points, if any, are stopped.
At this stage Macewen recommends attention to the three following
points : " First, the position of the suprameatal triangle — a triangle
formed by the posterior root of the zygoma above, the upper and
posterior segment of the osseous external meatus below, and an
imaginary line uniting these two extending from the most posterior
portion of the external osseous meatus to the zygomatic root (Figs.
215, 216). Within this triangle and touching its base the opening into
the mastoid antrum is made with safety. Second, the degree of
obliquity of the posterior osseous wall of the external auditory meatus,
as w^hen this wall is directed more obliquely from behind forward, the
mastoid antrum is situated slightly more anteriorly than when the
osseous wall of the meatus is directed more transversely from without
inward. Third, the depth of the inner wall of the tympanic cavity
from the level of the skull at the osseous portion of the external audi-
tory meatus, which may be determined by introducing a probe through
the external ear till it comes gently in contact with the inner wall of
the tympanum, the membrane having been previously perforated by
pathological processes, and then marking on it the limit of the outer
aspect of the osseous meatus. If the middle ear lie deep, the mastoid
antrum, which is more superficial, may be expected to be relatively
deeply seated." ^ The opening into the antrum is made slightly forward
^ Diseases of Br am and Spinal Cord, p. 297.
INJURIES AND DISEASES OF THE HEAD.
495
to avoid the sigmoid sinus. At the depth of half an inch Hes the
facial nerve, and this must be avoided, twitching of the facial muscles
Fig. 21!
—Schema of squamo-mastoid portion of the temporal, showing the suprameatal
triangle in relation to the sigmoid groove and facial nerve (Macewen).
Fig. 2i6. — Surface guides for the sigmoid sinus and the suprameatal triangle (Macewen),
artificial lines drawn upon the skull indicating the following : (i) The short vertical line from
the posterior border of the external auditory meatus to the posterior root of the zygoma marks
the base of the suprameatal triangle (a) ; the broken line indicates the anterior border of the
suprameatal triangle, its base being the dotted line marking a part of the root of the zygoma.
This broken line also indicates the course of the facial nerve. (2) The second vertical line,
extending from the parieto-squamo-mastoid junction to the tip of the mastoid; the upper two-
thirds of its length indicates the position of the sigmoid sinus. (3) The oblique line passing
from the asterion to upper limit of the external auditory meatus indicates the posterior two-
thirds of the sigmoid sinus from its commencement to its knee.
giving warning when the nerve is too closely approached. For its
avoidance Macewen advises keeping close to the floor of the middle
fossa and nearer to the posterior border of the opening, toward the
496 SURGICAL DIAGNOSIS AND TKEATMENT.
posterior superior angle of the suprameatal triangle. Should this ope-
ration fail to relieve the symptoms, the abscess must be looked for in
the temporo-sphenoidal lobe by a new opening. This opening should
be made one and a quarter inches behind, and the same distance above,
the external auditor)' meatus. A quarter-inch trephine is large enough
to begin with, the opening being afterward enlarged, if necessary, by
the rongeur forceps. The dura mater is incised and a grooved director
passed into the brain-tissue, as already described. The instrument
should be made to take a direction toward the opposite ala of the
nose — that is to say, downward, forward, and inward. Failing to find
pus in this direction, the director is withdrawn and careful search made
in other parts of the lobe.
Thrombosis of the lateral sinus is a sequel of suppurative
disease in the middle ear, and is usuall)- associated with pyemia. The
symptoms are so similar to those of cerebral abscess that until recent
years the two conditions were confounded. Like abscess, thrombosis
occurs in the course of chronic otitis media, and is ushered in by
vomiting, headache, and pain in the region of the sinus. Rigors and
rapid rise of temperature are common, there is edema behind and over
the mastoid, and the cervical glands may be enlarged. In many cases
there are the general symptoms of pyemia. When pyemic symptoms
are wanting the diagnosis must rest upon two points — viz. tenderness
along the course of the lateral sinu.s — that is, from the external audi-
tory meatus to the external occipital protuberance — and tenderness
along the course of the internal jugular vein, the vessel feeling hard
and knotted to the fingers. Choked disk is usually present, and the
temperature, as a rule, runs high, instead of normal or subnormal, as
in cerebral abscess.
Treatment . — When allowed to go unrelieved by operation, the dis-
ease is always fatal, while about 66 per cent, of cases operated upon
have ended in recovery. The mastoid is opened in the manner already
described and thoroughly cleansed. The sinus is next exposed, and
the thrombus or pus, as the case may be, washed out. Hemorrhage is
checked by packing the sinus with strips of iodoform gauze. Finally
the internal jugular is exposed down to the farthest limit of the throm-
bus, and here the vessel is tied to prevent the clot extending toward
the heart. Too much stress cannot be laid upon the importance of
properly treating otitis media, which is so common a source of abscess
and thrombosis.
IX. CEREBRAL TUMORS.
The tumors met with in the brain are the following : Glioma is
formed in the cerebrum, seldom in the cerebellum or the spinal cord.
Sarcoma occurs most commonly at the base of the brain, and in most
cases arises from the dura mater, the periosteum, or the bone itself It
varies in size from a walnut to the human fist, and may be solitary or
multiple.
Carcinoma is usually secondary to the disease in the breast, the lung,
or the pleura, and occurs as a soft tumor in the ventricles, frequently
causing hydrops ventriculorum. Tubercular growths are the most fre-
INJURIES AND DISEASES OF THE HEAD. 497
quent of all cerebral neoplasms. Their most common seats are the
pons, the cerebellum, and the cortex. Syphilomata or gummata
chiefly occur in the dura mater, and thence spread to the brain-sub-
stance. The growths, in appearance, closely resemble tubercles, but
are readily distinguished by absence of the tubercle bacilli.
Symptoms. — Tumors of the brain produce no symptoms until they
are sufficiently developed to cause irritation by pressure upon or de-
struction of the neighboring brain-tissue. Apart from pressure, how-
ever, it is certain that tumors, especially those of an infective character,
are capable of producing irritation of the adjacent parts, which may be
manifested by clearly-marked symptoms. The evidences of a cerebral
tumor are of two kinds, general and focal.
General Symptoms. — Hcadaclic is one of the earliest and most
constant of all the symptoms. It begins as a dull, indefinable pain
which the patient cannot localize. His head aches all over, and as the
disease advances the suffering may be so intense as to threaten his
reason. The slightest movement or the slightest percussion of the
head greatly aggravates the pain. It is difficult to imagine a more
pitiable condition than that caused by a cerebral tumor. Tormented
by day and by night, the patient has occasional remissions, but never
freedom from pain — pain that even continues in sleep, and wears and
wastes the sufferer till his nervous system becomes a wreck — no relief
from remedies, no hope of ease except through long-delayed death.
Pain, as distinguished from headache, is an almost constant symp-
tom. It is increased by pressure, but more particularly by percussion.
Vomiting is generally present. It has no connection with the inges-
tion of food, is unattended with nausea, furred tongue, or constipation.
Epileptiform convulsions may be general or confined to one side, and
in one or other of these forms they occur in about 50 per cent, of all
cases. Consciousness may or may not be lost during the attacks. The
value of convulsions as a diagnostic sign is thus summed up by Horsley :
" Of all the initial symptoms of cerebral tumor, the epileptic convulsion
is the most important, not only because it is a clear indication, but also
because tumors causing the most characteristic forms of epilepsy are
the most easily removed. The convulsions may be — i. General, and
so simulate idiopathic epilepsy ; 2. GeneraHzed, but preceded by a
localized aura ; 3. Though generalized, also commenced by a local-
ized muscular spasm ; 4. A typical Jacksonian fit, becoming in some
cases more generalized, and in some followed by a certain degree of
paralysis; or, 5. It may evince itself by single spasms, not grouped as
in a complete fit."
Some idea of the location of the tumor may be formed by studying
the characters of the fit. " Lesions of the frontal lobe appear to pro-
duce convulsions of the generalized type, and, above all, as Dr.
Jackson has often pointed out, convulsions in which movements of
a half-purposive character are very prone to be exhibited." The first
disturbance during the fit is the turning of the head and eyes to the
opposite side, and this is explained by the fact that the cortical center
for this movement is situated farthest forward of all the centers, and
the progress of the disease is from before backward.
" The parietal lobe may be assumed to be the seat of tumor if the
32
498 SURGICAL DIAGNOSIS AND TREATMENT.
convulsions arc of the pure Jacksonian type, because the parietal lobe
contains a large proportion of the most important motor-centers.
" Tumors of the parieto-occipital region will probably be cha-
racterized by general convulsions, with ocular deviation and visual
aura.'.
" Tumors of the occipital lobe most commonly present generalized
convulsions, hemianopsia from destruction of the cuneal region, and
are not infrequently accompanied by so-called hysteric manifestations.
Hemianopsia, it is to be noted, is also a frequent and, in fact usual,
accompaniment of tumors in the parieto-occipital region when the
lesion burrows deeply and so affects the optic radiations. Finally, in
the case of tumors exciting epilepsy from the occipital lobe it is to be
remembered that, owing to vertical pressure on the tentorium, they
may also give rise to symptoms resembling closely those of cerebellar
growth ; for example, nystagmus, tottering, etc. Epileptic convulsions
from lesions of the temporal lobe have been observed in cases of gross
organic disease (published by Dr. Thomas Wilson and others), and are
preceded by a sensory aura of the auditory type, also by the occur-
rence of amnesia ; and further, when paresis follows, it is apt to be of
a graduated type from the pressure on pyramidal fibers and areas of
motor representation in the cortex. Those cases of tumor of the inner
surface of the temporal lobe which have been carefully observed are
extremely interesting, for they have shown that the epileptic convulsion
is characterized by the occurrence of hallucinations of smell and taste,
the special-sense area of representation of these functions having orig-
inally been demonstrated by Dr. Terrier to be situated in this region.
It should be noted that, whatever be the nature of the fits in the sub-
sequent progress of the case, the initial attack is very often a general-
ized one. Moreover, in a certain number of instances the attacks are
sometimes localized and sometimes generalized in the same case. The
largest tumor I ever removed (the case of a lady operated upon six
months ago, she being still in good health and recovering from the
paresis) was treated for more than nine years as one of idiopathic
generalized epilepsy, and that even at a time when the growth was
already penetrating the skull. A careful analysis and observation of
the fits would have shown that many of them were characteristically
unilateral. The larger and more deeply seated the growth, the more
generalized are the convulsions. There is frequently present in cere-
bral tumor a general muscular weakness, which has often been con-
founded with simple neurasthenia, and has sometimes led to a mistaken
diagnosis of hysteria ; cases of this kind have from time to time been
reported." '
Vertigo is more characteristic of cerebellar than of cerebral tumor,
and a peculiarity of it is that it continues while the patient occupies the
recumbent position.
Iinpairnicnt of mental faculties constitutes another very important
general symptom. This is first noticed by the patient's friends, who
are grieved to find that his mind is becoming weakened. His memory
begins to fail, he loses himself in places that are most familiar to him ;
his movements become slow, awkward, and unsteady, and his face
^ American Year-Book of Medicine and Su7-gery, 1896.
INJURIES AND DISEASES OF THE HEAD. 499
assumes a vacant and listless expression. Although he may be highly-
educated, the simplest arithmetical problems are beyond him, and he
even forgets how to read and write. From this step to complete in-
sensibility is short, and he may become so helpless as to allow his
urine and feces to escape unheeded.
Eye-syinptoins are often of great value in arriving at a diagnosis.
Choked disk is pretty constant, and may be found in both eyes or
limited to one. If the latter, it may be fairly assumed that the tumor
is in the opposite hemisphere, but no idea can be formed of the size
and position of the growth. When choked disk and optic neuritis are
found coexisting in both eyes, it may be inferred that the tumor is on
the side opposite to the eye which has the most swelling. It must not
be forgotten that simple anemia may cause choked disk just as typical
as can be found in cases of cerebral tumor. Although neuritis may be
long continued, it must be regarded as a transient symptom. The
papillitis may have passed away, with the exception of remnants in the
form of spots of degeneration in the retina filling in the center of the
disk or white tissue along the line of the vessels.
Paralysis of a muscle or group of muscles about the eye is not of
special value in the diagnosis of tumor, except as corroborating other
symptoms. It is an evidence that the origin of the nerve or the nerve
itself is suffering pressure or irritation. Spasm of muscle is more
valuable as indicating that the cerebral center from which the nerve
arises, and not the triDik of the nerve, is the seat of pressure.
Hemiplegia has been observed in a number of cases, and, strange to
say, the tumor which appears to produce it may at the autopsy be
found in an indifferent area. We would naturally expect that a right-
sided hemiplegia would be associated with a tumor pressing on the
left Rolandic fissure, but in such cases the tumor has been found in the
white matter of the frontal lobes (Hirt).
Focal Symptoms. — The first of these to demand attention is hemian-
opsia. If each retina be divided into two hemispheres by a vertical
line, and it be found that the right half of each is insensible to vision, it
will also be found that objects in the left half of the visual field are not
seen. If, on the other hand, the left half of each retina is blind, it fol-
lows that objects in the right half of the visual field are not seen. This
condition is known as homonymous hemianopsia.
The great value of this symptom is, that it points to the cuneus as
the seat of the lesion, and the tumor, if such be the cause of compres-
sion, is situated on the same side as the blindness.
Aphasia. — Is the person right- or left-handed ? If left-handed,
motor aphasia is an indication that the pressure is upon Broca's area
on the right side, and if right-handed, it is upon the left side.
Sensory aphasia, or word-deafness, by which is meant the loss of
memory of the sound of a word, points to the posterior half of the
first left temporal convolution as the seat of the lesion.
Alexia, or word-blindness (the loss of memory of words as they
appear when written or printed), indicates that the tumor is situated in
the left parietal lobe and at the lower posterior portion, especially the
angular and supramarginal gyri.
Agraphia, or loss of memory of the movements necessary to con-
500 SURGICAL DIAGNOSIS AND TREATMENT.
vcy our thoufjhts in writini:^, points to a lesion either below Broca's
area or near the area which controls movements of the hand.
Paralysis. — Facial paralysis would be an indication that the lower
third of the opposite Rolandic fissure was suffering compression;
paralysis of the arm would point to the middle third ; and paralysis of
the leg, to the upper third of the fissure on the opposite side. The un-
certainty of hemiplegia as a symptom has already been noted. When
focal symptoms appear early in the disease it is an indication that the
tumor is basal, producing fatty degeneration and gray atrophy of the
involved cranial nerves (Hirt).
A tumor in the anterior fossa of the base will affect the olfactory,
the optic, the motor oculi, and the first branch of the fifth nerve.
A tumor in the middle fossa will affect the motor oculi, the pathetic,
and the chiasm if situated above the dura mater, and the ocular nerves
and the fifth if situated below the dura.
A tumor in the posterior fossa will affect the facial, the trigeminus,
the auditory, the glosso-pharyngcal, the vagus, the accessorius, and
the abducens (Hirt). In many cases it is impossible to differentiate
tumors of the posterior fossa from tumors of the cerebellum.
Diagnosis. — Although some cases present a train of symptoms
which, if properly interpreted, lead to a positive diagnosis and afford
beautiful examples of inductive reasoning, there are others in which
the most valuable symptoms are in abeyance throughout the entire
course of the disease. Headache is a leading symptom, but there are
cases in which it stands alone for months or even years, and without
the combination of other general or focal symptoms it is liable to be
regarded as obstinate hemicrania or migraine. Headache from causes
other than brain-tumor is never constant. It is relieved by ordinary
remedies, and there are remissions during which pain entirely ceases.
It is not so with cerebral tumors : once in pain, always in pain — no
remission that brings complete relief, no restful sleep, and no improve-
ment from the use of drugs.
In another class of cases vomiting and vertigo are the only symp-
toms. These two symptoms are common to so many morbid condi-
tions of the brain that if unsupported by other evidence they do not
give sufficient data for a diagnosis of tumor. They are, however, suf-
ficient to draw our attention to the possibility of a tumor, and an
exhaustive examination of the eye and other focal symptoms may
bring further evidence to light.
In still another class of cases convulsions may stand as the only
witness. The question of epilepsy must then be settled. Convulsions
of an epileptic origin generally come at intervals of considerable length,
and are more or less relieved by bromid of potassium and other reme-
dies. The convulsions of brain-tumors are persistent, and treatment is
of little or no avail. The brain-lesions which come nearest to tumors
are abscess, meningitis, and thrombosis of the lateral sinus. The onset
of tumor-symptoms is more gradual than in any of these : there is
an absence of fever and no change of temperature, except that in the
later stages it may be subnormal, and may be taken as an indication
that the end is not far off In abscess there is generally a cause which
leads up to infective inflammation and culminates in abscess. The pulse
INJURIES AND DISEASES OF THE HEAD. 50I
is increased in frequency, and the temperature is elevated during the
inflammatory stage and changed to subnormal conditions during the
existence of the abscess. Acute abscess of the brain should give rise
to no difficulty in diagnosis, but chronic abscess may in every par-
ticular so closely resemble tumor as to make a positive diagnosis
impossible. However, as pointed out by Horsley, this is not of so
much importance as might at first appear, since the skull must be
opened for the relief of either condition.
Meningitis is usually acute in its character throughout. Throm-
bosis of the lateral sinus has its tenderness along the line from the
external auditory meatus to the inion, and there is a knotty, tender
condition of the internal jugular vein.
In order to make the examination complete and exhaustive Weir
and Seguin recommend that in every suspicious case answers be ob-
tained to the following six questions: i. Is there a tumor ? 2. What
is the location of the tumor ? 3. At what depth does the tumor lie —
that is, is it cortical or subcortical ? 4. Is the tumor single or mul-
tiple ? 5. What is the size of the tumor? 6. What is the nature of
the tumor ?
In the present state of our knowledge our answers must be based
upon the following considerations :
1. Is there a tumor? The answer must be "Yes" if we find the
following symptoms or a majority of them : {a) Headache persistent
and not localized, with remissions, but never absence of pain, {li)
Localized tenderness elicited by pressure with the thumb. (' of the case shows that the several areas
have been encroached upon in their proper order.
502 SURGICAL DIAGNOSIS AND TREATMENT.
(r) The Occipital Lobe. — Hemianopsia is here a valuable symptom,
as pointing^ to the cuneus. Frontal headache, optic neuritis, optic
spectra, sometimes total blindness and widely dilated pupils, are the
leading sj-mptoms. The convulsions are generalized and accompanied
by the so-called hysteric manifestations.
{(i') The Pituitary Body. — According to Andriezen, lesions of this
body are manifested by the following symptoms : (i) Depression and
apathy ; (2) general muscular weakness ; (3) loss of fine co-ordination
equilibration; (4) generalized twitching and spasms of the muscles; (5)
subnormal temperature ; (6) wasting of the body-tissues ; (7) attacks
of dyspnea; and (8) rapid progress toward death. Woolcombe reports
a case in which all the symptoms except dyspnea and muscular
twitchings were present.'
{c) The Corpora Qnadrigcniina. — Tumors in this region are inter-
esting on account of the resemblance of their symptoms to those of
cerebellar tumors. In one case, that of a boy four years of age, double
ptosis was the first symptom, after which decided ataxia of locomotion
was developed, and of the upper limbs two weeks later. He was
drowsy, spoke slowly, presented complete double external ophthalmo-
plegia, lateral nystagmus, and blindness, but no optic neuritis or cho-
roiditis. He died six months after the first symptoms appeared. The
autopsy showed the corpora quadrigemina gray and gelatinous in
appearance, the result of glio-sarcomatous infiltration.^
3. At what depth does the tumor lie — that is, is it cortical or subcorti-
cal? This question is more easily asked than answered. In cortical
tumor there is usually an absence of anesthesia, the number of centers
pressed upon is not so great, and the focal symptoms are more sharply
defined. Local pressure by the thumb may possibly elicit tenderness,
and there may be a rise of temperature. We must admit that our
knowledge on this point is very limited, and when we undertake an
operation for the removal of brain-tumor we have to take chances as
regards its depth.
4. Is the tumor single or multiple ? The answer must rest upon the
precision of the focal symptoms. If only one area suffers pressure, the
tumor is single and probably small. If several areas far apart show
symptoms of pressure, there are several tumors or one very large
tumor.
5. What is the siae of the tumor? Here, again, the focal symptoms
must be our guide. The size of the tumor is probably in proportion
to the number and extent of the areas pressed upon.
6. What is the nature of the tumor ? Statistics are of some value in
answering this question. Before twenty years of age tuberculosis is
more frequent than any other disease. If the patient has suffered from
cancer of the breast, lung, or pleura, the brain-tumor is also probably
cancerous ; cases of this kind are of course beyond our help. Syphi-
litic gumma may be diagnosticated if the patient shows a history of
syphilis in other parts of his body. As in syphilis elsewhere, we can
always fall back upon therapeutics as an aid to diagnosis, and, putting
the patient upon antisyphilitic treatment, watch the result. If, after
pushing the iodid for six weeks, and increasing the dose until it reaches
^ Ann. of Med. Sciences, 1895, vol ii. p. 39, A. ^ Op. cit., p. 40, A.
INJURIES AND DISEASES OF THE HEAD. 5 03
half an ounce a day, there be no improvement, it will then be proper to
attempt the removal of the tumor by operation.
Prognosis. — The life of a person suffering from a tumor of the brain
(except those which are gummatous and yield to syphilitic treatment)
is practically without hope. The symptoms are steadily progressive,
and if left to Nature the only result is death. The duration of the dis-
ease varies greatly, and the wiseacre who is in the habit of setting dates
for his patients to die is likely to prove a false prophet. Roughly
speaking, the disease proves fatal at the end of one or two years, but
sudden death may occur at any time, as is peculiarly the case in brain-
lesions.
Treatment. — Except for syphilitic gummata, no medicinal treatment
affords the slightest hope of cure. Operation for the removal of the
neoplasm holds out the only hope in the majority of cases, for, although
the percentage of complete recoveries is not large, every case that lives
is a life saved. Not more than 10 to 14 per cent, of all cases of brain-
tumors are so situated as to warrant surgical interference. In 5 to 7
per cent, the neoplasm can be removed ; in an equal number benefit
may be obtained by relieving pressure. A great deal of skill and judg-
ment is necessary to decide upon the propriety of operating in any
given case, and the decision must not be hastily arrived at. The ope-
ration is practically the same as that described for abscess of the
brain.
Tumors of the Cerebellum. — The early symptoms of tumors of
the cerebellum are almost identical with those attending growths in
the cerebrum, except that they come on more rapidly. Headache is
severe, and, although it may be confined to the occipital, it is frequently
felt in the frontal, temporal, or parietal region. Vertigo, vomiting, con-
vulsions, and optic neuritis develop much more rapidly than in cerebral
tumors. Later, there are developed local symptoms which are very
characteristic — viz. cerebellar ataxia and the staggering gait. When
the staggering gait is observed, it indicates that the middle lobe of the
cerebellum is the seat of a lesion or is suffering pressure from sur-
rounding parts. If the symptoms appear early in the disease, we may
assume that the tumor began in the middle lobe ; if it comes on late in
the disease, the assumption is that the tumor had its beginning in one
hemisphere, and grew to such an extent as to exert pressure on the middle
lobe. In a case reported by Crafts the tumor began in the hemisphere,
and remained latent until it encroached upon the middle lobe, when
symptoms suddenly supervened, and death followed at the end of three
months. In a large number of cases it has been observed that the
patient staggers away from the side on which the tumor is situated.
In 20 cases in which staggering to one side was a prominent and con-
stant symptom, 16 staggered away from the side of the lesion and 4
toward the side of the lesion (Starr). According to Dr. Risien Russell,
the deep reflexes may afford valuable diagnostic data. He has proved
that in cerebral tumor the deep reflexes are exaggerated on the opposite
side, but in cerebellar on the same side as the tumor. Other authori-
ties place no value on the reflexes. The cranial nerve-affections, such
as strabismus, facial or Ungual paresis, etc., should be carefully studied.
The symptoms appear on the same side as the tumor. Paralysis of
504 SUKGICA]. DIAGNOSIS AND TREATMENT.
muscles about the eye is useful as a diagnostic point between tumor of
the corpora quadrigemina and tumor of the cerebellum.
If the ocular paralysis precedes the ataxic symptoms, the tumor is
in the corpora quadrigemina ; if the ataxic symptoms come first, the
tumor is in the cerebellum (Bruns).
TnatJiicNt. — The cerebellum is not within easy reach, as only one of
its three surfaces is in contact with the skull, nor is it possible to tell
whether a given tumor is near that surface or in a more remote and
inaccessible part. For these reasons operations for the removal of
cerebellar tumors are even less encouraging than operations on the
cerebrum.
X. EPILEPSY.
It has long been recognized that wounds and injuries of the head
are, in a certain proportion of cases, followed by epilepsy. In the
Franco-Prussian War, of 8985 individuals wounded on the head, 46
were afterward afflicted with epilepsy, while of 77,461 persons wounded
in the body or extremities, only 17 became epileptic.
This liability to epilepsy is one reason why scalp wounds, fractures,
and other head-injuries should receive the most careful treatment at
the outset. It is much easier to remove a depressed spiculum of bone
shortly after the accident than to cure an epilepsy which, as a result of
the depression, comes on months and years afterward.
In examining a patient suffering from epilepsy we must keep before
our minds the following varieties of the disease :
1. IdiopatJiic Epilepsy. — This is the ordinary disease as met with in
medical practice. It has no assignable cause, and its nature has never
been discovered. Patients suffering from this form of the disease are
suddenly seized with a fit ; they can give no warning, except perhaps a
faint cry ; they lose consciousness immediately, and fall down in con-
vulsions which are general, first of a tonic and then of a clonic cha-
racter. These movements last for several minutes, and then the patient
falls asleep, to awake in a worn and exhausted condition.
2. Jacksoniaii Epilepsy. — Dr. Hughlings Jackson as far back as 1864
recognized a class of epileptics in whom the convulsions began with a
conscious sensation in some definite part of the body, either one-half
of the face or one of the extremities. The sensation or aura is followed
by convulsive movements of the muscles of the part ; the patient, as a
rule, retains consciousness throughout, except when the convulsion
becomes general. Although Jackson's observations were made long
before the question of cerebral localization had received much light, he
positively affirmed that the parts of the brain affected in epilepsy of
this type were the convolutions on either side of the fissure of Rolando.
Cerebral localization has proved that he was correct. It is not un-
common to find this convulsion beginning in the face, thence spreading
to the arm, and lastly to the leg, indicating that the organic lesion is
producing irritation in the lower, middle, and upper thirds of the fissure
of Rolando consecutively.
The convulsion in Jacksonian epilepsy begins in four different ways :
id) The motor form, ]\x'sX mentioned, begins with disturbance in the
motor area, and the aura is felt in the face, the arm, the leg, etc.
INJURIES AND DISEASES OF THE HEAD. 505
{b) The Sc?isojy Form. — In this variety one of the special senses is
the seat of the aura. If a warning of an impending convulsion comes
to the patient as a sound, the affected area is in the temporal region ;
if as a perversion of taste or smell, the temporo-sphenoidal region ;
and if as an hallucination of vision, the occipital region is the part
affected.
ic) The Aphasic Form. — In one class of cases the convulsion begins
with spasm in one side of the face, immediately followed by loss of the
power of speech. This may be the one symptom noted in the whole
attack. In a right-handed person this would point to a lesion in the
third frontal convolution in the left hemisphere, and in left-handed per-
sons to a lesion in the corresponding area in the right side.
{d^ The Psychical Form. — In this form there is no convulsion. The
patient suffers a temporary aberration of mind. He becomes maniacal
or simply bewildered and stupid, and afterward has no recollection of
what occurred during the attack. In this class of cases the lesion is in
the frontal lobes.
The interesting feature in regard to epilepsy is that a large number
of cases result from injuries. A spiculum of bone, a dense cicatrix, a
depressed fracture, and a clot of blood resulting in a cyst are causes
which are within the surgeon's power to remove, while the ordinary
type of general epilepsy is beyond surgical aid.
Epilepsy resulting from traumatism is usually long delayed, the first
convulsions coming on weeks, months, or even years after the injury.
The fits at first are mild and less frequent than they are at a later stage,
when the disease is fully developed.
In examining a patient for epilepsy the history requires the closest
attention ; the minutest details of the accident, notwithstanding it may
have happened years before, must be thoroughly revived. To examine
the head for scars and depressions the scalp must be shaved. The cha-
racter of the convulsions must not be received from the patient's friends,
as they are usually unable to describe accurately what took place during
a convulsion, their minds having been occupied in the care of the patient.
When possible, the surgeon himself should observ^e one of these fits,
or at least have the evidence of a trustworthy nurse. Care should be
taken to ascertain the part in which the aura begins, the muscles first
affected, and the order in which the several areas are attacked. Thus
an aura beginning in the leg, followed by twitching of the extremity,
then twitching of the arm of the same side, and finally twitching of
the muscles of the face and of speech, would indicate that the irrita-
tion began in the upper third of the Rolandic area, and travelled
downward to the lower end and in front of the fissure.
Having studied the character of the fits, the muscles involved, and
the area of the brain which is the seat of the disturbance, the question
of operation is to be considered.
Be it remembered that the number of cases of epilepsy suitable for
operation is comparatively small. Starr carefully observed 427 con-
secutive cases, and came to the conclusion that 26 were " of organic
origin and suitable for operation, because it was possible to locate the
lesion with approximate certainty." The following rules may serve as
a cruide in the selection of cases :
506 SURGICAL DIAGNOSIS AND TREATMENT.
1. Cases of ordinary general epilepsy in which the lesion cannot be
definitely located are not operable.
2. In traumatic epilepsy, when the focal symptoms point to a definite
locality in the brain and the scar or other injury correspond, the trephine
opening should be made at the position of the scar.
3. When the focal symptoms do not correspond with the scar, the
position of the scar should be disregarded, and the opening made at the
point indicated by the focalizing symptoms, unless it be found that the
scar itself is very sensitive, and that simple pressure upon it is sufficient
to bring on a fit. In this case the scar only should be excised and the
result watched.
4. In epilepsy of a general type following depressed fracture, but in
which localizing .symptoms are absent, the trephine opening should be
made at the seat of the fracture.
Treatment. — The operation of trephining for epilepsy is conducted
in the manner already described. On reaching the dura mater the
membrane should be carefully inspected and incised for the purpose of
examining the brain. Should scars be found upon either the dura or
the brain, the whole of the scar-tissue must be removed — down to the
white matter if necessary. When it is necessary to remove a part of
the dura mater, its place should be supplied by a piece of the pericranium
of equal size, with the view of preventing hernia cerebri.
CHAPTER IX.
INJURIES, DISEASES, AND DEFORMITIES OF THE SPINE.
Surgical Anatomy. — The spinal column is composed of thirty-
three vertebrje, of which seven are cervical, twelve dorsal, five lumbar,
and nine are united to form the sacrum and coccyx. From the posterior
aspect of each vertebra is given off a bony arch which forms a canal
for the spinal cord. The bodies of the vertebrae, resting upon one
another, must necessarily be strongly supported in order to give
strength and security to the trunk. This support is secured (i) by
ligaments as follows : the anterior common ligament, the posterior
common ligament, and the ligamenta subflava ; (2) by five layers of
muscles ; (3) by articulations with the ribs in the dorsal region. The
normal curves of the spine are produced by variations in thickness of
the bodies of the vertebrae. There are three of these curves, all of
Avhich are antero-posterior. The cervical curve is convex in front, the
dorsal convex behind, and the lumbar convex in front. The spinal
cord in its passage through the spinal canal is well protected by its
membranes, by cerebro-spinal fluid, and loose connective tissue, which
latter contains a plexus of veins. These structures lie in the following
order from within outward : The pia mater with its vascular network
closely embraces the cord itself Next comes the arachnoid, between
which and the pia mater is the subarachnoid space containing the
INJURIES, DISEASES, AND DEFORMITIES OF THE SPINE. 507
cerebro-spinal fluid. The dura mater is the outermost membrane ;
the subdural space separates it from the arachnoid.
The cord is steadied by the spinal nerves as they pass through the
intervertebral foramina by the cerebro-spinal fluid and by the liga-
mentum denticulatum.
A practical point, which must be borne in mind, is that each nerve
after emerging from the spinal cord does not immediately pass out
through an intervertebral foramen, but runs down the cord for a variable
distance, and makes its exit through a foramen lower down. Thus the
eighth cervical nerve arises from the space between the fifth and sixth
cervical vertebrae, and passes out through the foramen below the spine
of the seventh cervical vertebra.
Bxamination of the Spine. — The patient should have all clothing
removed to the waist, and should stand erect, with the heels together,
the arms hanging down by the sides, and the eyes looking forward.
Infants should be examined in the sitting position. The following
questions can then be answered:
I. Is then- dcfonuity ? The natural curves of the spine may be
increased or diminished or the whole spine may be arched backward in
one great curve. This is a sign of debility. It is suspicious of rickets,
and when in conjunction with it we find swelling of the extremities of
the long bones and the fontanelles unclosed, we may call the case
rachitic spine. The spine may be sharply curved backward, as in
Pott's disease, or the vertebrae may be rotated one upon the others.
Rotation is determined by comparing the prominence of the angles of
the ribs, the lumbar transverse processes, the height and prominence
of the scapula, and the iliac crests. The patient is then viewed from
the front, and it is noted whether one breast is more prominent than
the other or whether there is flattening of the chest on one side. The
patient should now be asked to bend forward while he keeps the knees
straight. Standing behind him, you will be able to determine the free-
dom of movement of the spine and the presence or absence of rigidity
at any part. Rigidity of the muscles, or stiffness, is one of the earliest
indications of Pott's disease. The tips of the spines are next examined
by passing the fingers over them, when any irregularity or abnormal
prominence or lateral curvature can be noted. 2. Is there tendeniess
at any point? This can be elicited by passing the finger over the
spinal processes. If tenderness is felt at any spot, the skin should then
be pressed lightly or pinched up without pressing it against the bone.
If pain is still complained of, it is an indication of hysterical spine.
Tenderness can also be sought for by pressing downward upon the
spine, the hands of the surgeon being placed upon the head or upon
the shoulders of the patient according as the cervical or lower parts of
the spine are being examined. This method, however, must be used
with great caution, the pressure being at first very gentle and cau-
tiously increased. Rough pressure may prove very injurious in cases
of caries of the vertebrae, and cannot be too severely condemned. 3.
Is tliere pain / Many cases of spinal disease are attended with very
little pain. Sometimes it is felt in the spine itself, but much more fre-
quently the pain is felt in front, at the extremities of the nerves, and
gives the sense of constriction. Such pains are sometimes spoken of
508 SURGICAL DIAGNOSIS AND TREATMENT.
as " girdle pains." 4. Is movcnicnt restricted? The patient should
be asked to bend forward, backward, and from side to side. He
should pick objects from the floor, should walk, run, and jump from a
stool or chair. During these exercises it must be noted whether the
patient complains of pain or stiffness or tries to save his spine by
causing the arms or shoulders to bear his weight.
Injuries of the Spine.
Sprains. — Sprains of the back are very common injuries, and
occur with all degrees of severity. Violent exertion, as in lifting heavy
bodies, may cause injuries of the muscles alone, resulting in a stiffness
of the back and a local tenderness which soon pass off.
In more severe injuries the ligaments of the spine may be over-
stretched or torn, and in the case of the ligamenta subflava the rupture
may be attended with hemorrhage, resulting in paralysis. The bones
may be injured, the vertebrae separated from the intervertebral sub-
stance, and the cord itself may suffer.
Symptoms. — These will depend upon the extent of the injur}'. There
is usually more or less shock, pain, tenderness, and svvelling ; ecchy-
mosis is slow in making its appearance on account of the thickness of
the skin. In some cases a considerable quantity of blood is poured
out, forming a hematoma, which if not absorbed may require incision.
In severe cases it may be a difficult point to decide whether the spine is
fractured or not. The degree of paralysis will have to settle the ques-
tion. In severe sprains or contusions, as when a man falls across a
beam or iron bar and has his body forcibly doubled up, the lower limbs
may be more or less paralyzed, but the paralysis is never so complete
as that which results from fracture.
A rigidity of the muscles is usually a prominent symptom, and in
medico-legal cases plays an important part, owing to its resemblance
to Pott's disease. When the injury is unilateral the rigidity will be
confined to the injured side — a condition which cannot be simulated.
Treatment. — Shock, if present, must be relieved by stimulants, mor-
phin, or hot applications, after which absolute rest constitutes the
principal treatment. Friction and massage are very valuable in re-
ducing swelling and promoting absorption, and strapping the back
with broad bands of adhesive plaster extending around two-thirds of
the body will afford great relief
** Railway Spine." — The peculiar circumstances attending rail-
way accidents, and the frequency with which such injuries are the
subject of litigation, give them special interest to the surgeon. A
person whose back is injured in a railway accident may sustain any
degree of injury from simple strain or contusion of the muscles to
laceration of the ligaments or fracture of the spine, but additional
elements come into the case by reason of the fright and shock which
attend the accident. The passenger may be roughly awakened from
sleep by the catastrophe. The screams of his fellow-passengers, the
sight of dead and mangled bodies, the horrible sensation of being held
down by portions of the wreck, and, to crown all, the outbreak of fire,
which he feels will surely reach him before he can be extricated, produce
INJURIES, DISEASES, AND DEFORMITIES OF THE SPINE. 509
impressions on his mind which last for weeks and months and add a
neurotic element to the traumatism. Long after the injury has had time
to heal the patient complains of vague pains or pains that exist only
in his imagination. There are tender spots, lameness and weakness of
the back, inability to incline the body from one side to the other or
to move the shoulders. Numbness and tingling in the lower limbs are
frequently complained of, as also is anesthesia or hyperesthesia. The
skin is moist, or in some cases bathed in profuse perspiration, while the
kidneys act freely, compelling the patient to get up several times in the
night. The eyesight is affected, according to the patient's story, al-
though no changes in the retina or other parts of the eye can be found
to account for these subjective symptoms.
The mental condition is more or less affected. The patient is nervous
and incapable of concentrating his attention upon his business or any-
thing that requires continuous volition. He becomes despondent and
gloomy, looking forward without hope and filled with the idea that ruin
stares him in the face.
These are the cases that bring out two types of expert witnesses,
one side swearing that the man is seriously injured and permanently
disabled, the other side testifying that the symptoms are fraudulent and
only assumed for the purpose of mulcting the railway company. The
examination of such patients must be conducted with great care, and,
while it is necessary to be guarded against so-called " litigation symp-
toms," fairness and justice demand that all real symptoms should carry
due weight. The following suggestions may be of value :
1. Do not rely upon a single symptom, but weigh all the symptoms.
2. Study the manner of the patient, and test his truthfulness or
studied attempts to exaggerate his complaints.
3. Exclude all pains the existence of which cannot be confirmed by
any physical evidence, and which rest wholly upon the unsupported
statements of the patient (Dercum).
4. Admit all pains the signs of which are evoked without any
previous warning or suggestion (Dercum).
5. Pay especial attention to every symptom which is beyond the
control of the patient, as temperature, deformity, persistent rigidity of
muscles, vomiting, sweating, bloody urine, etc.
For estimating the value of pain as a symptom Dercum recommends
a method of examination which is often of great value. The superficial
tender spots are tested by injecting at one of the painful areas either
cocain or, as suggested by Keen, simple cold water. If the pain is
genuine, the injection relieves that particular spot, while the others
remain tender.
Deep-seated pain is most likely to occur at the position of the
injury, is more slowly developed, and is not attended with hyper-
esthesia, while superficial pain is often hyperesthetic and may occur at
points remote from the seat of the traumatism. Pressure upon one
part of the body while the patient's attention is directed to another is
often sufficient to detect fraud. Disease in the vertebrae or interverte-
bral substances can be detected by pressure upon the head or shoulders
transmitted through the spine. Percussion with an ordiiiary plex-
imeter is useful, for through its aid tenderness in bone can be elicited
5IO SURGICAL DIAGNOSIS AXD TREATMENT.
by blows upon the soft parts which are otherwise painless. When
spasm of the muscles is excited by percussion it is a valuable sign, as
no amount of practice on the part of the malingerer will enable him to
imitate it. h'raudulent persons are sometimes detected by the use of a
battery, as shown by Keen, one electrode being applied in the ordinary
way, while the cord of the other is concealed in the hand and discon-
nected. If the patient complains of pain, we may know he is dis-
honest.
Treatment. — The traumatic lesions require treatment on general
principles — viz. rest, support to the spine, etc. The neurotic element is
more difficult to manage. From the very first the aim of the surgeon
should be to prevent the patient from falling into the condition of
hypochondriasis. If financial compensation is expected, it is advisable
to have the matter settled as soon as possible, a prompt settlement
being better for the patient than living in suspense, even if there is a
prospect of obtaining a large amount. The idea of permanent inability
to work should be prevented, and the patient urged to resume his
employment as soon as possible.
Concussion of the spinal cord is a condition which probably
never occurs, owing to the effective manner in which the cord is pro-
tected and steadied in the spinal canal. When injuries of the cord
arise to which the term " concussion " seems applicable, the accident is
probably a capillary hemorrhage, a laceration of the cord, or a vaso-
motor disturbance with exudation of serum.
The syviptoms of so-called concussion are those of shock — viz.
pallor, nausea and vomiting, syncope, cold perspiration, etc. The
symptoms which point to the spine as the cause of the shock are
numbness, tingling or even paralysis of the upper or lower limbs, and
constriction of the chest. The treatment is absolute rest.
Compression of the spinal cord may arise from three different
sources :
1. Dislocation of a vertebra, or a fracture in which a fragment is
driven in upon the cord. In cases of this kind the symptoms come on
immediately after the accident.
2. Hemorrhage. — The blood may be poured out from the vessels
in the substance of the medulla, from the vessels lying between the
medulla and its membranes, or from the plexus of veins which lie
between the dura mater and the spinal canal. Hence there are three
varieties of spinal hemorrhage :
{a) Intra-medullary {Hemato-myeliei). — This form is recognized by
its sudden onset and by a history of an injury or of disease in which
there are marked changes in the blood. There are pain, rigidity,
spasms, and paralysis. The pain is referred to the back and encircles
the body as the so-called " girdle pain." The reflexes connected with
the affected area are diminished or entirely lost. The symptoms are
bilateral, are developed rapidly, and usually end fatally. Among the
most distressing accompaniments are bed-sores, retention of urine, and
incontinence of feces.
{b) Extra-meelnllary {Hemato-raehis). — In this form of hemorrhage
the pain is sudden, severe, and referred to the back. The symptoms
are pain, tingling, and hyperesthesia along the course of the nerves
INJURIES, DISEASES, AND DEFORMITIES OF THE SPINE. 51I
which have their origin near the seat of the extravasation, and paraly-
sis more or less marked, but seldom complete. Convulsions are not
uncommon, and there is frequently retention of urine.
Treatment. — The first principle of treatment is absolute rest. In
the way of drugs iodid of potassium and mercury have been relied
upon. The question of operating upon such cases is receiving atten-
tion. If the hemorrhage is low down in the spinal column and extra-
medullary, an operation should be considered. If also there be rapidly
advancing paralysis extending upward to the more vital centers, opera-
tion affords the only hope.
3. Meningitis and Effusion of Lymph causing- Compression. —
This is most frequently met with as a complication of Pott's disease. It
is a pachymeningitis, and its most distinguishing characteristic is that the
symptoms of paralysis appear from one to eight weeks after the first
appearance of meningitis.
Wounds of the Back. — While wounds of the back are commonly
flesh wounds, it occasionally happens that the penetrating instrument
enters the chest, the abdomen, or the spinal cord. Hence wounds in
this position should be examined with special care. The injuries to be
sought for are the following: (i) If in the cervical region, the vertebral
artery may be wounded and may result in a false aneurysm. To dis-
tinguish this from a wound of the carotid is often exceedingly difficult,
and several cases are on record in which the carotid was tied by mis-
take. The diagnosis can be settled by exposing the carotid sufficiently
to ascertain its relation to the aneurysm or by passing the ligature
around it, noticing the effect of constriction before tying. The thyroid
or occipital artery may also be wounded. (2) The cavity of the pleura
may be penetrated. This accident is recognized by air passing in and
out of the wound with each respiratory movement. (3) The wound
may penetrate the abdominal cavity, in which case the symptoms will
be those of wounds of the special organs involved.
(4) The spinal cord may be invoh^ed. The danger of injur}- to the
cord is greatest when the direction of the wound is from below upward,
the instrument passing between the spinous processes, the laminae, or
the transverse processes. This occurs most readily in the cervical
region, owing to the more horizontal direction of, and the greater space
between, the spinous processes. The penetrating instrument may
wound the bone, the membrane, or the cord itself A wound of the
bones alone would present no special symptom. A wound of the
membranes would be recognized by the escape of cerebro-spinal fluid.
A wound of the cord itself would produce paralysis, depending in its
extent upon the structures divided. If the entire thickness of the
cord is divided, complete paralysis, both of motion and sensation, is
the inevitable result. If only one side is divided, crossed paralysis will
follow — namely, paralysis of motion on the same side as the injury,
and paralysis of sensation on the opposite side. Later symptoms of
injury of the cord are paralysis of the bladder leading to retention of
urine, paralysis of the bowels resulting in incontinence of feces, and
trophic changes producing bed-sores.
Treatinoit. — Hemorrhage is not usually a marked symptom. When
a vessel of any size is wounded, the external opening should be enlarged
512 SURGICAL DIAGNOSIS A AW TREATMENT.
and the divided ends of the vessel secured by ligature. Wounds of the
aorta and vena cava are of course rapidly fatal. The wound must be
treated on general antiseptic principles, and fragments of bone or foreign
body pressing upon the cord must be removed ; the bladder and bowels
should receive close attention. The result will depend upon the extent
of the injury to the spinal cord.
Fractures of the Spine. — Injuries of the spinal column, like
those of the cranium, receive their importance from the delicate
nature of the contents of the strong bony canal. Fractures of the
vertebrre are serious injuries, because the risk of compression, lacera-
tion, or contusion of the cord is great and the results of such injury
are far-reaching. In the clinical picture of fracture of the spine the
salient points are paralysis of motion and sensation, loss of control
of the bladder and rectum, bed-sores, and a condition of utter help-
lessness.
Causes. — Falls from scaffoldings, bridges, or buildings, the caving-in
of tunnels or embankments, and the general smash-up attending rail-
way accidents are the common causes of fracture of the spine. A large
proportion of cases occur when the body falls and in striking the ground
assumes the position of forced flexion, the force being sufficient to crush
the bodies of the vertebrae. It is seldom that the fracture is uncom-
plicated. The force which breaks or crushes the bones lacerates the
ligaments and muscles, and produces hemorrhage of the spinal cord.
The part of the column above the fracture is usually dislocated forward,
compressing the spinal cord, or a fragment of bone may be driven into
the cord.
Symptoms. — When the fracture is compound the fragments may be
felt by the disinfected finger or by a probe. A case of fracture of the
vertebrae comes under our notice under circumstances more or less like
the following : A man falls from a ladder or is caught by a " cave-in,"
or is driving under a low arch which catches and doubles him up. He
lies still, is in great pain, and cannot bear to be moved ; there is more
or less paralysis of motion or sensation, or both. The seat of the injury
is painful to touch, and there may be evidence of displacement of the
bodies of the vertebrae or of their spinous processes. Later there is
evidence that the bladder and rectum are paralyzed. These symptoms
are, in the main, common to all fractures of the spine. They vary
according to the part of the spinal column which is affected, and to
arrive at an exact diagnosis we must divide fractures of the spine into
those occurring in the following sections :
First Section, tJie Three Loiuer Liiinhar Vertebrce. — We may set it
down as a rule that the higher the point at which the fracture occurs
the more marked are the symptoms and the more serious the conse-
quences. Fracture of the three lower lumbar vertebrae is below the
end of the cord, which terminates at the level of the second lumbar
vertebra. The cauda equina is, however, in the way of being injured,
but, as its fibers slip easily over one another, it is possible for them to
escape. In this event the fracture may be free from serious symptoms.
It is probable that many fractures in this locality have been diagnosed
as sprains of the back and treated accordingly, complete restoration of
function giving color to the assumption that the diagnosis was correct.
INJURIES, DISEASES, AND DEFORMITIES OF THE SPINE. 513
When the nerves are injured there is more or less paralysis of the parts
which they supply.
Second Scctio?i, between the Second Lnnibar and the Tenth Dorsal
Vei'tcbrcB. — From this portion of the spine proceed the nerves which
form the lumbar and sacral plexuses. The leading feature of fracture
in this section is, consequently, paralysis of the parts to which these
nerves are distributed. The lower limbs are palsied, the bladder loses
its power of expulsion, the bowels act involuntarily, and bed-sores are
inevitable. The average duration of life under these circumstances is
from six months to two years.
Third Section, the Dorsal Vcrtebm. — In addition to the symptoms
just enumerated, fracture between the tenth and second dorsal verte-
brae is attended with paralysis of the abdominal muscles and the lower
chest muscles. There are tympanites and great abdominal distention
from collections of gas. Respiration is interfered with, and owing to
the difficulty of expelling mucus from the bronchi and air-ves;cles,
hypostatic congestion and pneumonia are common complications and
may prove to be causes of death.
Fonrth Section, the Cer7'ical and Cervico-dorsal Regions. — When the
first or second dorsal vertebra is the seat of injury, only a portion of
the brachial plexus is involved ; consequently, paralysis of the upper
extremity is incomplete. If the fracture is in the lower cervical region,
the whole plexus is involved, and paralysis of the arms is necessarily
complete, both as regards sensation and motion. The respiration is
diaphragmatic ; breathing is interfered with, especially expiration, and
the voice is weak or wholly lost. In some of these cases the tempera-
ture rises to a remarkable degree — 108°, 110°, or 112° F. ; in one case
recorded by Teale it was 122°, and yet the patient recovered.
In the upper cervical region the fifth and sixth vertebrae are the
most likely to be fractured. Death may be instantaneous, owing to
paralysis of the nerve-center of respiration in the medulla oblongata or
injury to the phrenic nerve.
Fifth Section, the Atlas and Axis. — Fracture in this section is almost
certainly fatal, yet the patient lives, in a majority of the cases, from a
few hours to two weeks. Exceptional cases are on record in which
life was prolonged — in one case for fifteen months (Shaw), and in an-
other case for fourteen years (Hilton). The injury being in close rela-
tion with the medulla oblongata, and above the origin of the phrenic
nerve, respiration is naturally most dangerously interfered with.
There must, of necessity, be great difficulty in distinguishing this
accident from dislocation of the bones, and in some instances it is
impossible to settle the question except by a post-mortem examination.
Crepitus is the only symptom which can be considered of value, and it
is not advisable to search too diligently for it. Stiffness and rigidity of
the muscles of the neck, pain at the seat of injury, and paralysis of
everything below the fracture are the signs usually present and are
common to both dislocation and fracture.
Diagnosis of the Exact Position of the Fracture. — When there is suf-
ficient displacement to produce a deformity of the spine, or in the
exceptional cases in which crepitus can be detected, or in compound
fracture in which the finger or probe can be used to secure accurate
33
514
SURGICAL DIAGNOSIS AND TREATMENT.
information, there is no difficulty in localizing the seat of fracture. In
many cases, however, these evidences are wanting, and we have to
arri\'e at a diagnosis of the level of the fracture by the three following
methods :
I . /)')' Dctcrviiiniig the Extent of the Motor Paralysis. — In working
out the data afforded by this method the following table, from Keen's
article on " Fractures of the Spine," in Dennis's System of- Surgery,
will be found useful. The table is founded on one devised by M. Allen
Starr and elaborated by Mills :
Localization of the Functions of the Segments of the Spinal Cord.
Segment.
Muscles.
Reflex.
Sterno-mastoid.
Hypochottdrmtn (third
Trapezius.
to fourth cervical).
Second and
third! cervical.
Scaleni and neck.
Diaphragm.
Sudden inspiration
produced by sudden
pressure beneath the
lower border of ribs.
Diaphragm.
Papillary (fourth cervi-
Deltoid.
cal to second dorsal).
Biceps.
Dilatation of the pupil
Fourth cervi-
Coraco-brachialis.
produced by irritation
cal.
Supinator longus.
Rhomboid.
Supra- and infra-spi-
natus.
of neck.
' Deltoid.
Scapular (fifth cervical
Biceps.
to first dorsal). Irri-
Coraco-brachialis.
tation of skin over the
Brachialis anticus.
scapula produces con-
Supinator longus.
traction of scapular
Supinator brevis.
muscles.
Fifth cervical. -
Deep muscle of shoul-
Supinator longus { fourth
der-blade.
to fifth cervical). Tap-
Rhomboid.
ping the tendon of the
Teres minor.
supinator longus pro-
Pectoralis (clavicular
duces flexion of fore-
part).
arm.
Serratus magnus.
Sixth cervical. -
Seventh cervi-
cal.
Biceps.
Brachialis anticus.
Subscapular.
Pectoralis (clavicular
part).
Serratus magnus.
Triceps.
Extensors of wrist and
fingers.
Pronators.
' Triceps (long head).
Extensors of wrists
and fingers.
Pronators of wrist.
Flexors of wrist.
Subscapular.
Pectoralis (costal part).
Serratus magnus.
Latissimus dorsi.
Teres major.
Triceps (sixth to seventh
cervical). Tapping
elbow - tendon pro-
duces extension of
forearm.
Posterior wrist (sixth
to eighth cervical).
Tapping tendons
causes extension of
hand.
Anterior ii>rist (seventh
to eighth cervical).
Tapping anterior ten-
don causes flexion of
hand.
Palmar (seventh cervi-
cal to first dorsal).
Stroking palm causes
closure of fingers.
Sensation.
Back of neck and of
head to vertex (oc-
cipitalis major, oc-
cipitalis minor, au-
ricularis magnus,
superficialis colli, and
supraclavicular).
Neck.
Shoulder, anterior sur-
face.
Outer arm (supracla-
vicular, circumflex,
musculo-cutaneous,or
external cutaneous).
Back of shoulder and
arm.
Outer side of arm and
forearm to wrist (su-
praclavicular, circum-
flex, musculo-cuta-
neous or external
cutaneous, internal
cutaneous, radial).
Outer side and front of
forearm.
Back of hand, radial
distribution (chiefly
musculo-cutaneous or
external cutaneous,
internal cutaneous).
Radial distribution in
the hand.
Median distribution in
the palm, thumb, in-
dex, and one-half
middle finger. (Mus-
culo-cutaneous or ex-
ternal cutaneous, in-
ternal cutaneous,
radial, median.)
INJURIES, DISEASES, AND DEFORMITIES OF THE SPINE. 515
Segment.
Eighth cervi
cal.
First dorsal.
Second dorsal.
Second to
twelfth dorsal.
First lumbar.
Second lumbar.
Third lumbar.
Fourth lumbar.
Fifth lumbar.
First and
second sacral.
Third, fourth,
and fifth sac-
ral.
Fifth sacral
and coccygeal.
Muscles.
' Triceps (long head).
Flexors of wrist and
fingers.
Intrinsic hand - mus-
cles.
[ Extensors of thumb.
Intrinsic hand - mus-
I cles.
\ Thenar and hypo-
I thenar muscles.
I
Reflex.
Muscles of back and
abdomen.
Erectores spinae.
I
C Ilio-psoas.
Rectus.
Sartorius.
Ilio-psoas.
Sartorius.
Quadriceps femoris.
Quadriceps femoris.
Anterior part of bi-
ceps.
Inward rotators of
thigh.
Abductors of thigh.
Abductors of thigh.
Adductors of thigh.
Flexors of knee.
Tibialis anticus.
Peroneus longus.
Outward rotators of
thigh.
Flexors of knee.
Flexors of ankle.
Peronei.
Extensors of toes.
Flexors of ankles.
Extensors of ankles.
Long flexor of toes.
Intrinsic foot-muscles.
Gluteus maximus.
Perineal.
Muscles of bladder,
rectum, and exter-
nal genitals.
Coccvgeus muscles.
Epigastric (fourth to
seventh dorsal). Tick-
ling mammary region
causes retraction of
the epigastrium.
Abdotninal (seventh to
eleventh dorsal ) .
Stroking side of ab-
domen causes retrac-
tion of belly.
Cremasteric (first to
third lumbar). Strok-
ing inner thigh causes
retraction of testicle.
Patellar (third to fourth
lumbar). Striking
patellar tendon causes
extension of leg.
Gluteal (fourth to fifth
lumbar). Stroking
buttock causes dimp-
ling in fold of but-
tock.
Achilles tendon (fifth to
first sacral). Over-
extension causes rapid
flexion of ankle, called
ankle-clonus.
Plantar (fifth lumbar to
second sacral). Tick-
ling sole of foot
causes flexion of toes
and retraction of leg.
Vesical centers.
Anal centers.
Sensation.
Ulnar area of hand,
back, and palm, inner
border of forearm.
(Internal cutaneous,
ulnar.)
Chiefly inner side of
forearm and arm to
near the axilla (chiefly
internal cutaneous
and nerve of Wris-
berg or lesser internal
cutaneous).
Inner side of arm near
and in axilla (inter-
costo-humeral.)
Skin of chest and abdo-
men, in bands run-
ning around and
downward, corre-
sponding to spinal
nerves.
Upper gluteal region
( intercostals and dor-
sal posterior nerves).
Skin over groin and
front of scrotum
(ilio-hypogastric, ilio-
inguinal).
Outer side of thigh
(genito-crural, exter-
nal cutaneous).
Front of thigh (middle
cutaneous, internal
cutaneous, long saph-
enous, obturator).
Inner side of thigh, leg,
and foot (internal cu-
taneous, long saph-
enous, obturator).
Back and outer side of
leg; sole; dorsum of
foot (external pop-
liteal, external saph-
enous, musculo-cuta-
neous, plantar).
Back and outer side of
leg ; sole ; dorsum of
foot (same as fifth
lumbar).
Back of thigh, anus,
perineum, external
genitals (small, sciatic,
pudic, inferior, hem-
orrhoidal, inferior,
pudendal).
Skin about the anus
and coccyx (coccyg-
eal).
5i6
SURGICAL DIAGNOSIS AND TREATMENT.
2. By Dcicruiining the Extent of Cutaneous Anesthesia. — Chipault,
in a paper reported in the proceedings of the " Congres franqaise de
Chirurgie," 1894, classifies these lesions as follows :
{a) Cervical Type. — Anesthesia spares only the neck and the deltoid
regions before and behind. The four limbs and the trunk, including
the diaphragm, are paralyzed, while the sterno-mastoid and the supe-
rior part of the trapezius are still able to produce inspiration. Death
follows by interference with respiration. /// tliis type tlie lesion is
situated at the upper limit of the third cervical segment (Fig. 217).
Fig. 217. — Cervical type.
Fig. 218. — Superior brachial type.
{p) Superior Brachial Type. — Besides the region cited in the preced-
ing type, anesthesia spares the external part of the arm and the fore
arm as far as the extremity of the radius. In addition to those of the
neck and diaphragm, some of the muscles of the upper extremity are
preserved — /. e. the supra- and infra-spinati, the biceps, the brachialis
anticus, the deltoid, and the supinators. By action of these preserved
muscles, which are not balanced by their antagonists, the upper ex-
tremities take a position very characteristic in abduction and slight
external rotation of the arm with flexion and supination of the forearm.
The lesion is situated at the middle part of the sixth cervical segment
(Fig. 218).
{c) The Inferior Brachial Type. — The anesthesia, which crosses the
trunk at a level three or four fingers' breadth below the clavicles, is
limited in the upper extremity to a band occupying the axilla, the
internal surface of the arm and forearm, and about half of the hand.
Not only are the muscles enumerated in the preceding type preserved,
but a certain number of others — /. e. the supra- and infra-scapulars, the
pronators and extensors of the wrist, the triceps, the pectorales, the
latissimus dorsi and teres major — in short, the muscles affected in the
upper extremity are the flexors of the wrist and the intrinsic muscles
of the hands. The shoulder and the neck are capable of performing
all their movements, but the wrist, which can place itself in pronation.
INJURIES, DISEASES, AND DEFORMITIES OF THE SPINE. 517
remains in extension. Tlic lesion is situated at the middle part of the
eighth cervical segment (Fig. 219).
Fig. 219. — Inferior brachial type (after
Chipault).
Fig. 220. — Fracture in dorsal region.
When the fracture is situated at any point from the first dorsal to
the last lumbar segment, the anesthesia will be found at a corre-
sponding point, as seen in Figs. 220, 221.
3. By Deter77miiiig the Condition of the Reflexes. — When the patellar
tendon is quickly struck by the
ends of the fingers, the stimulus is
conveyed by the sensitive nerves
to the posterior cornu of the cord,
thence by the anterior cornu to the
motor root, and finally to the ex-
tensor muscles of the thigh, caus-
ing the leg to jerk involuntarily.
This can occur only when the cord
is intact. These quickly-passing
contractions can be brought out by
the skin as well as the tendons ;
hence we have j/^///-reflexes and
toidon-re^e-KQs. The third column
of the table on page 5 1 5 gives the
various reflexes and the manner in
which they can be produced. The
patellar and other reflexes are of
special value in determining whether
a lesion of the cord is total or par-
tial. If the cord sustain an injury
which produces a total transverse destruction, there will be total
motor paralysis below the level of the injury, complete anesthesia, and
Fig. 221. — Fracture in lumbar region.
5l8 SURGICAL DIAGNOSIS AND TREATMENT.
a total abolition of the reflexes. If the lesion of the cord be but par-
tial, the paral)'sis and anesthesia will be incomplete, and the reflexes
may be only impaired or may even remain normal. Generally speak-
ing, the cases in which there is total loss of motion, sensation, and
the reflexes are not suitable for the operation of laminectomy. A few
cases, however, are recorded in which there was total abolition of the
patellar and other reflexes, and yet recovery followed the operation.
Trcatincjit. — When the patient is examined at the scene of the acci-
dent, there is little difficulty, as a rule, in arriving at a diagnosis of the
injury; the manner in which he fell or was struck, the intense localized
pain in the back and the inability to move the lower limbs, give almost
an assurance of fracture, and the case should be treated with the care
which that injury demands. In removing the patient to his home or to
a hospital a smooth stretcher, a door, or a shutter should be provided.
When the clothing is removed, a careful and thorough final examina-
tion should be made, so that further disturbance may be avoided. The
patient should, if possible, be placed on a w^ater-bed, but, if this cannot
be obtained, a smooth hair mattress covered with waterproof sheeting
makes a good substitute. Reduction of the fracture can only be
attempted by gentle traction on the lower limbs, w^hile counter-exten-
sion is made from the shoulders by assistants, the surgeon meanwhile
bringing about coaptation by direct manipulation of the fragments. In
some cases it is necessary to keep up extension by means of weights
and pulleys, as employed in fracture of the thigh. For keeping the
parts in apposition it has been recommended to suspend the patient
and apply a plaster-of-Paris jacket extending from the axillae to the
trochanters. I have in two cases used a much simpler device with
great benefit. It consists of two straight splints three inches wide and
long enough to reach from the scapulae to the pelvis. They are placed,
properly padded, one on each side of the spinous processes, and united
at intefvals with strips of zinc or tin. If the fracture is in the cervical
region, the head should be steadied by sand-bags.
Throughout the case the greatest care must be observed to prevent
bed-sores, to keep the bladder emptied, and to ensure perfect clean-
liness.
The results of treatment of fracture of the spine have been so un-
satisfactory that an attempt should be made in suitable cases to cut
down upon the injured area and remove all pressure from the cord. To
this operation the name laminectomy is applied. In deciding upon the
propriety of the operation w^e must be guided by the following con-
siderations :
1. The condition of the reflexes. It is generally conceded that if
the patellar and other reflexes are entirely lost, the case is not one for
operation. At the same time we must remember that in a few cases
of such a condition recovery has followed operation.
2. The higher the lesion the less favorable the conditions ; and, as
a rule, it may be said that operations above the seventh dorsal verte-
bra will rarely prove successful. The most favorable situation is below
the second lumbar vertebra.
Regarding operations in the region of the cauda equina Chipault
draws the following conclusions : " {a) In case of lumbar or sacral frac-
I.VJUJilES, DISEASES, AND DEFORMITIES OF THE SPINE. 519
ture with permanent or irreducible displacement of the bony fragments
we should interfere at once. (/?) In case of fracture which is reduced,
either spontaneously or by surgical manipulations, wait. If the course
of the case is toward recovery, wait ; if the case remains stationary,
intervention is justified toward the end of the first month — not earlier
— since functional restoration may not begin till toward this period ; not
much later, since incurable spinal degeneration may be established."
3. The time at which the operation should be resorted to. Com-
pression of the cord very speedily brings about destructive changes,
and, if the case is one for operation at all, the earlier it is performed the
better.
Operation. — Having prepared the field of operation in the usual way,
the patient is placed in the Sims position ; an incision is made in the
middle line not less than four inches in length, which can afterward
be extended if required. The muscles are then exposed and separated
from the arches upon one side. Horsley has shown that this can
best be done by clean cuts of the knife rather than by blunt instruments.
In this part of the operation there is usually hemorrhage. On this
account the dissection should be carried on as rapidly as possible, and
the cavity packed with sponges wrung out of water as hot as can be
borne by the hands. Vessels of any considerable size must of course
be caught by forceps and afterward ligated. Having packed one side,
the muscles on the other side are separated and packed in a similar
manner. The first packing is now removed and the periosteum
reflected. To do this an incision is made along the angle formed by
the spinous processes and the laminae ; the edge of the periosteum is
grasped with a pair of dissecting forceps and separated by the aid of a
curved periosteal elevator. The opposite side is similarly treated. The
muscles are held apart by retractors, which must be small and so
shaped as to be out of the operator's way. When the bone has been
fully exposed the spinous processes are divided close to their bases by
strong bone-forceps set at an obtuse angle. The laminae are next
divided in the following manner : Begin with the vertebra at the middle
of the incision, and by the tips of the fingers find the vertebral spaces
above and below ; then apply the forceps as near the transverse pro-
cess as possible, and divide the lamina by a number of short nips of the
instrument. Having removed the laminae, the dura mater comes into
view and should be carefully examined. If there is no pulsation, we
may infer that the subdural space is obliterated at that point, probably
by adhesions or by swelling of the cord. Increased tension is sug-
gestive of a tumor. A yellow color would indicate the existence of
pus beneath the membrane, while a purple tinge would suggest extrav-
asated blood. In either case the membrane should be opened by
picking it up with toothed forceps at the middle of the incision, open-
ing it with knife or scissors, and dividing it for the required distance up
and down upon a director or with blunt-pointed scissors. The dura
mater is then retracted, and the subdural space explored by the tip of
the finger or by the aid of a bent probe or pedicle needle. Splinters of
bone or any other cause of compression of the cord should be removed.
When the body of a displaced vertebra is producing pressure, the cord
itself can be held aside, as recommended by Chipault, and the projecting
520 SURGICAL DIAGNOSIS AND TREATMENT.
portions cut off with s^ouge, chisel, or curette. A tumor on the surface
of the cord should be removed, but if it infiltrate the substance of the
latter, it is best to let it alone. Having completed the operation on the
spine, the dura is closed, either by interrupted or continuous catgut
stitches, a small rubber drainage-tube and a few strands of chromicized
catgut are laid along the length of the wound ; over this the muscles
are sutured by buried chromicized catgut, and the skin and fascia closed
by silkworm gut, silk, or silver wire.
Gunshot Wounds of the Spine. — In the diagnosis of gunshot
wounds of the spine great difficulty may be experienced in determining
the location of the missile and the injuries produced by it. The bullet
may wound the bone alone, it may partially or completely sever the cord,
or it may divide one or more of the large vessels near the column and
cause death by hemorrhage. Vincent divides gunshot injuries of the
cord into three classes: i. The cord maybe compressed by extrav-
asated blood, by fragments of bone, or by the projectile lying outside
the medulla or canal. 2. The projectile in passing through the spine
has injured the cord. 3. The projectile is lodged in the .spinal canal.
In the examination the disinfected finger and probe, although useful
in certain cases, must not be relied upon. The degree of paralysis, the
extent of the anesthesia, and the state of the reflexes will serve to
localize the injury, as already described under Fracture of the Spine.
When the bullet enters by way of the chest or abdomen one or
more of the important organs of these cavities will probably be wounded,
and thus greatly increase the gravity of the situation.
Treat j/icjit. — When the injury is confined to the bone, the cord re-
maining unharmed, all loose spiculae of bone and foreign bodies, such
as clothing, should be removed and a rubber tube or strip of iodoform
gauze placed in the position which can best maintain drainage. When
there is compression of the cord the cause should be removed by
an operation. The compressing agent will prove to be a clot, a
fragment of bone, or the projectile itself. The most serious cases are
those in which the projectile is lodged in the spinal canal. These
cases, if allowed to take their course, are almost sure to result in
myelitis, meningitis, cystitis, and death, and, although affording little
hope, an operation gives the only chance for recovery. Cases in which
the cord is severed had better be let alone.
Dislocation of the Spine. — Although this accident is generally
a complication of fracture, there are many cases recorded of pure dis-
location. The injury occurs most frequently in the cervical region,
owing to the smaller size of the vertebrae and their less intimate apposi-
tion. The fifth cervical seems to be the most liable to displacement.
In the dorsal region the twelfth segment is the one most frequently
displaced. In the lumbar region the accident is very rare. The dis-
location is generally bilateral, but a number of unilateral luxations are
recorded. The causes of the injury are forced flexion or extension,
extreme lateral motion or rotation.
Symptoms. — The symptoms so closely resemble fracture, in a large
proportion of cases, that it is very difficult to arrive at a diagnosis. The
presence of deformity and the absence of crepitus cannot be relied upon,
for deformity may be present in fracture, and crepitus we cannot with
INJURIES, DISEASES, AND DEFORMITIES OF THE SPINE. $21
propriety look for, lest serious injury be done to the cord. Our main
reliance must be placed upon the following points : The neck is rigid
and the head turned to one side in unilateral luxation ; the spinous and
transverse processes may be felt to be displaced. If the dislocation is
in the upper cervical region, respiration is difficult, or it may even be
suddenly arrested, producing death. The finger should explore the
pharynx for displacement of the body of a vertebra. For the rest, the
paralytic symptoms will afford some evidence. Dislocation above the
brachial plexus causes paralysis of both upper and lower extremities,
as well as of the trunk. Motor is more marked than sensory paralysis,
and may range from slight paresis to complete paraplegia. The attitude
assumed by the patient is sometimes very characteristic, as in a case
reported by Ayres, in which the head was thrown back, the neck per-
fectly rigid, and the larynx projecting forward.
Treatment . — This dislocation is a serious injury, and the patient's
friends should be warned of two dangers. If reduction is attempted,
instant death may result, especially if the displacement is in the upper
cervical region. On the other hand, to allow the pressure of the dis-
placed vertebra upon the cord to continue is certain to result in
destructive changes and probably death. An attempt at reduction
should therefore be made. This is effected by gentle and steady trac-
tion upon the occiput and chin. If a displaced vertebra can be felt in
the phaiynx. the finger of the operator should make firm pressure upon
it while steady traction is kept up. Should the luxation be unilateral,
rotation of the neck should accompany extension.
Deformities of the Spine. — Deformities of the spine are con-
genital or acquired. The congenital varieties embrace the fol-
lowing :
I. Spina Bifida. — This is the most frequent of all defects of the spine,
and, roughly speaking, occurs in i of every looo children born. Its
mechanism is thus explained : In the embryo a furrow represents the
spinal canal. The sides of the furrow unite to form the laminae, which,
in their turn, coalesce at the spinous processes. If the laminae should fail
to unite in the middle line, a cleft is the result, through which the
membranes or the cord itself projects. The tumor thus formed is nearly
always found in the back, but rare cases are on record in which the
cleft was in the bodies of the vertebrae and the tumor formed in front
of the spinal column. It is worthy of note that in the lumbo-sacral
region the medullary groove closes at a later period than elsewhere,
and this accounts for the clinical fact that in this locality three-fourths
of all cases of spina bifida are found. Next in frequency is the neck ;
in exceedingly rare cases the cleft occupies the entire length of the
spine. This malformation frequently exists in combination with other
defects, such as club-foot, squint, cleft-palate, hydrocephalus, and im-
perfect mental development.
A form known as spina bifida occulta is difficult of diagnosis from
the fact that no cleft in the spine can be recognized and there is no
tumor. Many of these are characterized by a growth of hair over
the part.
Varieties. — The classification of the varieties of spina bifida is based
upon the contents of the tumor :
C22
Si'KGlCAL DIAGNOSIS AND TREATMENT.
1. If the membranes alone escape through the cleft and are filled
with the cerebro-spinal fluid, the tumor is called a meningocele.
2. If both the cord and its membranes protrude through the cleft,
the tumor is called a ine)ii)igo-inyelocclc.
3. If, in addition to the protrusion of the cord and membranes the
central canal of the spinal cord is distended with fluid, the term syringo-
myelia is applied to the tumor.
Fig. 222. — Spina bifida (from a photograph in the Cook County Hospital, 111.).
The diagnosis of the variety is important in deciding the question
of treatment.
Symptoms. — A congenital tumor situated in the lumbo-sacral re-
gion over the center of, and closely connected with, the spine can
almost with certainty be pronounced a spina bifida (Fig. 222). On
closer examination it will be found to have the following characters :
INJURIES, DISEASES, AND DEFORMITIES OF THE SPINE. 523
In shape it is usually round, uniformly smooth, or with a furrow run-
ning down its middle line and terminating in a pit-like depression above
and below. Sometimes a groove runs on each side of the middle
furrow like the meridians of longitude on a globe, wide apart at the
equator, but meeting in the pit-like depression at each pole. The
tumor may be of any size up to that of a child's head. The color of
the skin over the protrusion is usually red, but it may be natural ; the
skin is thin, and in some cases covered with a copious growth of hair.
Sometimes the sac is translucent, permitting us to see, by the aid of
transmitted light, the nerve-cords coursing through it. The fluid is
cerebro-spinal, and is therefore subject to changes of tension. If it is
pressed upon, the impulse can be felt at the anterior fontanelle ; when
the child cries or coughs the tumor becomes more tense, and the same
is observed when the sitting posture is assumed. In many cases the
cleft in the bone cannot be palpated, but this is not essential to the
diagnosis.
The diagnosis of the variety of spina bifida is not always easy.
Meningocele is recognized by its fluctuation and by the absence of
any nerve-cords when examined by palpation or with transmitted
light.
Meningo-myelocele is often attended with atrophy, and possibly
paralysis of the lower limbs and paralysis of the sphincter muscles.
Syringo-myelia may be determined by the presence of a deep dimple,
which denotes the termination of the spinal cord and its attachment
to the skin, and by the presence of nerve-cords seen by transmitted
light.
Treatment. — In a majority of cases the child is so ill-nourished and
defective in development that death takes place at an early age. The
skin over the tumor may ulcerate and slough, allowing the cerebro-
spinal fluid to escape. If infection takes place, spinal meningitis is
almost sure to prove fatal.
The treatment is generally simply palliative. A pad of absorbent
cotton covered with vaselin or a moulded splint of rubber or celluloid
should be placed over the tumor and kept in position by a broad flan-
nel belt, so as to exert gentle pressure. A layer of cotton saturated
with collodion is a good application and has a tendency to cause
shrinking of the parts.
If at the end of two months the tumor is found to be increasing in
size and the general condition is going on from bad to worse, the ques-
tion of a radical cure by operation may be considered. Two operations
are recognized by surgeons :
I. The Injection of lodin.^ — Morton of Glasgow was the first to use
a fluid which has since gone by his name. It consists of iodin gr. x,
iodid of potassium gr. xxx, and glycerin 5J. The skin over the tumor
is disinfected in the ordinary way, and by means of a trocar one dram
of Morton's fluid is injected at the side of the tumor, the trocar passing
obliquely through the skin and sac. This gives a valve-like puncture
which prevents escape of the cerebro-spinal fluid. As the trocar is
withdrawn the skin should be closely pressed around it to prevent
entrance of air or escape of fluid, and the opening closed with iodo-
formized collodion and absorbent cotton. In successful cases rapid
524 SURGICAL DIAGNOSIS AND TREATMENT.
shrinking of the cyst takes place and the tumor is diminished in size.
Should no improvement follow the operation, a second injection should
be made at the end of ten days or two weeks.
2. Excision. — Two varieties of spina bifida are amenable to opera-
tion — viz. meningocele and favorable cases of meningo-myelocele ; the
third variety, s)-ringo-myelia, is best let alone. In any case where the
tumor is very large, the skin thin, and there is no likelihood of obtain-
ing a sufficient flap to cover the parts, excision is not advisable. The
operation should not be resorted to before the child has reached the
age of two months. On this point Bayer draws the following con-
clusions :
1. The operation for sacral and lumbo-sacral spina bifida should be
undertaken at once in all those cases with ruptured sacs that do not
show paralysis and are not complicated by other malformations except
club-foot.
2. It is to be done in cases that show paralysis as soon as the child
is well developed.
3. In cases in which the sac is unruptured and covered by normal
skin the period of infancy should not be selected for operation, although
operation must not be postponed too long for fear of injuries.
The Operation. — In simple meningocele make an elliptical incision,
leaving sufficient healthy skin on each side to cover in the parts. Dis-
sect out the sac down to its neck or base. If the neck is .small, it may
be simply ligated and cut off; if the neck is broad, the sac is excised
and the cut edges sutured together, serous surface to serous surface.
The sutures should be close together, with the view of preventing
escape of cerebro-spinal fluid, for if this take place a fistula will result,
with an ever-present danger of infection and spinal meningitis. The
flaps are then brought together as accurately as possible, the stitches
being made to alternate with those in the sac, thus aiding to prevent
escape of fluid.
In meningo-myelocele, after opening the sac the nerv^es must be
separated from the posterior part of the sac to which they are usually
attached and replaced within the spinal canal. The remainder of the
operation is devoted to the formation of a proper covering for the canal,
and can be carried out in one of two ways :
1. The muscles on each side of the spine are loosened and brought
together in the middle line (Bayer). The fascia and skin are similarly
sutured.
2. The arches of the vertebrae are divided close to their bases by
means of bone-forceps, pushed close to the middle line, and retained by
sutures (DoUinger).
Choice of Methods. — It is very evident that the operation of ex-
cision is gaining favor among surgeons, and will continue to do
so, as better technique will fulfil two indications — viz. first, to pre-
vent escape of cerebro-spinal fluid and subsequent fistula; and sec-
ond, the securing of a proper covering for the defective portion of the
spine.
Already statistics show a balance in favor of the operation as against
injection with iodin. Morton collected 65 cases treated by injection,
with 55 recoveries and 10 deaths, and Powers has shown a mortality
nVJURIES, DISEASES, AND DEFORMITIES OF THE SPINE. 525
of 26.6 per cent. Powers also collected 34 cases treated by excision,
from which he deducts 3 in which the cause of death was indefinite,
leaving 31 cases with 24 recoveries — a mortality of 22.58 per cent.
Robson reports 20 cases, of which 16 recovered — a mortality of 20
per cent. — and, according to Hildebrand's statistics, 66 per cent
recover after injection and 73.5 per cent, recover after the operation of
excision.
2. Sacro-coccygeal Tumors. — These are congenital tumors, and in
some instances are varieties of spina bifida. They occur in girls
more frequently than in boys, the proportion, according to Malte,
being 44 to 14.
In the diagnosis of these tumors the following points must be kept
in mind. They differ from spina bifida by lying in front of the coccyx,
while spina bifida lies behind the coccyx and continuous with the spinal
canal. The tumor varies in size from a hazelnut to a child's head ; it
is usually cystic, and is therefore elastic and fluctuating in parts. The
coccyx is pushed backward if the tumor is large, and the patient may
experience considerable difficulty in sitting down ; the anus and genitals
may be displaced forward. The growth bears a strong resemblance to
a fatty tumor, for which it has sometimes been mistaken. The treat-
ment is excision, which must be complete, and the greatest care must
be taken to prevent injury to the rectum.
3. Curvature of the Spine. — The spine may be abnormally curved
in one of three directions: i. Laterally — scoliosis ; 2. Antero-poste-
riorly, with the convexity backward — kyphosis, or excurvation ; 3. An-
tero-posteriorly, with convexity forward — lordosis, or incurvation.
Lateral Curvature. — Girls in delicate health who are growing
rapidly, and who are obliged to keep up such muscular action as
draws the spine to one or the other side, girls who sit for long hours
at a desk or piano with insufficient support to the back, the poor girl
who carries around a baby brother until she becomes lop-sided, the
child with rickets or tuberculosis, — all these are liable to lateral curva-
ture. Disease of the spinal cord when it produces atrophy of the
muscles on one side, over-use of muscles causing one-sided hyper-
trophy, empyema resulting in contraction of one side of the thorax,
obliquity of the pelvis, and sacro-iliac disease, are also exciting causes.
In examining a case for curvature the child should be stripped to the
waist ; she should stand upon both feet, with head erect and arms
hanging by the sides. If the spinous processes form a straight line in
the middle of the back, if the shoulder-blades are at an equal distance
from this line, if both sides of the thorax are symmetrical, and if the
gluteal fold is at right angles with the middle line, there is no curvature
of the spine. The patient should be asked to stand in this position for
several minutes. If the back is weak, she will be observed to drop one
shoulder as soon as she becomes fatigued, and the line of the spinous
processes will curve to one side or the other (Bradford). This is the
so-called flexible spine. The curve is readily rectified by voluntary
effort on the part of the patient. The history of a case of lateral
curvature will show that the patient belongs to one of the classes
just mentioned. If a boy, the first indication of deformity is that his
suspender is constantly slipping over his shoulder ; if a girl, the dress-
526
SURGICAL DIAGNOSIS AND TREATMENT.
maker is the first to notice that one side needs padding to ensure a
good fit.
The oLithne of the curved spine can usually be detected by the eye.
In fat subjects it ma)' be necessary to run the finger with firm pressure
along the spinous processes, which leaves a red line, indicating their
position and demonstrating the presence of curvature. The most com-
mon situation of the curve is in the upper dorsal region and with its
convexity to the right (Fig. 223). In the lumbar region there is a com-
pensatory curve with its covexity to the
left, and in marked cases there is fre-
quently found another compensatory
curve in the cervical region, its convexity
being on the opposite side from the
original curve.
Curvature is not the only deformity,
for the spine is more or less rotated on its
axis, the spinous processes pointing to
the convexity and the bodies of the ver-
tebrae to the concavity of the curve. The
scapula on the affected side is slightly
prominent, the ribs are abnormally sepa-
rated, their direction horizontal, and their
angles projecting.
On the concave side the obliquity of
the ribs is exaggerated, so that in bad
cases they touch the crest of the ilium.
Bradford recommends that the four fol-
lowing points should be determined: ist.
Whether the spine is flexible; 2d. Whether
there is any rotation ; 3d. Whether the ro-
tation can be corrected by any slight force ;
4th. Whether any muscular weakness is present.
Rotation may be assumed to be present when one shoulder-blade,
usually the right, is more prominent than the other, and rotation may
also be assumed when one hip is higher than the other. The amount
of fixed rotation can be roughly determined by placing the patient flat
upon her face on the floor or upon a hard table. " An ordinary rule is
placed directly across the back above the middle of the shoulder-
blades or across the points of the greatest projection,
present, the rule will not be parallel with the plane
patient lies " (Bradford).
The question as to whether the deformity can be corrected by a
shght amount of force is settled by suspending the patient or by making
traction while he is in the recumbent position. Muscular weakness is
best determined by a dynamometer fastened to the floor, the straps of
which pass over the patient's neck. In the act of straightening the
body the muscular force is recorded upon the instrument.
In the prognosis of lateral curvature the rate of growth of the child,
the height and weight compared with tables of the average of children
of the same age, the persistence of a faulty attitude in standing or sitting,
and the general health of the patient should be taken into account.
Fig. 223. — Lateral curvature
greater severity (Bradford).
If rotation be
on which the
INJURIES, DISEASES, AND DEFORMITIES OF THE SPINE. 527
If the child is growing rapidly and is ill-nourished, it may be fairly pre-
dicted that the curvature will increase, and the condition is more
Fig. 224. — Normal back, a lack of support from chair (Bradford).
serious if there is marked rotation. A slight curvature in a healthy
child of normal rate of growth need not cause anxiety.
Fig. 225. — Normal back curved from sitting in FiG. 226. — Normal back curved from stand-
a one-sided position (Bradford). ing on one foot (Bradford).
Treatment. — The practitioner will do well to heed two warnings : ist.
Do not tell the friends of the little patient that the disease is of slight
528
SURGICAL DIAGNOSIS AND TREATMENT.
importance, and that under the use of tonics the spine will rectify itself.
2d. Do not employ braces, corsets, plaster casts, or other mechanical
supports ; these are required only in exceptional cases and where it is
necessary to correct deformit)-. The muscles need development, which
can be secured by exercise only. Mechanical appliances, therefore, by
keeping the muscles at rest, do harm instead of good. The treatment
must be directed toward three objects — first, to correct a faulty attitude
or carriage ; second, to increase the flexibility of the spine ; third, to
correct excessive deformity. Children with any tendency toward lateral
curvature should be provided with suitable chairs. Fig. 224 shows the
lack of support afforded by an ordinary chair ; Fig. 225 shows how
the normal back is curved from sitting in a one-sided position ; Fig.
226 shows the effect upon the normal back of standing upon one foot.
The bed used by such patients should be smooth and firm, and they
should be restricted to one small pillow. Before deciding upon the
necessary exercises the back should be examined while the patient is
stripped to the waist. The faulty position should be corrected, as far as
possible, by the patient's voluntary efforts, aided, if necessar>% by the
surgeon's hands. She should then be instructed to maintain the cor-
227. — Recumbent backward bending (Bradford).
rected position as much as possible, and to always return to it after
every movement during exercises. The simplest and perhaps the most
useful movements are those wdiich cause a backward bend of the body.
This can be done by the patient's assuming the recumbent position and
repeatedly raising the chest from the table or floor (Fig. 227) ; or the
patient can lie on a table with the trunk projecting over the end and
an assistant steadying the body at the hips and knees. She should
then be directed to flex and extend the body at the hips while resist-
ance is made by the hands of the attendant placed upon the shoulders.
The patient should be instructed to lie upon a smooth flat surface for
half an hour each day, to walk for a certain length of time daily carry-
ing a light weight balanced on the head, and to swing for a few minutes
by the hands from a cross-bar. Swedish movements, massage, and
electricity are valuable aids to treatment.
2d, To increase the flexibility of the spine. When the deformity
cannot be corrected by the voluntary effort of the patient, aided by
moderate pressure of the surgeon's hands, or when it does not disap-
pear while the patient is suspended or assumes the recumbent position,
we must infer that a certain amount of fixed rotation is present. It
then becomes necessary to use moderate force to stretch the contracted
INJURIES, DISEASES, AND DEFORMITIES OF THE SPINE. 529
tissues and overcome the deformity. Hoffa of Wiirzburg has devised
a simple apparatus, which is shown in Figs. 228, 229. The ordinary-
suspension apparatus, aided by belts of webbing, can be employed to
good advantage. In cases of severe deformity it is sometimes neces-
FlG. 228. — Recumbent correcting appliance for pressure-correction, made of iron piping.
The patient lies on a stretched sheeting hammock, and correction-pressure is applied by screws
(Bradford).
sary to apply a plaster jacket while the patient is in the corrected posi-
tion. The plaster should be changed once or twice in the month, and
this treatment persevered in until the deformity is overcome. After
Fig. 229. — Recumbent correcting appliance seen from above (Bradford).
this suitable exercises and gymnastics should be employed, and the
case kept under observation during the whole period of growth.
Posterior curvature, excurvation, or kyphosis, may occur at any age,
but is more frequent in people of advanced life. The term should be
restricted to cases of true curvature, and should not embrace the
angular deformity so commonly seen in Pott's disease, and which has
gone under the mathematically impossible term " angular curvature."
Kyphosis in children may be induced by permitting them to sit up
34
530
SURGICAL DIAGNOSIS AND TREATMENT.
at a vciy early age, by nursing them in a sitting posture, or it may be a
consequence of rickets. In adolescents it is produced by the same con-
ditions that cause scoliosis. In adults it is found in persons whose occu-
pation compels them to maintain a stooping
posture, and especially if the subjects are
ill-nourished and live under bad hygienic
conditions. It is common in those subject
to asthma, emphysema, and rheumatism,
and is then due to the position voluntarily
assumed for the relief of their sufferings. It
is readily distinguished from the angularity
of Pott's disease by the presence of a true
curve, by the absence of muscular rigidity,
pain, tenderness, and suppuration.
Treatment. — In infants and adolescents
the muscles must be developed by judicious
exercise, the correction of faulty positions,
and on the general principles laid down
under scoliosis. In old persons the condi-
tion is usually permanent, but in marked
cases much benefit may be gained by the
use of a suitable spinal brace.
Anterior airvatnre, inairvation, or lordo-
sis, is an antero-posterior curvature with its
convexity forward, and is usually found in
the lumbo-dorsal region. It is often con-
genital. The most common causes of this
condition are diseases of the posterior por-
tions of the bodies of the vertebrae, ankylosis
of the hip-joints, and rickets (Fig. 230).
Treatment must be directed to the dis-
ease that causes the deformity.
Tuberculosis of the Spine, Spondy-
litis, or Pott's Disease. — When the tu-
bercle bacillus finds lodgement in the spine
it selects the cancellous tissue of the bodies
of the vertebrae, and produces there a group
of changes similar to those found in tuber-
culosis of the hip or other joints. A brief survey of these changes
will aid us in understanding the symptoms that mark the course of
the disease.
The presence of the bacilli in sufficient numbers in tissues too weak
to resist them is soon followed by inflammation in the bone. Pain is
the result, greatly aggravated on movement. To guard against pain
the muscles of the affected part become rigid, and this rigidity is one
of the earliest signs of the disease. The patient by voluntary action
assumes a posture that gives the greatest steadiness to the spine.
He stoops, and places his hands upon his hips to relieve the diseased
area of the weight of the head, shoulders, and all parts above ; if he
picks an object from the ground, he gets down to it by bending the
knee, while the spine is kept rigid.
Fig. 230. — Hip-joint disease
with lordosis (from a photograph
in the collection of Dr. Gillette).
INJURIES, DISEASES, AND DEFORMITIES OF THE SPINE. 53 1
The inflammation in the bone may possibly be arrested at this point,
and by resolution return to a healthy condition. Unfortunately, this
rarely occurs. The inflammation is a rarefying osteitis, and destructive
changes soon become apparent ; caseation and disintegration of the
bodies of the affected vertebra take place, and the bony substance is
replaced by granulation-tissue. The process extends to the interverte-
bral disks, and they also are destroyed.
Even from this point a return to health is possible. Fibrous tissue
may take the place of the caseous masses, and ankylosis may result
with little or no deformity.
If the disease progresses still farther, liquefaction of the caseous
masses takes place and a collection of tubercular fluid (improperly
called pus) is formed, which, following the path of least resistance,
makes its way to the surface as a spinal abscess. Should this abscess
be opened carelessly or burst of its own accord, infection by septic or
putrefactive germs, or both, is sure to take place, and the dire conse-
quences of suppuration are added to the already serious condition
produced by the tubercular process. Whether the abscess appears or
not, destructive changes in the bodies of the vertebrae and in the inter-
vertebral disks go on apace. So much loss of substance must neces-
sarily alter the shape of the spine, and, as the loss is at the anterior
part of the bodies of the vertebrae, the healthy vertebrae above and
below come nearer together, causing the spinous processes to project
in angular prominences, the so-called " angular curvature." So im-
portant a feature is this deformity that " angular curvature " has long
been recognized as one of the synonyms of Pott's disease.
The position of this angularity is generally the dorsal region, and it
is not uncommon to find a compensatory curve below it in the form of
lordosis in the lumbar region. If the disease occurs in the cervical or
lumbar region, where there is a natural curve, the effect may be to
cause this normal curve to disappear, and a straightening of the spine is
the result. In diagnosis, therefore, a straightness of the cervical or
dorsal portion of the spine and an obliteration of the normal curves
must be regarded as of the same clinical value as " angular curvature."
Another symptom of spinal disease yet remains to be accounted
for — /. e. paralysis. The inflammatory process is not confined to the
osseous tissue. In many cases there is inflammation of the dura mater
and of the connectiv^e tissue between it and the walls of the canal. A
thickening of the tissues results, which by pressure upon the nerves
produces paralysis. If the thickening is in front and affects the ante-
rior roots of the nerves, motor paralysis only is observed. If both
roots are involved, there is paralysis of both sensation and motion.
Paralysis may also be caused by inflammation of the cord itself or by
the pressure of a displaced vertebra upon it. It is an important clinical
fact that the liability to paralysis is greater the higher the portion
of the spinal column that is affected, owing to the larger size of the
spinal cord and the smaller size of the bodies of the vertebrae.
Symptoins. — In typical cases the symptoms of Pott's disease are so
characteristic that an error in diagnosis is scarcely possible. There are
cases, however in which the symptoms are far from typical, and per-
haps no disease assumes a greater variety of forms or appears under so
532 SURGICAL DIAGNOSIS AND TREATMENT.
many different guises as tuberculosis of the spine. In the lumbar
region it may so closely simulate hip-disease as to deceive the most
careful observer, while in the cervical region the evidence may point to
a simple wry-neck and nothing more.
Pain is present in nearly every case, and is one of the leading symp-
toms. It requires the most careful study, as it is sometimes misleading
to both parents and surgeon. It is generally symmetrical, and is often
confined to the peripheral ends of the nerves. Hence, instead of being
felt in the back, it may be felt in the abdomen, giving rise to the belief
that the patient has stomach-ache or some abdominal disorder ; or it
may be confined to the chest and pass for intercostal neuralgia ; or
it may run down the arms or lower limbs and take the name of
" growing pains." Like all pains connected with bone, it is worse
at night, and may even assume the character of the " starting pains "
which cause such suffering in hip-disease. The location of the pain will
vary with the part of the spine affected. In disease of the lumbar
region abdominal pains are felt, and not infrequently there is irritability
of the bladder ; in the dorsal region the pain is felt in the epigastrium
or along the course of the intercostal nerves, and the breathing is
sometimes affected ; in the cervical region the disease may cause pains
or numbness in the arms, difficulty in swallowing, and a tickling cough.
It will thus appear that pain is not a symptom of definite value. Its
uncertainty should put us on our guard and lead us to a close examina-
tion of the spine itself Persistent pain, worse at night, in any of the
positions just mentioned should create a suspicion of Pott's disease.
The most significant characteristic of the pain is its being aggra-
vated by movement of the spine, by jumping, or by twisting the body.
The patient should be asked to jump from a chair to the floor; pressure
should also be made upon the shoulders, so as to gently crowd the
vertebrae together. If these tests are borne without pain, the spine
may be considered free from disease. Another test consists in gently
lifting the patient by placing the hands under the chin and occiput
while he is in the erect position ; this gives relief if the pain is due to
Pott's disease.
Rigidity of the muscles is a symptom of the greatest value. Pain
may be absent, or, if present, it may be misleading, while deformity does
not occur until after much damage has been done ; but rigidity is an
early and ever-present symptom. It is an effort to keep the dis-
eased bones at rest and prevent the movement that causes such
intense pain. The patient should be stripped of all clothing and caused
to walk across the floor. The gait is unnatural and the attitude is
peculiar. Draw his attention to an object behind him, and instead of
looking over his shoulder he will turn his whole body. Ask him to
pick an object from the floor, and he bends the knee, while the spine is
kept rigid (Fig. 231). This rigidity gives rise to peculiar attitudes
varying with the location of the disease. When the cervical vertebrae
are affected, the head is sometimes tilted, giving the appearance of
torticollis. Disease in the upper dorsal region causes the patient to
assume the attitude seen in Fig. 232. A very aggravated case is
shown in Fig. 233, in which the patient assumes the attitude of a
quadruped in all his locomotion.
INJURIES, DISEASES, AND DEFORMITIES OF THE SPINE. 5.33
Deformity. — The mechanism of the so-called " angular curvature "
has been already described. It should be carefully sought for, as it is
the earliest symptom of destructive change, just as shortening of the
limb is evidence of the destructive process in disease of the hip-joint.
It is advisable to keep an accurate record of the amount of deformity,
and this can best be done by photographs. They do not give an idea
of the amount of rotation in cases of
lateral curvature, but this can be ob-
tained if the patient stoops forward
and a photograph be taken of the
bent back, or if a mirror be placed
directly on the patient's head at such
an angle as to reflect the contour of
the back below ; if the reflection be
photographed the rotation will be re-
corded (Bradford).
Abscess. — Many cases of Pott's dis-
ease run their course without suppu-
ration, or without the formation of
liquid collections improperly called
" tubercular abscesses." Early and
Fig. 231. — Manner of picking up an
object in Pott's disease (Agnew).
Fig. 232. — Disease in upper dorsal region
(from a photograph in the collection of Dr.
Gillette).
efficient treatment has much to do in the prevention of these disagree-
able complications, though abscesses may form in spite of the most
careful treatment. Beginning as they do in the anterior portion of the
vertebrae and in close proximity to the important organs contained in
the thoracic and abdominal cavities — xiz. the esophagus, the lungs, the
534
SURGICAL DIAGNOSIS AND TREATMENT.
large vessels, and the contents of the peritoneum — it is remarkable that
spinal abscesses are not more frecjuently followed by fatal results.
They afford examples of the manner in which pus can travel far from
its point of origin, seeking an outlet to the surface in the direction of
least resistance.
When an abscess takes its origin from the bodies of the cervical verte-
brae it may point to one of the following directions : {a) Retro-pharyn-
geal, the fluctuation being felt to one side of the middle line ; (/;) The fluid
may burrow outward and point behind the angle of the jaw; {c) It may
Fig. 233. — Quadruped locomotion.
follow the course of the esophagus and enter the posterior mediastinum ;
(^) It may burrow between the longus colli and scaleni muscles, and
point in the neck at one or other side of the sterno-mastoid muscle.
When the dorsal vertebrae are affected, which happens in the majority
of cases, the first collection of fluid is in the posterior mediastinum.
From this position it may travel in one of three routes : {a) Passing
between the transverse processes, it may appear in the back — the so-
called dorsal abscess, (b) It may burrow downward to the diaphragm,
pass under the ligamentum arcuatum externum, and appear in the ilio-
costal space and become a lumbar abscess (Fig. 234). {c) It may pass
beneath the ligamentum arcuatum internum and between the two origins
of the psoas muscle, and become a psoas abscess. Its place of point-
INJURIES, DISEASES, AND DEFORMITIES OF THE SPINE. 535
ing is generally in the groin below Poupart's ligament and the outer
side of the femoral vessels. In some cases it points above Poupart's
ligament, and by gravitation it may burrow down the thigh or even
below the knee.
Disease in the lumbar vertebrae produces an iliac abscess which
usually points in the abdominal wall a little above Poupart's ligament.
We cannot place much reliance upon the position in which an abscess
Fig. 234. — Lumbar abscess (Hoffa).
Fig. 235. — Severe grade of psoas contrac-
tion (from a photograph in the collection of Dr.
Gillette).
points, for pus, with ever-increasing pressure, constantly burrows in
the direction of least resistance.
It is very important to make a diagnosis of abscess before pointing
takes place. The formation of an abscess may be suspected when
there is a sudden increase of pain, loss of appetite and flesh, and
general constitutional disturbance in a patient who had previously been
doing well. As the psoas abscess is the most common form, contrac-
tion of the psoas muscle is an early symptom and a valuable diagnostic
point. In some cases the contraction is marked and causes great
deformity (Fig. 235). The manner of estimating mild forms of con-
traction is shown in Fig. 236. Psoas abscess must not be mistaken for
536 . SURGICAL DIAGNOSIS AND TREATMENT.
hernia. When an -abscess appears suddenly, is egg-shaped, and free
from tenderness and heat, as it frequently is, its resemblance to hernia
Fig. 236. — Method of e.xamining for psoas contraction in Pott's disease (Hoffa).
may mislead the unwary. Its position outside the femoral vessels, cor-
roborated by other signs of Pott's disease, should leav^e no room for
doubt.
Paralysis. — This symptom, as already described, is due to a pachy-
meningitis or to a transverse myelitis. Paralysis of motion is usually
the first to appear, varying from mere muscular weakness to com-
plete paresis. The reflexes are exaggerated, except when the lumbar
vertebrae are affected, and muscular spasms frequently occur. If the
posterior roots suffer pressure, there is paralysis of sensation. Paralysis
is greatly influenced by treatment. On this point Bradford and Lovett
say : " It occurs without regard to the amount or character of the
deformity, and is often preceded by much pain ; on the average it lasts
a little less than a year. Its prognosis is extremely favorable in mild
cases, or in severe ones if they can be treated early. Recovery, when
it occurs, is generally complete, no trace of the disability of the limbs
being left. Incomplete recovery is uncommon, but incomplete paralysis
often is present. In fact, the early commencement of efficient treatment
will often seem to render abortive an attack of paraplegia, and change
what threatened to be a complete loss of power to a comparatively
trifling disability which is merely enough to prevent walking for a few
weeks or months."
Differential Diagnosis. — A typical case of Pott's disease cannot be
mistaken for anything else. There are cases in which pain is for a long
time the only symptom, and these are fruitful sources of error. The
surgeon, misled by the position of the pain, gives his attention to intes-
tinal disorders, gall-stones, intercostal neuralgia, or rheumatism, and
never thinks of examining the spine for rigidity or deformity.
Sprains of the spinal column may simulate Pott's disease by causing
the patient to assume an attitude resembling the latter. There may
even be rigidity of the muscles, and the patient in attempting to walk
may place his hands upon his thighs to support the weight of the trunk.
Sprains seldom occur in childhood. The suddenness of the symp-
toms, their evident connection with a traumatism, and the speedy
recovery under appropriate treatment settle the question of sprain.
INJURIES, DISEASES, AND DEFORMITIES OF THE SPINE. 537
Hysterical or JiypcrcstJictic spine occurs in young growing girls and
in neurotic persons. The spine is tender in spots, and there may be
intense pain, but the attitude and
gait of Pott's disease, the angu-
larity, and to a certain extent the
muscular rigidity, are absent.
Wry-neck is one of the symp-
toms of disease of the cervical
vertebrae. Simple muscular wry-
neck is distinguished by the
rigidity of certain muscles and
the absence of pain attending
movements of all other muscles.
Lateral curvature, rickets,
aneurysm, rheumatism, and
many other disorders may sim-
ulate Pott's disease. If, however,
the two characteristic symptoms,
muscular rigidity and deformity,
be carefully studied, it is hardly
possible to make a mistake.
Fig. 237 illustrates a case of
rachitic curvature. Note the
true curve instead of the " an-
gular curvature " as seen in
Pott's disease. The true curve
also exists in chronic rheumatic
arthritis, aneur}^sm, and malig-
nant disease. Hump-back maybe
a marked feature of lateral curv-
ature, but it is caused by a projec-
tion of the rotated spine and
distorted ribs, and not by the
spinous processes. In a case of
any doubt repeated examinations should be made, and the case kept
under observation pending development.
Treatnioit. — We have seen in the case of the hip-joint that if the
parts are completely immobilized in the early stages, there is a good
prospect of arresting the tubercular process ; the same may be said of
Pott's disease. Early and complete rest of the diseased part is one of the
most effectual means of treatment. But the disease is full of complica-
tions ; its course is a long one, and, whatever methods of cure are em-
ployed, they must be persevered in through months and years. In the
early stages we must aim to arrest the tuberculous process and bring
about resolution of the inflammation which has attacked the bone. De-
formity must be prevented. In the later stages, when deformity has
already occurred, it must as far as possible be corrected ; bone-destruc-
tion having already taken place, we must aim at a cure by ankylosis ;
abscesses are to be evacuated, sequestra, if present, removed, and pres-
sure upon the cord by pus, bone, or thickened dura averted.
Rest is the most valuable of all agencies in the early stages. The
Fig. 237. — Rachitic posterior curvature (from a
photograph in the collection of Dr. Gillette).
538
SURGICAL DIAGNOSIS AND TREATMENT.
diseased vcrtebni.' suffer from the weight of the portion of the trunk
wliich hes above them, and this weight it is necessary to remove.
This is effectually accomplished by placing the patient in the recumbent
position and keeping him there. The mattress must be smooth and
hard, so as to prevent sagging of any part of the spine. To carry out
this measure thoroughly the patient must lie either upon his back or his
face ; turning upon the side or bending forward while lying on the side
Fig. 238. — Extension in the recumbent position (from a photograph in the collection of Dr.
Gillette).
twists and flexes the spine and disturbs the parts which we are trying to
keep at rest. When the disease affects the cervical vertebrae, the head
and neck should be steadied by sand-bags laid one on each side and kept
in position by tapes. The sand-bags should extend from the top of the
head to the shoulder. No pillows should be used. Extension is a
valuable adjunct to rest in the recumbent position. It can be applied
to the head and occiput by a sling connected with a weight and
a cord which runs over a pulley at the head of the bed, as shown in
Fig. 239. — Frame to secure recumbency and fixation and to allow patient to be moved about
(Hoffa).
Fig. 238. The head of the bed being raised to ensure counter-exten-
sion, the weight need not exceed one pound, or the foot of the bed
can be elevated to the extent of several inches, and extension by Buck's
method made upon the lower limbs.
Treatment by recumbency is indicated where the symptoms are
acute, and especially when the disease is in the cervical or in the lower
lumbar regions. It is often effectual in preventing paralysis or the
INJURIES, DISEASES, AND DEFORMITIES OF THE SPINE. 539
formation of an abscess. It also has its disadv^antages, one of the most
serious of which is the close confinement within doors. To obviate
this and to allow the patient to be taken into the open air various con-
trivances have been devised, one of the simplest of which is the frame
shown in Fig. 239. On this frame he can lie when in bed or be carried
into the open air without disturbing the spine. This treatment should
be persevered in until all signs of the disease have disappeared, either
by resolution or by ankylosis. Constitutional treatment directed
toward the tubercular condition should be kept up throughout. Sun-
light, fresh air, nourishing diet, cod-liver oil, phosphates, and syrup of
the iodid of iron are indispensable.
Trcatuicnt by Suspension and Piaster Jackets. — An endless variety of
appliances has been devised for producing fixation of the spine. The
simplest and most practicable of these is the plaster jacket, for the
general adoption of which we are indebted to Dr. Sayre. This method
of treatment is suitable when the disease is below the mid-dorsal ver-
tebrae and is not in a very acute stage. The object aimed at is to steady
the spine and to transfer the weight
of the parts above the disease to the
pelvis and hips. The spine is put
in the best position for receiving
the plaster jacket by suspending
the patient in the apparatus shown
in Fig. 240. The patient is stripped
and a closely-fitting woollen under-
shirt put on. He is then suspended
by means of the chin and occiput,
and in the case of older persons by
the axillary bands in addition. The
pulleys are used to deviate him so
that the heels, and if necessary the
toes, leave the floor. The shirt is
now pulled down so as to make all
parts of it smooth ; the bony promi-
nences, such as the iliac spines and
the crest of the ilium, are padded
with cotton ; and a towel, folded
into the shape of a wedge, is placed
with its broad end upward over
the abdomen. This is called the
dinner pad, and is to be removed
after the application of the jacket,
so as to leave a space which will
permit the distention of the abdo-
men after eating. The bandages
are then applied, beginning between
the trochanters and the crest of the
ilium and extending to the axillae.
The most convenient size of band-
age is three inches wide and six yards long, and about three layers are
sufficient. In about fifteen or twenty minutes after the plaster is ap-
FiG. 240.-
Tripod for the suspension of the
patient (Sayre).
540
SURGICAL DIAGNOSIS AND TREATMENT.
plied it will have set, and the patient can then be lifted by the arms and
placed upon a smooth surface, where he must lie for about an hour
to allow the jacket to become hardened.
The jacket, if skilfully applied, can be worn for ten or twelve weeks,
but should there be any suspicion that an abscess is forming or that
undue pressure is being exerted at any point, it should be removed, the
parts carefully examined, and if found satisfactory a new jacket can be
applied. Sometimes it is advisable to have a removable jacket. This
can be done by cutting it down the front, binding the edges with adhe-
sive plaster, and inserting eyelets at a suitable distance from the edge,
by which it can be laced. A ready and useful position for receiving a
plaster cast is shown in Fig. 241.
Fig. 241. — Position of patient for receiving plaster jacket (from a photograph in the collection
of Dr. Gillette).
When the disease is above the mid-dorsal region, additional support
must be given to the head and neck, and this is secured by the "jury-
mast." It consists of a vertical steel bar shaped to the curves of the
neck and head, and attached to which is the sling that supports the
chin and occiput (Fig. 242). The lower end of the bar can be incor-
porated with the plaster jacket or riveted to the leather or poroplastic
jacket. A great variety of appliances can be used instead of the plas-
ter cast. A neat and comfortable support of this kind is seen in
Fig- 243-
Treatment of CoDiplicatioiis. — The most common and serious com-
plication of Pott's disease is spinal abscess. The abscesses which form in
the lumbar and iliac regions are probably the most dangerous and most
uncertain in their course. When an abscess has formed it should not
be temporized with by aspiration, for this has been thoroughly tried
and found wanting. Two methods of treatment deserve attention :
First. Tapping and injection of iodoform emulsion. When the abscess-
cavity can be wholly evacuated and the emulsion made to penetrate
every part of it, this form of treatment is fairly successful. Many
INJURIES, DISEASES, AND DEFORMITIES OF THE SPINE. 54I
abscesses, however, burrow through the tissues and appear in situ-
ations far removed from their starting-point, and nothing but con-
tinuous drainage will effect total removal of the fluid. Second. Free
evacuation and drainage. The treatment wall depend upon the situ-
ation. Retropharyngeal abscess was formerly opened by way of the
mouth, the incision being made a little to one side of the middle line
and by means of a long straight bistouiy. The objection to this
Fig. 242. — Jury-mast and leather jacket (Gillette).
method is that the tubercular fluid is almost sure to become infected,
and true suppuration is thus added to the tubercular process. An
external opening should be made when possible, and infection pre-
vented by the strictest aseptic treatment. The incision can be made
at either border of the sterno-mastoid muscle, and the abscess reached
by dissection, care being taken to avoid the great vessels. When the
abscess is in the dorsal or lumbar region, it should be laid freely open
and explored with the finger in search of sequestra or outlying pockets.
542
SUKGICAL DIAGNOSIS AXD TREAIMENT.
Psoas abscess is generally a double abscess, divided in the middle
by PoLipart's ligament. The upper cavity is usually much the larger,
and for these reasons it is difficult to drain. The opening should always
be made in the l^ynbar region. An incision is made along the outer
edge of the e're^-^^^pin;i,' muscle, and all the structures divided down
to the quadratuS^imborum ; the tip of the third lumbar transverse
process is sought for, and opposite to this the fibers of the quadratus
and the anterior layer of the transversalis fascia are divided. The
finger is then passed along the anterior surface of the quadratus until
Fig. 243.
-Antero-posterior support for Pott's disease in the lower dorsal region (from a photo-
graph in the collection of Dr. Gillette).
the psoas and the abscess are reached. A second opening is usually
required where the abscess points. If a drainage-tube can be made to
connect these two openings, so much the better.
Paralysis. — If proper treatment be adopted in the early stages of
the disease and faithfully persevered in, paralysis will seldom occur, and
even if it be present when the case comes under the care of the sur-
geon, the prognosis need not be unfavorable : most excellent results
have been obtained by rest in the recumbent posture, and especially
when combined with extension. When these means fail and the paral-
ysis is steadily increasing, the operation of laminectomy may be con-
DISEASES AND INJURIES OF NERVES. 543
sidered, with the idea of relieving pressure on the cord and possibly
removing the diseased bone. The operation is open to serious objec-
tions, and is only justifiable when under other treatment the paralysis
continues to increase, especially that of the bladder and rectum (Kraske).
CHAPTER X.
DISEASES AND INJURIES OF NERVES.
A NERVE, be it large or small, is composed of the following parts :
I. A nerve-sheath or perineurium ; 2. A lymph-space between the
perineurium and the nerve proper ; 3. The endoneurium, composed of
offsets from the perineurium, which pass to the interior of the nerve
and there form the sheaths which surround bundles of primitive nerve-
tubules ; 4. Blood-vessels; 5. Ner\i nervorum.
Neuritis, or Inflammation of a Nerve. — When a nerve becomes
inflamed, one of the first changes is an increase in the connective tissue
of the sheath or perineurium, which is further thickened and swollen
by exudation of serum. Changes in the nerve-tubules rapidly follow ;
they undergo granular and fatty degeneration and are consequently
softened. In rare cases suppuration occurs in the nerve-structure, and
occasionally hemorrhage.
When inflammation takes the chronic form, the sheath becomes
permanently thickened and adherent to surrounding tissues. By pres-
sure it produces atrophy of the nerve-fibers, which disappear to a great
extent.
Inflammation of a nerve may be idiopathic, but its most common
causes are injury and exposure to cold. Certain diseases also give rise
to it, such as gout, rheumatism, syphilis, typhoid fever, and the exan-
themata. The nerves most commonly affected are the sciatic and the
facial. Many of the cases of sciatica and of facial neuralgia are really
due to inflammation of the nerve. Neuritis may be acute or chronic.
Syviptouis. — These are constitutional and local. Unless the neuritis
is severe and extensive the constitutional signs may be wanting. When
present they are rigors, high temperature and pulse, with delirium in
exceptional cases. The local symptoms are much more important and
constant :
I. Acute Neuritis. — The earliest indication of acute neuritis is gen-
erally an aching pain along the course of the nerve, worse at night and
increased by movement of the part. By digital pressure the nerve-
trunk, if superficial, may be felt to be enlarged and exquisitely tender,
while in rare cases the skin over it is streaked with redness. The pain
radiates over the parts to which the nerve is distributed ; the sensation
may be a tingling or numbness, a dull aching or burning. The muscles,
sooner or later, show the effect of disturbance of the nerve-current. The
w^iole of a muscle or certain of its fasciculi may be thrown into contrac-
tion. This contraction may take the form of twitching, but tonic spasm
is more common. At a later period the muscle loses its power, respond-
544 SC'KGICAL DIAGjyOSIS AXD TREATMENT.
ing imperfectly to the faradic current, and in unfavorable cases advancing
to complete paralysis and atrophy. When the neuritis is of traumatic
origin it has a tendency to extend along the course of the nerve until
it reaches the branches. These in their turn become involved, and so
the ner\cs of an entire limb may be affected. From this condition the
inflammation may subside, leaving no ill effects, or the disease may be-
come chronic, the muscles wasted, the joints stiffened, and the general
health impaired from prolonged suffering.
Diagnosis. — Rheumatism and neuralgia are sometimes difficult to
distinguish from neuritis. The pain of neuritis follows the track of a
nerve, and in confirmed cases there are sensory, motor, and trophic
changes. Neuralgia is recognized by the absence of febrile symptoms
and by the more diffuse character of the pain.
2. Chronic nvnritis is often a sequel of the acute form. The sheath
of the nerve becomes thickened and adherent to the surrounding tis-
sues ; the nerve atrophies, and may even disappear. The whole nerve
is increased in size, but in the advanced stages it shrinks to less than its
normal diameter.
Multiple neuritis is associated with alcoholism and syphilis, but it
possibly arises from the same conditions which produce simple acute
or chronic neuritis. As a rule, it begins on the extensor surface of the
legs. From feet and hands it spreads to various parts of the body.
Tenderness and redness of the skin along the course of the nerves are
characteristic, and the nerves can frequently be felt as firm cords. The
muscles lose their power and begin to waste, the reflexes disappear, and
the movements simulate those of locomotor ataxia. The course of the
disease varies. In some cases improvement takes place, but in others
the condition goes on from bad to worse, until the spinal cord becomes
invoh^ed or the patient dies of some intercurrent disease. The difficulty
in diagnosis is to distinguish it from tabes dorsalis. There may be
lightning or girdle pains and ataxic gait, but in spinal disease the mus-
cles respond normally to the electric current, while in multiple neuritis
they do not.
Treatment. — The first essential in the treatment is absolute rest. In
the case of the nerves of a limb this can be best secured by the appli-
cation of a splint. When due to rheumatism, syphilis, or other dis-
eases these must receive proper attention. For the relief of the acute
pain warm fomentations, belladonna liniment, or the subcutaneous
injection of morphin are indicated. After the acute symptoms subside
iodin, blisters, and acupuncture are useful remedies, but best of all
is the constant galvanic current. Hot or Turkish baths at night often
secure sleep. The constitutional remedies most to be relied upon are
quinin, salicylic acid, iron, and tonics. Nerve-stretching has met with
varying success, and undoubtedly has proven beneficial in many cases.
When there is much hyperemia, or in the rare instances in which there
is suppuration in the nerve-sheath, the nerve should be cut down upon
and the sheath laid freely open.
Neuralgia signifies pain in a nerve. It is of an acute paroxysmal
character, coming on suddenly, and as suddenly disappearing. Many
of the cases diagnosed as neuralgia are really neuritis. It is only when
the symptoms of inflammation are wanting, and when there is an ab-
DISEASES AND INJURIES OF NERVES. ^ 54$
sence of disease or injury to the parts supplied by the affected nerve,
that we are justified in pronouncing the pain neuralgic. In a very
large number of cases the cause is unknown. The following, however,
may be set down as among the most frequent causes : i. Injury to the
nerve, often obscure ; 2. Irritation by a foreign body ; 3. Pressure of a
tumor; 4. Compression by a cicatrix; 5. Certain toxic conditions of
the blood, as in malaria, lead-poisoning, or mercury-poisoning ; 6. Over-
distention of veins near nerves as they pass through long bony canals,
as in the intraorbital canal ; 7. In some instances the neuralgia is reflex,
irritation in one nerve producing pain in another.
Symptoms. — Pain of a burning, cutting, darting, or boring character
along the course of a nerve, continuous, remittent, or intermittent, is
the most prominent symptom. Pressure, as a rule, increases the pain,
but in some cases gives relief From a surgical standpoint neuralgia
is seen chiefly in three forms : (i) neuralgia of the trifacial nerve or tic-
douloureux ; (2) sciatica ; (3) the neuralgia of stumps and scars.
Tic-douloureux may be confined to one or all of the branches of the
fifth pair, and is often attended with the most excruciating pain. The
slightest cause, such as a draft of cold air, a slight touch, or a loud
noise, may suffice to bring on a paroxysm. The movements of masti-
cation are likely to start up the pain, so that the patient is in dread
every time he eats.
Sciatica is a painful and common affection. It is frequently a
functional neurosis, but autopsies have shown that in some cases it is
an organic disease characterized by softening of the nerve-tissue, dila-
tation of the vessels, and exudation of serum into the sheath. In cases
due to functional neurosis no anatomical changes are found.
For diagnostic purposes it is convenient to divide sciatica into three
varieties: i. Sciatic neuralgia; 2. Sciatic neuritis; 3. Symptomatic
sciatica — /. e. sciatica which is the result of some other disease.
Symptoms. — Pain is the leading symptom. It is usually worse at
night, and in some cases this appears to be because the patient cannot
bear to extend the leg while in bed. During the day there is less suf-
fering, especially if the patient remains quiet ; but standing or walking
speedily aggravates the pain. Tenderness can generally be detected at
the four following points : the sciatic notch, the lower margin of the
gluteus maximus, the popliteal space, and the head of the fibula.
When, even after years of suffering, the disease produces no atrophy
of the muscles of the limb (except what we might naturally expect
from want of use), we may safely assume that the disease is of the
neurotic type. If there be a iiairitis, trophic changes will develop,
especially atrophy of the muscles with reaction of degeneration (Nonue).
The patellar reflex is diminished. Double sciatica is very significant of
spinal disease or of general disease of the nervous system, as tabes, or
it may be associated with syphilis or diabetes. The urine should be
examined for sugar. " It has been shown by Braun and others that
sciatica may react upon the vaso-motor nerves and cause a small
amount of sugar to appear in the urine, which may subside as the
pain ceases to be troublesome. Robson Roose reports 3 cases in
which this symptom was present. If, then, we find sugar in the urine,
two things may enable us to determine whether the sciatica is a cause
35
546 SURGICAL DIAGNOSIS AND TREATMENT.
or a symptom — viz. the knowledge as to whether any sugar was
present before the appearance of the sciatica, and inquiry as to the
amount of sugar present, and whether it is controlled by the cause
of the sciatica." '
Neuralgia of scars may be divided into two classes. In one form
there is localized pain, excited by pressure on a particular spot, and
there can generally be felt an induration or adhesion of the scar to the
underlying bone. In the other form the pain is more widely diffused,
attentled with superficial hyperesthesia, intermittent in character and
accompanied by jerkings. This form is found in anemic individuals,
mostly women, and is of constitutional origin, while the first is purely
local. The importance of diagnosticating between these two forms is
that the local variety can be best treated by operation, while the con-
stitutional form will not be benefited until the system is put into better
condition. In a case of this kind mentioned by Moullin amputation
was resorted to four consecutive times, and the nerves stretched almost
to the point of tearing them out of the stump, and still the pain con-
tinued.
Treatviciit. — When the cause can be discovered its removal is the
first point in treatment. If the disease is due to malaria, quinin is
indicated, large doses often being required. When there is anemia iron
should be employed. In the majority of cases the suffering can be
relieved by full doses of quinin, acetanilid, phenacetin, chloral, or
morphin, while applications of aconite, belladonna, veratria, or menthol
can be used locally. The general health should in all cases be im-
proved by tonics, fresh air, and easily digested food. In sciatic neur-
algia subcutaneous nerve-stretching is indicated when ordinary means
fail. The patient is put under an anesthetic, and while the leg is kept
in full extension the thigh is forcibly flexed upon the body. Stretching
of the nerve through an incision has a more marked effect, probably
from the fact that adhesions of the nerve and its sheath are more com-
pletely broken up.
Epileptiform neuralgia is another form requiring careful study. It
often resists every form of treatment except operative, and even that
often produces only temporary benefit. It is distinguished from other
forms by the twitching of the facial muscles. The teeth may be ex-
tracted, one by one, without affording a particle of relief Morphia
only makes the condition of the patient worse and worse, and other
anodynes are useless. Galvanism, persistently employed, will benefit
some cases.
Nerve-stretching has had its advocates, and many satisfactory results
are reported. When the superior maxillary is the branch involved,
excision of Meckel's ganglion is a justifiable procedure, although even
after this formidable operation the relief obtained will not probably last
more than a few months. The ganglion can be reached and excised
from the front by trephining the antrum. A crucial excision over the
infra-orbital foramen is made down to the bone. From immediately
below the foramen a half-inch disk is removed by a trephine. The
nerve is then traced back to the posterior wall. Through this wall a
second trephine opening is cautiously made and the ganglion is ex-
1 Dr. D. O. Thomas : Pacific Med. Joiirn., 1895.
DISEASES AND INJURIES OF NERVES. 547
posed. The ganglion should be removed, together with its posterior
dental branches, and the whole of the infra-orbital.
When the inferior dental is the nerve involved, it can best be reached
by the mouth, and operation in this region has the advantage of leaving
no unsightly scar. Having first inserted a gag and forced the mouth
as widely open as possible, make an incision along the projecting fold
of mucous membrane which passes from one jaw to the other behind
the last molar tooth. By pushing the finger between the internal ptery-
goid muscle and the ramus the sharp spine of bone can be felt which
is the landmark for the orifice of the dental canal. A blunt hook or an
aneurysm needle is then used to draw the nerve forward, when it can
be separated from its attachments and divided.
Injuries of Nerves. — Although, as a rule, nerves are well pro-
tected, they nevertheless are liable to a variety of injuries. Tumors
may compress a nerve, as, for instance, aneurysm of the aorta pressing
upon the recurrent laryngeal. In dislocation of the shoulder the head
of the humerus may compress and contuse the brachial plexus. When
fracture occurs, one of the fragments may compress and even lacerate
a neighboring nerve. A drunken man falling asleep with his arm over
the back of a chair has had the limb paralyzed from pressure upon the
brachial plexus. The pelvic nerves are frequently injured from long-
continued pressure during delivery, and the seventh nerve of the child
has been injured during the application of forceps, with facial palsy as
a result.
Svinptoms. — Compression or contusion of a nerve is recognized by
the tingling sensation, which is commonly spoken of as " pins and
needles." In more severe contusions the functions of the nerves may
be lost and more or less marked paralysis be manifested, or a neuritis
may be developed along the course and distribution of the nerve. Much
information can be gained by the employment of the faradic current.
Should the muscles respond readily, the injury is probably slight.
Should there be no response and should the muscles begin to atrophy
and degenerate, the prognosis is unfavorable.
Treatment. — Removal of the cause, when possible, is the first indi-
cation. To restore the function of the nerve absolute rest is of the
utmost importance. In the case of a limb complete immobilization by
a splint is good treatment. When pain is intense hypodermic injections
of morphin and atropin will be required. In prolonged and obstinate
cases arsenic and the use of the galvanic current will prove valuable
remedies.
Wounds of Nerves. — A nerve may suffer complete division or
it may be only lacerated. In many cases it is a complication of a large
wound which divides other structures. It is very important to bear in
mind that when a nerve is severed degenerative changes immediately
begin, hence the importance of uniting the divided ends of a nerve at the
earliest possible moment. Indeed, it is just as important to perform this
operation as to approximate the fragments of a broken bone. Common
causes of nerve-wounds are fragments of glass, gunshot wounds, and
punctured wounds produced by knives, scissors, needles, or splinters
of wood.
Symptoms. — The best evidence of all is afforded when the divided
548 SURGICAL DIAGNOSIS AND TREATMENT.
or partially divided nerve is visible in the wound. In many cases the
wound is small or punctured and we cannot see the nerve. Diagnosis
must then rest upon the effects produced, not only upon the nerve itself,
but upon the area to which it is distributed. These may be considered
as immediate and remote :
I. Ivuncdiatc Effects. — Pain is of varying significance. In some
cases it is so slight as to be scarcely noticeable ; in others, even when
the nerve is small, the suffering is so intense as to produce profound
shock. Such a condition is common in gunshot wounds. A marked
s}-mptom immediately after the injury is anesthesia, and in most cases
it can be traced over the parts supplied by the nerves in question. At
the same time too much reliance must not be placed upon this evidence,
for it is possible to find sensation remaining after complete division of
a nerve-trunk.
Blindfold the patient and place the limb at full extension on a firm
support, so that no vibration can be communicated. Tactile, thermic,
and electrical stimuli can then be successively applied and their effects
carefully noted. For the examination of tactile sensation a light touch,
such as that communicated by a pencil, a feather, or a pin, may be
used. The esthesiometer is an instrument for testing sensation, and
consists simply of a pair of compasses fitted with a graduated scale
which measures the distance to which the two points are separated.
An ordinary pair of dividers will answer the purpose. In using the in-
strument care must be taken to touch the skin at the two points
simultaneously, and each time the result must be compared with the
corresponding part on the opposite side of the body. The test is to
ascertain the ability of the patient to distinguish the ends of the instru-
ment as two points or as one. Different parts of the body in health
give different results when thus tested. At the end of the finger two
points can be recognized when the distance between them is only 2 to
2\ mm., while on the back 40 to 70 is the minimum. A difference
\y'A\ also be observed, depending upon whether the instrument is placed
transversely or longitudinally to the axis of the limb. In a typical
case three areas can be distinguished : {a) the area of anesthesia (total
loss of sensation) ; {b) the area of paresthesia (partial loss of sensation) ;
(yC) the area of normal sensation. In some cases there is observed an
area of supplementary sensation. This is where a nerve-trunk is
divided and its current cut off, yet sensation is not impaired. It has
been explained on the theory that the nerves anastomose, and the
nerve-current is maintained just as the collateral circulation in the case
of a divided arter)\ In studying a case it is customary to mark the
area of total anesthesia by a dark shading, while that of partial anes-
thesia is indicated by a lighter shade.
Having completed the examination by the sense of touch, other
stimuli may be employed. Heat is used by taking a sponge and dip-
ping it in hot water or by placing the limbs in water of a known tem-
perature. A very simple and ready method is to first breathe upon the
part and then gently blow upon it. If more accuracy is desired, the
thermesthesiometer can be employed. It consists of two cylindrical
wooden vessels with metal buttons, into which water of differing tem-
peratures is poured ; a thermometer in each registers the degree of heat.
DISEASES AND INJUR] ES OF NERVES. 549
Two test-tubes can be utilized in the same manner. Lastly, electricity is
employed. When tactile and thermic stimuli fail the nerves will often
respond to the electric brush.
Examination as to loss of motion is much simpler. In the case of
the forearm the patient is asked to grasp the hands of the surgeon,
when any difference of muscular power is readily detected. Any given
group of muscles may be tested by asking the patient to use the mus-
cles while the examiner resists the movement.
Reflex paralysis is a very interesting phenomenon observed in some
cases. Wound of a nerve in the lower extremity may produce paral-
ysis of the opposite limb, or even of both limbs on the opposite side.
This has been explained on the theory that the nerve-centers of motion
and sensation have become exhausted.
2. Remote Effects. — To the observations of Drs. Mitchell, Morehouse,
and Keen during the American Civil War we are indebted for much
valuable knowledge on this point. Loss of motion is more marked and
more persistent than loss of sensation. The muscles soon show signs of
weakness and wasting, which steadily increase to the degree of com-
plete palsy. Gradual and steady contraction is observed in some cases,
and deformity is the result. The changes in sensation are marked by
anesthesia, or it may be hyperesthesia or intense pain. In the area
supplied by the nerve, and at a distance from the seat of injury, cha-
racteristic changes may be observed. The skin has an appearance as
if varnished. It is generally red and dry, or it may secrete an acid,
foul-smelling perspiration. The hair of the part becomes scanty and the
nails curve in both directions. Sometimes ulceration takes place under
and around the nail, and even gangrene of the ends of the digits has
been observed. A peculiar burning pain has been described by Mitchell
under the name of " causalgia." So exquisite is the sensibility in this
condition that even to point at the limb so affected causes the patient
to draw away in terror. Keeping the part cool and moist relieves the
causalgia, and patients often wrap the hand in a moist handkerchief or
wear a glove which is kept constantly wet. In certain cases eruptions
resembling chilblains or eczema are observed.
One of the most striking effects of nerve-degeneration is perforating
ulcer of the foot. It is observed in leprosy, in locomotor ataxia, in
fracture of the spine, but it may occur when there is nerve-degeneration
from any cause. The ulcer is painless and usually attracts httle atten-
tion. It begins as a corn, the center of which breaks down, forming a
small opening. It may remain small in circumference, but if a probe
be inserted it will be found to pass deeply into the tissues or the meta-
tarso-phalangeal articulation. Placing the foot in an elevated position
and enjoining perfect rest will, in most cases, effect a speedy cure. The
ulcer is liable to recur, however, as soon as the patient resumes the use
of the limb.
Treatment. — In any wound in the vicinity of a nerve-trunk a careful
examination should be made of the divided tissues. If the nerve is
found to be severed, its two ends should be brought together in as close
apposition as possible and united by chromicized catgut or fine silk.
In the case of small nerves the suture must pass through the substance
of the nerve. When the trunk is large the sheath should be sutured
550 SURGICAL DIAGNOSIS AND TREATMENT.
as well. The needle should be round and as small as possible. Per-
fect immobilization of the limb on a splint is necessary, and the wound
must be treated with strict asepsis. In favorable cases the function of
the nerve is restored with remarkable rapidity ; in others it may be
long delayed. The time varies from two days to many months.
Sensation is the first to return. In cases of long standing the prox-
imal end of the nerve becomes bulbous, while the distal end is
slightl}' changed. After dissecting out the divided ends of the nerve
the bulbous portion must be removed and a small portion cut off the
distal end. They can then be stretched sufficiently to bring their freshly-
cut surfaces together and sutured as already described.
When the ends are so widely separated that they cannot be brought
together with a moderate degree of stretching, one of several methods
may be resorted to. One of the ends of the severed nerve may be
split for a certain distance, and the nerve-flap turned over to bridge the
intervening space. The space has been bridged across by catgut
sutures with the idea of furnishing a " scaffolding " along which the
new nerve-tissue may be reproduced. This method has not fulfilled
the hopes formed of it.
Transplantation of a section of nerve has been fairly successful.
This is done by taking a piece of nerve from one of the lower animals,
accurately fitting it to the breach, and stitching it there, or the nerve
can be removed from a freshly amputated limb.
Injuries of Special Nerves. — i. Facial. — The intra-cranial
lesions of this nerve have already been referred to. The injuries which
affect the nerve after it has left the Fallopian canal (extra-cranial
lesions) are of great importance and of common occurrence.
The nerve may suffer injury by gunshot wounds or other trauma-
tisms, but the paralysis of this nerve most frequently met with is due
to the influence of cold, and is sometimes called the rheumatic form.
A person who is exposed to a draft of cold air, as in sitting by an open
window or travelling in an open carriage and exposed to a strong side
wind, or passing from a heated room into the extreme cold of a winter's
night, is surprised after a few hours to find that the appearance of his
face is changed in a remarkable manner. He can only wrinkle one
side of his brow ; one eye remains open in spite of his efforts to close
it ; he cannot whistle, for in attempting to do so one side of his mouth
is properly puckered, while the other just forms a loop ; the mouth is
drawn to the sound side. While eating the food gets between the
cheek and the teeth on the affected side, and has to be removed with
the finger.
The diagnosis must settle the following points :
1. The Side of the Face which is Affected. — This question may seem
superfluous, but there are cases in which care is necessary before coming
to a decision. In old persons the skin is so wrinkled and inelastic that
the muscles of the sound side cannot alter the expression, and the only
change in appearance is a rounded, more youthful expression on the
paralyzed side.
2. The Part of the Nerve Involved. — When the paralysis is due to
an intra-cranial lesion there is facial paralysis, but there is something
more, such as disturbance of the sense of hearing and of taste, paraly-
DISEASES AND INJURIES OF NERVES. 55 I
sis of the velum palati, etc. The following points, formulated by Hirt
and based upon Erb's diagram, will aid us :
" {a) If the lesion be between the exit of the facial stem (from the
pons) and the geniculate ganglion, we shall find a paralysis of the
velum palati, abnormal acuteness of hearing, and diminished salivary
secretion.
" (/;) If the facial be affected in the region of the geniculate ganglion
itself, then we find, in addition to the just-mentioned symptoms, altera-
tions in the sense of taste.
" {c) A lesion between the geniculate ganglion and the stapedius
nerve produces the symptoms described in {a) and (/^), but no abnor-
mality of the velum palati.
" \d) A lesion between the origin of the nerve to the stapedius
muscle and the giving off of the chorda tympani give alterations in
the sense of taste and diminished salivary secretion, but no abnormality
of hearing or the velum palati.
" {c) If, finally, the nerve is diseased below the giving off of the
chorda in the Fallopian canal, we only find paralysis in the distri-
bution of the posterior auricular branch, without any trouble with '
taste, hearing, the condition of the velum palati, or the secretion of
saliva."
When it has been determined that the nerve-affection is extra-
cranial and due to exposure, an electrical examination of the mus-
cles should be made before expressing an opinion on the probable
duration of the affection. The following are the chief points to guide
us :
" I. If W'e find no changes either in faradic or in galvanic excita-
bility, the prognosis is favorable ; recovery in from seven to twenty
days (light form).
" 2. If we find the faradic and galvanic excitability of the nerve
diminished, but not lost, the galvanic excitability of the muscles,
however, increased, and the usual formula of contraction changed
(A. C. C. > C. C. C), then the prognosis is relatively favorable ; recovery
in from four to six weeks (intermediate form of Erb).
" 3. If the reaction of degeneration be found — /. c. if the faradic and
galvanic excitability of the nerve and the faradic excitability of the
muscles be lost, while there is an increase in the galvanic excitability
of the muscles associated with qualitative changes and changes in the
mechanical excitability — then the prognosis is relatively unfavorable,
and for recovery two, four, six, eight, even twelve, months may be
required (grave form). These are those bad cases in which secondary
contractures and spasmodic twitchings of the muscles also appear,
which, according to Hitzig's opinion, are to be referred to an obscure
abnormal irritation of the medulla oblongata. It is well to know that as
convalescence begins voluntarily motion may return long before the
electrical excitability, so that often the patient is able to perform some
slight voluntary movements before faradic stimulation provokes the
least contraction." '
Treatment. — In the majority of cases of facial paralysis brought on
by exposure to cold no treatment is needed, as the nerve returns to a
1 Op. cit., p. 90.
552
SURGICAL DIAGNOSIS AND TREATMENT.
healtliy cvondition and the paralysis passes off in due time. When the
disease is more protracted, electricity
affords the best results and should
be persevered in. Both galvanic and
faradic currents are valuable. The
motor points from which the prin-
cipal facial muscles can be stimulated
are shown in Fig. 244.
2. The Pneumog-astric. — The
pneumogastric nerve has been ligated
in operations for tying the carotid
artery, and its recurrent laryngeal
branch has been divided in removing
goiters. The effects of this accident
are hoarseness and change in the voice
from paralysis of the vocal cord of
the injured side. Should both re-
current laryngeal nerves be severed,
suffocation would result from paral-
ysis of the larynx, and an immediate
tracheotomy is necessary to save the
patient's life. Division or ligation of one pneumogastric is not a very
serious matter, as it only produces hoarseness.
Fig. 244. — Some of the so-called " motor-
points " on the face and neck (after Hirt).
Fig. 245. — Right-sided serratus paral-
ysis (after Eichhorst).
Fig. 246. — The same case with the arms raised
(after Eichhorst).
3. The posterior thoracic arises from the fifth and sixth cervical
nerves, and supplies the serratus magnus muscle. A lesion of this
DISEASES AND INJURIES OF NERVES.
553
nerve, producing paralysis of the muscle, is sometimes observed in
persons who carry hea\y loads on the shoulder, or in certain occu-
pations, such as mowing, shoemaking, and tailoring, which produce
over-exertion of the serratus ; sometimes the paralysis appears to follow
an exposure to cold.
Syniptouis. — When the arm is at rest the scapula appears elevated,
and its lower angle is abnormally near the v^ertebral spines (Fig. 245),
this position being due to the action of the rhomboids, the levator
angulae scapulae, and trapezius, which are the muscles antagonizing the
serratus. When the arm is raised in front of the chest the posterior
border of the scapula is tilted outward, so that the inner surface of the
bone can be felt (Fig. 246). This form of paralysis is extremely ob-
stinate, and may last for weeks, months, or even years, in spite of all
treatment.
4. The Musculo-spiral Nerve. — Paralysis of this nerve produces
the very characteristic deformit)' known as wrist-drop (Fig. 247). Its
most common cause is a fracture of
the humerus, which involves the mus-
culo-spiral groove. The extensor
muscles become paralyzed and the
patient is unable to rai.se his hand
into line with his outstretched arm.
When the injury is above the branch
supplying the supinator longus,
flexion and supination are impaired,
but not entirely lost, as the biceps
and supinator brevis are still intact.
5. The Radial Nerve. — This nerve
is sometimes divided just above the
wrist on the back of the forearm. It
produces no paralysis, as it supplies
no muscles : it is marked by loss of
sensation in the skin over the meta-
carpal bones and first phalanges of the thumb and fore finger.
6. The Median Nerve. — This nerve may be divided in any part of
the forearm, but especially above the wrist. If the injury be above the
elbow, all the flexors and pronators of the arm will be paralyzed, except
the flexor carpi ulnaris and the ulnar half of the flexor profundus. The
muscles of the thumb, except the adductor and half of the flexor brevis
pollicis, will also be affected ; flexion of the wrist on the radial side will
be lost, and the thumb cannot be opposed to the other fingers. The
changes in sensation are as follows : On the palmar surface anesthesia
or paresthesia will extend over half of the palm and the palmar surface
of the thumb, index, and middle finger, the radial side of the ring finger
except a small part at its tip. On the posterior surface anesthesia
affects the whole of the fore and middle fingers and the radial side of
the ring finger (Figs. 248, 249).
7. The Ulnar Nerve. — Paralysis of this nerve occurs in certain
occupations in which the workmen are obliged to press the elbow
firmly upon a hard surface or to use the ulnar side of the hand in
striking instruments. It may also suffer injurj^ or division at the
Fig. 247. — Paralysis of musculo-spiral
nerve after fracture of the humerus (" wrist-
drop "); but when fingers have been flexed
into palm, a, they can be extended, b, at
first inter-phalangeal joints by lumbricals
and interossei, which are supplied by the
ulnar and median nerves (Erichsen).
554
SURGICAL DIAGNOSIS AXD TREATMENT.
elbow, the upper arm, or, most frequently, just above the wrist. Paral-
ysis of both motion and sensation follows.
JSIotor Paralysis. — In the forearm the flexor carpi ulnaris and the
inner half of the flexor profundus are paralyzed. In the hand the
Ml
/
>f ^
Fig. 248. — Section of median nerve :
regions of anesthesia and dysesthesia on
dorsal surface of hand (Bowlby).
Fk;. 249. — Section of median nerve :
areas of anesthesia (heavy shading) and
of dysesthesia (hght shading) on palmar
surface of hand (Bowlby).
whole group of muscles forming the hypothenar eminence, the two
ulnar lumbrical muscles, the adductor pollicis, half of the flexor brevis
pollicis, and all of the interossei are affected. The muscles soon be-
come atrophied ; the interosseal spaces on the back of the hand
Fig. 250. — Paralysis of ulnar nerve from wound at A ; contracture of common extensor with
posterior luxation of first phalanges ; B, head of metacarpal bone (Duchenne).
become hollowed; and, if wasting is confined to the interossei and
lumbricales, their antagonists, the extensor communis digitorum and
the flexor digitorum, produce that disagreeable deformity known as
claw-hand or main en griffe. It consists in a dorsal flexion of the first
DISEASES AND INJURIES OF NERVES.
555
phalanges and a complete palmar flexion of the second and third
(Fig. 250).
Sensation. — Allowing for changes in the distribution of the nerve in
different individuals, sensation will be lost over the ulnar portion of the
skin of the hand, the whole of the little finger, and the ulnar half of
the ring finger, except a small point at the tip which is supplied by the
median nerve (Fig. 251).
Fig. 251. — Loss of sensation on anterior and posterior surfaces of hand after division of the
ulnar nerve (Bowlby).
8. The Sciatic. — This nerve is seldom injured except in gunshot
wounds. When the external popliteal branch is divided, as sometimes
happens in tenotomy of the biceps, the muscles of the anterior surface
of the leg are paralyzed, so that the foot drags in walking. It can be
neither flexed, abducted, nor adducted. The toes are constantly trip-
ping over prominences on the floor, and to overcome this the patient
forms the habit of rai.sing the thigh higher than usual. In the course
of time the contraction of the calf-muscles are apt to produce talipes
equinus or talipes equino-varus. This nerve may be injured by pressure
where constant kneeling is required, as in asphalt-paving.
The internal popliteal branch supplies the muscles of the back of
the leg and the sole of the foot. Injury to this nerve interferes with
plantar flexion of the foot and with flexion and lateral motion of the
toes. The patient is unable to stand on tiptoe. If the interossei mus-
cles are paralyzed, the first phalanx of each toe is dorsally flexed,
w'hile the second and third are in plantar flexion, and a deformity is
produced similar to the claw-hand already described.
55^ SURGICAL DIAGNOSIS AND TREATMENT.
CHAPTER XI.
INJURIES AND DISEASES OF THE RESPIRATORY SYSTEH.
I. THE NOSE.
Bxternal injuries of the nose are of importance in the surgery
of the respiratory tract only as they affect the nasal orifices. They
may be the result of falls, blows, gunshot wounds, burns, and scalds,
and if deep and extensive tend to bring about, by the contraction of the
resulting cicatricial tissues, the partial or complete closure of one or
both nasal orifices.
Treatment is preventive rather than curative. Occlusion should be
prevented and the caliber of the nostril maintained by the insertion of
sponges, bougies, etc. Repeated dilatations may be necessary, and
also incision of the cicatricial tissue at various points.
Elephantiasis occurs very rarely — only in middle and old age,
attaining at times excessive proportions.
The treatment is excision. It has little or no effect upon the
respiratory tract, being unlike in that respect the much graver affection
which we shall next consider — viz :
Rhino-scleroma. — This disease, starting at the edge of the nostril,
may invade not only the external parts of the nose, but also the upper
lip, septum, and nasal passages, and even the mouth, larynx, and
pharynx. It is due to the action of a bacillus which is capable of
inoculation. It is really a tumor of a densely hard, smooth sort,
raised somewhat above the cutaneous or mucous surface, and may
appear as one patch which enlarges slowly, or as several with slight
separations between, giving them a lobulated appearance. There is
little if any ulceration or pain. It may not differ markedly from the
skin in color, or it may be somewhat darker of a grayish-pink color.
The growth, whether within or without, gives excessive deformity to
the nose, and hence tends to occlude the nasal passages.
It differs from other tumors and malignant growths by its great
hardness, and can be differentiated from syphilis by its slow growth
and resistance to specific treatment. Treatment is of little avail. Dou-
trelepont reports a case which was cured by repeated inunctions of
lanolin containing i per cent, of corrosive sublimate.
If the nasal passages are obstructed, portions of rhino-scleroma
therein can be removed by excision or caustics, and tracheotomy must
be performed if it reach as far as the larynx. Operations in the nasal
passages must be frequently repeated, for the growth recurs after
removal.
Bxtemal tumors of the nose may be either benign or malignant,
epithelioma being a common type of the latter class. Lupus is also
common. These diseases present no characteristics differing from those
that they manifest in other parts of the body, and their treatment is the
same as elsewhere. They have no bearing upon the respiratory tract,
except when by the contraction of cicatricial tissue they cause obstruc-
INJURIES AND DISEASES OF THE RESPIRATORY SYSTEM. 557
tion to respiration. In that case the treatment is the same as for
external injuries.
Internal Injuries. — The internal parts of the nose may be impli-
cated in traumatism of the soft parts of the face, or internal injuries may-
be due to the entrance of foreign bodies through the anterior nares, occa-
sionally through the posterior nares. Through the integument various
substances may be introduced as the result of an accident, as pieces of
glass, splinters, fragments of weapons, bullets, shot, etc. Through the
posterior nares an act of vomiting may force foreign bodies into the nose.
Through the anterior nares various articles, as buttons, beads, peas,
beans, bits of wood, etc., are often pushed by children and insane people.
Symptoms. — If these foreign bodies are rough and jagged, an acute
rhinitis is set up. If they absorb moisture and swell, great discomfort
and distress from pressure and pain may result. If they are smooth
and hard, no immediate discomfort may be felt. In addition to rhinitis,
more remote symptoms may manifest themselves, as pain, headache,
facial neuralgia, and finally a fetid catarrh. When the latter condition
exists, a thorough washing of the nasal cavity is necessary more accu-
rately to determine the nature of the offending substance, and par-
ticularly if no history of a foreign body in the nasal passage can be
elicited. If the patient can furnish a history of a foreign body, the case
is comparatively easy.
Necrosed bone in the nasal cavity may produce a like train of symp-
toms, though probably in that case others of a constitutional sort
would afford ground for a differential diagnosis.
In any event, the existence of a profuse nasal discharge, giving
evidence, as it does, of intense irritation, would lead the surgeon to
institute a thorough examination of the nasal cavity and thus bring to
light the foreign body.
Treatment. — The foreign body must be removed. Local anesthetics
may be sufficient, but in the case of children, with whom the greater
number of such accidents occur, ease, certainty, and rapidity of ope-
ration are best secured by completely anesthetizing the patient. Then
a small pair of forceps, especially one consisting of separate blades that
may be carefully adjusted, is usually sufficient for its removal. A
snare, a hook, a probe, a curved bougie, a loop of wire, or other con-
trivance suited to the nature, size, and situation of the object and the
ingenuity of the operator, will each at times serve the purpose. Gen-
erally the foreign body can be best reached from the anterior nares.
Sometimes, however, all attempts in this direction are unavailing,
serving only to push it farther away. Then other methods of pro-
cedure are open to the surgeon — either that of pushing it backward
through, or of withdrawing it from, the posterior nares by some suit-
able instrument, or of pushing it forward by a curved, slender, flexible
instrument thrust up behind the velum. If you push it backward, be
careful that it does not enter the larynx.
If the foreign body is not firmly impacted, some simple method may
effect its dislodgement. Sneezing may loosen it. The action of an
emetic when the mouth is closed has been known to force it forward.
A thorough douche or strong injection through the nostril or through
the posterior nares may drive it forward. Sometimes by the softening
558 SCKGICAL DIAGXOSIS AND TREATMENT.
of the surrounding parts from ulceration its removal is in time effected
without instrumental interference.
If the irritation which it produces is \Q.ry intense, and none of the
methods mentioned effect its remo\al. it ma)' be necessarj' to resort to
an operation the character of which will be determined by the location
and size of the foreign bod}-. The ala of the affected nostril may be
dissected away from the face and lifted up, or there may be a median
incision, or the whole nose ma)' be raised after an incision through the
margin of the upper lip.
Parasites within the nasal cavities constitute a species of foreign
bodies fortunately less common in temperate than in tropical climates.
Ascarides lumbricoides may find entrance through the posterior nares,
either during the act of vomiting or b)' creeping up through the ali-
mentar)' tract. The Lucilia hominivora is a common insect of the class
of ^luscids which deposits its eggs even in healthy noses. A fetid
catarrh b)' its odor attracts flies, and they lay their eggs within the
nostrils while the person is sleeping. The larvje develop rapidly,
favored by the warmth and moisture. Centipedes, earwigs, leeches
hav^e all been demonstrated within the nasal cavities.
The mucous membrane is first intensel)^ hyperemic from the pres-
ence of such intruders, then it ulcerates, and is finally destroyed, its
destruction being followed by necrosis of bone and cartilage even to the
point where meningitis is set up.
Symptoms are, first, itching, then a sense of fulness and discomfort,
soon followed by headache and a severe throbbing, and often agonizing
pain. Delirium, coma, and death may rapidly ensue.
The nose, throat, face, palate, and eyes are swollen and distorted,
and blood)- and fetid discharges occur ; abscesses form through which
maggots are discharged.
Diagnosis is clear upon demonstration of the parasites.
Treatment. — ]\Iorphin may be used to relieve the intense pain.
Calomel by insufflation, and injections of turpentine, alcohol, and
tobacco, have been found useful. Chloroform, either diluted or of full
strength, is used as a wash in the nasal passages. Because of the
violent irritation which this drug produces upon mucous membranes,
it is best to produce local anesthesia by cocain before using a douche
of full strength. Disinfectant washes should follow the use of chloro-
form. If the parasites make their way into any of the sinuses, an
operation will be necessar)*.
Rhinoliths are nasal calculi, and they differ from calculi formed in
other parts of the body only in so far as they are modified by location.
The nucleus is a particle of solid foreign matter lodged in the nasal
passage. It may be something which finds its way into the nostril
from without, or it may be a bit of inspissated mucus or a pathological
product which has been retained within the cavity. Successive strata
of calcareous matter derived from the alkaline salts of the secretions
and blood are deposited around it until a calculus is formed, its size
depending upon the shape and dimensions of the space in which it
originates. Rhinoliths may be so small as not to be noticed, or they
may be so large as completely to occlude the nasal passages and weigh
even so much as four drams. Thev are sometimes ver\' hard, but gen-
INJURIES AND DISEASES OF THE RESPIRATORY SYSTEM. 559
erally are quite friable, and may even have a central portion not so
hard as the outside. They are generally found in the lower portion
of the nose, either next to the septum or in the inferior meatus, though
it is not uncommon for them to lie in the middle meatus. They are
usually unilateral.
The commonest symptoms are those which attend partial or com-
plete occlusion of the nasal passage, although, since the process of
formation of a rhinolith is gradual, the symptoms assert themselves
more slowly than in other forms of occlusion. Pain is constant,
increasing in severity and in the extent of its effects with the growth
of the calculus.
If the concretion is large, the external appearance of the nose may
be altered. A constant symptom, due to the irritation, is a nasal dis-
charge, muco-purulent or even sanious. Respiration is interfered with,
and there may be anemia.
In diagnosis perhaps the commonest mistake is to regard the case as
one of ozena or a common fetid catarrh, judging from the character of
the discharge. If the nose is seen to be distorted or if a thorough rhino-
scopic examination is made, this error may be avoided. Calcareous
degeneration of the mucous membrane is to be differentiated by the
fact that the rhinolith is movable ; osteomata, by their being immov-
able and by their greater hardness. Necrosis of bone is usually less
painful locally, attended by pronounced constitutional symptoms, and
inspection gives different results. Polypi must be differentiated by
inspection. Absence of the characteristic cachexia and their slow
growth distinguish them from cancer.
The treatment is removal, differing in no respects from that of other
foreign bodies.
Polypi occur more frequently in the nasal fossae than do all other
growths combined. They are mucous or gelatinous in character, and
are to be regarded as myxomata, or, if slightly fibrous, as fibro-myx-
omata. In color they are pale pink, grayish, or of a blue tinge. They
are soft, pulpy, semi-transparent, and easily torn. They contain few if
any blood-vessels, and no nerves. A simple polypus has no connection
with bone or cartilage, but grows only from the mucous membrane,
most commonly from that covering the middle turbinated bone ; the
next most common site is the superior turbinated bone and middle
meatus, and rarest of all the septum. They are covered with epithe-
lium, that of the mucous membrane, and hence are often ciliated. They
are pendunculated, and really have but one original place of attach-
ment. If they have or appear to have more, it is because, from their
large size, they have become pressed against the other polypi, the
septum, or other parts, and by ulceration and healing have either
formed a second attachment at some late period in their growth or
merely seem to do so — an appearance corrected on close inspection.
They may be single, either large or small in size, but are quite as apt
to be multiple, and they are of varied form, determined by the space in
which they grow. A single small polypus is pyriform in shape, the
larger portion downward because of the weight of its contents. The
constant pushing downward and forward of the epithelium of the
mucous membrane from a single point makes a narrow stem-like part
560 SURGICAL DIAGNOSIS AND TREATMENT.
near the place of orii^in. Pressure from one or several directions
naturally alters its shape and apijcarance.
The cause o{ polypi is a matter of much doubt. In general it may
be said that the immediate cause is some irritation in the nasal pas-
sages, possibly a purulent discharge from the sinuses, and only theories
can be advanced to explain why an irritant should produce polypi in
one case and not in another. Something additional as a predisposing
cause must exist. ■
Some authors, Mackenzie among them, find a predisposing cause in
a constitutional condition, in an inherited dyscrasia, as tuberculosis,
syphilis, malarial poison, etc. It is generally believed that polypi
occur more frequently in men than women. They are exceedingly rare
in children. It would seem that the irritation arising from exposure or
overwork is an exciting cause.
Symptoms. — During the very earliest stages there are probably no
appreciable symptoms. As a polypus develops, an indefinite sense of
local discomfort is present and the amount of secretion is increased.
When of sufficient size to occlude wholly or partially the nasal passage,
respiration is more or less interfered with, especially when the polypus
is swollen from damp air. At times breathing is audible, almost snoring.
The voice gives the nasal " twang " heard in all obstructions of the
nasal chambers.
The discharge from the nostrils becomes more irritating and offen-
sive in character, and may even be mixed with blood, or frequent and
severe attacks of epistaxis may be the strongest indication of an abnor-
mal condition.
Reflex symptoms are common, such as hemicrania, facial neuralgia,
partial or complete loss of hearing, anosmia, and cough. The nose
may become large and distorted, and the polypi may press backward
into the naso-pharynx.
Diagnosis is usually unattended with difficulty or embarrassment, at
least when the disease has advanced beyond the first stage. Other
pathological conditions of the nasal cavities are so unlike this that they
need scarcely be considered if attention be given to the distinctive cha-
racteristics of polypi. By rhinoscopic examination they are seen to
depend from the nasal cavity, and are easily movable, even swaying or
flapping with a slight sound at times under the impulse of a current of
air. If this sort of movement is not present, some delicate instrument
in the hands of the surgeon easily produces motion of the dependent
pyriform portion.
Prognosis as to life is favorable, but not as to recurrence. Since
the cause of their occurrence is so obscure, it is difficult to predict
that polypi will not return. The cause may still exist and produce
a new crop, or the mass may not be wholly removed, and still con-
tinue to grow ; or if a large mass is thoroughly eradicated, small ones
may be overlooked and grow rapidly.
Treatment. — Various methods of removal have been employed, but
a surgical operation only is to be recommended, simple or complex
according to the conditions of the case and the adaptation and inventive
genius of the surgeon.
Avulsion probably stands as the operation most generally employed.
INJURIES AND DISEASES OF THE RESPIRATORY SYSTEM. 56 1
and consists in removal by forceps, rotary motion being used to twist
the polyp from its pedicle.
The forceps should be light, strong, and curved to keep the sur-
geon's hand from obstructing his view. The nostril is dilated with
some suitable nasal speculum and well illumined. The mstrument (one
with separate blades is sometimes an advantage) is made to grasp the
base of the polyp as firmly as possible, and by a steady twisting motion
sever the growth from its connection. Bleeding is generally slight, and
depends upon the position of the growth. The surgeon ought to see
or feel the pedicle in order to secure rapid and accurate adjustment of
the forceps. If this is impossible, as when the growth is large or far
back or not veiy friable, he may be obliged to take it away a little at a
time. If it is well formed and of firm consistency, it may be partially
drawn out of the nostril and its pedicle cut with knife or scissors.
Stoker's forceps were invented especially for the removal of nasal
polypi, and are well spoken of
Avulsion by the ecraseur or wire snare is a convenient method of
treatment. The loop of the instrument is first adjusted about the
pedicle and then tightened until it cuts through. It is a slower process
than that in which forceps are used, but the hemorrhage is probably
less. Jarvis's snare (Fig. 252), invented for this particular kind of
surgery, is the best now in use.
Fig. 252. — Jarvis's wire snare-ecraseur.
The galvano-cautery presents also a possible method of eradication.
Objections to it are the great pain, the difficulty of adjusting it in many
cases, and the fact that it makes no traction, and hence may leave a
fragment i)i situ and make repetition necessary.
With any of these methods cocain is locally applied, disinfectant
washes should be used, and if hyperemia and inflammation follow the
operation, astringent applications are indicated. If the patient decline
the operation, attempts at removal may be made, as they were in former
years, by the action of caustics or astringents applied or injected.
For applications are recommended tannin (by insufflation), iodin,
perchlorid of iron, nitrate of silver, zinc chlorid, gallic acid, etc.
The drugs employed for injection are carbolic acid, glacial acetic
acid, chromic acid, or some strong astringent, as Lugol's or Monsell's
solution.
Fibro-myomata and Fibromata. — Between the simple gelatinoid
polypus and the true fibroma may be found mixed tumors of all grades,
from those containing the slightest trace of fibrous material to those dif-
ficult to differentiate from a true fibroid ; the gravity of the case varies
in proportion to the amount of fibrous substance, because that is very
vascular, and the chief danger of removal lies in the hemorrhage. Pure
fibromata within the nose are very rare.
A naso-pharyngeal fibro-myxoma is recognized by its occupying the
position indicated by its name, and arises generally from the basilar
36
562 SURGICAL DIAGNOSIS AND TREATMENT.
process of the occipital bone and from bony structures in its immediate
vicinity. It grows rapidly and to a large size.
Other nasal fibrous polypi arise from any portion of the walls of the
nasal fossa;, generally farther back than is the case with mucous polypi,
and their favorite site is the superior turbinated bone, the roof of the
nose, and rarely the vomer or the foramen lacerum anterius (Roberts).
They may originate in some of the sinuses and extend into the nose,
protruding at the anterior nares, and may have several places of attach-
ment as the result of as many points of ulceration. In pathological
structure they differ in no way from similar growths in other parts of
the body.
Fibrous polypi often attain enormous proportions, distorting hideously
the nose and face, often producing the so-called " frog-face " and even
exophthalmos. By pressure also they destroy adjacent parts, thereby
endangering the brain, producing convulsions, coma, and death.
The syviptovis are those of foreign bodies in the nasal passages if
we emphasize the constant epistaxis, the greater severity of all symp-
toms, and the magnitude of the displacement and distortion.
The diagnosis from other foreign bodies and growths heretofore
described is plain if we keep in mind the distinctive characteristics of
the latter. From malignant growths, and even from those of syphilitic
origin, the diagnosis at times presents difficulties. Microscopic exam-
ination of a detached portion in the former case and specific treatment
in the latter will clear the diagnosis.
These growths occur more frequently in males than in females, and
their cause is entirely unknown.
Prognosis as to life must be guardedly given, for they tend to
become malignant. On removal fatal hemorrhage may supervene,
and finally they may recur with new complications. Attempts at
removal may betray a connection with the dura mater or reveal a
hernia of the brain through the distended cribriform plate of the eth-
moid bone. Cases have been recorded of the spontaneous detachment
and expulsion of such growths, but the proportion of such cures is too
small to modify the general law that surgical interference affords the
only true remedy.
Treatment. — Complete extirpation is the only proper course, and few
conditions present greater obstacles to the surgeon, both from the dif-
ficulty of reaching them and from the liability to hemorrhage. When
they are found in the anterior nasal chambers the same methods are
available as in the case of the gelatinoid polyp.
When, outgrowing the nasal, it has invaded contiguous cavities and
displaced or destroyed neighboring structures, or when, arising more or
less remote from the nasal chambers, it has invaded and distorted them,
the question of removal becomes a veiy grave one.
Avulsion, the ecraseur, caustics, electrolysis, the ligature either
simple or the galvano-caustic ligature, have each their advocates, and
with each successful operations have been performed. Preponderance
of modern surgical opinion is decidedly in favor of the use of the knife
in radical operations, these older methods being merely accessory,
choice as to one or the other depending upon the location, size, place
of origin, extension into other cavities, involvement of other structures.
INJURIES AND DISEASES OF THE RESPIRATORY SYSTEM. 563
and as to whether eradication with the knife alone is possible or whether
complete ablation must be accomplished by some additional means.
Operations through the mouth produce no deformity, but afford too
little space for checking the hemorrhage and for removing the growth
if it be of large dimensions. The nose may be divided or lifted or the
nasal bones may be resected, either alone or with the superior maxillary
bone ; the upper jaw may be wholly or partially excised.
Partial excision of the superior maxillary bone is the common ope-
ration, giving the best exposure of the polypus, the largest space for
operating and removing the growth and for managing hemorrhage, as
well as the least disfigurement after repair takes place.
Papillomata are found at the junction of the skin and mucous
membrane, being somewhat soft in the latter position, hard in the
former. Caustics easily effect their removal, though a loop of wire,
the knife, or scissors may be used.
Adenomata and cysts are to be regarded as modifications of
mucous polypi, with similar symptoms and treatment, though the
former may take on the characteristics of carcinoma, and the latter
do not tend to recur when once their contents are evacuated.
Hnchondromata are usually found on the anterior portion of the
septum, and are to be regarded as outgrowths or thickenings of its
cartilaginous portion. Careful slicing with the knife easily effects their
remo\'al.
Osseous growths present two or three varieties. They occur
farther back in the nasal fossa than do enchondromata, and spring
from the bony part of the septum, from the vomer, from the palatine
plate of the superior maxillar>^ or from the floor or roof of the nose.
Exostoses differ in no way from those found in other parts of the body.
Other growths, osteomata proper, are either of a density like ivor>' or
they are composed of cancellous bony tissue with frequent admixture
of cartilaginous tissue, or of a mucus-like substance within relatively
large cavities.
Treatment. — When the growth is very hard it can be sawn or
chiselled away or removed with the dental engine, or, if the pedicle
be slight, with scissors, wire loop, forceps, or knife. Only occasionally
it is an opening larger than that afforded by the natural cavity required,
and then usually some minor osteoplastic operation is employed. Oste-
omata of cancellous tissue are friable, and may be removed piecemeal
without enlarging the nasal opening, and generally do not recur.
Angeiomata are rare, with epistaxis as the chief, persistent, and
even dangerous symptom.
Malignant growths are not infrequently found in the nasal
passages, sarcomata more frequently than carcinomata. Either may
be primary, but most of the benign varieties of tumors already de-
scribed show a tendency to malignant degeneration, particularly the
fibrous polypi, the adenomata, fibromata, papillomata, and even the
simple mucous polypi. Osteomata are often of mixed type — osteo-sar-
comata. They originate from all parts of the nasal cavities, sarcomata
preferring the septum.
Of the two, sarcoma is the more frequent, and quickly declares
itself, even to external inspection, by its red, lobulated appearance,
564 SCRGICAL DIAGNOSIS AND TREATMENT.
its extreme vascularity, and its being sessile. It spreads rapidly to
the contiguous or connected cavities, often invading the throat, mouth,
orbit, or cranium. Its ulceration gives rise to frequent and alarming
epistaxis.
Carcinoma begins more insidiously as an insignificant growth,
wart, or pimple. The local symptoms are in general the same as
those of benign growths, and the constitutional symptoms are those
which distinguish malignant tumors elsewhere. If they are secondary
in the nose, the constitutional symptoms have, very likely, existed for
a considerable time.
Microscopical examination of a portion finally determines the
diagnosis.
The prognosis is most unfavorable.
In treatment extirpation is the only rule, either with the knife or the
galvano-cautery. However, access to the posterior regions is so dif-
ficult, and invasion of the lymphatics in this vicinity so certain, that the
surgeon can rarely be sure of the success of his operation. Not only
is recurrence the rule, but imperfect attempts at removal stimulate and
accelerate the growth, and so tend to shorten rather than prolong life.
Kpistaxis. — Hemorrhage from the nose, though in the majority of
cases a trifling matter, may become of very grave import. It is not a
disease, but a symptom. It may occur spontaneously without dis-
coverable cause as an expression of personal dyscrasia or idiosyncrasy.
It is sometimes a symptom of local pathological conditions ; frequently
it is the result of external injuries, blows, falls, etc. It may be the
symptom of a constitutional disorder either recognized or unknown, or
it may be congenital. The hemorrhage is either active or passive —
active when there is a sudden determination of blood to the head ; pas-
sive when the cause exists for a considerable time, as in the case of
acute specific diseases and in subjects of the hemorrhagic diathesis.
It is common in those of plethoric habit, either children or adults,
and likewise in those suffering from anemia. Slight erosions of the
nasal mucous membrane, deviation of the septum, growths and ulcers
in the nose, picking at the nose, inhalation of irritant gases, blows
and falls upon the nose, face, or head, over-exertion, passing from a
dense to a rare atmosphere, coughing, sneezing, blowing the nose, ex-
citement, mental emotion, are all mentioned as common causes of
epistaxis.
Various acute diseases and morbid conditions of the blood predis-
pose to it, as scarlet fev^er, measles, leukemia, typhoid fever, and the
like. Cardiac, renal, and hepatic diseases may lead to it ; so also, occa-
sionally, may tuberculosis. It is commonly a concomitant of hemo-
philia, and also is often vicarious. The Schneiderian membrane is very
vascular, and its vessels have comparatively slight support from sur-
rounding tissues ; hence it has a greater tendency to bleeding than
other mucous membranes.
Symptoms. — The blood coming from the nostril is of course the
main symptom This may be preceded by a sense of fulness or dizzi-
ness in the head, headache, tickling in the nose or a sensation of
warmth, so that a subject prone to attacks of epistaxis is warned of
their approach. Usually the flow of blood is from only one nostril.
INJURIES AND DISEASES OF THE RESPIRATORY SYSTEM. 565
though when it is a constitutional symptom it may proceed from both.
It is arterial in color, and coagulates easily. When the epistaxis arises
from a grave constitutional disorder it is, of course, far more apt to be
excessive and to resist treatment than when the cause is merely within
the nose itself, and especially if it is only a temporary condition.
There is usually no confusion in the diagnosis. If the ruptured
capillaries are far back in the nares, and especially if the hemorrhage
occur during sleep, the blood may flow backward and be expectorated
as if coming from the lungs or stomach. A close inspection of blood
that thus makes its appearance, if there is no previous histor}^ pointing
to possible hematemesis or hemoptysis, will make the case clear. In
cases where the origin of the bleeding is in the sinuses its exact loca-
tion may be extremely difficult. Sometimes when the flow is profuse,
though its origin is in only one nostril, it flows from both, and until the
flow is checked it may not be possible to establish the fact of its
unilateral origin.
Prognosis is grave in exact proportion to the gravity of the cause
and to the depletion of the system before the patient is seen.
Treatment. — Most of the common methods of preventing " nose-
bleed " are known to the laity, such as pressing the ala against the
septum, the application of ice or cold water to the bridge of the nose or
back of the neck, dropping a cold key down the back, raising the arm
of the corresponding side above the head, placing a wad of paper lightly
under the upper lip, pressing the finger against the facial arter}', plugging
the anterior nares, the use of hot water in the nose, washing the face
in hot water, and even the application of the drugs most common in
domestic use, as borax, alum, etc. The patient should remain erect or
nearly so ; he should not bend the head or blow the nose. If the sub-
ject is of plethoric habit or the hemorrhage arises from some obstruc-
tion to the circulation, as in cardiac disease, or is vicarious, moderate
bleeding is beneficial rather than harmful. If it passes the bounds of
moderation or is an accompaniment of a depressing constitutional dis-
ease, and if the simple methods above mentioned are of no avail, more
vigorous measures should be undertaken by the surgeon.
In many cases the blood comes from a single point, and, when pos-
sible, this point should be found, wiped with a piece of dry cotton, and
touched with silver nitrate, chromic acid, or the galvanic cautery.
Astringents — nitrate of silver, tannin, perchlorid of iron, antipyrin,
etc. — either as sprays or applied upon cotton, are sometimes of service.
Ergot, internally, is usually given in obstinate cases. Quinin is given
if malaria is seen to be the main feature in the case, and cases rescued
by transfusion have been reported.
When all such measures prove unavailing plugging is resorted to.
Various devices have been invented for this purpose, among them
the dilatable air-bag with two bulbs an inch apart. It is inflated after
having been placed in the nares, and fits all parts with equal pressure.
It is easily removed after allowing the air to escape. So suitable an
instrument is, however, seldom at hand at the critical moment, and the
surgeon is left to meet the situation with instruments of more common
use. If the hemorrhage is believed to be in the anterior nares, that
may be plugged either with iodoform gauze or lint as tampons pressed
566 SURGICAL DIAGNOSIS AND TREATMENT.
gently and snugly into place with a probe. To make removal easy and
certain they are tied at interv^als to a string whose end is external to
the anterior narcs. If their use is inadequate, then the posterior nares
must be subjected to like treatment, and if the details are well in mind
it is not a difficult procedure.
Passing the index finger behind the velum, the surgeon notes the
exact location and size of the aperture to be plugged and the presence
of abnormalities if any exist. The most convenient instrument for this
operation is Bellocq's cannula (Fig. 253). If it is not at hand, a soft-
Fu;. 253. — Bellocq's cannula for epistaxis.
rubber catheter serves the purpose. This, thoroughly disinfected, is
threaded with a stout sterilized thread of good length and passed along
the floor of the nose until it enters the pharynx and can be seen. One
end of the thread is then brought out through the mouth by means of
a pair of forceps, and the catheter is withdrawn from the nose. The
string is now in position. A plug of antiseptic cotton or sponge is then
fastened to the string, guided through the mouth and pharynx by the
surgeon's finger, and fixed firmly in position in the posterior nares by
traction on the string through the nostril, aided by gentle pressure with
the finger from behind. The ends of the string are now tied. When
the plug is to be removed gentle traction on the end of the string which
emerges from the mouth is usually sufficient. If desirable, anterior
plugs may be placed in position after the posterior nares is fitted.
To avoid decomposition and consequent ulceration none of these
should remain in situ longer than two full days. If epistaxis still
threaten, the operation must be repeated after using antiseptic and
astringent douches. Appropriate constitutional treatment should be
maintained meanwhile.
Ulcers. — Simple catarrhal ulceration as a result of acute or chronic
coryza is a rare thing, and consists of nothing more than an erosion of
the mucous membrane easily amenable to cleanliness, antisepsis, and
general remedies.
Ulceration is common when two mucous surfaces are brought
together, as in deviated septum, hypertrophy or pressure of the sur-
faces of two polypi, or other benign tumors pressing against the sep-
tum. Removal of the cause disposes of them. Surfaces of malignant
growths are especially prone to ulceration, both from the same causes
that produce ulceration of such growths in other parts of the body,
and from the fact that they are quickly subjected to pressure from the
relatively small space in which they develop. Bleeding and offensive
discharge are the symptoms of ulceration.
Extirpation of the malignant growths is their only cure, but much
may be done to make the patient more comfortable and the pain en-
INJURIES AND DISEASES OF THE RESPIRATORY SYSTEM. 567
durable if the necrotic tissue be thoroughly removed by curette,
cautery, or knife.
TranniatisjH, as from the introduction of foreign bodies, may pro-
duce ulcers that will disappear with the cause. Exhausting diseases, as
severe fevers, small-pox, scarlet fever, or scurvy, may produce ulcera-
tion in the nasal cavity. Rodent ulcer, beginning externally, may be
so sev'ere as to destroy the entire nasal organ, or, if checked, may
impede respiration by its cicatricial tissue.
Modern scientific research has declared the bacillus of tuberculosis
and that of lupus to be identical, so that they must be regarded as
different manifestations of the same disease. The former is said to be
very rare as a lesion in the nasal cavity, only a few cases having been
reported, and none at all until 1S77. Even of these rare cases only
one or two were absolutely proven to be primary. The nodules or
tubercles are at first of a grayish color and are covered with epithelium.
When this is softened ulceration occurs, nodules and small ulcers exist-
ing side by side. There is increased secretion, but the pain is insig-
nificant, and obstruction seldom takes place.
Diagnosis depends upon microscopical examination.
Prognosis. — Life is not endangered by the mere presence of tuber-
culosis in the nasal cavity. In most cases it is secondary to an ad-
vanced stage of the disease in other parts of the body. If primary,
removal by the curette or wire loop, though difficult, might eradicate
the disease, but it generally recurs.
Antiseptic douches or the insufflation of powders may contribute to
comfort. Radical extirpation is the only cure, and usually this is not
advisable, considering the general condition qf the patient.
lyUpus on the cutaneous surface of the nose is a serious matter,
because of the cicatricial tissue resulting from its ravages, and the
consequent effect upon respiration. If it occur as a primary lesion on
mucous membrane, scars are less common and thorough eradication
comparatively sure.
Lupus must be differentiated from epithelioma and sarcoma, and
particularly from syphilis. Sarcomata grow very rapidly and are
usually not multiple.
Hpitheliomata begin as tiny papillomata, and even break down
in ulceration with involvement of neighboring glands. Microscopical
examination will establish the character of sarcomata or epitheliomata.
The diagnosis from syphilis presents peculiar difficulties, and may be
settled by recourse to specific treatment. The age of the patient, his-
tory of the case, absence of signs of syphilis in other parts of the
body, the slow advance of the disease, the tendency to heal in one
place and progress in another, and the fact that necrosis of bone occurs
at a late stage in the disease, are points to be taken into consideration
in differentiating lupus from syphilis in the nasal cavities.
Treatment. — Thorough eradication is the only course. This may be
accomplished by scraping or curetting, followed by caustic applications
to ensure complete removal of the tissue. Some authorities advocate
the application of caustics alone ; zinc chloride, potassic hydrate,
chromic acid, lactic acid, silver nitrate, terchloracetic acid are all of use
in different cases.
568 SURGICAL DIAGNOSIS AND TREATMENT.
Tlic galvano-cautery, the actual cautery, multiple scarification, and
puncture are possible methods of eradication. The irritation set up by
any of these radical measures should be treated on the general princi-
ples for allaying inflammation.
S5T)hilis in the nasal cav^ities is far from unccmimon, though
doubtless its manifestation in the tertiary stage is much more frequent
than in either of the others. Chancre of the nasal passages has been
occasionally reported, and Burow has drawn attention to several cases
due to infection by Eustachian catheters. The commonest manifestation
of secondary syphilis is simply an acute coiyza of persistent type.
This may be the only symptom, and so rarely are mucous patches seen
on the nasal mucous membrane that their existence there has been
doubted. However, they may be found — upon the septum as a rule,
and not so near the junction of skin and mucous membrane as is the
case on the buccal mucous membrane. Ulceration is never deep, unless
it is in the latter part of the secondary stage, when the early indications
of the tertiary stage may be suspected.
It is in the tertiary stage of syphilis that its presence in the nasal
passages is most plainly and seriously manifested. Gummata form
either upon the periosteum or occur as an infiltration in the mucous
membrane. Upon the septum they occasion little pain, but upon the
turbinated bones they are somewhat painful. They may obstruct
respiration, and on examination they may at first be mistaken for other
tumors, as they show little tendency to ulceration. However, the gen-
eral condition of the patient is usually such as to leave no room for
doubt as to the character of the tumor. When ulceration begins
destruction of tissue goes on very rapidly. Perforation of the septum
is an early result of gummatous periostitis, and its complete obliteration
may rapidly follow. The turbinated bones, the vomer, the perpendicular
plate of the ethmoid, and the roof and floor of the nose are destroyed.
Perforation of the hard palate is not uncommon, either by extension
from the nose or else from independent gummata in its periosteum.
The cartilaginous tissues are rapidly destroyed as well. This of course
leads to great deformity, and the cranial cavity may be invaded, and
very rarely septicemia may follow from exposure of bone. While this
rapid destruction is going on bits of necrosed bone and shreds of tissue
either block the passages or are discharged with the secretion, which is
bloody and purulent-fetid to an almost intolerable degree.
The kind and amount of deformity depend upon the location of the
first gummata and the point at which the process of destruction is stayed.
Slight perforation of the septum or destruction of the turbinated bone
may not produce deformity. If necrosis proceed farther than this, a
varying degree of deformity will result, even to complete obliteration
of the nose. Contiguous bones, as the malar or maxillary or palate,
are occasionally destroyed, but this may be due to original infiltration
into their own substance rather than to extension from the nose.
The diagnosis of syphilitic lesions in the nasal passages presents few
difficulties. The history of the case and the presence of the syphilitic
cachexia are sufficient to establish the diagnosis. Lupus, cancer, or
ozena may be mistaken for syphilis. The microscope or specific treat-
ment will differentiate the first two (together with the history of the
INJURIES AND DISEASES OF THE RESPIRATORY SYSTEM. 569
case, age of the patient, and absence of characteristic cachexia). The
foul odor of ozena may be taken for syphiHs in the secondary stage,
but douching and syringing will temporarily remove the odor of ozena,
whereas the decaying tissue in syphilis gives a persistent odor.
Prognosis in all respects is favorable in the secondary stage and at
any time before necrosis of bone has commenced. When this has been
established the prognosis is serious as to future deformity. As to life,
it is the same as for the tertiary stage generally under the same
conditions.
Treatment must be both local and constitutional, the first to limit the
ravages of the disease in the nasal cavity, the latter to effect a complete
cure.
If the local manifestation is only that of an acute coryza, antiseptic
sprays and syringing, combined with the use of mercury, will be suffi-
cient. To mucous patches some caustic must be applied. If a gumma
has not begun to ulcerate, constitutional treatment should be pushed
in the hope of causing its absorption before ulceration with its conse-
quent necrosis takes place. If necrosis has begun, cleansing and
removal of dead tissue must be most thorough. Ulcers, even if
superficial, should be cleansed and disinfected regularly and frequently.
If they are deep, more energetic measures are necessary, even to
curetting. The discharge should be checked and all scales and crusts
removed. If the bone has been attacked, all detached portions must be
removed, for they act like foreign bodies, maintaining a constant irrita-
tion. They may be loosened from their positions by a strong spray or
syringe in some cases, but generally the probe or forceps must be
employed.
If a portion of necrosed bone has even slight attachment, it is gen-
erally best not to use force in separating it, but to wait for further
necrosis to loosen it completely, because of the danger of hemorrhage.
After the parts have been thoroughly cleansed an insufflation of
iodoform may be used.
lodid of potassium in full doses three or four times a day, with or
without mercury, constitutes the treatment. Cod-liver oil, iron, and
other tonics may be indicated if the patient is greatly reduced. Various
rhinoplastic operations may be resorted to with the view of concealing
or repairing deformities, or an artificial nose may be worn.
In hereditary syphilis the infant appears at first to be merely suf-
fering from a severe attack of acute coryza with profuse discharge, or
is said to have the " snuffles." Other indications of syphilis are, how-
ever, usually present in the old look and emaciated condition of the
child, in the hoarse cry, cutaneous eruptions, and mucous patches on
tongue, cheeks, lips, and around the anus. The discharge becomes
muco-purulent and excoriates the lip and nose.
In the coryza of infantile syphilis the mucous membrane is hyper-
emic and swollen, and there is a thin, watery discharge. This condi-
tion so interferes with respiration that nursing becomes difficult, and
adequate nourishment of the child is almost impossible. Constitutional
treatment must at once be begun, supplemented by thorough and sys-
tematic cleansing of the nasal passages by antiseptic sprays. If the
thickened discharge completely blocks the nasal passages, the accu-
570 SURGICAL DIAGNOSIS AND TREATMENT.
mulatcd secretion may be forced from one nostril by the compression
of air in a rubber ball within the other. The excoriated portions of
skin must be dressed with soothin<^ applications. A child thus afflicted
should not be allowed to nurse the breast of one untainted with the
disease nor use drinking vessels to which others have access.
If the health of the child be not too completely undermined, vigor-
ous treatment from the time of the first indications of the disease —
usually within the first month of life and seldom later than the third —
may prevent its further development. As a rule, however, it goes on to
the third stage, when the same course of treatment must be adopted as
for adults, and, should the child surviv'c this period, it is rare indeed
that it escapes all evidences of the ravages of the disease.
The ulcers of leprosy in the nasal cavity are not unknown. They
are similar to those found in other parts of the body. Cleanliness and
antiseptic sprays will lessen in some degree their offensive character.
They are found only when the whole system is invaded and under-
mined by the disease. Treatment is of no avail.
Rhinitis. — Acute. — This is the condition produced by an acute
inflammation of the pituitary membrane. There is tumefaction accom-
panied or followed by a secretion, at first thin and acrid, later of a
thicker consistency, due to discharge of epithelial debris. In the last
stage of rhinitis the secretion again becomes thin, and disappears as the
nasal mucous membrane returns to its normal condition.
The commonest form of rhinitis is that known as " cold in the
head," due to sudden chilling of some portion of the body. Other
causes less generally recognized may also produce an acute coryza.
That caused by syphilis is discussed elsewhere. It is quite frequently
a symptom of the early stages of the exanthemata and influenza. It
may also be due to inhalation of irritating gases, as bromin, also to
powders, dust, and odors — to the pollen of plants, as in that condition
popularly known as " hay fever." It is set up by the presence of
foreign bodies and growths in the nasal cavities, and by extension
from other mucous membranes, as from the conjunctiva. The internal
administration of certain drugs, particularly iodid of potassium, will
also produce it. It often occurs at the same time with asthma. It is
impossible also from its epidemic character at times to escape the con-
clusion that its origin may be microbic. This may almost be assumed
when it is only a forerunner of an acute general disease that develops
later.
Symptoms. — There may be no sign of the presence of an acute
coryza until the patient begins to sneeze or until the discomfort arising
from the congestion and the swelling of the membrane is noticed. In
most persons, particularly in the case of the aged and feeble or if the
exposure be prolonged or severe, a marked chill may be present or at
least a feeling of chilliness. This is followed by a rise in temperature,
usually somewhat proportionate to the severity of the chill. In some
cases there is a general feeling of malaise, or the whole body may ache
as a preliminary symptom. Frontal headache is common. In any
case, after the congestion of the mucous membrane has lasted a few
hours, the discharge of the secretions begins, assuming the characters
noted above.
INJURIES AND DISEASES OF THE RESPIRATORY SYSTEM. 5/1
Nasal respiration may become impossible ; smell and taste lose
their acuteness. Commonly, these symptoms increase in severity for
two or three days, then begin slowly to disappear. However, by the
involvement of other structures the case may become much more
complicated. By extension the pharynx may be involved, producing
" sore throat." The frontal sinuses, the antrum of Highmore, the nasal
duct, the Eustachian tube may all be affected to a greater or less degree,
each giving the characteristic symptoms of inflammation in that locality.
Discomfort and uneasiness, rather than pain, are the symptoms of un-
complicated acute coryza. If the complications just mentioned are
severe, pain becomes a marked feature.
Treatment. — Many cases of acute coryza require little or no treat-
ment, for the disease, unless it is a part of some acute general malady,
runs its own course in a few days. Often, however, slight exposure,
after it has once commenced, adds to its intensity or brings on a relapse
after convalescence has begun, so that the case becomes very protracted
unless checked by prompt treatment. This may be both local and
general, both abortive and curative.
Quinin in large doses sometimes aborts a " cold," particularly if
sudorific treatment is combined with it. Tincture of aconite is used for
the same purpose. A recent writer recommends the use of bicarbonate
of soda to abort a " cold," on the theory that the Schneiderian mem-
brane is irritated by some acid in the blood. Fifteen to thirty grains
are given in water every half hour until three doses have been taken,
and a fourth dose at the end of an hour. At the end of three or four
hours these doses are repeated if there are still left any signs of the
coryza. Even a third or a fourth trial may be made at suitable intervals
if desired.
Cathartics at night, followed by a saline purge in the morning, is
good treatment, whether the object is to abort or cure. With the first
object in view opium in \- to ^-gr. doses may be taken. Dover's powder
both reliev^es pain and produces sweating. Some form of belladonna
may also be combined with the opium.
Hot drinks, a hot mustard foot-bath, after which the patient is kept
very warm in bed for several hours, will in many cases be sufficient to
cut short a threatened attack of acute coryza, especially if it is due to
exposure to cold only. To this may be added the inhalation of steam,
medicated or otherwise. A sponge saturated with the hot liquid is held
to the nose, and through it the patient breathes. Persons accustomed
to them find Turkish baths useful in aborting a cold.
However, after the corj'za is fairly established measures to control
and limit inflammation are indicated, both internally and locally.
Phenacetin, antipyrin, lactophenin, or aconite may be used to control
the fever. Atropin or belladonna and opium are useful in the later
stages, as in the beginning.
Astringents, locally applied, are of little use in acute coryza, their
value being greater in the chronic form ; cocain, either as a spray or as
a powder, is far better. A powder composed of subnitrate of bismuth,
with a little morphin, inserted as an insufflation occasionally gives great
relief Silver nitrate used in the same way is recommended. If the
discharge becomes muco-purulent, antiseptic spray may be used. Rhi-
5/2 SURGICAL DIAGNOSIS AND TREATMENT.
nitis due to irritating vapors yields to the administration of opium. In
the acute form of rhinitis, known as hay, rose, or June fever or the
catarrh of autumn, no specific treatment is known, and what avails
with one patient may be of no use to another or with the same person
at another time. Change of climate is probably of more service than
any other one thing, and general nutrition must be kept at as high a
point as possible.
Opium should not be employed in the acute coryza of childhood.
Care must be taken to see that the nourishment of the child is main-
tained, ev^en if feeding through a tube is necessary. A soft-rubber tube
may be inserted into the nostril if there is severe dyspnea.
Chronic. — Different clinical aspects of chronic inflammation suggest
a simple classification. If there is a simple catarrh without structural
alterations, it is known as chronic nasal catarrh, coryza, or chronic rhi-
nitis. If the Schneiderian membrane and the underlying structures are
thickened and enlarged, it is called Jiypcrtropliic catarrJi or hypertrophic
rhinitis. If, on the other hand, the nasal passages are unusually wide
and open, the turbinated bones small, and the overlying tissues thin and
atrophied, the condition is known as atropine nasal catarrh.
Simple nasal catarrh is generally due either to an acute attack w^hich
does not go on to complete recovery, but which, neglected or improp-
erly treated, continues with mitigated sev^erity, or to the habit or con-
dition established by repeated acute attacks, perhaps in a patient pecu-
liarly susceptible. The symptoms are mainly those of the acute attack
modified and lessened in severity. If it confines itself strictly within
the limits implied in its definition, it is scarcely to be considered in
itself a surgical disease at all, but comes more properly within the
domain of the medical therapeutist. However, it is so frequently the
precursor, if not the cause, of the other forms of chronic rhinitis that
it must not be overlooked. It is rare indeed that a long-continued
simple nasal catarrh does not involve the naso-pharynx and the poste-
rior pharynx. So generally is this true that with some authors a
chronic coryza is understood to include a retronasal and a retropharyn-
geal catarrh. In such a condition as this the Schneiderian membrane
is not thickened, although the vault and posterior pharynx, owing to
the large amount of glandular tissue, may be somewhat hypertrophied,
giving rise to a large amount of thick mucous secretion. By extension
also the Eustachian tube may become involved, and partial or complete
deafness, either temporary or permanent, follow.
True hypertrophic nasal catarrh consists of a thickening of the epi-
thelium of the pituitaiy membrane, and also of the underlying adenoid
and connectiv^e tissues, together wath enlargement and dilatation of
blood-vessels. The nasal mucous membrane is well supplied with
glandular tissue, and the distention of the mucous glands is no small
factor in the hypertrophy of this membrane.
The secretion is thick and viscid, and is generally increased in amount,
though the discomfort from its presence in the narrowed passages and
the constant efforts at removal may make it appear excessive when it
is really normal or diminished. Sensibility and smell are impaired ;
nasal respiration is interfered with ; retronasal and retropharyngeal
catarrh are practically the accompaniments of this disease.
INJURIES AND DISEASES OF THE RESPIRATORY SYSTEM. 573
The lower and middle turbinate bones are the ones most affected,
particularly the lower. The membrane over these bones, as viewed
from the anterior nares, is hyperemic and swollen, and upon the lower
of a dark-red color that brightens up somewhat in the middle. The
hypertrophy is neither wholly smooth nor regular, but is raised,
inclined to be nodular, and of irregular outline. It may be so great
as to extend from the turbinate bones across to the septum and de-
pend toward the floor. In such a case respiration would be com-
pletely obstructed from the blocking up of the anterior nares. Ob-
struction to respiration is more apt, however, to occur from hyper-
trophy of the membrane around the posterior nares than from the
anterior nares, for it is most pronounced in the retronasal region at the
posterior portions of the inferior turbinated bones. If there is a deviated
septum, early irritation of its protruded portion by the encroaching
spongy tissue of the hypertrophy may cause also hypertrophy at that
point, particularly opposite the posterior end of the inferior turbinated
bone, and impede respiration very early in the progress of the disease.
The appearance of the membrane posteriorly is paler than at the ante-
rior end of the turbinated bones ; also above it is less vivid in color.
The middle turbinated bone may not be involved at all, or the membrane
may be so grossly hypertrophied as to resemble a polypus.
Since the result of chronic inflammation in other parts of the body
is hypertrophy, analogy forces the inference that hypertrophic nasal
catarrh is no exception. Acute coryza is followed by the simple
chronic form, and this, if unrelieved, gradually merges into genuine
hypertrophy. This seems to be the history of this condition, although
some observers claim that the acute and chronic coryzas which ap-
parently precede and cause the hypertrophy are simply early and cha-
racteristic manifestations of the incipient hypertrophy. Without doubt
the rapid and extreme changes of climate that are characteristic of
most parts of the temperate zone are to be reckoned as factors.
Occupation in trades or arts where irritating vapors or dust are con-
stantly present may be a cause.
The symptoms are the obstruction to nasal respiration, the thick
discharge, impairment of sensibility, smell, and perhaps hearing ; when
the inflammation has extended to the pharynx there may be a change
in the quahty of the voice, sore throat, coryza and hawking and raising
of mucus. In cases of long standing the inflammation will extend to
the larynx and trachea, with additional symptoms referable to those
parts.
Anterior and posterior rhinoscopy will reveal the pathological con-
ditions in the nares already described, usually bilateral.
The vault of the pharynx has been called " the pharyngeal tonsil "
because of the abundance of its glandular tissue. So prone is this to
hypertrophy that adenoid vegetations as the result of inflammation are
exceedingly common, and hypertrophic nasal catarrh is believed some-
times to originate by extension from pharyngeal inflammation, and may
become very extensive — so much so that the vault and the posterior
pharynx are completely filled with the adenoid hypertrophies, and can
be seen through the mouth by lifting the edge of the velum.
In the majority of cases, however, such excessive hypertrophies are
574 SURGICAL DIAGNOSIS AND TREATMENT.
not found, but there is marked thickening of the membrane, even so
much that it Hes in ridges. The hypertrophied mass is soft and varies
in color from a flesh tint to a turgid red. As a general thing such
hypertrophies are found only in children and young adults.
Diag)iosis is easy from the symptoms and careful rhinoscopy.
Hypertrophy of the nasal mucous membrane at first glance might
resemble polypi, but the latter usually are pedunculated and originate
on the upper part of the middle turbinated bone. Perichondritis is
more apt to begin on the septum.
Prognosis is good as regards life and relief from the disease, and
recovery may be complete. Most observers claim, however, that long-
continued hypertrophic rhinitis terminates generally in the atrophic
form of rhinitis.
Treatment. — Clinically, as regards treatment, cases of hypertrophic
rhinitis fall naturally into two classes — those in which the process is
only slight and which may be checked by topical applications of one
sort or another,, and those in which the hypertrophic process has pro-
gressed more extensively and decidedly, and in which removal of
redundant tissue by instruments or caustics is the only suitable measure.
In either case there must be thorough cleansing of the passages of
the secretion and of crusts, though the latter are not common. This
may be accomplished in many cases by the patient's blowing his nose,
and where possible this is the better way, because it is less irritating to
the delicate and sensitive membranes.
In case the aid of a surgeon is required he has at his command
both instruments and the spray. The probe with a bit of cotton at the
end may be used to remove adherent secretions. No great force should
at any time be used, but it may be necessaiy gently to push aside the
obtruding parts in order to make a way for the entrance of the spray.
Generally, however, unless the hypertrophy be very great a solution
of cocain will sufficiently contract the membrane to afford a passage for
the spray. A coarse spray of some alkaline solution is the one com-
monly used for cleansing. For the removal of the tenacious mucus in
the vault of the pharynx or at the posterior nares a nasal syringe may
be more serviceable. In the first class of cases, where the hypertrophy
is only slight, after thorough cleansing astringent and antiseptic
remedies may be used, preferably in the form of a solution through the
nasal-spray apparatus. Soluble bougies, ointments, and snuffs each have
their advantages in certain cases, particularly as no apparatus is neces-
sary for their application. Gradual dilatation with bougies is a possible
mode of treatment, and, when combined with systematic cleansing and
local treatment, may be of value.
As a rule, it is the more pronounced cases which come into the
surgeon's hands, those where there is much redundant tissue, where
occlusion of the nasal passages is almost wholly complete, and where
nasal respiration is nearly or quite impossible. In order to restore
respiration the removal of tissue in one or both nostrils is indicated,
and here the surgeon has his choice either of instrumental interference
or of caustics.
Cocain is first used to anesthetize the parts. Caustics may be ap-
plied on a bit of cotton, the greatest caution being observed. Chromic
INJURIES AND DISEASES OF THE RESPIRATORY SYSTEM. $J$
acid, nitric acid, glacial acetic acid, or trichloracetic acid will serve the
purpose. Nitrate of silver is slow in action, and also has a stimulating
effect — ^just what is not desired — and is now seldom used. Alkaline
washes should follow the application of any of these acid escharotics.
The galvano-cautery under skilful manipulation does good service,
and instruments of different shapes, suited to the cavity and to the tissue
to be removed, can be adjusted to the various electrodes. It is not,
however, of univ^ersal application — as, for instance, at the posterior
extremity of the inferior turbinated bone it is not always possible to
estimate precisely the degree of heat, and too extensive and too deep
an eschar may be produced.
Electricity is said also to sometimes produce anosmia, and sometimes
perversion of smell. Until sloughing and healing of the surface are
complete, cleanliness and asepsis must be carefully maintained, as is
also the case when chemical caustics are used. Besides the relief
gained immediately by the removal of tissue, much may be hoped
from the subsequent contraction of the cicatrix.
In most cases, however, some instrument which cuts away the
redundant tissue without profuse hemorrhage provides the most de-
sirable method of treating the membrane in hypertrophic rhinitis. Of
these the ecraseur — of which Jarvis's snare is the best form — is the
most satisfactory (Fig. 240). After careful study of the location of the
parts the wire loop is slipped over the portion to be removed, tightened
around it, and then slowly made to cut its way through. Scissors or
forceps may be employed, but the tearing of the forceps is painful and
the bleeding profuse. In the vault of the pharynx a sharp spoon,
curette, or sharp-bladed cutting forceps, if the vegetations are anything
more than slight thickening, may be used. New blood-vessels are a
characteristic feature of rapidly-forming hypertrophic tissue, and scari-
fication or puncture by destroying these may put an end to the process.
If there is much hemorrhage, whatever the mode of treatment, appli-
cation of hot water should first be tried. If bleeding is excessive, plug-
ging of the nares must be resorted to.
Atrophic Nasal Catarrh. — In this disease instead of hyper-
trophied tissues and occluded passages there is present precisely the
opposite condition — atrophied tissues and abnormally wide nasal pas-
sages. Nevertheless, most authorities claim that the last condition is
only a secondary phase of the first. In fact, all shades of opinion find
expression. By some it is held that it never exists as the result of
hypertrophic rhinitis ; others regard it as occasionally being caused by
that form of catarrh. Still others regard it as an entirely independent
affection, in no way connected with that disease. Certainly we may
conclude that its etiology is obscure, and, while the weight of evidence
is in favor of its being a later stage of the hypertrophic variety of
chronic catarrh, there may be constitutional conditions which produce
it or it may possibly result occasionally from unnoted injuries.
Hyperplasia of connective tissue in other parts of the body usually
results in atrophy of parenchymatous elements both from its weight
and from the pressure it exerts in contracting. So in the Schneiderian
membrane this pressure from hypertrophied tissue is exerted to the
destruction of the abundant glandular tissue. The surface becomes
5/6 SURGICAL DIAGNOSIS AND TREATMENT.
dry and covered with thick crusts, whicli again tend to bring about the
same result from their pressure upon the epitheHum and underlying
parts. Not only the mucous and submucous tissues, but the turbinated
bones themselves, are partially absorbed from the weight of inspissated
secretions and the weight and contraction of connective and elastic
tissue. All this makes unusually wide nasal chambers, so that at
times the posterior wall of the pharynx may be viewed from the ante-
rior nares. When the hardened secretions and crusts are removed,
together with the muco-purulent and often bloody secretions that lie
underneath them, the membrane is hyperemic at first, but soon may
look pink and almost healthy or even almost colorless. If no crusts
are present, it has a glazed appearance. Crusts are more commonly
adherent toward the anterior nares than at the posterior, and may
be so large or abundant as to stretch across or block the nasal pas-
sages, causing temporary occlusion and interfering with nasal respira-
tion.
Symptoms. — There are usually discomfort and itching and an inclina-
tion to remove the crusts, even forcibly. Erosions, ulcerations, and
epistaxis are therefore not uncommon, and perforation of the septum
has resulted from such causes and treatment. The most distinctive
feature of this disease, however, one so common as to characterize it,
is the fetor almost constantly present. This arises from the decompo-
sition of the secretions retained under the crusts and within the blocked
meatuses.
Diagnosis is easy from the symptoms.
Prognosis as to recovery must be guardedly given, for it is a most
obstinate disease to cure.
Treatment is cleansing, disinfecting, and stimulating. Cleansing can
generally be effected by persistent spraying and douching. Occasion-
ally, however, mechanical interference is necessary. The surgeon, using
gentle force, removes with a probe adherent scales and crusts, cleansing
any underlying ulcers and erosions, removing all muco-purulent secre-
tions. At all events, after thorough cleansing disinfectant sprays and
douches must be used to remove the fetor. Their name is legion —
boracic acid, a weak solution of carbolic acid, iodin, permanganate of
potash, resorcin, chlorid of ammonia, and salicylate of soda. Powders
are often used, among which iodoform perhaps stands first. Disin-
fectant sprays should be followed by stimulation. For this purpose
cotton tampons are used, either dry or moistened with glycerin or
other stimulant. They exclude germs and air and prevent the forma-
tion of crusts, and by their use a more natural condition of the mucous
membrane is maintained. Such treatment is certainly more rational
than the application of astringents to a surface already deficient in reac-
tion, or than caustics and scarifications on a surface already depleted.
O^ena is a term rather loosely used to describe either a symptom
or a disease according as the author means only the fetor which arises
from a diseased condition or the disease which gives origin to the fetor.
Some waiters employ it to include also all fetid ulceration due to any
disease whatever, while others restrict its meaning to where it becomes
merely a synonym for atrophic nasal catarrh, otherwise known as fetid
nasal catarrh or fetid rhinitis ; and this is probably the signification
INJURIES AND DISEASES OF THE RESPIRATORY SYSTEM. 577
more commonly given it, although almost as frequently it is used to
mean only an odor.
The fetid odor arising from caries of bone or malignant growths or
a decaying foreign body differs from that usually termed ozena, as it
accompanies atrophic nasal catarrh, yet ozena is sometimes present
when there is no atrophic rhinitis. It is then supposed to be due to a
similar condition existing within the sinuses. In any case, the fetor is
believed to be due to the decomposition of retained secretions. Unlike
fetors arising from decayed bone, it temporarily disappears after thorough
cleansing and spraying.
Giving to the term its narrower meaning, the symptoms and treat-
ment are the same as for atrophic nasal catarrh. If it includes all fetid
ulceration, then the treatment is that of the disease giving rise to it.
Diphtheritic and Membranous Rhinitis. — Should the micro-
organisms of diphtheria first find lodgement on an abrasion of the
Schneiderian membrane, there is no reason why a true diphtheritic mem-
brane should not be developed there as well as in the throat. Some-
times the diphtheritic membrane passes from the pharynx into the pos-
terior nares. More commonly, however, an abundant sero-fibrinous
exudation, caused by acute rhinitis, rough surgical treatment, or an
injury, deposits a false membrane, which may be quickly diagnosed
from true diphtheria by the fact that it is easily, removed without
hemorrhage. There may be some fever, but constitutional .symptoms
are less marked than in diphtheria. It should be treated as an ordinary
acute rhinitis, with more than ordinary attention to the removal of the
exudation and disinfection of the nasal passages.
Purulent rhinitis is, as a rule, due to gonorrheal infection ; in the
case of the infant it results from contact with the maternal secretions,
in the case of the adult from auto-infection. Other causes are possible,
such as injuries, the presence of foreign bodies, the exanthemata, and
incipient ozena. The exact character of the discharge may perhaps be
determined by microscopic examination.
Treatment resolves itself into thorough cleansing by spraying,
douching, syringing, disinfection, and the application of astringents.
Diseases and Injuries of the Septum.
Most of the affections of the nose already treated of belong to the
septum in common with the parts covered with the Schneiderian mem-
brane. But there are certain lesions (to which it alone is subject)
dependent upon its anatomical character and position.
Of such lesions deviation of the septum, either congenital or
acquired, is certainly the most noticeable, and, considering the long
train of evils to which it may give rise, the most important.
A perfectly normal septum, being on the median line of the body,
should divide the entire nasal cavity into two .symmetrical halves. Any
departure from such a position is termed a deviation. It may be of all
degrees, from the merest inclination to one side or the other, to a single
or double bend in the septum, either horizontal, vertical, or both,
sufficient to completely occlude the nostril and exert considerable
pressure upon its outer wall. One lateral curve constitutes, as a rule,
37
578 SURGICAL DIAGXOSIS AND TKEATMENT.
the deviation, but there may be two, giving a sigmoid curve to the
deviation. Quite naturally, from its greater flexibility, more and greater
deflections occur in the cartilaginous portion of the septum than in the
bony part, and cjuite frequently, when the deviation is the result of
traumatism, it occurs at the junction of bone and cartilage. Only the
perpendicular plate of the ethmoid may be warped or the vomer alone,
and finally the septum as a whole, including bony parts and nasal
cartilages, may curve toward one side. As much as one nostril is
occluded by the distorted septum is the other enlarged as a general
rule, but in addition to the occlusion caused by the bulging on the
affected side there is often hypertrophy of the turbinated bones. At
the sutures of the various parts there is sometimes an unusual degree
of thickening, virtually an exostosis extending antero-posteriorly.
This gives the effect in one nostril of a deviation both in appearance
and results. It may also be bilateral. There may be quite an exten-
sive deviation of the septum without any appearance of external
asymmetry. At times the nose is badly twisted from its normal con-
tour. Much attention has been given in recent years to the deviated
septum, and study of skulls has established the fact that symmetry of
the septum is the exception, and not the rule. While there is not
perfect agreement in the conclusions reached, there is substantial
unanimity in placing the proportion of asymmetrical septa at about 75
per cent.
In many cases, at least, such statistics have referred to the bony
septum alone. Hence, certainly the conclusion is a safe one that dur-
ing life anterior rhinoscopy would reveal a much larger percentage,
owing to the greater readiness of the cartilage to yield to pressure.
Dr. Hegman places it as high as 99 per cent, of all persons examined.
Deviation of the septum may be congenital, may occur suddenly from
traumatism, or may result from causes that act more slowly and con-
stantly. There is no agreement of authorities as to the causes of
deviated septum of the last sort mentioned. Should it happen, for
any reason, that the bony walls between which the septum is placed
are of unequal thickness and resistance, it would naturally be affected
by such pressure and yield somewhat, moving in the direction of the
least resistance. Since the deviation is more commonly toward the left,
some find an explanation of the condition in the fact of wiping and
blowing the organ most frequently with the right hand. Foreign
bodies may have their influence in determining it to one side or the
other ; so also unilateral new growths. Some authors deny that it is
ever congenital. But it is a well-established anatomical fact that there
is a lack of perfect symmetry in many skulls. As the body develops
some cause or other, either forgotten or totally obscure and inappre-
ciable, determines a greater development on one side than on the other.
It is certainly to be expected that the septum will be exposed to its
share of all such untraceable influences.
Symptoms. — If the deviation is only slight and tends to remain so,
there are no diagnostic symptoms. If it encroaches to any great extent
upon the nostril, we have all the symptoms of occlusion that are pro-
duced by any other cause. Most important of all, respiration is inter-
fered with. Secretions are retained, rhinitis is set up. Pressure on the
INJURIES AND DISEASES OF THE RESPIRATORY SYSTEM. 579
turbinated bodies and the overlying mucous membrane causes them to
atrophy, and the result is atrophic rhinitis.
The usual complications and seqiielcB of rhinitis may be present in
their turn, together with headaches and reflex symptoms.
Diagnosis is easy by comparison of one nostril with another, and
by using the probe to ascertain by the tactus eruditus that the pro-
tuberance is of bone and not a new growth.
Treatment. — The object in treatment is. first, to relieve obstruction,
and, second, to restore the septum as nearly to an ideally normal posi-
tion as possible, and thus preclude the possibility of recurrent obstruc-
tion from this cause.
Much depends upon the skill and ingenuity of the surgeon. Fur-
thermore, inasmuch as this branch of surgery is of comparatively
recent date, the profession do not seem, as in many other departments
of surgery, tacitly to have settled upon one or more operations as
practically superior.
One of the earliest proposed methods was that of Adanus. He
grasped the deviated septum between the blades of forceps and reduced
it to its proper position by crushing and fracturing. After this pro-
cedure rather elaborate apparatus was necessary in order to maintain
the proper position until repair was complete — head-bands, screw-com-
pressors, plugs, etc. — and this is the case always where forcible com-
pression is employed. If the deviation is only slight and in a young
subject, retentive plugs or something similar may serve a useful
purpose.
Excision, in some way, of the bulging portion seems to be the better
plan. This may be done with various instruments, as saw, scissors,
chisels, etc. Even a dental engine has been proposed. Steele employs
Fig. 254. — Steele's stellate forceps for deflected septum.
forceps (Fig. 254) by which he cuts a stellate incision and also forces
the septum back into position. He retains it there by ivory or wooden
plugs.
Another plan is to lift the mucous membrane, and sometimes the
perichondrium with it, excise a portion of the septum, replace the
mucous membrane, and keep it in place by a sponge until repair is
complete. Some operators by punch or forceps remove a portion of
the septum. This leaves a perforation which heals possibly at the
edges, so far as the mucous membrane is concerned, but is open to the
same objections that apply to a perforation caused by other means, and
if large it may cause external deformity. Slicing away portions of the
deviated cartilage has been quite successful, as a number of incisions
made antero-posteriorly make the cartilage lose its resiliency, so that it
can easily be retained in place until it has healed.
580 SURGICAL DIAGNOSIS AXD TREATMENT.
Steel pins are used, thrust through from the outside, so pressing
upon the septum as to force it into position. They must be retained
for some tla\"s.
Hematomata. — As the direct result of traumatism, especially when
the septum is fractured, separating the cartilaginous part from the bony
portion, extrax'asation of blood often occurs between the cartilage and
mucous membrane. Having a relatively broad base, they vary in size
from minute spots to tumors so large as to protrude from the nose.
They are of a dark-red or bluish color, usually with marked fluctu-
ation, although tension may be so great as to prevent it. If small and
promptly treated with cold applications, they may be absorbed. If
absorption does not occur, they must be incised at the most dependent
portion. They are usually bilateral and communicate through a per-
foration, so that one incision will empty both lobes of the tumor if
gentle pressure be applied ; otherwise, each side must be incised. They
are apt to degenerate into abscesses unless promptly treated, and per-
foration from them may be so large as never completely to close.
Abscesses are either acute or chronic. The acute abscess is gen-
erall}' the immediate result of injury. It is red, tender, painful, bilateral,
and fluctuating, and often by extension involves the lips and cheeks
and the internal parts of the nasal cavity, though the abscess proper is
situated anteriorly on the cartilaginous part of the septum. Slight fever
is common. Early and free incision on one or both sides is the only
treatment. If delayed, periostitis and perichondritis are likely to result.
Perforation of the septum is the common sequel.
Chronic abscesses are of slower development, and the intensity of
all the symptoms is less marked ; indeed, the patient may not even be
aware of their existence. They may occur without known origin, yet
are usually caused by syphilis. Prompt incision and constitutional
treatment are the indications.
Perforation of the Septum. — The most common cause of this
condition is syphilis, and formerly it was believed that it was the sole
cause — that, given a case of perforated septum, it was safe to assume
a previous history of syphilis even if wholly beyond the patient's
knowledge or memory.
Other causes are now admitted : traumatism resulting in blood-
extravasations or abscess will indirectly produce it.
Erosions caused by the continual removal of crusts upon the car-
tilaginous part of the septum often deepen into perforations. A local-
ized perichondritis or periostitis may be followed by it. Some believ'e
that it may be congenital.
Usually the edges of the perforation heal well and they are of slight
importance. Sometimes they are so large and so placed that a current
of air produces a slight whistling as it passes through. Rhinoplastic
operations to repair the deficiency have been tried, but have met with
but little success.
Deformities, Congenital Malformations, and Defects of the Nose.
As has been seen in the discussion of Diseases and Injuries of the
Nose, deformities of various sorts are common, due to alterations in
INJURIES AND DISEASES OF THE RESPIRATORY SYSTEM. 58 1
either the external or internal parts. Such structural changes may be
the result of accident or disease. By far the greater number are due
to destruction of tissue and to cicatricial contraction following the
ravages of destructive diseases. Among these syphilis stands first,
both in frequency of occurrence and rapidity of advance.
To such as are caused by destruction of tissue may be added those
resulting from the opposite cause — the development of an abnormal
amount of tissue, as in elephantiasis and rhinoscleroma, already de-
scribed — or, finally, those in which the nose is distorted by the presence
of neoplasms within the nasal cavity. A good example of the latter
class is seen in the so-called " frog-face " associated with naso-phar}m-
geal polypi.
Co)ige7iital malformations idW naturally into three groups: i. Those
in which a whole or a part of the organ has not kept pace in develop-
ment with other parts of the body, and is relatively small or asym-
metrical ; 2. Those in which development has gone on more rapidly
than in other parts of the body, making the nose abnormally large ;
3. Those in which there is arrested development, leaving gaps between
parts which are fully developed, perhaps in one direction, but have
failed to unite properly w^ith contiguous parts in other directions.
Absence of the nose is not unknown, the site of the nasal organ
being a plane surface, with or without perforations for nostrils. The
nose may fail to develop in its long axis, making it too short — a " snub
nose." The nostril may be contracted also at birth. Should one side
of the nose develop and the other not, the organ then lacks symmetry
and gives a most peculiar appearance to the face. Slight asymmetr}^
of the nose is not uncommon, but can scarcely be called congenital.
Nor is it the result of disease, but is due to greater pressure on one
side than on another when the organ is blown and wiped.
Sometimes a nose is abnormally large from disproportionate develop-
ment, and the organ may even be double or be furnished with three nos-
trils or with a small outgrowth at the root or on one side that simulates
a nose on a small scale. Sometimes one or both nostrils are occluded
by the development of adventitious tissue at the opening or within the
cavity. Should this extra tissue remain, the result will be not an
abnormally large nose, but an undersized one, because the nostril,
being shut from the air, contrar}^ to Nature's designs, suffers from
diminished nutrition. Sometimes the nasal cartilages do not unite in the
middle line, or the alae are too much separated at their bases from the
face, leaving clefts or fissures. Such deficiencies are usually found in
connection with hare-lip and cleft-palate, being a continuation of the
fissure in lip or palate.
Plastic operations maybe undertaken to close such fissures and also
to correct some deformities that are due to cicatricial contraction.
Outgrowths, making abnormally large noses or double noses, may
sometimes be removed. Rhino-scleroma and hypertrophy have already
been discussed.
If the nose has failed to develop from contracted or occluded nos-
trils, dilatation or removal of adx-entitious tissue is indicated.
When the entire organ is lost by accident or destructive disease an
artificial nose may take its place.
582 SURGICAL DIAGNOSIS AND TREATMENT.
Rhinoplasty.
Rhinoplastic art has for its object the restoration of the whole or
such part of the nose as may be wanting. Deficiencies of the nose
may be congenital, the result of accident or of destructive ulceration,
and they may be limited to the soft structures, or there may be impli-
cation of bony tissue as well. Thus, rhinoplasty, varying from a trifling
operation where a slight fissure is filled in to where the entire organ is con-
structed, naturally divides itself into partial and complete rhinoplasty.
Whatever the operation, it should not be undertaken until all dis-
eased and necrosed tissue is removed, nor until the destructive process
is clearly at an end without prospect of renewal. Tissues to repair
deficiencies arc taken from the cheek or lip, the forehead or the arm.
If the restorative process is to be only slight and on the side of the
nose, it is best generally to take the graft of skin from the cheek ; if it
is of considerable extent, from the forehead. If a new columna nasi
is to be formed, a graft is cut from the median portion of the upper lip,
and the lip is closed and dressed exactly as in hare-lip. Such a flap
may be made to do further duty in forming the ridge of a nose by dis-
secting the mucous membrane of the lip away from the skin, and
extending it as the prolongation of the skin up to the root of the nose,
the mucous membrane in its unwonted situation taking upon itself the
characteristics of cutaneous tissue. When this is done the sides of the
nose may be supplied by flaps from the cheeks. Something might
depend upon the fulness of the upper lip and cheek in deciding upon
such an operation. Commonly, however, if a considerable portion of
the nose is to be restored, the forehead furnishes the desired graft. If
only a small portion of the lower part of the ala be wanting, the upper
part of the nose itself may be made to furnish the skin for transplanta-
tion. Fistulous openings, the result of scarlet fever and other exan-
themata, are repaired usually with flaps from the cheeks.
In all these operations some pattern of the desired graft must be
traced out on forehead or cheek, allowance being made for retraction
of the skin. A pedicle must be left to ensure a blood-supply, and care
must be taken not to twist the pedicle too severely, since that alone,
by cutting off the circulation, will frustrate an otherwise successful ope-
ration. When the engrafted tissue has grown firmly in its new position
the pedicle is severed. Some trimming and adjustment of edges may
then be necessary, also a suture or two to complete the operation.
A nose too short has been improved by cutting transversely across
it, drawing it down to a suitable position, where it is held in place by
pins, and filling in the triangular space with tissue cut from each cheek
and meeting in the median line on the ridge of the nose. The bare
mention of such an operation suggests the thought that the opposite
procedure, removal of a similar shaped portion of tissue in a too pro-
tuberant proboscis, might afford an opportunity for a more brilliantly
successful operation.
Some of the earliest attempts at plastic surgery were made in the
effort to construct an entire nose, and both of the methods now most
in vogue are with more or less modifications those that were employed
when other operations of modern surgery were hardly dreamed of
INJURIES AND DISEASES OF THE RESPIRATORY SYSTEM 583
Whichever is selected, a definite idea must be obtained as to the
amount and size of tissue needed to construct the organ. Generally
upon the face of the patient a form is made of wax or other plastic
material. From this a pattern is made pyriform in outline, from which
the graft is traced out, allowance being made for the retraction of the
skin. It is usual to allow one-third for retraction.
Tagliacozzi was a learned Italian surgeon of the latter part of the
sixteenth centur}-^ and just at the close of the century he published a
description of the operation that now bears his name — the Tagliacotian.
He cut from the upper arm a skin-graft of the required size and shape,
leaving it attached by a pedicle. After this was done he left it for about
two weeks, that it might thicken and granulate. Then he freshened the
stump of the nose to which it was to be attached, adjusted the flap, and
fastened it with sutures. Since absolute immobility of the arm must
be maintained for about two weeks, numerous slings, bandages, and
appliances were necessary to keep it immovably fixed. At the end of
that time the pedicle was severed, the arm released, and a columna nasi
fashioned from the upper lip. Modern operators use a flap from the
4 ^ "^^
Fig. 255. — Indian method of rhinoplasty (Prince).
forearm instead of the upper arm, and, though this operation possesses
the advantage of not disfiguring the forehead, it is exceedingly difficult
to secure absolute immobility, and then very tiresome to maintain it for
the necessary length of time.
The other method, known as the Indian because originally practised
in India, is now more generally employed than any other. The size
and shape of the flap are determined as in the other operation.
Beginning at the root of the nose, the narrow end widens into the
broad end of the pyriform flap, either in the middle or on one side of
the forehead (Fig. 255). If made to one side of the median line, the
operation gives a fairer promise of success, because there necessarily
is less rotation of the flap upon its pedicle.
All the soft tissues are incised down to the periosteum of the frontal
bone. Some authorities recommend that the periosteum also be in-
cluded in the tissues, and even some fragments of the outer table of
the frontal bone, so that bone may be developed from the osteoblasts,
and a better shape for the nose be ensured. The stump is then fresh-
ened and bevelled, to be united with the properly bevelled edge of the
584 SURGICAL DIAGNOSIS AND TREATMENT.
flap, or the skin may be slit and the flap, after being bevelled on its
outer surface, may be inserted into this groove. Numerous fine sutures
are employed to hold the flap in place ; the ala^ and nostrils are shaped
and stitched, and a septum made by drawing down the inner part of
the flap and stitching it to the upper lip. The nostrils are kept open
with tubes or plugs, and the nose supported with dressings which are
kept on for several days. The patient is confined to bed, and the tem-
perature of the room kept warm and even. When union is firm the
pedicle is severed, the edges trimmed, and final adjustment made of the
flap at the root of the nose. The columna nasi is made from the upper
lip, as before described. Some operators by prolonging the original
flap at the middle of the base provide a covering for the columna
nasi. The objection to this plan is the unnecessarily long forehead
incision.
The forehead wound is drawn together as much as possible, and
left to heal by granulation.
Too much allowance should not be made for shrinkage, or the nose
may be so extraordinary in size as to constitute a deformity almost as bad
as the one it was intended to remedy. Various surgeons have made
modifications of these operations, for the details of which the student is
referred to special works.
If there are objections or contraindications to operations of this
sort, artificial noses, held in position by spectacles, offer a very credit-
able substitute for Nature's handiwork.
Rhinoscopy.
Rhinoscopy as now practised owes its existence to the discovery of
laryngoscopy, for posterior rhinoscopy employs practically the same
instruments and means as does the sister art. Anterior rhinoscopy was
no doubt practised in the surgery of very early times, but its import-
ance, considered alone, has been greatly enhanced by the ability to
view also the naso-pharynx.
Only a few simple instruments are really necessary for the practice
of rhinoscopy. Of prime importance is some good source of illumi-
nation. This may be a simple oil lamp or a gas or an electric light
with complicated fixtures. A student lamp with a metallic chimney in
which is adjusted a plano-convex lens for condensing the rays of light,
if that is necessary or desirable, is a very good light.
A good gas-light in suitable position with reference to that of the
patient will do very well. Such a light, so attached to a bracket that
it will move in all planes, with the chimney and lens for condensing,
constitutes a very excellent source of illumination.
A concave forehead reflector with a central perforation, having a
ball and socket on the rim, adjusted either by a band or a spectacle
frame, a nasal speculum and a nasal retractor for anterior rhinoscopy,
a small-sized laryngoscopic mirror, and a tongue-depressor for poste-
rior rhinoscopy, are all the instruments needed.
In anterior rhinoscopy an ear-speculum of small size and a little
larger than usual may be employed. Thudicum's speculum, a bivalve
instrument, is very useful (Fig. 256). Self-retaining wire dilators are of
INJURIES AND DISEASES OF THE RESPIRATORY SYSTEM. 585
Fig. 256. — Thudicum's nasal speculum.
great convenience and cover the minimum amount of the .surfaces to be
examined. Those known as Frankel's and some varieties invented and
used by Prosser James are the best.
Special rhinoscopic mirrors are not
necessary ; the small sizes of larj'n-
goscopic mirrors are generally used
with the handle bent to an angle of
about 105°.
Anterior Rhinoscopy. — For the
practice of anterior rhinoscopy the
patient is seated directly in front of the
surgeon in an upright position, the
head thrown slightly backward. The
light is placed so as to come over the
right shoulder of the patient. The
rays are focussed upon the forehead
mirror, and thence thrown into the
nasal fossa, which it is thus possible to
explore completely from roof to floor and from septum to side. The
middle and inferior turbinated bodies, the middle and inferior meatus,
come plainly into view ; the superior turbinated body is rarely or never
seen. If the nostril is unusually spacious, it may be possible to see
the posterior wall of the pharynx.
Not all portions of the nasal mucous membrane are of the same
color. The middle turbinated body is of a pale color, the septum is
darker, and the inferior body the deepest red of all.
Cocain should ordinarily be applied in a first examination. After
tolerance has been established it may be less necessary. The lower
turbinated body has much erectile tissue, which on irritation is apt to
become distended and occlude the passage. Application of cocain pre-
vents this, and reduces the abnormal sensitiveness of inflamed parts
of the surface.
Posterior Rhinoscopy. — In posterior rhinoscopy the position of
the patient and of the light are the same as in anterior rhinoscopy,
but here the light is thrown into the mouth and concentrated upon a
mirror at the back of the throat, so that the observer does not get a
direct view of the parts he is examining, as before, but an image only.
The mouth must be opened widely, and the tongue well depressed on
the floor of the mouth. The mirror is warmed to prevent condensation
of vapor upon it, and, introduced at the corner of the mouth, is carried
up behind the velum, and should be brought to a standstill midway
between that and the posterior pharyngeal wall.
Certain difficulties present themselves here in some cases. The
hard palate may be prolonged so far backward that there is scant room
between it and the pharyngeal wall, and this may be so pronounced
that it is not possible to obtain an image at all. Adenoid vegetations
may present themselves in the way. These have to be removed before
the examination is practicable. A long soft palate may hang so low as
to obscure the image. In this case it must be held aside by a retractor
or palate hook ; or a ligature may be passed around it and fastened to
a tooth, thus giving freedom to the surgeon's hand. A tape may also
586
SURGICAL DIAGNOSIS AXD TREATMENT.
be passed throuL:^h the nostrils and brought out of the mouth, Hfting
the pahite out of the way. The tape is generally carried over and tied
behind the ears. Another obstacle to examination is that the patient as
soon as he opens his mouth begins oral respiration, and the entering
current of air carries the uvula tightly against the pharygneal wall.
This can quickly be corrected if the patient will, even with the mouth
open, acquire the ability to breathe through the nose. He may be
directed to place his hand tightly over the widely-open mouth. He
will then be forced to nasal respiration. Removing the hand, he can
easily continue the same mode of breathing.
The rays of light from the reflector must fall upon the mirror in the
fauces in such a manner that they will be reflected from it upon the
posterior nares. The mirror will thus receive the " rhinoscopic image."
Only rarely, however, will a complete image be reflected upon it. The
mirror is held so as to examine first one side, and then the other, and
the mind combines the two halves so as to make the perfect picture.
At first the observer will be able to make out little, but patience and
care will soon make the different parts stand out clearly (Fig. 257).
Fig. 257. — Representation of posterior rhinoscopic image.
When the mirror is finally adjusted at the proper angle, about 130
degrees with the horizon, first the posterior surface of the uvula, then
that of the velum, come into view. The velum arches up in the field of
vision so as to always obscure a part of the lower posterior nares.
The septum nasi is most prominent, and soon asserts itself as the land-
mark to which the other parts are instinctively referred. It is narrow,
glistening, and pale below, but widens out into the pharyngeal vault,
deepening in color as it increases in width, though the darker color is
partly due to the fact that above it is less brilliantly illuminated. On
either side are two somewhat oval spaces, much darker in color than
the septum, since they are hollow or receding — the choanae or posterior
nares.
Stretching across from the external side of each are three bulbous
structures, the turbinated bodies. The middle one is the most promi-
nent, really overshadowing the other two. The superior turbinated
INJURIES AND DISEASES OF THE RESPIRATORY SYSTEM. 587
bodies are small, of triangular shape, pointing downward and inward,
and, indeed, are sometimes scarcely visible, being overlapped by the
middle ones. The inferior turbinated bodies fill in the lower outer angle
of the space external to the septum and overlie the lower part of the
middle body. Owing to the arch of the velum, their lower part is
rarely visible, though here, as elsewhere, there is great variety in the
configuration of the parts. This shape of the velum prevents the
inferior meatus from appearing in the rhinoscopic image. The middle
one comes out distinctly as a depression between the middle and infe-
rior bodies toward the outer boundary of the space. The superior
meatus looks like a line above the middle turbinated body. The orifice
of the Eustachian tube presents on each side opposite the upper part
of the inferior turbinated body. It is a depression situated on a smooth
rounded projection, and lies in a different plane from the parts just de-
scribed. It is scarcely necessary to say that for the successful practice
of rhinoscopy a thorough knowledge of the normal parts is indis-
pensable.
A great variety of instruments and also of medicaments are em-
ployed in the treatment of diseases of the nasal passages. Most of
these have been discussed in the treatment of nasal diseases, and men-
tion has also been made of the different methods both of cleansing and
of treatment ; the student is referred to complete works on rhinal
therapeutics for more detailed information.
The douche, both in the profession and among the laity, is the most
widely known of any method both for cleansing and for treating the
nasal passages.
The simplest arrangement is that of a reservoir of some sort, a cup,
a bottle, or a small fountain syringe, to which is attached rubber tubing
ending in a nose-piece. The nose-piece is passed into one nostril, the
patient bending slightly over a basin. He must resist the inclination to
swallow as the liquid strikes the pharynx, so that it will not pass into
the Eustachian orifice, and im-
mediately the stream will pass
into the posterior nares of the
other nostril.
Many surgeons prefer, in-
stead of the douche, a coarse
spray. There are many varieties
of nasal spray-producers, of
which Leffert's is one of the
best (Fig. 258).
Syringes are useful for re-
moving crusts and inspissated
secretions. A common bulb-
syringe, fitted with suitable
nasal tubes, may be used, al-
though syringes especially for
the nose are manufactured.
For the anterior nares a straight hard tube is used or the aurist's
syringe, but for the posterior nares a tube curved at the end so as to
enter and fit into the posterior opening is necessary.
588 SURGICAL DIAGNOSIS AND TREATMENT.
Compressed air-atomizers of complicated structure are a desideratum
in the treatment of obstinate chronic cases, especially those of syphilitic
origin.
Insufflators are of common use, and apply a powder instead of a
liquid to the nasal mucous membrane.
Bougies of soluble materials are often used in treatment of the nasal
passages. Dilators, either solid or hollow, of soft or hard material, are
a necessary part of the outfit of those who treat diseases of the nasal
passages.
The medicaments used resolve themselves into astringents, stim-
ulants, cleansing solutions, antiseptics, and caustics, and their name is
legion, though they are the same as are used to accomplish the same
results in other parts of the body.
II. DISEASES AND INJURIES OF THE ACCESSORY SINUSES OF THE
NOSE.
The Antrum of Highmore or the Maxillary Sinus. — In-
juries. — " This cavity hollowed out of the body of the maxillary bone "
is more open to injury than any other accessory sinus of the nose,
both from its exposed position at the most prominent portion of the
face, and because its walls are very thin and yield readily to pressure or
violence. A blow upon the cheek may fracture the w^alls of the
antrum, or it may be penetrated by a weapon or by bullets, in wdiich
case the fracture is compound.
If the fracture is simple without depression, the pain and soreness
may quickly subside, giving no marked symptom of inflammation and
without permanent injury. If the fracture is comminuted, depression
is likely to occur. The bone may be restored to position by operative
interference either through the nose or the mouth. It is rarely possi-
ble for fractures of the walls of the sinus to occur without setting up
inflammation of the mucous membrane lining the cavity, followed by
abscess as a rule.
Foreign bodies in the antrum are usually either bullets or insects.
To these, as occurring rarely, may be added the crusts formed by an
ozena of the antrum, spicula of bone, portions of broken instruments,
drainage-tubes, bits of gauze, etc. from former operations.
Diseases. — Inflammation may be either acute or chronic.
Simple acute inflaviination without abscess is, no doubt, a frequent
occurrence as a complication of severe coryza. The symptoms are
negative, however, unless the process, instead of ending in steady
resolution, goes on to the acute purulent form. In this case the ostium
maxillare is temporarily closed from the congestion and inflammation of
the mucous membrane in the narrow orifice. Other causes are — trau-
matism, as previously mentioned ; the presence of polypi in the nose,
closing the ostium maxillare (or of polypi within the antrum, effecting
the same thing) ; or, more frequently than anything else, dental caries,
particularly that form in which an alveolar abscess infects the antrum
by extension from the root of a tooth that projects up into the floor
of the antrum. It has been observed in the case of infants from
injuries received during labor.
INJURIES AND DISEASES OF THE RESPIRATORY SYSTEM. 589
Syuiptonis. — There may be no physical signs of acute purulent in-
flammation of the antrum, but in severe cases they are usually present
in a more or less pronounced degree. If there is no outlet for the
pent-up pus, then the objective symptoms are most marked and the
subjective most painful.
The abscess, even though it is surrounded by bony walls, produces
marked distortion. It may crowd the teeth downward until they pro-
ject abnormally in the mouth ; it may flatten the normally convex
hard palate ; it may push up the floor of the orbit until the eyeball
bulges forward ; it may crowd the adjoining nasal wall until it closes
the nostril or may cause marked enlargement of the cheek over the
malar bone.
With such signs fluctuation is generally present, because the bone
is much thinned, and eventually, unless the pressure is relieved by
surgical interference, the abscess will burst at the point of least resist-
ance, either into the nostril or the mouth, or very rarely through the
cheek or the floor of the orbit. Crepitation is frequently detected over
a thinned portion of bone. If, however, the ostium maxillare is patent,
pus will be discharged into the middle meatus of the nostril from
beneath the turbinated bone on one side. This may be continuous or
intermittent, and may increase or decrease in amount according to the
position of the head. When this is the case, it is frequently observed
that the color of the discharge is ozenic. When pus is confined within
the antrum there are tenderness on pressure, pain radiating in various
directions, and a feeling of distention and distress in the head generally.
The soft parts of the face may be greatly swollen. There may be also
constitutional symptoms, such as accompany the accumulation of
purulent matter in other parts of the body, rigors, sweats, fever, and
severe headache.
Diagnosis is made by the discharge of pus into the middle meatus
if the opening into the nostril is patulous — by the physical signs and
constitutional symptoms if it is occluded.
Some authors advocate transillumination by means of a small elec-
tric lamp placed in the mouth as a means of differential diagnosis. It
will be seen, however, that this would be little more than confirmatory
of other symptoms. The patient is placed in a dark room, and the
lessened illumination of the diseased side of the face gives evidence of
opacity in the antrum. Such opacity might, however, be due to thick-
ened bony walls, to tumors or cysts, or to greater thickness of the
overlying tissues on the one side. Should abscess of the antrum be
bilateral — a condition not unknown — transillumination would be of no
value unless it could be demonstrated that the illumination of the
face was less than in the case of a large number of other people.
Possibly the Rontgen rays may, at no distant time, become avail-
able in clearing a diagnosis in such conditions. Foreign bodies,
cysts, and tumors in the antrum may present some difficulties to the
diagnostician, but the evidences of acute inflammation under these con-
ditions is, as a rule, absent, and the cachexia of malignant growths is
wanting in abscess.
When pus appears persistently in the nostril of an adult, it may be
from any one of the sinuses. If all signs of its source are absent, the
590 Si'MG/CAL D/AGXOS/S AND TREATMENT.
patient may be directed to bend the head low, when the discharge will
be increased if it is from the antrum of Highmore. On resuming the
erect position it will, if wiped away, not return at once. If it comes
from the other sinuses, removal will not stop the flow. In children
foreign bodies in the nose most commonly produce a unilateral discharge,
and from anatomical considerations young persons seldom suffer from
antrum-disease. If, after all attempts to settle the question of abscess
of the maxillary sinus, doubt still remains, an exploratory incision may
be made, preferably through the canine fossa, or the inferior meatus,
where the bone is so thin that moderate force will effect an entrance.
Trcatuioit. — In acute inflammation of the maxillary sinus without
the formation of abscess antiseptic and detergent washes in the nasal
chamber, with hot applications, are generally all that is necessary both
to cure the existing condition and to prevent further trouble. On the
first indication of the accumulation of pus, here, as elsewhere, free
evacuation is the rule. If a carious tooth can be profitably spared
here, through its socket is the ideal opening, both for ease of access
and thoroughness of drainage, and such a route was formerly the only
one attempted, even if a sound tooth were sacrificed. Now, however,
if no decayed tooth present itself for vicarious extraction, an opening
is made, either with probe or trocar, at the lower part of the canine
fossa or near the floor of the nostril in the inferior meatus, or in both
places, by which drainage is more rapid and irrigation more thorough.
If it is suspected that the purulent inflammation is caused by a foreign
body or by necrosed bone, thorough search for such must be made
with a probe, even to the breaking down of septa of bone. The re-
moval of such foreign material may make it necessary to enlarge the
opening.
Chronic inflainination of the antrum of Highmore may persist for
years. It may run a rather steady course, or a chronic condition, with
discharges comparatively slight in amount and at rather long intervals,
may with some regularity give way to more acute exacerbations, during
which both the frequency and the amount of the discharge are notice-
ably increased. In either case there is evidence of accumulated secre-
tion in the fact that lying down or bending the head to one side or low
down will increase the amount of the discharge. Pain is not generally
a marked symptom, though headache is common, and there is a depres-
sion of spirits and a generally lowered tone to the system.
Constant discharge of pus over the Schneiderian membrane is
believed by some to cause nasal polypi, and these, on the other hand,
by occluding the opening into the antrum, may bring on acute inflam-
mation, though by some authors a form of chronic inflammation is
described in which the outlet is occluded.
Diagnosis must rest upon the unilateral discharge, usually fetid,
from the nose ; and since it is possible for a discharge from the frontal
sinus through the fronto-nasal canal and the ostium maxillare to reach
the antrum, and also from the ethmoidal cells through the hiatus semi-
lunaris to reach the same place, it is plain that an absolute diagnosis
without confirmatory symptoms is sometimes impossible, for these dis-
charges would reach the nasal cavity from the antrum, appearing under
INJURIES AND DISEASES OF THE RESPIRATORY SYSTEM. 59 1
the middle turbinated bone, and, nevertheless, the mucous membrane
of the antrum be wholly free from the inflammatory process.
Treatment. — Under the conditions last sketched treatment of the
antrum of Highmore would be utterly futile. If, however, the dis-
charge really has its origin in the sinus, and will not yield, as it fre-
quently does, simply to intranasal douching with antiseptic and astrin-
gent lotions, then the antrum must be opened, cleansed, and drained.
The choice as to openings is to be made as in the case of acute inflam-
mation. Antiseptic solutions, as boric acid, are then used to cleanse
the antrum. After exploration and removal of foreign substances or
necrosed bone a drainage-tube (either Myles' or Bosworth's, according
to circumstances) is inserted, and the antrum should be thoroughly
washed after each meal. When there is no further evidences of pus,
the drainage-tube is withdrawn and the opening heals very quickly,
although so long as it persists the flushing of the antrum must be
maintained because of the liability to infection from food.
Sometimes, after the operation has been most thorough, evidences
of chronic inflammation again make their appearance and the operation
must be repeated.
Foreign Gro"wths. — Cysts have been known to exist within the
antrum of Highmore, also serous accumulations and extravasations
of blood. Tumors, both benign and malignant, are not relatively
uncommon, as hematomata, fibromata, bony tumors, myxomata, and
both sarcomata and carcinomata. (According to the table of Weber,
based on 307 cases analyzed by him, carcinoma is by far the most
common, and sarcoma next.)
Symptoms appear rather insidiously, and may be confined to local
pain and distress, with the addition of cachexia and involvement of
glands in malignant disease, or there may be evidence of involvement
of contiguous structures.
Extirpation, if the age and health of the patient permit, is the only
course, and even then the trouble may be too extensive to be checked.
Frontal Sinus. — Injuries. — This cavity communicates with the
nasal cavity through the fronto-nasal canal, a relatively long and nar-
row opening. It is subject to simple, compound, and comminuted
fractures. The first is usually the result of direct violence, as a fall or
a blow upon the forehead, while the last is the result of gunshot
wounds, stabs, falls, blows, explosions, etc.
In simple fracture commonly only the anterior wall is broken, and
in that case the most frequent and serious symptom is emphysema of
the face and forehead because of the escape of air from the nose into
these tissues. The posterior wall of the sinus may be fractured, with
consequent access to the brain. If the outer wall is depressed, it must
be elevated to avoid disfigurement of the face. If the dura mater is
exposed, an operation may be necessary.
In compound and comminuted fracture all pieces of bone or frag-
ments of other tissue must be removed from the sinus, and also all
foreign bodies, as bullets or splinters. Jagged points of bone must be
removed, and the parts restored as nearly as possible to their normal
position. Plastic operations may be necessary to secure this end.
It is said that the frontal sinus is the most liable to invasion by
592 SURGICAL DIAGNOSIS AND TREATMENT.
insects, as flics, centipedes, etc. Strict antisepsis must be maintained
whatever the operation, and particularly if there is likely to be any
involvement of the brain.
Diseases. — fiifJaiiiii/atioii may either be acute or chronic. The
acute fonii is frequently caused by an extension of inflammation from
the Schneiderian membrane. It is also the result of such injuries as
were described in the previous section. It may also result from tertiary
syphilis, and whatever the cause, there may or may not be abscess. From
the frequency with which it is involved in acute coryza it would seem
at first thought that it is affected more frequently than the other
accessory sinuses of the nose, but this probably is not the case. The
canal to this sinus is so narrow that it is easily occluded by the swell-
ing of its mucosa. Secretions are thus retained, and consequent .symp-
toms appear eadier and are more marked than in the case of other
sinuses, where some outlet is generally preserved, even when the
mucous membrane is considerably congested or inflamed.
Svniptflins. — A sense of fulness in the forehead, intense headache
and pain in the frontal region, are the usual symptoms of inflammation
of the frontal sinus without abscess. If an abscess form, all these are
aggravated, constitutional symptoms appear, and local signs are marked.
There are chills, fever, and, if there is pressure upon the brain or
invasion of it by the products of inflammation, there may be delirium.
There are local pain and tenderness on pressure, bulging and distention
of the parts, even to exophthalmos. If the pent-up pus finds access to
the cranial cavity and implicates the brain, there is delirium. Over the
affected part the skin often becomes intensely red, simulating erysipelas.
If the inflammation is of syphilitic or tubercular origin, there are very
likely both local and constitutional manifestations of its presence in the
system. The eyes usually share in the affection to some extent, photo-
phobia, conjunctivitis, and lachrymation being common.
Absorption of the bone takes place if the pressure is great, and
consequently, if there is spontaneous evacuation, the pus finds vent at
the point of least resistance.
Fluctuation and crepitation are often very noticeable before this
occurs.
Treatment. — In simple acute inflammation without abscess pain may
be controlled by opium, with the usual treatment of an acute coryza,
and leeching if there is fear of abscess. When there is evidence of the
accumulation of pus, free evacuation is the only rule. An attempt may
be made to reach it through the nasal outlet. If this fail, as it is apt to
do, an external incision is to be made, even though it leave a scar.
The cavity is washed out with disinfectant solutions and a drainage-
tube inserted. If syphilis is the cause of the abscess, necrosed bone
will probably be found ; this must be carefully and completely removed
and specific treatment must be begun.
CJironic inflauiuiatioii of the frontal sinus is generally, if not always,
purulent. It may be the result of repeated attacks of acute inflam-
mation, or it may be the outcome of a single acute attack of unusual
severity. Chronic inflammation of the Schneiderian membrane may
involve that of the frontal sinus ; also abnormal nasal conditions, as
hypertrophy, a deviated septum, nasal polypi (by causing partial ob-
lyjURIES AND DISEASES OF THE RESPIRATORY SYSTEM. 593
struction of the fronto-nasal canal), will produce a chronic inflammation
of the mucosa lining the frontal sinus. Syphilis and tuberculosis,
foreign bodies and tumors, are all causative factors in producing chronic
purulent inflammation of this sinus.
Syinptovis. — All of the symptoms and local signs of acute inflam-
mation may be present in the chronic form, but are generally less
severe, pain being rather dull and constant, with occasional re-
mission, alternating with exacerbations. Pus is generally to be seen
in the nose, but may be so small in amount as almost to escape notice.
If this is the case — that is, if the discharge is not marked and constant
— there is frequently an unusually large discharge, followed by a tem-
porary quieting of all the symptoms. It is sometimes impossible to
differentiate with certainty between a discharge of pus in the nose,
coming from the frontal sinus, and that coming from the other acces-
sory sinuses, and, as we have seen, it may really come from the maxil-
lary sinus when the inflammation is in the frontal sinus. If it originates
in the maxillary sinus, bending the head and wiping away the pus will
stop its coming for a time ; if it is from the frontal sinus, its flow will
be continuous. If, on examination with a probe of the ethmoidal
sinuses, there is no evidence of exposure of bone by the absorption
of its mucous covering, then ethmoidal disease may safely be excluded.
If the disease give evidence of having its seat well forward, sphenoidal
disease may be set aside. However, all the sinuses may be involved at
once, or any two or three of them. For instance, purulent inflamma-
tion originating in the frontal sinus may set up the same trouble in the
antrum of Highmore, and it may finally reach the ethmoidal cells by
extension from the pituitary membrane.
TreatvicJit. — Two possible routes for evacuation present themselves
— one through the natural passage, and one by external incision through
the frontal bone. The difficulties are threefold in respect to the former :
the opening to the passage may not be found by the probe in the hand
of the surgeon, since we must find it by touch alone, illumination being
out of the question ; secondly, if by chance the probe engages in the
proper orifice, it may be impossible to clear the passage to the sinus ;
lastly, there is great danger to other contiguous localities should the
probe slip. So that, in spite of possible deformity, an external incision
is the safer. It may be made above or below the end of the eyebrow,
but preferably below, because the scar is there less noticeable. The
contents of the sinus are evacuated, a probe is passed downward into
the nose, and a drainage-tube inserted into the passage, through which
the sinus is washed out daily. The wound is closed and dressed as in
other situations. Complications and sequelae must be met as they occur.
Mucocele and cysts have been frequently reported as found in the
frontal sinus.
Foreign bodies, as bullets, splinters, and insects, have already been
referred to, and in addition concretions similar to rhinoliths may form
in the frontal sinus.
Tumors, both benign and malignant, are of not infrequent occur-
rence.
Polypi and osteomata are the most common types of the former.
Both carcinomata and sarcomata are found, the latter being the more
38
594 SURGICAL DIAGNOSIS AND TREATMENT.
common. Great deformity and destruction of parts from pressure are
the usual sequelse, with local and reflex symptoms of great variety and
intensity as the disease develops.
Whether or not extirpation is to be attempted must be determined
in each case b\^ its own peculiar character.
Bthinoidal Sinuses. — It is by analogy rather than by demonstra-
tion that we arrive at conclusions regarding cthmoiditis. Owing to its
position and the thinness of its mucosa and limiting walls it is, of all
the sinuses, the most prone to acute inflammation with or without
abscess, or to chronic inflammation with absorption of the mucosa and
the underlying bone. But none of these are capable of demonstration.
It is only when the probe strikes bare bone that we are absolutely
certain of disease in this locality.
The cause of ethmoiditis must be chiefly in the extension of inflam-
mation from the nasal fossae. Diphtheritic membranes have been formed
in the ethmoidal cells, and ozena probably often arises here.
The syuiptovis are, in the main, those of acute rhinitis or of frontal
disease. By exclusion ethmoiditis may probably be diagnosed.
Treatment. — If the probe finds exposed bone or if by exclusion
ethmoidal inflammation has been diagnosed, then the curette affords
the only means of relief after removal of all polypi, hypertrophied
tissue, and spurs of bone or correction of deviated septum in the nasal
passages.
Sphenoidal Sinus. — Sphenoiditis is even more obscure and
doubtful in its manifestations than ethmoidal inflammation, and is
usually a complication or a sequel of the latter disease. The sphe-
noid sinus lies in close relation to so many important structures that
it may well be implicated in lesions affecting them ; on the other hand,
its own injury or partial destruction would immediately be felt by the
nerves and blood-vessels in its neighborhood. If it is distended with
an accumulation of pus, reflex and remote symptoms are caused from
the pressure.
Diagnosis is reached by exclusion. Operations may be through the
mouth, the orbit (after enucleation of the eye), and the nose.
III. NEUROSES OF THE NASAL PASSAGES.
The olfactory nerve is the only one concerned in the special sense
of smell, and hence any abnormalities as to smell must be due to
disease of this nerve. The fifth nerve is the nerve for common sensa-
tion and touch. Either of these may be affected separately or both
together.
Anosmia is the absence of smell, and strictly the term should be
used to express entire abolition of the sensation. A rather loose use
of it, however, permits us to speak of the impaired sensation as partial
anosmia. It may be temporary or permanent, because its causes
naturally fall generally into two great groups — those in which the nerve
itself is injured or destroyed, and those in which obstruction in the
nasal cavity prevents the exercise of its function.
Sometimes no cause can be found to account for the condition, and
then it is said to be idiopathic, the real cause being constitutional or an
INJURIES AXD DISEASES OF THE RESPIRATORY SYSTEM 595
overlooked traumatism. It is believed that there may be inflammation
or rupture of either the olfactory bulb or the nerve before it reaches the
opening into the ethmoid plate or in passing through that opening,
or that there may be a hemorrhage into the tissues of the bulb or the
nerve within the cranium. Tumors on the distended lateral ventricles
pressing upon the nerve or its roots, particularly the external root, may
prevent its functional activity or even destroy the nerve. Blows upon
any part of the head, since the olfactory bulbs lie on the floor of the
cranium, may sever the connection with the brain. Atrophy and
degeneration of the nerve are not unknown. Besides lesions within
the cranium, the nerve may suffer injury within the nasal cavity.
Anosmia may be caused by long-continued hyper-stimulation from
powerful odors. Well-credited instances are recorded where ether has
been the causative factor in producing anosmia.
Douches have been known to produce it, probably because the
lotions used were too strong. Prolonged rhinitis is no doubt the com-
monest cause of temporary anosmia. Paralysis of the fifth nerve is
said, finally, to produce it. In the main, injuries to the bulb, the nerve,
or its terminal filaments will result in permanent anosmia, though of
course there may be cases of temporary anosmia where the cause lies
in the lesion of the nerve itself
On the other hand, where obstruction produces the symptom it is
far more apt to be only temporary, and is generally only partial.
One has only to recall the common causes of obstruction to enume-
rate the causes of obstructive anosmia — nasal polypi, tumors, hyper-
trophic rhinitis, deviated septum, crusts of inspissated mucus, acute
coryza, cicatricial contraction, etc. Generally with the removal of the
obstruction the power of smell is regained. Any cause also which
produces dryness of the surface of the mucous membrane will interfere
with smell, as moisture is essential to its exercise. Paralysis of the
dilator muscles of the nose may cause temporary or permanent anos-
mia according to the duration of the paralysis.
Frequently anosmia is unilateral, and may thus exist without the
knowledge of the patient. Plugging the other nostril is necessary then
to verify the condition.
Anosmia may also be due to congenital causes, either congenital
occlusion of the nasal fossae or congenital absence of the olfactory
tract.
Anosmia is frequently observed in connection with hysteria, and is
then accompanied with the suspension of other sensations, as taste, all
of which are believed to be of central origin.
Dr. William Ode has conducted researches to estabHsh the fact
that diminution or absence of pigment in the olfactory region impairs
the sense of smell. This may be a coincidence and not a cause.
Taste is closely connected with smell. Our appreciation of flavors
is really due in large measure to smell, and when this sense is dulled or
absent its loss may first be noticed by the fact that well-known flavors
are not recognized by the sense of taste.
Further, when the olfactory nerve is unimpaired and the anosmia is
due to obstruction, the odoriferous particles may reach the nerve at
times through the posterior nares.
596 SURGICAL DIAGNOSIS AND TREATMENT.
Diagnosis rests in the obstructive cases upon examination, otherwise
upon the statement of the patient, since it is a subjective symptom.
Prognosis depends upon the cause. Cases due to obstruction have
the best hope of recovery; next in order are those due to rhinitis,
which are almost hopeless if the rhinitis is long continued. Anosmia
due to lesions in the nerve itself seldom improve.
Treatment. — Removal of the obstruction by any of the methods
already detailed is usually sufficient for cases that are due to obstruc-
tion. For those due to rhinitis the treatment for that disease is all
that can be given. When the nerve is diseased little can be done
except to maintain generally good nutrition of the nervous system.
Galvanism has been tried, but the strongest current that can be used in
this locality is too weak to be of any service. Strychnin locally applied
with a brush is advocated, but the danger of poisoning by this method
must not be overlooked. It is better given as a tonic. If the disease
is of central origin, treatment is useless. Stimulation by snuff or strong
odor may be tried.
Hyperosmia or Hyperesthesia of the Olfactory Nerve. —
The sense of smell may become abnormally acute. Such a condition
may exist apart from disease, or it may be developed with disease or as
a result of disease. Certain people have a peculiar susceptibility to
certain smells, and betray no special acuteness in respect to others ;
others possess an unusual sensitiveness in smell while in certain states
of health — as, for instance, hysterical people not infrequently lay claim
to extreme sensitiveness in the perception of odors or at least of par-
ticular odors.
Closely connected with hyperosmia, and perhaps at times not to be
distinguished from it, is the condition known as parosmia — a perverted
or altered appreciation in regard to smell. Of such a sort is the odor
so often definitely perceived by epileptics just as the seizure is felt.
Probably the perception of odors by hysterical patients at times bor-
ders closely upon parosmia. Insane people often complain of odors,
usually disagreeable ones. This may be imagination or it may be due
to structural changes in the nerve within the cranial cavity. Tumors
within the bulbs or pressing upon them or degenerations of various
sorts are known certainly to cause parosmia. Such odors are usually
disagreeable in themselves ; but, whatever their character, if they per-
sist they become unpleasant. Olfactory derangements, such as these
last described, must result in anosmia when the obstruction is com-
plete. Certain people seem also to have dull or perverted appreciation
of odor even when the condition is far from being anosmia. Some are
uncertain or indifferent as to odors, or odors widely different may seem
to them just the same. Such olfactory abnormalities are not unlike
color-blindness in the optic nerve.
Reflex Neuroses. — Of late years much attention has been given
in medical Hterature to the " sensitive reflex area " in the nose, which
either by pathological conditions within the nose or by irritants from
without, is so stimulated as to produce effects in remote parts of the
body. Its location is at the posterior end of the middle and inferior
turbinated bones, and somewhat upon the septum opposite these parts.
The normal intent evidently of such an area is to protect the air-
INJURIES AXD DISEASES OF THE RESPIRATORY SYSTEM. 597
passages against the intrusion of unsuitable substances. It is only
when the sensitiveness of this area exceeds the normal that the remote
effects of neuralgia, photophobic nausea, etc. are felt from its stimula-
tion. On the other hand, atrophy of the mucosa in this region destroys
the reflex sensitiveness. Cocain, locally applied, destroys temporarily
all manifestations of reflex irritability.
Some of the conclusions based upon the existence of this area have
" proved too much," and a conservative attitude may well be maintained
until their importance and influence are established by further investiga-
tion and experiment.
The fifth nerve may become paralyzed, leading to loss of sensation
in the Schneiderian membrane, or it may become hyperesthetic and
lead to violent and prolonged sneezing, which is usually unimportant,
but may lead to hemorrhage.
IV. THE LARYNX.
I/aryngfOSCOpy is the inspection of the interior of the larynx.
The discovery that this portion of the body can be brought into view
for study and treatment is of comparatively recent date, and marked a
decided advance in the methods of treating throat-diseases.
Mirrors have long been employed for inspecting such parts of the
teeth as the dentist cannot readily see. Manuel Garcia, a singing-master
of London, employed such a mirror to make investigations as to the
structure of the larynx. His researches and experiments, however,
went no farther than to establish the fact that phonation depends upon
the true vocal cords. But just as Garcia had employed the instrument
of the dentist to establish new facts regarding his own profession, so
Czermak of Pesth, taking up his investigations where Garcia had
stopped, added a new specialty to medical surgery by the use of arti-
ficial light reflected from a concave mirror upon the mirror in the throat
to produce an image of the larynx.
Laryngoscopic mirrors are made in sizes varying from three-eighths
of an inch to an inch and an eighth in diameter. They must be attached
to a firm, slender handle at an angle of 135°. Those of about an inch
are used for adults ; smaller ones are employed for children and for
adults with unusually narrow fauces.
Any convenient light, direct or reflected, may be used for illumina-
tion, and here sunlight is really the best, although a gas-light or elec-
tric or oil light serves excellently well if carefully adjusted at the proper
angle and falling over the right shoulder of the patient.
Concentrators are not necessary if the light itself is really brilliant.
The head reflecting mirror has a central perforation, and is mounted
on the head by a band or a spectacle frame and should move freely in
all planes. It need not be more than three or four inches in diameter.
Instead of the head-mirror, one attached to the lamp- or gas-fixture
may be used, as in Tobold's laryngoscope (Fig. 259), and for many pur-
poses this is simpler and easier to adjust, but the practitioner should be
master of both methods, that his services may be available away from
his office.
When the light is adjusted the patient opens his mouth as widely as
possible, extends his tongue, and keeps it in that position by holding it
598
SURGICAL DIAGNOSIS AND TREATMENT.
with a liandkcrchicf in his liancl. The surgeon, having previously-
warmed the laryngoscopic mirror, takes it in his hand much as he
would hold a pen, the handle pointing downward and outward. With
the reflecting surface outward he carries it back over the dorsum of the
tongue until it strikes the uvula. This is pushed backward by the
mirror, the lower edge of which should touch the pharynx, and all of
it be plainly in view, its surface at an angle of 90° with the line of
vision. Practice only makes these manoeuvers both quick and firm
enough to prevent gagging on the part of the patient, and they should
be supplemented by most intimate knowledge of the regional anatomy
of the parts and of their normal appearance. Cocain may be applied
if there is hypersensitiveness of the parts. Study of the normal throat in
living subjects and of the larynx removed from the cadaver, both
Fig. 259. — Tobold's large laryngoscope and student's lamp.
directly and with the laryngoscopic mirror, is the only method of
preparation for such work.
An artificial light gives to the parts of the larynx a deeper color
than normal.
A little care is necessary on the part of the beginner in the laryngo-
scopic art to appreciate the correct relations of the image presented to
him, for he sees in a nearly vertical plane what he has been accustomed
to think of as a horizontal plane, and with the anterior and posterior
portions seemingly reversed. This reversal in a normal throat should
be of no moment whatever. With neoplasms or other disease invading
the larynx a moment's reflection will assure the observer of its real
position.
In the normal larynx the mucous membrane is of about the same
color as in other parts of the body. Where the cartilage, which in this
region is fibro-cartilage, shows through, it gives a yellow tinge to the
overlying mucous membrane. On the other hand, it appears a deeper
INJURIES AND DISEASES OF THE RESPIRATORY SYSTEM. 599
red than in most of its extent when it overHes glandular tissue. Also
the parts best illuminated, those that are farthest forward in the laryngo-
scopic image, "the high lights," will appear the lightest in tone, while
those that are deepest will assume a darker hue.
Repeated examinations will acquaint the observer with the normal
appearance as a whole as seen either by sunlight or artificial light, and
he will be quick to observe any departure from this condition as indica-
tive of disease.
No one position of the throat-mirror will suffice to reveal all portions
that become visible in the successive positions, and the instrument must
be moved slightly to present the best possible views.
The first thing to be noted in the laryngoscopic image is the
epiglottis. Behind and above this is visible a portion of the base of
the tongue. At the lowest part of the arch of the epiglottis on each
side are the lingual fossae, separated by the middle glosso-epiglottic
ligament and bounded externally by lateral ligaments of the same
name. A view of the lingual face of the epiglottis shows these three
ligaments or folds of mucous membrane passing from above downward,
connecting the tongue with the epiglottis. On the laryngeal face of the
epiglottis is seen the cushion of the epiglottis, a rounded portion some-
FlG. 260."
-The laryngeal image during pho-
nation.
Fig. 261.-
-The laryngeal image during in-
spiration.
what higher than the rest ; at about the center of the face we also see
the posterior portion of the anterior palatine folds, and also the poste-
rior palatine folds, the ligaments attaching the tongue to the hyoid
bone, and those connecting the epiglottis to the same bone and the
posterior and lateral portions of the tonsils. All the parts so far men-
tioned are really exterior to the larynx proper, but incidentally come
into view as the mirror is placed in position for inspection of the
larynx, and are not visible by direct inspection.
Within the larynx are to be inspected the parts at the level of the
vocal cords and a variable portion of the walls of the larynx and
trachea below that plane.
Most distinctively in the center of the larj'ngoscopic image are seen
two white glistening bands, the true vocal cords. They may serve as
landmarks from which other parts are located on either side. During
the act of phonation they are approximated closely, and it is then im-
possible to view the parts below (Fig. 260). During inspiration the
600 SURGICAL DIAGNOSIS AND TREATMEA'T.
vocal cords arc widely separated, and it is during this interval that the
parts in the lower part of the larynx and upper part of the trachea must
be inspected (Fig. 261). The rima glottidis is thus seen to vary in extent
from a mere line in phonation to an opening of relatively large dimen-
sions during respiration.
Immediatel)' external to the true vocal cords on either side are to be
seen the ventricular bands or false vocal cords, the entrance to the
ventricular looking like a dark band next to the true vocal cords. Ex-
ternal to the ventricular bands and somewhat posterior to them are the
arytenoid cartilages. They nearly meet behind the vocal cords when
the latter are appro.ximated, but arc shorter and farther apart during
inspiration. Between the posterior ends of the arytenoid cartilages lies
the arytenoid commissure.
Forming the lateral walls of the larynx and merging into the
arytenoid commissure are the aryepiglottic folds, ridges of mucous
membrane that arise from the lateral border of the base of the epiglot-
tis. Lying upon the arytenoid cartilages can sometimes be made out
the cartilages of Santorini. The " staff of Wrisberg " is also observed,
and the vocal processes during respiration. On either side of the
aryepiglottic folds are seen, darkly shaded in the image, the laryno-
pharyngeal sinuses.
During inspiration the infraglottic portions of the larj'nx are in-
spected, showing the mucous surfaces of the cartilages forming the
larynx, the cartilaginous ring of the trachea, and, in exceptional cases,
its bifurcation into the bronchial tubes.
Such is the normal appearance of the human larynx. The surgeon
will find in studying lesions of the larynx alterations in either its mucous
membranes or its shape, injuries or neoplasms.
Injuries of the I/arynx. — These are produced by the operation
of internal or external causes, the former chiefly by foreign bodies
within the larynx, by burns or scalds ; the latter in a great variety of
ways, accidental or intentional.
Internal injuries may also result from intra-laryngeal operations un-
skilfully performed, also from substances vomited, especially in the
case of the insane and of patients under anesthesia.
Internal injuries caused by the entrance of foreign bodies into the
larynx are very common, and vary greatly in the severity of the lesion
and the urgency of the symptoms, since the number of different objects
that may find their way into the larynx is wellnigh innumerable. To
attempt to make a list of the objects that have entered or may be found
in that cavity is useless, for any object that may be placed in the mouth,
thoughtlessly or otherwise, may slip past the fauces and find lodgement
in the larynx. The student can enumerate them for himself, placing as
most common those objects which children especially are apt to have in
their hands, as toys, or can most easily obtain from their surroundings.
The closing of the passage may be so complete as to prove fatal
almost immediately, or the object may be such as to remain concealed
in the mucous membrane and excite an extreme or only a slight degree
of congestion or inflammation. Objects may reach the interior of the
larynx also from without, as bullets or the detached fragments of
sharp-pointed weapons or instruments. Internal wounds may be
INJURIES AND DISEASES OF THE RESPIRATORY SYSTEM. 6oi
punctured, lacerated, or contused. The foreign bodies may be quite
accessible, or may be so deeply buried in the tissues, either from the
mode of entrance or from subsequent swelling of the parts, as to make
it almost impossible to locate them. Even when there is no real wound
of the laryngeal mucous membrane there may be spasm of the glottis,
and respiration be so interfered with that the results are fatal. S}'mp-
toms of pronounced character may be wanting, and from such a nega-
tive condition there are symptoms of varying severity up to those
of great intensity. Pain, cough, laryngeal and phar>'ngeal neuroses,
spitting of blood, extravasation of blood into underlying connective
tissue, and severe inflammation of mucous membrane are the usual
symptoms in cases of this sort.
On evidence of laryngeal irritation, whether the history of the
entrance of a foreign body can be obtained or not, a laryngoscopic
examination should be made. If the foreign body is visible, it is gen-
erally easily removed. If it is concealed by tumefaction of the tissues,
measures must be taken to reduce the swelling by the use of astringents
and local sedatives. In cases where its presence is undoubted, but it is
too low to be demonstrated, tracheotomy may be performed, and this
operation may be necessary if the bleeding has been so considerable as
to cause an obstruction in itself
Burns and scalds of the larynx usually are accompanied by similar
lesions of the tongue, mouth, throat, pharjmx, esophagus, and even of
the nasal passages. Burns are produced by the inhalation of steam,
hot air, and smoke during fires. Scalds are due to hot and caustic
fluids, swallowed usually without design.
When it is intended to swallow such fluids, they quickly pass the
epiglottis ; when not, the instinctive effort to arrest deglutition throws
them back upon the larynx, which often then suffers the most of any
of the structures exposed to the action of the fluid. Acute laryngitis
of an intensely severe type immediately follows, and usually implicates
not the mucous membrane alone, but the underlying tissues, the extent
of such involvement depending upon the degree of heat and the con-
centration of the fluid. Edema of the lar>'nx is an almost constant
attendant of such lesions, and constitutes one of the chief dangers.
Burns and scalds produced by hot water, air, and steam assert
themselves at once, while the destructive effects of many caustics are
less prompt. Pain of an agonizing character is the most distinctive
symptom.
If life be not at once sacrificed, sloughing of necrosed tissue will be
followed by cicatricial contraction, which in itself may later present
problems of no small difficulty to the surgeon.
If suffocation is imminent, tracheotomy should be immediately per-
formed, and morphin injected subcutaneously to relieve the intense
sufiering. Cooling and soothing washes may be used both upon the
lar}mx and accompanying lesions of the mouth, nose, and throat ; but
the outlook is very bad at best in severe cases of this sort. Such cases
are commonly the attempts of the insane or of the sane would-be
suicides, and the condition is concealed as long as possible, thus losing
the advantage of prompt assistance. Too much stress cannot be laid
upon the imminent danger of edema of the larynx, whatever the cause
602 SURGICAL DIAGNOSIS AND TREATMENT.
or nature or severity of the injury. It has been known to occur even
when the offendini^ substance entered the larynx during the act of
vomiting.
If the outlook is fairly favorable for recovery, it is altered for the
worse if at any time suppuration supervene.
External injuries of the larynx are caused in many ways, either
intentionally or accidentally. In battle the larynx seems to sustain
relatively few injuries, and blows, whether accidental or designed and
however aimed, seem more often to fall upon the back or side of the
neck than upon the front part. Attempts at homicide or suicide afford
the largest number of external injuries of the larynx. They are con-
tused, punctured, lacerated, incised, and gunshot wounds. Contused
wounds from accident or design, and incised wounds made with the
intent to take life, greatly exceed all others in number. From this
cause, as well as clinically, fractures of the larynx may be regarded as
a species of contused wound, since, although injury may be very
slight, it may be so considerable as to fracture a cartilage, generally
the cricoid or the thyroid (without interruption to the continuity of
the integument). Rupture of muscles and ligaments or of the vocal
cords, dislocation of other cartilages, fracture of the hyoid bone, and
injuries to the trachea similar to those of the larynx may all be asso-
ciated with fracture of the larynx. Kicks from animals, falls, blows
with the fist or weapons, may be the cause of such injuries. The
greater number of them, however, are produced by attempts at stran-
gulation by the hands of an assailant or by homicidal or suicidal
attempts with rope or strap or improvised cord.
Extravasations of blood into the tissues beneath the integument are
usually associated with injuries to the larynx.
Punctured wounds, even in battle, are rare. In civil life they result
from accident, generally by falling upon sharp-pointed sticks or por-
tions of machinery.
The same may be said of lacerated wounds. Their cause, aside
from gunshot wounds, is the crushing force of some jagged instru-
pient, as broken glass or crockery or the cog-wheels or other portions
of machinery.
Incised wounds of the larynx outnumber all other varieties put
together, because a "cut-throat" seems to the ordinary murderer or
suicide to offer so ready a means of putting an end to life. Yet the
fact that the case so often falls into the surgeon's hands before it
reaches the undertaker's shows that a miscalculation is made some-
where. A much neater piece of work from a chirurgical point of view
would be the severance of the large vessels of the neck, and much
more certain and effective from the standpoint of the original operator
if he were not too ignorant to appreciate what he is missing in every
sense of the word. The would-be suicide stretches back his throat and
makes a gash from left to right generally, and if the knife goes in
deeply enough he may injure all structures from integument to pharynx ;
he may sever the epiglottis at any place between its free border and its
attachment at the angle of the thyroid cartilages ; he may cut the vocal
cords or any of the cartilages of the larynx, gash the thyroid gland
and tongue, injure the hyoid bone, or he may cut low down, and, ex-
IA[/URIES AND DISEASES OF THE RESPIRATORY SYSTEM. 603
pending the force of his blows on the trachea, the larynx may escape
almost or wholly uninjured. The gash is generally a long one, and
retracts greatly, and yet with such injuries as those mentioned it
is not necessarily fatal. The sterno-cleido-mastoid muscles are ad-
vanced and lie over the large blood-vessels of the neck, so that the
latter escape. There may be considerable hemorrhage from smaller
vessels, and if this find its way into the trachea, it may cause suffo-
cation. If there is much hacking of the cartilages, portions may fall
into or over the trachea in such a way as to obstruct respiration
completely.
Gunshot wounds of the larynx, either from bullets or bits of shell,
are uncommon except in the army during battles. The relative infre-
quency of such injuries in military service is a matter of remark. They
make up the greater number of lacerated wounds, although they may
cause a contused wound, depending somewhat upon the force of the
missile. The comparative immunity of the larynx from injury when it
is apparently not less exposed than other parts of the body is no doubt
largely due to the resiliency of its cartilages, so that a ball striking it
is deflected.
Symptoms. — The symptoms of injuries to the larynx from external
causes are usually self-evident, the only exception being in some con-
tused wounds. In such cases the bruise will be suggestive. If, in
addition, there are pain and tenderness on pressure or in deglutition,
dyspnea, cough, bloody expectoration, retraction of muscles, nervous
manifestations, swelling of the integument, the symptoms are certainly
characteristic and make the diagnosis very clear. Laryngoscopic ex-
amination may reveal tumefied and reddened or lacerated tissues or
ruptured structures.
In punctured wounds, besides the external appearances, emphysema
is common, and threatened suffocation the rule from the emph)'sema
and the presence of blood in the larynx and trachea.
Incised "Wounds. — Most prominent and important of all the sj^mp-
toms is the wound itself, and the other symptoms depend largely upon
its extent. If it is small, the hemorrhage may be less than when it is
large, but more dangerous from the fact that in such a case it is more
apt to find its way into the trachea and cause suffocation. In any case,
even if the large vessels are not implicated, hemorrhage is apt to be an
important symptom and an important factor in the prognosis, for the
blood-supply is large here, and, either from the primary or the second-
ary hemorrhage, suffocation is imminent.
Fragments of tissue also may occlude the trachea dangerously or
fatally.
The patient is weak from loss of blood, may suffer extreme thirst,
and lose his voice from injury to the vocal cords or from gaping of the
wound. If the pharynx is involved, swallowing may be difficult or
impossible. There may be distressing cough from the blood in the
trachea, and the mental and physical distress which always attends
dyspnea is present. Emphysema is common. Fluids swallowed may
escape through the incision. There is great pain, usually with great
tenderness of surrounding parts.
Gunshot -wounds may be attended by any or all of the symptoms
604 SURGICAL DIAGNOSIS AND TREATMENT.
characteristic of other wounds, and, in addition, arc most apt to be
followed by neuroses of one sort or another.
In all wounds of the larynx a secondary hemorrhage which may
quickly cause suffocation is to be feared after the closure of the exter-
nal wound.
Diagnosis is based upon the wound and resultant symptoms.
Prognosis must be guarded, although it is not wholly unfavorable.
Sometimes with small contused or gunshot wounds the shock is greater
than with large incised wounds, and, on the whole, the latter, even
though extensive, promise the best as to recovery.
If the patient survive both primary and secondary hemorrhages, the
system may finall)^ yield to the shock and depiction, or suppuration may
supervene at a later date in the wound itself or in the air-passages.
Pneumonia is a frequent result of the entrance of blood and other
extraneous substances into the air-passages.
So much of injured tissue may eventually slough as will bring
about a fatal issue by causing septic infection or by reopening the
wound.
Finally, after the healing of the wound, gaps and fissures may
remain ; the function of the parts may never be fully restored ; and
cicatricial contraction may go on to such an extent as to endanger
life by stenosis. If there is not cicatricial contraction, the cartilages
may be enlarged and distorted by the healing process until the function
is greatly impaired.
Treatment. — In most severe cases of injury to the larynx after
removal of extraneous substances from the trachea, tracheotomy is the
first step in treatment, because suffocation is imminent, either immedi-
ately or when tumefaction of the tissues shall have begun, or when
secondary hemorrhage shall have set in after recovery from syncope.
Even in wounds of comparatively slight importance the surgeon will
save himself all possibility of unpleasant future complications if trache-
otomy be performed as a prophylactic measure in a course of treat-
ment that, under favorable circumstances, is certain to be long and
tedious.
The next step is the stopping of hemorrhage. If large vessels —
either of the thyroids, for instance — have been severed, they should be
ligatured ; compression and the application of cold may be of service, or
the local application of astringents.
Hemostatics may be given internally. If hemorrhage prove ob-
stinate, it may be necessary to ligature the carotid. The strength of
the patient must be maintained by prompt stimulation either hypo-
dermically or per rectum.
With these preliminaries disposed of, the surgeon must as speedily
as possible give his attention to the condition of the wound itself
He must study it that he may determine his method of procedure
before the tissues are distorted by swelling, and also that he may
remove any fragments that cannot be saved, le.st they in some way
occlude the air-passages. If the tongue is severed, the parts should
be sutured to prevent the posterior portion from falling back upon
the larynx.
It is seldom of any avail to attempt to suture the cartilages, not
INJURIES AND DISEASES OF THE RESPIRATORY SYSTEM. 605
even portions of the epiglottis uniting kindly. If the wound is later-
ally extensive, some sutures may be placed through the soft paits at
its extremities. If the wound were entirely closed, there would be
great danger from suffocation from secondary hemorrhage, and em-
physema is much less easily controlled if the wound is sutured in its
entire extent.
If the wound is not extensive, sutures may be entirely dispensed
with. The edges of the wound are coapted and held in position by
strips of adhesive plaster. The position of the patient is important.
He must be so placed in a semi-reclining position that the head in-
clines enough to favor close juxtaposition of the edges of the wound
without their overlapping. The head is then held immovable by
bandages skilfully applied over the head and fastened to a band under
the arms or around the waist. Rather loose antiseptic dressings should
be placed over the w^ound, and frequently inspected that exudations may
be promptly wiped away. If suppuration occur, its treatment is the
same as in other wounds.
Unless the pharynx has been wounded also, there is generally little
difficulty in feeding the patient. If, however, for any reason, the wound
is distended in taking food, the surgeon must be equal to the emergency
by placing tubes in throat or nostrils or by providing for rectal alimen-
tation.
There is generally a tendency to cough from the presence of blood
or other liquids or excessive secretions due to the irritation. This
must be repressed by the administration of codeine or opium.
Sometimes, especially if there is no tearing open of the wound,
there may be little cicatrization. Occasionally fistulous openings remain,
which always must be covered, both for appearances and to preserve
the function of phonation, or a plastic operation may be done to fill
the breach.
If stenosis of the trachea or larynx result from cicatricial contraction,
it is best corrected by gradual dilation, though persistent efforts in this
direction are sometimes wholly fruitless.
Foreign Bodies in the Air-passages. — No accident is more
common than the entrance of some substance into the air-passages. It
may occur during the act of sw^allowing, when for some reason the
epiglottis has failed to close normally, or if something is being held in
the mouth, a careless habit in which no one should indulge, and to
which children are especially prone, a sudden inspiration may carry it
into the larynx, where it may remain or pass on into the trachea.
During dental operations or those upon the mouth and throat for-
eign substances like a fragment of tooth, the cork or bit of wood
which has been used as a gag to keep the teeth apart, bits of sponge,
or fluid may find their way into the windpipe. Emesis, especially
during anesthesia, may provide the substance that enters the air-
tube. Artificial teeth have an uncomfortable habit of traveling back-
w^ard, especially during sleep. A bronchial gland or large masses of
mucus or quantities of blood may be coughed up and occlude the
trachea or larynx from below. Foreign bodies may enter by per-
forating the external wall, as bullets in gunshot wounds. They may
also work their way in from the interior parts of the body by pene-
6o6 SURGICAL DIAGNOSIS AND TREATMEmXT.
trating the tracheal wall, as, for instance, from the esophagus. Foreign
bodies may also enter the air-passages through wounds previously
sustained.
In most cases reflex cough or spasm is at once excited ; the sub-
stance is expelled almost before it has found lodgement, and the affair
is forgotten. In others vigorous slaj)ping upon the back, or at most
inversion of the patient with slapping, brings to a happy termination the
slight struggle for breath and the choking sensation.
In others the foreign body is not expelled, and the annoyance and
discomfort from its presence are slight and transient. In others dis-
tressing symptoms occur at intervals. In still others severe laryngitis,
even of a suppurative form, asserts itself with more or less rapidity. In
others there is immediate distressing dyspnea and the services of the
surgeon are in urgent demand. In still others the occlusion is so com-
plete that a fatal termination is immediate, and that under circum-
stances most painful and agonizing.
Organic materials are apt to undergo changes, even decomposition.
Seeds, for instance, may increase in size from absorption of moisture if
long retained in the air-passages. Inorganic substances may become
almost encysted, so covered are they with secretions and calcareous
deposits. Those of smooth outline and small size may remain indef-
initely without serious discomfort, but never without danger from
possible change of position.
Symptoms. — Symptoms may be almost or wholly negative, or they
may remain in abeyance until the irritation has induced a laryngitis
which is obstinately prolonged. Generally, however, there is spasm
of the glottis, spasmodic cough, pain, and change of color, the face
becoming at first crimson and then purple. The eyes may protrude,
and the countenance express the utmost anxiety and distress. The
patient throws himself about and tears at his throat. This may be fol-
lowed by unconsciousness, from which he may recover or which merges
into death, or the spasm may pass and an almost or a quite normal
state be regained. Only one paroxysm may ensue, or the first may be
succeeded by others at regular or irregular intervals. Even when the
initial symptoms are comparatively slight a change of location of the
intruding body may suddenly precipitate secondary spasms of great
severity. There may be dysphagia from pressure on the esophagus.
Local pain usually indicates where the foreign body has lodged,
cough is common if it is in the trachea or bronchus, and hoarseness
or aphonia will follow its lodgement in the larynx.
Severe lesioas of the lungs may either be simulated or actually exist
as a result of the introduction of foreign bodies into the air-passages,
according to the nature and location of the offending matter.
Diagnosis. — With a history of the intrusion of a foreign body into
the air-passages diagnosis is a matter of no difficulty. Where such a
history is not forthcoming and laryngoscopic examination reveals
nothing, the diagnosis is exceedingly difficult. If the body is of hard
material, the probe may reveal its presence, but not necessarily. Aus-
cultation will assist to some extent. If a tube be largely but not wholly
occluded, a sonorous rale will be betrayed. If it is wholly occluded,
respiratory murmur will be wanting. Unilateral bronchitis should
INJURIES AND DISEASES OF THE RESPIRATORY SYSTEM. 6oj
always suggest the presence of a foreign body in the lower air-passages.
Difficult respiration will suggest that rather than disease.
Prognosis. — This is always grave. Even if the comfort of the
patient is not seriously interfered with, there is always danger in
change of location and in the possibility of the lighting up of an
acute inflammation or in the supervention of edema. The substance
may be expelled spontaneously, but if its presence is unquestionable,
no risks should be taken ; it should be removed. After spontaneous
expulsion recovery is usually complete, but death has resulted from the
inflammation set up before its expulsion.
Treatment. — If the symptoms are not imperative, slapping upon the
back and inversion are naturally first tried.
Removal by the natural orifice is desirable if possible. If the object
can be located by the laryngoscope, it may then generally be removed
by the finger or by slender forceps suitably curved. Cusco's larj^-ngeal
forceps are a most excellent instrument. Flexible forceps may be
bent at the desired angle (Fig. 262).
Fig. 262. — Cusco's laryngeal forceps.
Substances of irregular, jagged shape must be xtxy carefully manip-
ulated in order not to tear the tissues during their removal, and such
as can be so treated should be crushed, as nutshells, and removed
piecemeal or coughed up.
If none of these expedients succeed, tracheotomy must be per-
formed, and sometimes it should be done as a precautionary measure,
lest in efforts to remove the object through the larynx it assume such
position as to occlude the larynx or trachea completely.
Whether the operation should be above the thyroid gland, through
it, or below it depends upon the shape, position, and size of the object,
and upon the shape of the neck to be operated upon. Unless it is
absolutely certain that the foreign body lies high, the low operation is
to be chosen, for there is more space here than above the glands for
operating, and the gland is so very vascular as to make it desirable to
avoid wounding it if possible. However, if the incision must go
through the gland, the isthmus should be ligatured twice and cut
between the ligatures. The edges of the wound must be retracted,
and an improvised retractor will serve very well, though good instru-
ments are made for the purpose (Fig. 263). The incision should be
an inch or an inch and a quarter in length. Ordinarily, if the object is
6o8 Si'KGICAL n/A GNOSIS AND TREATMENT.
in the trachea or bronchial tubes, it at once presents itself at the open-
ing, is spontaneously expelled, or can be easily removed by the surgeon.
Slapping upon the back and inversion will remove more obstinately
retained objects. The surgeon may blow or force air into the opening,
and the expiration of this condensed air will usually force out the
object. Search may have to be made for it. It is rare, indeed, that
tracheotomy docs not succeed ; if not at first, then after the inflamma-
FlG. 263. — Minors trachea-retractors.
tion of the tissues has had time to subside. The ingenuity of the
surgeon will usually overcome all difficulties.
Diseases of the Larynx.
I^aryngitis. — Catarrhal. — Acute laryngitis usually involves the
whole larynx, but it is not uncommon to find the disease limited to one
or several parts, constituting the circumscribed variety. Thus the vocal
cords alone might suffer, but commonly a cause sufficient to affect
them would implicate also the contiguous portions of the mucous mem-
brane. It may be primary or secondary — /. c. it may be due to ex-
tension from the trachea, naso-phaiynx, mouth, or tongue. The com-
monest cause when it is primary is exposure to cold or dampness.
Other causes are overstrain of the larynx in talking or singing, inhala-
tion of irritating vapors, dust, or smoke, and traumatism either from
internal or external injuries.
It is also caused by certain drugs, as iodin and mercury, and by con-
stitutional diseases in which the system suffers greatly, as the exan-
themata, gout, rheumatism, pyemia, and erysipelas.
On laryngoscopic examination the mucous membrane appears red
and swollen, with patches of mucus here and there, which at first sight
may look like pus. These patches appear particularly upon the vocal
cords. In simple acute catarrhal laryngitis the secretion is not pus. The
microscope is therefore useful to settle the diagnosis. Inflammation
is bilateral. The congested membrane tends to occlude the passage
and so interfere with respiration.
The ordinary form of laryngitis is not a protracted disease, two
weeks being rather an extreme limit and it may last only a few hours.
The circumscribed form may be only temporary or may merge into the
chronic form of laryngitis.
INJURIES AND DISEASES OF THE RESPIRATORY SYSTEM 609
The symptoms vary from scarcely perceptible uneasiness to extreme
pain, cough, hoarseness or aphonia, difificult deglutition, dyspnea, and
fever.
If only the larynx is invaded, none of these symptoms, as a rule,
are severe, but many times other portions of the respiratory tract are
also inflamed, and the aggregate symptoms produce a disease of great
severity.
Diagnosis may be determined with tolerable accuracy from the
symptoms. If they are at all persistent, a laryngoscopic examination
should be made to exclude other graver diseases whose early symp-
toms do not differ noticeably from those of acute catarrhal laryngitis.
Prognosis. — The prognosis in simple, uncomplicated acute laryngitis
is good. There is no danger of extension to other parts of the
respiratory tract. Repeated attacks at frequent intervals may predis-
pose to the habit or lead to chronic laryngitis. When the disease
accompanies a constitutional dyscrasia, it is then a local manifestation
of a constitutional disorder, and the prognosis depends upon that of the
disease. When due to traumatism it depends upon the severity and
extent of the lesion caused by the traumatic injury. A circumscribed
laryngitis has, on the whole, a less hopeful prognosis than the diffused
form.
Treatment. — Mild purgative hepatic stimulation and restricted diet
constitute a sufficient constitutional treatment for most cases, since
many recover without any medical treatment whatever. External
applications of cold or leeches just above the sternum may serve to
diminish the inflammation. Mercuric chlorid is an excellent drug in
this affection. Inhalations of steam charged with astringent and heal-
ing solutions, as balsam of tolu, balsam of Peru, oil of pine, oil of tar,
tincture of benzoin, etc., are excellent local remedies. Applications of
astringents with brush or swab are apt to be made with some rudeness
and consequent injury to the mucous membrane. They should be
made with the hand-atomizer instead, as rough treatment may bring on
an edema.
Internal remedies, such as are found in the form of troches, are of
benefit, not because of their local healing powers, but because of their
constitutional stimulation of the secretory function. Aconite may be
used for the fever.
The large majority of cases of laryngitis that come under the physi-
cian's care are those of the public speakers and singers whose voices,
having failed temporarily from over-use or strain, must nevertheless be
put into good condition as soon as possible. Rest and confinement to
the house, absolute discontinuance of the use of the voice even in con-
versation, and faithful continuance of the treatment outlined above, will
effect the speedy cure hoped for.
Bosworth believes that many cases of so-called acute laryngitis are
really the lighting up of an exciting chronic inflammation, a sequence
of repeated attacks of acute rhinitis or of naso-pharyngeal catarrhal
inflammation. Accordingly, he would treat such inflammations as
an antecedent measure and also while treating the laryngitis proper. He
advocates the rather free use of cocain in this connection.
Acute Infantile Laryngitis. — In children the mucous mem-
39
6lO SURGICAL DIAGNOSIS AND TREATMENT.
brane, both above and below the i^Iotti.s, is more vascular and sensitive
than is the case with adults, and also more richly supplied with glandu-
lar tissue. It is of smaller caliber also, so that tumefaction of the
mucous membrane more readily leads to stenosis.
Inflammation above the glottis is similar to that of adults, except
that there is a greater intensity of symptoms, as might be expected
from the anatomical differences just noted.
Quiet, warmth, restricted diet, and the same line of treatment as
indicated for adults, modified to suit the age of the little patient and
the severity of the symptoms, is all that is needed, for, though at times
alarming, the inflammation above the glottis, if it extend no farther, is
rarely dangerous.
Below the glottis, however, inflammation takes on a more serious
aspect. Here lymph-glands are numerous, far more so relatively than
in adults, and in some there is a special tendency to enlargement of
those structures. Exposure to cold aggravates this tendency, and we
have the quickly supervening phenomena of " croup." In some adults
there lingers, long after the period of childhood is passed, a croupous
tendency, only explicable by the fact that subglottic lymphatic tissue
is relatively abundant, especially sensitive, and subjective to inflam-
matory changes. Dr. Francke H. Bosworth maintains that in children
who are subject to attacks of " croup " there is a chronic inflammation
of this lymphatic tissue, and that when there is exposure to cold or
damp it takes only a brief time for this chronic inflammation to
change to an acute form of great severity. The tissues become
greatly swollen and tend to occlude the upper air-passages, hence
respiration is greatly interfered with.
Symptoms. — Paroxysmal attacks come on usually at night, in which
a severe, high-pitched barking cough and a peculiar stridulous inspira-
tion are the characteristic features. There may be aphonia, and yet
the " croupy " cough due to the irritation of the swollen, turgid mem-
brane just beneath the glottis may be present. There are fever, flushed
face, restlessness, pain, and distress in the throat, at which the child
clutches during the spasms.
During the day there may be almost entire remission of the symp-
toms, but the voice becomes hoarse toward night, and there is an
occasional barking cough which is suggestive of the paroxysm that
will occur during the night.
The presence of accumulated mucus, still further filling up the
clearly narrowed lumen of the larynx, probably explains the nocturnal
exacerbation of the symptoms. As the disease progresses secretion is
more abundant than at first, and the raising and expectoration of this
mucus seems temporarily to mitigate the symptom. Suffocation,
though always seemingly impending, rarely occurs, and when the dis-
ease is fatal there are complications from bronchitis or pneumonia as
a rule.
The disease runs its course in from three or four days to two weeks.
In the cold damp days of spring and autumn, especially when children
are allowed to play out of doors, have wet feet, or wear damp clothing,
recurrent attacks may be expected.
A laryngoscopic examination, though difficult in the case of children.
INJURIES AND DISEASES OF THE RESPIRATORY SYSTEM. 6ll
should be insisted upon. The disease must be differentiated from mem-
branous croup and diphtheria. In the early stages it is at times
difficult. In diphtheria there is a membrane in the fauces and generally
marked constitutional symptoms. In membranous croup the progress
of the disease is slower and dyspnea is not so marked at first. Con-
stitutional symptoms are also less marked.
Trcatuic}it. — As a prophylactic measure a child who betrays a pre-
disposition to this disorder should not be exposed to extremes of
temperature nor to sudden changes, nor be allowed to remain in damp
clothing, nor to breathe damp air. The feet should be kept warm and
dry. Attention should be given to the general health, and a plain,
nourishing diet should be the only one tolerated.
The bowels should be made to move freely. Calomel or hydrar-
gyrum cum creta, as in other forms of laryngitis, seems of especial
benefit.
To control spasms antispasmodics may be administered internally,
and hot water should be freely used externally in the forms of fomen-
tations upon the throat, and as baths into which the child should be
placed at intervals of four hours.
Inhalations of chloroform or of amyl nitrite or of ether may be
necessary when prompt action is desirable during a severe spasm.
Astringent sprays, applied with the atomizer, should be used at inter-
vals, especially during the day, when the child is more tractable owing
to the absence of the paroxysms.
Inhalations of steam impregnated with healing and sedative drugs
have a good effect, and for a like reason the atmosphere of the room
should be kept moist.
Sometimes emesis is of avail in relieving the larynx, but it is not
necessary to administer emetics for this purpose. Tickling the fauces
will accomplish the same result and not charge the stomach with drugs.
Cough-medicines and sleeping-potions should be avoided if possible, so
that the stomach may not be overtaxed. Muriate of ammonia favors
secretion, and may be given with that end in view. If respiration is
seen to become more difficult, a soft catheter may be inserted. If
suffocation seems imminent, intubation or tracheotomy is indicated, but
is rarely necessary in an uncomplicated case of even severe subglottic
lar\mgitis.
Chronic I/aryngitis. — Chronic Catarrhal Laryngitis. — Cases
arise which cannot be traced to extension from other structures or to
acute attacks of laryngitis. Such may be called primary or idiopathic.
Most cases of chronic catarrhal laryngitis are secondary in their etiology,
coming from extension of inflammation from the nose or naso-pharynx.
Many forms of rhinitis compel the patient to breathe through the
mouth, and the air, being damp, cold, and unpurified by not passing
through the nasal chambers, acts as an irritant to the laryngeal mucous
membrane. Possibly exposure to dust and impure air, improper use
of the voice in speaking or singing, or the continuous use of alcohol
and tobacco may cause a primary chronic catarrhal laryngitis, and in
such cases as cannot be traced to the extension from the upper tract
the cause must be found in such conditions or in a dyscrasia. This
disease is more common in males than in females, in adults than in
6l2 SURGICAL DIAGNOSIS AND TREATMENT.
children. The mucous membrane is thickened, with dilated blood-
vessels and hyperplasia of tissue. Sometimes the muciparous glands
seem to be chiefly involved, though it is doubtful if inflammation of
chronic character in mucous membrane is ever confined to them alone.
When they are largely involved secretion is excessive and accompanied
by desquamation of epithelial elements. Erosions are the exception.
Symptoms. — Noticeable among the symptoms is the altered quality
of voice. At first or in mild cases this betrays itself only on prolonged
use of the voice or in the effort to sing. When singing is attempted
the patient is unable to sing either clearly or to reach the higher notes
with the accustomed ease, if at all. Later, hoarseness is continually
present. The voice has a more strident quality in the morning, becomes
clearer as the nocturnal secretion of mucus is raised, but if much used
may give out entirely, and the patient then suffers from temporary
aphonia, and there are pain and an " aching " sensation if, forgetting his
temporary disability, he attempts to make himself heard. There is
some cough and a general feeling of uneasiness and discomfort which
the patient attempts to relieve by " clearing the throat." In ordinary
chronic catarrhal laryngitis there is no pain, or only transient pain,
and little secretion, unless an acute attack supervenes upon the chronic
condition or there is accompanying bronchitis.
Diagnosis. — Since the disorder usually comes on gradually and
asserts itself somewhat strongly at times, only to be followed by ap-
parent improvement, and finally to settle down into a well-marked
chronic disease, the patient is generally able to diagnose his own con-
dition fairly well. With the symptoms detailed and a laryngoscopic
examination the diagnosis is clear.
Prognosis. — This is good as to life ; as to continuance, it is dependent
upon the cause. If due to extension from the nose, or naso-pharynx,
no cure can be expected until the morbid condition in these localities is
corrected, and treatment should be directed to that end. If the disease
is idiopathic, both topical applications and constitutional remedies are
needed ; certainly the latter when it is suspected that the cause is some
fault in the constitution.
It is a disease of indefinite duration, and rarely if ever is spon-
taneously cured. If not directly causative of neoplasms, it certainly
paves the way for their development and furnishes a favorable soil for
their incipient growth.
Treatment. — Nasal respiration should be restored and nasal affec-
tions corrected by the treatment therapeutic and surgical detailed under
the Surgery of the Nose and Naso-pharynx. Pure air, careful exercise,
frequent baths, moderate and restricted use of the voice, careful atten-
tion to the general health, and rigid avoidance of everything that is
known to aggravate the disease, are of great importance in this
affection.
In addition, local treatment should be employed. Astringent sprays
are useful applied with an atomizer, either a hand bulb-instrument or the
one with compressed air. One remedy will sometimes succeed when
another fails, and, again, better results are obtained by alternating
one with another. Silver nitrate, a half-grain or more to the ounce ;
zinc sulphate, five grains to the once ; ferric chloride, three grains to
INJURIES AND DISEASES OF THE RESPIRATORY SYSTEM. 613
the ounce, Monsel's solution, ISTTI to the ounce; copper sulphate five
grains to the ounce ; alum, ten grains to the ounce, — are all good.
Tannic acid is sometimes used, also jaborandi, to promote secretion.
Instead of sprays, or along with sprays, inhalation of drugs may be
practised. To accomplish this hot water is impregnated with the drug
— preferably an alkahne — and the steam inhaled for several minutes.
Opium may be added to either the spray or inhalation if there is much
pain. Cocain should be applied if the membrane is hypersensitive.
Most surgeons treat the larynx and trachea as they do the nasal
cavities by means of compressed-air apparatus, using a variety of
astringent and antiseptic solutions according to the demands of each
particular case.
Subglottic chronic catarrhal laryngitis bears the same relation
to the ordinary chronic form that the infantile subglottic acute laryn-
gitis bears to the ordinary acute form. It is altogether a graver
affection.
Chronic subglottic laryngitis is almost invariably the result of
repeated acute attacks. It tends to produce stenosis of the larynx,
and its gravity is proportionate to the amount of occlusion. Gradual
loss of voice, increasing dyspnea and cough, are its most distinctive
symptoms.
Diagnosis is to be made by laryngoscopic examination, when the
tissues below the vocal cords are seen to be much hypertrophied and
of a pale grayish color with diminished secretion. Only perichondritis
is likely to be confused with this. In perichondritis pain is more acute.
Prognosis is doubtful, depending upon the cause. It is not very
favorable as to complete recovery, but it may be possible to hold it
sufficiently in check to avoid the necessity of tracheotomy.
Treatment. — If excess of lymphatic tissue is plainly the cause, ab-
sorbents must be used (iodid of potassium or iodid of iron) in large
doses.
In many cases surgical interference is necessary. Excessive tissue
may be cut away or the galvano-cautery may be developed. Dilatation
by hollow tubes is the most rational and the most generally successful
method, though absorption goes on slowly under pressure of this sort.
Laryngitis sicca is the term applied to a peculiar form of chronic
laryngitis in which secretion is deficient and crusts form and adhere to
the mucous membrane, as in atrophic rhinitis.
The cause is obscure. Since in most cases it is accompanied by
atrophic rhinitis, both diseases are due either to one and the same
original cause or the laiyngitis, as maintained by some, is an extension
from the rhinitis. This, however, is usually difficult of demonstration,
and it seems more reasonable to conclude that the same cause is in
operation in the system to produce both. The crusts vary in color
according to whether they are composed of inspissated mucus alone
or of mucus mixed with pus and blood from below the glottis. Some-
times they are- annular, being formed on the trachea — sometimes of
irregular shape, especially if found in a ventricle.
Erosions are common from the attachment of crusts. A consider-
able quantity collects beneath the crusts and slight hemorrhages are
not uncommon.
6 14 SURGICAL DIAGNOSIS AND TREATMENT.
Symptoms. — Morning cough in the effort to expel the crusts that
have formed during the night, together with the naturally attendant
conditions, dyspnea, fetid breath, and aphonia, constitute a marked
group of symptoms.
Irritation of the throat is sometimes excessive, and is made the
worse by attempts to clear it.
Laryngoscopy makes positive the diagnosis.
Trcatiiioit. — Removal of crusts, cleansing of the underlying surface,
and stimulation of the membrane are the indications.
To effect removal the crusts are first softened with some solution
from the atomizer, and then gently removed with swab or brush or fine
instrument. After this is done all pus should be removed and all
bleeding stopped. Silver nitrate is one of the best substances for appli-
cation to the membrane. Any of the astringents mentioned in the
Treatment of Chronic Catarrhal Laryngitis may be employed.
Chorditis tuberosa (trachoma of the larynx ; Singer's node) is a
variety of chronic laryngitis first recognized and described by Tuerch.
It consists of a small white tumor upon one or both vocal cords, more
commonly, it is said, upon the left one, situated at the junction of the
anterior and middle thirds of the cord. It is due to an extreme effort
to reach the highest notes in singing where there is already a condition
of chronic laryngitis. It does not increase in size after its first appear-
ance. It produces hoarseness even in conversation, and makes the use
of the voice in singing an impossibility. It is readily seen on laryngo-
scopic examination.
It may be removed by the application of silver nitrate or by the use
of the galvanic cautery. In any case the use of the voice should be
interdicted, even in conversation, and both the chronic laryngitis and
the general health should be treated.
Diphtheritic laryngitis, as a rule, results from extension of the
disease from the fauces. It belongs more properly to the domain of
the general practitioner of medicine, and becomes of interest from a
surgical point of view only when intubation or tracheotomy is to be
performed. The operation will be described in its proper connection,
for it is called for in a variety of crises, not in diphtheria only.
^detna of the larynx by an earlier nomenclature was known as
edema of the glottis, but, as it is the larynx chiefly, and not the
rima glottidis that is involved, the modern requirement of making the
name of the disease describe both its position and character brings
about a rejection of the older term. It may be either acute or chronic.
By the term is meant an infiltration of the submucous connective tissue
of the larynx or of the epiglottis on either or both surfaces. It may
be a true edema, a " hydrops " resulting from venous congestion. The
constituents of the infiltrating fluid may be serum, lymph, pus, or blood
in any combination, and it may accumulate slowly or be practically
instantaneous in its manifestations, especially when due to traumatism.
When the lesion is of inflammatory origin, the inflammation is very
acute, and extends deeply below the mucous surface into the cellular
connective tissue — really a cellulitis or phlegmonous laryngitis.
Exposure to cold and moisture is the commonest cause, though it
may possibly be due to over-use of the voice, but probably in that case
INJURIES AND DISEASES OF THE RESPIRATORY SYSTEM. 615
there is a preceding laryngitis of mild type of which the patient is
unaware. It may follow the passage of foreign bodies into the larynx,
especially if the intruder is of such a character as to lacerate the tis-
sues. It often occurs after extremely cold or hot or caustic liquids
have been swallowed. It accompanies or follows many acute systemic
disorders, in many cases hindering coalescence. Slight exposure to
drafts or cold, especially damp cold, is then the exciting cause in a
system already debilitated by disease, as scarlet fever, typhoid, ery-
sipelas, gout, measles, diphtheria, croup, quinsy, nephritis, pneumonia,
bronchitis, or affections of the tongue and throat. Septicemia is said
to furnish conditions especially favorable to its development. Clumsy
operations upon the larynx or the inevitable contusion and laceration
attending the removal of neoplasms may cause it. Men are more prone
to edema of the larynx than women, because of their greater exposure
to cold and dampness.
The non-infiammatory form of edema is due to causes not within
the larynx itself; the cause is to be sought for in conditions predis-
posing to dropsy in other parts of the body. Whatever prevents normal
venous return, as renal, cardiac, and hepatic disorders, may cause it,
especially if there is a morbid condition of the mucous membrane, as
relaxation or chronic inflammation.
The epiglottis, especially the posterior surface, the epiglottic folds,
and the ventricular bands are the portions most commonly infiltrated,
the vocal cords and the subglottic portions suffering only rarely. The
swellings are tense, hard, with some fluctuation under the touch of the
finger, and in severe cases portions of the enlarged masses may be seen
on depressing the tongue.
Synnptouis. — At times the edema comes on so suddenly that death
ensues before relief can be summoned. In such cases there may be
spasms of the constrictors of the glottis or paralysis of its dilators, or
the condition may have been present for some time, and some untoward
movement of the parts, as a cough or hasty inspiration, may have in-
creased it or so changed the position of some portion of tissue as to
occlude the opening.
In the edema of venous congestion the suddenness of the onset is
more marked, and the premonitory symptoms less so than in the
phlegmonous type.
In the phlegmonous variety there are no pyrexia, discomfort, and
increasing distress in the throat, and the symptoms are all developed
within twenty-four hours.
Pyrexia is absent in the serous edema of venous congestion, and
pain is not so marked as in the inflammatory form. In both there are
increasing dyspnea, stridulous breathing, dysphagia, and restlessness.
The face is anxious. Sleep is impossible from the fear of suffocation.
In acute edema all these symptoms manifest themselves in intense
paroxysms when the disease is fairly present. The patient may die in
the first paroxysm or the paroxysms may increase in severity, with
cyanosis, protruding eyeballs and tongue, and rapid pulse, until a fatal
issue is reached.
In chronic edema the symptoms steadily increase in severity. The
paroxysms are followed by temporary reHef, but gradually grow more
6l6 SURGICAL DIAGNOSIS AND TREATMENT.
severe and frequent. Excitement may renew the paroxysms when they
have apparently been quieted.
The diagnosis indicated by the symptoms is confirmed by the
laryngoscope.
Prog)iosis. — Suffocation is the one great danger. As has been said,
it may occur instantaneously at the first or any succeeding paroxysm.
Or apnea may come on gradually from the insufficient oxidation of the
blood. Unrelieved, an acute case will increase in the severity of its
symptoms, go on from bad to worse, and terminate fatally, ending in
coma, generally in three or four days.
Chronic edema is not the less dangerous because its development is
slower. Since its causes are likely to be of long duration, if not in-
curable, there is slight hope of recovery from chronic edema. What
would be a trifling edema in other parts of the body is here sufficient
to threaten life, and it is often necessary to resort to tracheotomy as a
means of relief and to take away the element of danger while the
general condition is under treatment.
Deuteropathic cases, provided means are taken to relieve immediate
danger, must depend upon the disease accompanying or causing them.
Edema below the glottis is less favorable than that above.
Treatment. — Depletion of the infiltrated tissue by any and all means
is here the indication. Free puncture and incision or scarification by a
laryngeal knife or by ordinary lancet or curved bistouiy covered with
thread or court-plaster almost to the point affords immediate outlet to
the accumulated fluid. This may be repeated in six or eight hours if
necessary. The laryngoscope should be used if possible ; if not, the
knife must be guided by the finger. The cuts must be as far away
from the median line as possible, so as not to complicate an already
bad condition by the entrance of fluid into the air-passages. Gargling
with warm water or inhalation of steam causes relaxation or dilatation
of blood-vessels, so that hemorrhage is more free. If this fails to give
relief, tracheotomy should be performed at once. In severe cases it is
used as a precautionary measure, for edema is so treacherous a disease
that suffocative apnea has often been known to take place after the
departure of the surgeon and before he could be recalled. The sur-
geon must also bear in mind the fact that congestion of the brain or
lungs may occur, and even after a fair degree of respiration has been
restored the patient may die from suboxidation. In country practice,
where the surgeon can see his patient only at long intervals, these are
considerations not to be neglected. Tracheotomy rather than laryn-
gotomy is to be performed, as better meeting the possible complications.
Intubation is practically out of the question in these cases, for, if the
difficulties of insertion are happily overcome, retention is almost im-
possible because of the swelling and distortion. In moderate cases a
catheter might possibly be retained. Spontaneous subsidence is not
unknown. In edema from nervous congestion and in chronic edema
from any cause, in addition to the above line of treatment the cause
must be treated and systemic depletion of the infiltrated tissues be
resorted to by catharsis, diaphoresis, and diuresis.
Edema of the larynx from causes that produce anasarca is practi-
cally incurable, so that the treatment can only be palliative.
INJURIES AND DISEASES OF THE RESPIRATORY SYSTEM. 617
Abscess of the I/arynx. — This affection may be intra-laryngeal
or peri-laiyngeal. It may be primary or secondary, but is usually the
latter, being commonly secondary to perichondritis, phlegmonous
laryngitis, or acute diseases, among which are enteric fever, typhus
fever, the exanthemata, small-pox, diphtheria, pyemia, tuberculosis,
syphilis, and glanders. Traumatism, especially that due to the entrance
of foreign bodies, is a cause, and when this is so the location of the
abscess is determined by the place of the injury. When due to sys-
temic diseases it shows a preference for the cartilages in the following
order : the inferior surface of the epiglottis, the internal surface of an
arytenoid cartilage, and the ventricular bands.
The abscess may " point " externally or internally ; only rarely does
an internal abscess point externally. The external may find an outlet
on the cutaneous surface, even by a somewhat extended fistulous track,
although when it is a retro-pharyngeal abscess it naturally " points "
into the pharynx.
Symptoms. — There are pain, aphonia or dysphonia, dysphagia,
dyspnea, and cough. When peri-laryngeal on the anterior or lateral
aspect of the larynx, a tumefaction is often visible on inspection and
palpation, with pain, tenderness, and fluctuation on pressure. When it
is retro-pharyngeal deglutition may become impossible from the pain
that the attempt induces. Dyspnea may be extreme and suffocation
imminent, either from the large size and amount of occlusion or from
the contraction and paralysis of muscles in neurotic patients.
Diagnosis of the intra-laryngeal variety is by the laryngoscope. A
tumor presents, red and angry at the base, with a yellowish apex,
though the accompanying inflammation of the mucous membrane may
tend to conceal the abscess ; it must then be diagnosed by circum-
scribed sensitiveness of the membrane. Peri-laryngeal abscess is
diagnosed by the physical signs.
Prognosis is favorable unless it is a sequel or complication of ex-
hausting diseases, and then it depends upon them. Precautionary
tracheotomy will remove danger of suffocation, and if the system
recovers only slowly, the opening should be maintained for a short
time, as under such circumstances there may be a succession of laryn-
geal abscesses. After one abscess, and especially after several, stenosis
may result, but it is rare.
Treatment. — Spontaneous discharge with immediate relief is not
unknown, but should not be waited for. Once diagnosed, an intra-
laryngeal abscess should be incised, either with the laryngeal knife or
a curved bistoury protected to within a short distance of the end. If,
for any reason, the surgeon cannot reach it, tracheotomy presents the
only safe course. Peri-laryngeal abscesses are opened at the most
prominent point.
Chondritis and Perichondritis. — Chondritis is invariably second-
ary to perichondritis, and the latter is almost as invariably a secondary
disease, although a primary form due to protracted exposure to cold
and moisture, especially when the voice is much used at the same time,
is not unknown. Perichondritis is essentially also an acute disorder.
Other causes than cold arc — traumatism, typhoid fever (which seems
especially prone to bring on acute inflammation of the perichondrium).
6l8 SURGICAL DIAGNOSIS AND TREATMENT.
the exanthemata, diphtheria, pneumonia, erysipelas, tuberculosis, ma-
lignant disease, and syphilis. Men are more subject than women,
adults than children, probably from the greater frequency of the ex-
posure. Between twenty-five and forty is the period most apt to suffer
from this disease.
The pathological changes are inflammation, with occasionally great
tumefaction. If there is pus, the perichondrium separates from the
cartilage, and the latter then undergoes necrosis ; as a rule, and some-
what tardily, sloughs are removed. Usually one cartilage only is
involved, especially at first, but they may all be affected together or
successively. The arytenoid cartilages are liable to become separated
from their attachment and be discharged en masse, though the affection
is apt to be unilateral.
The cricoid is affected most frequently on the posterior portion,
causing destructive and painful deglutition.
Perichondritis of the thyroid is usually unilateral on the inner sur-
face, though no part is wholly exempt from possible implication.
Perichondritis of the epiglottis is invariably a secondary affection,
and generally occurs in syphilis, advanced stages of tuberculosis, and
carcinoma, and is then an ulcerative form of the disease.
Syuiptouis. — These vary with the location and intensity of the
affection, but there are present the usual signs of suppurative disease
and chills, or occasionally marked rigors and fever (ioo°-i02° F.),
general pains in the muscles and bones, loss of appetite, and occa-
sionally slight nausea.
The symptoms of acute laryngitis quickly assert themselves, accom-
panied by an acute sensation or a localized soreness not common to
simple laryngitis. There is sometimes pain during phonation and
deglutition, and it is said to be more severe when the abscess is caused
by syphilis than when caused by other diseases.
Hoarseness is followed by loss of voice, respiration becomes difficult
and stridulous, and apnea threatens. Cough is not a very common
symptom until the abscess begins to discharge pus or fragments of
necrosed cartilage.
Diagnosis. — The laryngoscope, in addition to subjective symptoms,
is all-important here when the interior aspect of the cartilages is in-
volved, and physical signs, together with subjective symptoms, are
sufficient when the external surfaces are affected.
A cricoid perichondritis produces irregular tumefaction beneath the
vocal cords, usually at the back, but sometimes laterally, and pushes up
toward the surface of this space, tending to occlude it.
Upon the arytenoid cartilage the perichondritis limits movement, and
may make an ankylosis between the cricoid and itself, and is usually
unilateral, tending to press backward toward the esophagus.
The symptoms of chills, fever, and general malaise, with sore throat,
may at first confuse the diagnosis, since phlegmonous laryngitis and
croupous laryngitis begin somewhat similarly.
In both of these diseases, however, the fever runs higher than in
perichondritis — up to 104° F. at times — while in perichondritis it rarely
reaches 102° F. In croupous diseases the peculiar cough is present and
the tumefaction is more nearly annular. In phlegmonous laryngitis the
INJURIES AND DISEASES OF THE RESPIRATORY SYSTEM. 619
inflammation and tumefaction are uniform, and may be almost wholly
above the larynx. New growths are without acute inflammation.
Prognosis. — Those cases of perichondritis that are caused by expo-
sure to cold and dampness or by traumatism are of favorable prognosis.
Those caused by tuberculosis or malignant disease or other progressive
disorders, and in which all the cartilages are successively involved,
rarely recover.
When perichondritis is caused by the more acute diseases, complete
recovery may occur with resolution of the disease. But quite likely,
as has been seen, extensive necrosis of cartilage may ensue, with con-
sequent deformity, stricture, and stenosis — conditions that must be met
as they arise.
Treatment. — At first measures must be taken to check inflammation
and promote absorption. Leiter's coils and ice applied externally,
together with the swallowing of ice, are all of great value here.
Among absorbents, mercury or iodin may be applied as an ointment,
and solution of iodin may be applied internally.
The bowels must be kept open, and the cause may be treated if it
is acute or systemic disease. Tonics and stimulants are often indicated.
Severe pain may be relieved by injections of morphin or by the appli-
cation of cocain to the laryngeal mucous membrane. Syphilis should
receive specific treatment.
Laryngotomy should be performed if obstruction threatens, and is
better than tracheotomy for the removal later of the necrosed portions
of cartilage.
In many cases bougies or other dilators have to be used for a long
time to overcome stenosis, and in others tracheal tubes have to be per-
manently worn. Plastic operations are not successful.
Ulcers of the I/arynx. — Ulceration of the larynx may simply
affect the mucous membrane or it may be the result of the breaking
down of tumors, either benign or malignant, or of those of tubercular
or syphilitic origin.
A chronic inflammation of the laryngeal mucous membrane predis-
poses to ulceration, as in other mucous surfaces, but the process is not
at all distinctive. The ulcers may be slight erosions due to traumatism
or to desquamation of epithelium in a condition of low vitality, or they
may have considerable depth if the cause and condition of the mem-
brane both persist. Such ulcers often exist quite commonly upon the
vocal cords without the knowledge of the patient, and are regarded
simply as a manifestation of the chronic process under circumstances
more or less tending to aggravate it. Stimulation of the surfaces and
edges with nitrate of silver, with general treatment of the chronic lar-
yngitis, is the treatment. Rest and non-use of the voice often effect a
cure without therapeutic interference.
Tuberculosis of the I/arynx. — Without doubt, in the majority
of cases tuberculosis of the larynx is secondary to pulmonary disease,
yet there is no reason why its first area of invasion may not be there,
since the tubercle bacillus may find primary lodgement in any part of
the body. In fact, we may go farther, and declare that a process of
reasoning, unsupported by clinical facts, might lead us to the conclusion
that the larynx from its anatomical position is particularly exposed to
620 SURGICAL DIAGNOSIS AND TREATMENT.
primary invasion by the tubercle bacillus. But, clinically, it is found
that in many cases pulmonary tuberculosis goes on to the fatal end
without invasion of the larynx at all, or it occurs very late in the his-
tory of the disease ; and further that laryngeal tuberculosis unaccom-
panied by pulmonary lesions is so rare as to be practically unrecog-
nized. When laryngeal tuberculosis has been believed to exist alone,
it has been followed so promptly by signs of the disease in the lungs
that the conclusion was almost inevitable that it was present before or
simultaneously with the affection in the larynx. In any event, the
existence of the disease in the larynx affords the strongest probability
of its speedy migration to the lungs, though of course this is not a
demonstrable certainty.
Since the sputum charged with the bacillus is constantly passing
over the mucous membrane of the larynx, it needs only the presence
of an erosion to effect inoculation, and no doubt such is the clinical
history of the great majority of cases of tuberculous disease of the
larynx. The generally lowered tone of health and the tendency to
" catch cold " lead to a condition of the mucous membrane especially
favorable for the development of micro-organisms.
The disease is most common in male adults between twenty and
forty years of age.
Pathology. — If the larynx come under observation during the incip-
ient stages, it is seen to be anemic and paler than normal. Later there
is thickening of the mucous membrane from tubercular infiltration.
Tuberculosis of the larynx generally shows first at the arytenoid
cartilage or commissure, and later the aryepiglottic folds. It invades
the ventricular and the vocal bands and the epiglottis in the order
named, but all parts are subject to it. At first it may be unilateral,
but as the disease advances both sides are involved, particularly in the
lymph-glands, with great deformity. As the tumefaction progresses
small yellowish points appear studding the mucosa, but the integrity
of the epithelium is not at first impaired. Later, each of these yellow-
ish points becomes the seat of ulceration. These diminutive ulcers by
increasing in size coalesce, and ulcers of larger and larger size are
formed until the membrane is almost one continuous ulcer. It is of a
grayish-yellow color, not depressed, not differing markedly in color
from the anemic infiltrated mucous membrane at its edges. Secretion
is somewhat scant and of a thick, ropy consistency, with a relatively
large amount of mucus compared with pus, and charged with the
tubercle bacillus. Infiltration is always extensive, and prevents the
loss of tissue which is really going on from the surface of the ulcer
from becoming prominently manifest. Though beginning in the
mucosa, the infiltration deepens, and perichondritis with consequent
chondritis is not uncommon. Necrosis occurs as in perichondritis
due to other causes ; the arytenoid cartilages also may be discharged
entire or in part ; on the other hand, there may be ankylosis of the
crico-arytenoid joint. Edema may really be present, but more fre-
quently the excessive tubercular infiltration simulates the edematous
condition.
Symptoms. — One of the earliest symptoms, and the one which per-
haps first draws attention to the disease, is loss of voice. Infiltration
INJURIES AND DISEASES OF THE RESPIRATORY SYSTEM. 62 1
at the commissure prevents approximation of the vocal cords, and the
voice is wholly gone at once. In others, where the disease commences
elsewhere or is only slight, there is hoarseness, followed by a weak
voice which gradually merges into aphonia. When the tubercular
infiltration is higher the voice may not be lost, but this is rare.
There is excessive sensitiveness of the parts, and pain is early, severe,
and lasting, particularly when the epiglottis is invaded. Food passing
over renders deglutition almost impossible, and an already grave con-
dition is rendered more so by the diminished nourishment. When
destruction of tissue has gone to a considerable extent the case is
complicated by the passage of food into the larynx or posterior nares.
Cough is an ordinary concomitant of the pulmonary lesion, but is in-
creased and is much more painful after the involvement of the larynx.
Dyspnea is not especially characteristic of the disease, though it
may be present. Hemorrhage in large amount never comes from the
larynx. The laity are apt to feel that laryngeal disease is especially
serious, and the patient frequently betrays his anxiety in his face.
Diagnosis. — The almost invariable existence of pronounced pul-
monary tuberculosis renders the probability exceedingly strong that
ulceration in the larynx would be of the same origin. However, ulcers
of syphilitic origin may exist along with tubercular disease, so that a
differential diagnosis must be made. Tuberculosis of the larynx is
also to be differentiated from malignant disease.
Syphilitic ulcers are round in shape, excavated, and have an areola
of reddish color. There are usually other indications of the disease in
the system.
In malignant disease the ulceration is unilateral, irregular in outline,
and nodular ; there are profuse ulceration and much destruction of
tissue, and the characteristic cachexia is usually present. Micro-
scopical examination of the sputum is employed to establish a doubtful
diagnosis.
Prognosis. — This is exceedingly grave as to life, inasmuch as it
usually complicates an existing condition already serious in itself
If the disease were actually primar>^ and seen in its early stages, it
might no doubt be wholly arrested, but practically this never happens.
Its course may be checked and the patient rendered more comfortable.
According to the statistics of Bosworth, it shortens life on the average
one year. The average duration of pulmonary tuberculosis being three
years, a patient will probably live one year and six months after the
appearance of the disease in the larynx.
Treatment. — Assuming that constitutional treatment, both medicinal
and dietetic, would already be in progress, we need here consider only
the local measures suitable for tuberculous ulceration in a locality so
easily accessible as the larynx.
Cleansing should be thorough. This is accomplished by an alkaline
spray thrown upon the part, as Dobell's solution, or boric-acid solution,
or a solution of peroxid of hydrogen. Astringents may then be ap-
plied, as nitrate of silver, sulphate of zinc, or tannin in glycerin.
Pain, which is always persistent and often severe, may be controlled
by solutions containing morphin. Cocain should be used with care,
as absorption takes place rapidly ; deglutition will be easier and nutri-
622 SURGICAL DIAGNOSIS AND TREATMENT.
tion will be better maintained if its application be made before food is
taken.
Iodoform or aristol or boric acid should be dusted on the parts after
the cleansing. The odor of iodoform is so extremely disa<^reeable that
europhen in solution may take its place.
Lactic acid is a time-honored remedy. Menthol in olive oil is men-
tioned by some authors.
Medicated inhalations often afford marked relief to the parts, but
their curative qualities are very small.
Regular treatment, as indicated above, should be given two or three
times a week.
Tracheotomy may be necessary if there is an edematous infiltration.
It has even been advocated as a curative measure, its value being the
rest afforded to the larynx and in the greater amount of oxygen
thereby furnished to the system. At best, it may render the patient
more comfortable and possibly somewhat prolong his life, but is certain
to impress him with the progressive and hopeless character of the
disease.
Syphilis of the I/arynx. — Syphilitic disease of the larynx occurs
both in the secondary and tertiary stages, and in general it may be said
its manifestations in either stage are identical with those in the nasal or
buccal mucous membrane, modified only by the anatomical situation.
Following the cutaneous eruptions of the secondary stage is at times an
erythema of the mucous membrane of the larynx. Mucous patches
are somewhat common manifestations of the secondary stage, but are
frequently the first evidence of the disease in the larynx. They may
appear on the vocal cords, the epiglottis, the arytenoids, and the ven-
tricular bands, and may be few or many, the symptoms depending upon
the location. Ulceration is a late manifestation of the secondary stage,
but is a constant lesion in the tertiary. It is symmetrical and bilateral,
and is either superficial or deep. The superficial ulcers may almost be
said to mark the border-line between the secondary and tertiary stages,
while deep, destructive ulcerations are the inevitable result of the
unchecked progress of the disease in the tertiary stage.
Gummata characterize the tertiary stage, and their natural termina-
tion is ulceration.
The superficial ulcer, but slightly depressed below the surface, is
rounded or ovoid in form, has no areola, and secretes a yellowish pus.
The amount of necrotic tissue is relatively small.
The deep ulcer results from the breaking down of the gummy tumor.
It is, as a rule, a rapid process, and the amount of necrotic tissue dis-
charged is relatively large. It generally invades the perichondrium,
setting up a perichondritis with chrondritis, resulting in necrosis of
cartilage. The arytenoid cartilages are apt to be first attacked, and
may be wholly destroyed. The cricoid, the thyroid, and lastly, the
epiglottis, are attacked in the order named. In the fibro-cartilage of
the epiglottis the process of destruction is more like constant erosion
than is the case with true cartilaginous structures, where a sequestrum
is formed which may slough as soon as fully detached, or may remain
in situ indefinitely or until destruction of all surrounding tissue sets it
free.
INJURIES AND DISEASES OF THE RESPIRATORY SYSTEM. 623
Symptoms. — Impairment of voice in all degrees is a marked symp-
tom, depending for its extent upon the location of the lesions. Dys-
phagia is another symptom, particularly if the posterior portion of the
cricoid is involved or the epiglottis much eroded.
Superficial ulcer gives only slight symptoms, pain being often wholly
absent. In contrast with the negative signs of superficial ulcers deep
ulceration is often exceedingly painful, especially when the perichon-
drium is involved. Dyspnea may be present, especially if a gummy
tumor obstruct the air-passage. After it has broken down in ulcera-
tion this symptom is relieved.
Diagnosis presents few difficulties, particularly if the existence of
the disease in the system is known. Mucous patches show a grayish
area slightly raised above the general level of the membrane. The
bright-yellow pus of the superficial ulcer is characteristic. A gummy
tumor is smooth and rounded.
The deep ulcer has a sharply-defined edge, is crater-like, and has a
dark-red areola, much secretion, and necrosed tissue.
It must be differentiated from tubercular disease and malignant
disease.
In tuberculosis the ulcer is irregular, of a grayish color like the
surrounding membrane, has little secretion, and may be accompanied
by pyrexia. Microscopical examination will show also the tubercle
bacillus. Malignant disease is irregular, nodular, and unilateral.
Microscopic examination of a bit of the tissue will show the cell-
arrangements peculiar either to sarcoma or carcinoma.
Prognosis. — Taken in the earliest stages, laryngeal syphilis yields
readily to constitutional treatment, combined with such local treatment
as would be given for the comfort of the patient in ordinaiy catarrhal
laryngitis.
Treatment. — For all manifestations of syphilitic disease before the
appearance of the superficial ulcer constitutional treatment alone usually
suffices. With the appearance of this ulcer cleansing and antiseptic
remedies should be topically employed. The treatment of a gummy
tumor is constitutional only, its absorption before ulceration begins
being the thing to be desired. Deep ulceration must be treated locally
by cleansing, astringent, and antiseptic solutions, and iodid of potas-
sium is to be pushed internally.
Resulting cicatricial stenosis must be treated, as that condition is
elsewhere, by dilatation or division.
Tumors of the I/arynx. — Morbid growths in the larynx are
common, and of these the greater number are benign. They may
appear either externally or internally, but more frequently they are
internal, occasionally both. The symptoms are such as naturally give
great alarm to the patient and his friends, but danger to life is rela-
tively slight.
Benign Tumors. — All or nearly all varieties of benign tumors have
been found in the lar>'nx, and, in the order of frequency, are papilloma,
fibroma, osteoma, myxoma, adenoma, lipoma, angeioma, enchondroma,
and those of mixed character. Some of them undergo degeneration,
fatty, colloid, and amyloid.
Papillomata outnumber all other kinds of neoplasms put together.
624 SURGICAL DIAGNOSIS AND TREATMENT.
and, while most morbid growths are single, these are occasionally
multiple.
Men suffer more frequently than women from this disease, and
during the more active period of life, from thirty to fifty. It appears so
early in infancy that it may be assumed to be congenital, nor is ad-
vanced old age free from it.
The favorite sites of neoplastic growths are the anterior parts of the
larynx, notably the vocal cords, though they appear anywhere on the
laryngeal surface.
The size varies from that of a millet-seed to a growth large enough
to protrude from the larynx and threaten life from asphyxia.
Etiology. — The cause is obscure, and it is rare indeed that a definite
one can be found for any particular case.
Acute and chronic laryngitis, especially under exposure to cold and
to irritating vapors, over-use of the voice, the deuteropathic laryngitis
of acute and constitutional diseases, and traumatism have all been as-
signed as causes of benign tumors in the larynx. But such diseases do
not produce tumors in the majority of cases, and, on the other hand,
tumors develop when no morbid process can be assigned, and are sur-
rounded by perfectly healthy tissue, just as a "wart" develops on the
cutaneous surface of the hand.
Symptoms. — All varieties of benign tumors produce the same symp-
toms, according to size and location. Since most of these tumors are
either upon the vocal cords or near enough to them to modify their
function, phonation is either altered or lost. Before or in place of
complete aphonia there may be either a weak or a hoarse voice, and
the earliest indication of the presence of a laryngeal tumor may be
a certain, almost indefinable, alteration in the quality and tone of the
voice, such alterations being more pronounced or being replaced by
aphonia as the disease progresses.
If there are growths on the two sides, so that the chink of the glot-
tis is divided, double voice or diphthonia may result.
Position rather than size determines the alteration in the voice. A
small tumor seated on the weak bands may impair their function
greatly, w^hen one many times the size situated at some distance will
affect the voice little or none at all.
Respiration, especially during inspiration, may be interfered with,
and dyspnea may become pronounced with the enlargement of the
growth.
Dysphagia is not common unless the morbid growth occupies the
posterior part of the larynx. Cough is seldom present, as nerves are
rarely injured, and pain is uncommon for the same reason.
Hemorrhage is either absent or slight. The growth itself may not
be felt, and its presence may be unnoticed except for interference with
phonation, or it may give a feeling of discomfort and uneasiness.
Diagnosis is made by the laryngoscope, and the practitioner needs
to be thoroughly acquainted wdth the external and histological cha-
racters of the different varieties of tumor, as well as the probable site,
size, and mobility. In children, the use of the laryngoscope being
sometimes non-practicable, the tactus erziditus alone must give the
desired information. Even when the laryngoscope is used, a snare or
INJURIES AND DISEASES OF THE RESPIRATORY SYSTEM. 625
probe may be needed to bring a growth into full view. When possible
a portion may be removed for microscopical examination, but this is
not always desirable.
Papilloniata may be single, but are often multiple, either sessile
or pedunculated, and usually found at the anterior part of the vocal
cords. The surface is wart-like, and the interior on section shows the
same formation in its central papilla covered with multiplied epithelial
layers. They vary in color, through shades of pink, from white to red.
Their appearance when they are multiple has been compared to that of
mulberries. They are common in childhood and adolescence — a diag-
nostic point between them and epitheliomata which occur in middle life.
Fibromata, situated most commonly also on the vocal cords, are
single, smooth, hard, rounded, pedunculated, and have a surrounding
areola.
Cystomata are caused by the retention of a secretion in a mucous
gland from an obstructed duct. As it fills it projects above the surface
and may attain the size of a small marble. It occurs most frequently
on the epiglottis, is round, smooth, semi-transparent, movable, com-
pressible, and pink in color.
Myxoinata are probably due to the myxomatous degeneration of the
mucous membranes or of other tumors, and are found most frequently
upon the vocal cords. In situation and external character they so
much resemble papillomata as to suggest the idea that they are a
degeneration of that common form of laryngeal tumor.
Angeiomata are rare, and are usually seated upon the vocal cords,
but may be found anywhere. They vary in size from that of a pea to
a hazelnut, and are of a deep-red color.
Adenomata are so rare that their occurrence is denied by some
specialists in throat diseases, but there can be no doubt of their occa-
sional existence.
Lipomata are supposed to be external neoplasms as a rule, though
Bruns reports one of intra-laryngeal origin.
EiicluvidroDiata are more commonly seen upon the posterior por-
tions of the larynx, selecting as favorite sites the cricoid, the thyroid,
and the epiglottis in the order named. These tumors are always hard,
large, and sessile, projecting inward. Their contour is irregular, and when
the mucous membrane is eroded they are seen to be hyaline in struc-
ture. They may be very small, or so large as to fill the laryngeal
cavity, giving rise to extreme dyspnea. Few tumors are composed of
one histological substance, but, as in other parts of the body, are of
mixed type.
Prolapse of the ventricle may be mistaken for neoplastic growth.
It can be diagnosed by noting the absence of the ventricle and by
replacing the membrane temporarily with an instrument.
Prognosis. — Per sc, tumors of this sort do not menace life. By
occlusion, if they are allowed to attain a large size, they may cause
suffocation ; but the increase in size is always slow, and if there are any
reasons why the growth cannot be removed, the operation of trache-
otomy can be performed. As a rule, also, prognosis as to recovery of
voice is good if this has been impaired or lost, though in rare cases it
may never be restored.
40
626 SURGICAL DIAGNOSIS AND TREATMENT.
When a growth has been removed by the external operation,
cicatrization of the thyroid cartilage may so distort the parts that the
normal voice is lost.
Occasionally benign growths undergo transformation into malignant
tumors, especially when they are subjected to some constant irritation
or when repeated clumsy attempts at operation are made, but the
proportion of such degenerative alterations is exceedingly small.
Sometimes spontaneous expulsion, or still more rarely spontaneous
absorption, takes place.
Treatment. — Treatment is wholly surgical, and two methods of
removal are recognized, the intra-laryngeal and the extra-laryngeal.
With the laryngoscope and the variety of laryngeal instruments now at
the surgeon's command it is rare indeed that intra-laryngeal operation
will not be abundantly successful. Not all intra-laryngeal growths
demand immediate operative interference. If the symptoms and the
inconvenience are slight and the growth does not enlarge, it is optional
whether the operation is performed or not. Such a growth may remain
stationary for an indefinite period, and then begin to enlarge, and this
indicates prompt removal.
Operation through the natural passages is by cauterization, incision,
abscission, excision, crushing, ecrasement, and avulsion.
Cauterization is effected by chemical or electrical agency. When the
former is selected, as it may be in the case of small, easily accessible papil-
lomata, a variety of caustics has each its advocates, as nitric acid, nitrate
of silver, zinc chlorid, caustic potash, mercuric nitrate, London paste,
Vienna paste, or chromic acid. A tiny crystal of chromic acid is fused
on the end of a curved laryngeal probe and applied to the neoplasm.
A concentrated solution may be applied by means of a bit of sponge
or cotton held firmly in catch-forceps. The greatest care must be used
in such operations not to drop foreign substances into the respiratory
passages, and also to accustom both patient and surgeon to the neces-
sarily delicate manipulations. Preliminary attempts may be made with
the simple instruments not carrying any caustic whatever, for in the
actual operation the greatest care must be exercised to touch no por-
tion of the laryngeal surface except the papilloma.
Similar precautionary measures may be taken when the galvano-
cautery is used. Various cautery points are made for laryngeal treat-
ment, and may require wrapping down almost to the point to protect
all tissue but that under operation, for traumatic laryngitis or edema
of the larynx may follow clumsy manipulations. The point must be
carefully adjusted before the current is turned on, and the current
should be turned off before the instrument is removed. Cauterization
by the galvano-cautery is really one of the least desirable of all methods
of treatment unless in the hands of a most skilful operator.
Incision is employed for cysts only, and a curved knife is used.
Abscission and excision, practically one and the same operation on
growths of slightly different shape, are done by knives of various curve
properly protected nearly to the end, by scissors, or by the guillotine.
Crushing is accomplished by forceps, and is not primarily a removal,
but a destruction of the vitality of the neoplasm, with the expectation
that it will eventually slough.
INJURIES AND DISEASES OF THE RESPIRATORY SYSTEM. 627
Ecrasement is detachment by means of the snare, and is applicable
only to growths of small size, but has the advantage of only slight
hemorrhage if done slowly.
Evulsion is the method adapted to the greater number of new
Fig. 264. — Storck's forceps : A, wire ecraseur ; B and C, guillotines ; D, E, and F, forceps ;
G, guillotine, half closed ; H, the same, open.
growths. The growth is grasped by forceps and torn away either
en masse or piecemeal. Soft growths, either pedunculated or sessile,
come away very readily, but those of harder consistency, as fibromata,
often are removable with great difficulty. If hemorrhage is so great
Fig. 265. — Gottstein's forceps.
as to obscure the field in the case of a growth removed in fragments,
several sittings may be necessary. A finger in the lar>'nx sometimes
easily detaches foreign growths.
What form of instruments to use is a question of some nicety, and
628
SURGICAL DIAGNOSIS AND TREATMENT.
different surgeons have devised instruments adapted to their own par-
ticular manner of operating. Mackenzie of London perfected a forceps
bent at right angles and intended to operate in the entire circumference
of the larynx. He has also invented tube-forceps, less generally used
than the other, and of a less wide range of usefulness.
Storck's instrument (Fig. 264) is bent to the quadrant of a circle,
and may be adjusted to a universal handle.
Gottstein has an instrument (Fig. 265) with one curve nearly at
right angles in the distal end, and another at the junction of the
handle and the instrument proper, but most operators use it awkwardly.
Many find Shrotter's instruments (Fig. 266) very useful on account
Fig. 266. — Schrotter's laryngeal lancet and forceps.
of the handles being bent horizontally out of the operator's line of
vision.
The extra-laryngcal operation is to be performed when the growth
is so large or so situated as to make thorough eradication through the
mouth either doubtful or impossible.
A preliminary tracheotomy may be done and the method through
the mouth again attempted, or the tracheotomy may be performed
only with a view to removal. Where entrance shall be made must
depend upon the individual case. It may be through the median line
of the thyroid, or through the crico-thyroid ligament, or through both
cricoid and thyroid, or the trachea may be opened, or the section made
partly in the trachea and partly in the larynx. Section may be between
the hyoid bone and the larynx, but this reaches little surface that is not
equally accessible by the mouth ; a lateral section has been proposed.
The cricoid, having a comparatively small blood-supply, is prone to
necrosis, and, as has been said, cicatrization after operation upon the
thyroid cartilage is apt to distort the vocal cords and impair the voice.
All considerations must be duly weighed before commencing the ope-
ration.
After having entered upon so important an operation the surgeon
will see to it that extirpation is so radical that repullulation is inevitably
forestalled. Thorough cauterization of the parts upon which ablation
has been practised will secure this. If hemorrhage after thyrotomy is
large, the operation may have to be done in two stages, and it is best
to leave in a tracheotomy-tube if possible, as resolution is more rapid
when perfect rest to the parts is thus secured.
INJURIES AND DISEASES OF THE RESPIRATORY SYSTEM. 629
Cocain should be used before commencing internal operation upon
the throat. The case should be treated immediately with caustics if
there is any appearance of remaining fragments or if recurrence
threatens.
It is only practice upon the cadaver that will give the requisite
rapidity and delicacy of manipulation.
Malignant Ttimors. — Tumors of malignant character are either
sarcomata or carcinomata, the proportion of the latter to the former
being 612 to i (Bosworth).
1. Sarcoma. — All or nearly all varieties of sarcoma have been
reported as found in the larynx. Sarcomata are not excessively large,
about the size of a walnut being the limit. They extend by involving
adjacent tissue, and not by the lymphatics. The disease occurs most
frequently in adult males between the ages of twenty-five and sixty,
with the majority of cases in old age. The disease is usually primary,
with no evidence of hereditary predisposition, though a very few cases
have been reported as secondary.
No cause is known, but possibly persistent laryngitis may have some-
thing to do with it, though an otherwise healthy larynx may be the
seat of sarcoma.
Symptoms in the early stages may be nearly negative, or at least
may not differ from those of the non-malignant tumor. Pain may be
more marked, but in some cases is wholly absent. As the disease
advances cough may assert itself, and the sputa may alter in character,
containing some blood and eroded fragments.
Diagnosis. — Diagnosis is made by the microscope. Yet to the
practised eye certain distinguishing characteristics will declare the
malignancy of the growth, for it does not exactly resemble any of the
benign tumors. Occasionally it resembles a papilloma, but it is situated
more posteriorly. There is an abnormal-looking mucous membrane
immediately surrounding the growth, either pale or too vascular, and
sometimes there is superficial ulceration. There is a thick deposit of
muco-pus upon the irregularly-shaped mass.
Sarcoma is distinguished from carcinoma by the fact that the
lymphatic glands are not involved.
Prog-}iosis. — Let alone, the disease is fatal, and may be quickly so,
for at times, especially in the later stages, the tumor grows very rapidly,
filling the larynx, death resulting from suffocation. If the growth is
wholly removed, the prognosis becomes favorable.
Treatment. — Extirpation is the only safe procedure, and here radical
treatment is surgical. In so grave a disorder, where the removal of
every particle of the growth is essential and where repeated manipulations
result only in evil, the operation through the mouth does not sufficiently
promise certain success. Thyrotomy must be the rule here. Some-
times there must be resection of a portion of the larynx, or even
laryngectomy. If the disease is confined to the epiglottis, that may be
removed entire.
2. Carcinoma. — Of all the cases of cancer, only a very small per-
centage are located in the larynx. Here it is usually primary, but has
been known to be secondary by extension from neighboring organs. It
is not circumscribed, but spreads rapidly into contiguous tissues, and
630 SURGICAL DIAGNOSIS AND TREATMENT.
hence, though generally unilateral to begin with, it becomes bilateral
by extension.
Ifitriiisic cnrcijioina hovers about the vocal bands, while the extrinsic
variety more frequently selects the epiglottis as its site. Lymphatic
glands are not always involved, especially in intrinsic carcinoma, the
extrinsic variety being more apt to extend to the lymphatics.
It occurs at all ages, but is most frequent in the last part of the
so-called middle life and in old age from fifty to seventy, and occurs in
males far more frequently than in females.
The cause is obscure, but acute, and especially chronic, laryngitis,
traumatism, the contraction of cicatrices, over-use of the voice, the
irritation of benign growths, and especially clumsy attempts at their
removal, have all been assigned as causes.
Symptoms. — The symptoms arc essentially the same as of malign
growths in the early stages.
The glands are early involved. There is generally some ulceration,
a more abundant secretion than normal, and thus the breath becomes
fetid and offensive and the sputa charged with abnormal constituents
and tinged with blood. Although it is rare, the ulceration may eat
through small arteries and hemorrhage ensue.
Pain is not constant, but is usually more marked than with
benign tumors or sarcoma, and a peculiar feature is that it radiates
up behind the ears and over the neck, particularly in extrinsic car-
cinoma.
Salivation may be excessive. Cough in the ulcerative stage is
usually present.
Sometimes dyspnea is so extreme as to threaten suffocation. After
a time these extreme symptoms remit, the reason being the removal of
tissue by the ulcerative process.
Diagnosis. — The true character of carcinoma of the larynx may be
overlooked at first, from the fact that it is deep within the tissues
before its presence is known. Careful study of the subjective symp-
toms and superficial appearance of the tumor, particularly in the
ulcerative stage, the fetid breath, and the pain running up toward the
ears, will be enough to suggest cancer.
The final diagnosis is by the microscope, and fragments should be
removed from a suspected tumor for that purpose. Its nodular, ragged,
irregular, and greater extent serves to distinguish it from sarcoma.
Cachexia is characteristic also, but less so than with cancer in other
parts of the body, and it does not appear early as a rule. By micro-
scopic examination it can be differentiated from tuberculosis, and by
specific treatment from syphilis.
Prognosis. — It is a fatal disease. Removal may lengthen life, but
will not save it.
Treatment. — Since the patient becomes, from the fetor, very offensive
to himself and his attendants, it is best to use sprays of antiseptic and
deodorizing material, as carbolic solutions, peroxid of hydrogen, per-
manganate of potash, etc.
Pain is to be relieved by the use of morphin.
If dyspnea is extreme, tracheotomy is to be performed.
Whether actual attempts at surgical extirpation shall be made
INJURIES AND DISEASES OF THE RESPIRATORY SYSTEM. 63 1
depends upon the strength and wish of the patient and the position
and extent of the growth.
If it is external, operation is useless. If it is intrinsic and unilateral,
a half section of the larynx may eradicate it, or if of limited extent and
bilateral, laryngectomy may be justifiable.
Neuroses of the Larynx.
Neuroses of the larynx are either sensory, paralytic, or spasmodic.
Sensory neuroses, in comparison with the paralytic disorders of
the larynx, seem relatively unimportant, and are usually transitory or
mere concomitants of disease of the larynx.
During certain diseases, notably tuberculosis and carcinoma, there
is hyperesthesia of the mucous surface of the larynx; this occurs more
transiently and to a lesser degree in acute than in chronic laryngitis.
After certain diseases, as diphtheria, and sometimes after syphilis,
there is anesthesia of the mucous surface. This is a concomitant also
of some purely nervous diseases involving the superior laryngeal nerve.
In neurotic individuals paresthesia is not uncommon. It may be
due to some disease or it may be purely or nearly imaginary. Exam-
ination often reveals unsuspected disease, and sometimes no cause can
be found.
Neuralgia of the larynx, though very rare, may be a part of neur-
asthenia or the result of a generally anemic or depleted condition, and
is then, as a rule, accompanied by neuralgia in other parts of the body.
It may also occur independently of the disease elsewhere. It is usually
most painful. Sensory neuroses, except as symptoms of surgical dis-
eases of the larynx, possess little interest for the surgeon, and fall more
properly within the domain of the medical practitioner.
Paralysis. — Functional paralysis occurs chiefly in hysterical sub-
jects, and requires the same treatment which that disorder receives
whatever its manifestations.
By paralysis is meant an organic affection of the nerve supplying
the larynx. It may be due to a lesion in the nerve itself anywhere in
its course or to mechanical interference with its function, as when there
is pressure upon it from tumors or infiltrations. Ankylosis of an artic-
ulation may put an end to the function of the part, but is not a true
paralysis, since the nerve is wholly unaffected. Paralysis may be partial
or complete.
Paralysis of the Superior Laryngeal Nerve. — Sensation for the
mucous membrane of the entire larynx is provided by this nerve, and
it supplies motor fibers also to the crico-thyroid muscle and partly to
the ar>^tenoids. Hence a complete paralysis of this nerve would pro-
duce anesthesia of the lar>mgeal mucous membrane and motor paral-
ysis of the crico-thyroid and arytenoideus muscle. Tension of the
cords would be interfered with, and there would be lack of approxima-
tion of the arytenoid cartilages. This affection may be unilateral or
bilateral, the former condition being due more frequently to local dis-
ease or injury, the latter to cerebral disease or extensive local injury.
The commonest cause of paralysis of this nerv^e is diphtheria. It
is then accompanied by complete anesthesia, and by anesthesia and
632 SURGICAL DIAGNOSIS AND TREATMENT.
paralysis of neighboring parts, as in the pharynx when the muscles
of deglutition are involved. Other exhausting diseases, as typhoid
fever, have been known to produce this condition.
Diagnosis is based upon the history of the case, with a study of the
action of the laryngeal muscles by means of the laryngoscope, together
with the fact that anesthesia of the mucous membrane is also present.
If paralysis is bilateral, only the vocal processes touch during
phonation, making an elliptical opening in front and a triangular pos-
teriorly. If it is unilateral, the laryngoscopic image is less distinctive,
for it then resembles merely a relaxed condition of the cord (Bosworth).
Prognosis is good, though complete recovery is slow.
Treatment. — The diet must be nutritious. Electricity, the faradic
form, is of good service. Strychnin is the best drug for this condition,
but general tonics are usually needed. If the origin of the disease is
syphilitic, specific treatment is necessary. If it is of central origin,
nothing can be done unless the central lesion is due to syphilis.
Recurrent Laryngeal Paralysis. — This nerve supplies with motion
all muscles of the larynx except the crico-thyroid, and hence when it
is paralyzed there is complete absence of motion in all parts of the
larynx, for the crico-thyroid muscles act to no effect alone, if indeed
they act at all. Long-continued paralysis of these nerves leads to
degeneration of the nerve itself, and consequently to degeneration and
atrophy of the muscles which they innervate, and not infrequently to
ankylosis of the cartilages of the larynx from long-continued disuse.
Etiology. — The commonest cause of paralysis of this nerve is pres-
sure upon it at some part of its course. The course of the right and
left recurrent laryngeal nerves respectively is not the same on both
sides of the body, it being on the left side, as it winds around the arch
of the aorta, more exposed to pressure from aneurysmal tumor of
that vessel. Statistics, however, do not seem to show that aneurysm
is accountable for the relatively larger number of paralyses of the left
recurrent laryngeal nerve, but to such a cause must be added also its
greater exposure on that side.
Lesions existing anywhere in the course of the nerve will cause
paralysis.
Any disease of the brain where this nerve in its beginning is involved
or pressed upon will cause paralysis. During its course it may be pressed
upon by aneurysm, enlarged lymphatic glands, mediastinal tumors, pleu-
ritic or cardiac effusion, cancer of the esophagus, or enlargement of the
thyroid gland. Causes affecting the peripheral terminations are less
frequent probably than any other. They are inflammation of the laryn-
geal mucous membrane, usually involving that of the pharynx as well,
and inflammation of the muscles of the larynx, especially with great
effusion into their substance. Rheumatism of these muscles is believed
to cause it, also anemia, syphilis, poisoning by drugs, blood-poisoning
by diphtheria, typhoid fever, and the exanthemata.
The paralysis due to pressure on the recurrent laryngeal nerve
of one side sometimes is accompanied by paralysis of the nerve of
the other side, and this has never been satisfactorily explained. The
suggestion has been made that the irritation of the one affected leads
to central changes felt by the other.
INJURIES AND DISEASES OF THE RESPIRATORY SYSTEM. 633
Ziemssen reports a case where there was bilateral paralysis, that on
the left side being due to aneurysm of the aorta, the other to aneur>^sm
of the subclavian artery.
Symptoms. — At the onset of the affection in unilateral paralysis the
voice is weak, but with time it nearly recovers its normal strength.
In bilateral paralysis phonation is completely lost, and there is rapid
loss of air through the glottis when the attempt to speak is made.
Dyspnea is common. Laryngeal paralysis is really a symptom, as a
rule, of some grave disease, and the concomitant symptoms of that
disease are present as well.
Diagnosis. — Objective symptoms in lar>nigeal paralysis will suggest
the disorder, especially in connection with the history. Diagnosis,
however, is verified by the laryngoscope.
The vocal cords occupy the cadaveric position of Ziemssen between
extreme abduction and adduction. In unilateral paralysis the cord on
the affected side is in the cadaveric position ; the other passes the
median line a little, as if to compensate as much as possible for
the disability of its fellow. The arytenoid cartilage also goes a little
past the normal position. These deviations from the normal give
to the rima glottidis an apparent deflection toward the paral)'zed
side.
In many cases of recurrent larjmgeal paralysis the cause is perfectly
apparent, for the paralysis, as has been said, is but a symptom of a
grave disorder. On the other hand, the laryngeal paralysis may be the
first indication of a serious systemic affection, and it then becomes the
duty of the surgeon to trace backward, as it were, until he finds the
seat of the obscure disease — it may be in the central nervous system,
in tumors or aneurysm within the chest, or in tumors or enlarged glands
in the cervical region.
Prognosis. — If the cause is some acute disease or even poisonous
drug, the outlook is more encouraging than for pressure on the nerve-
trunk, and least of all is it hopeful when the trouble originates in the
brain, for this is usually incurable.
Treatment. — Remove the cause if possible. If the peripheral nerves
only are affected because of some local inflammation, local measures
are indicated, as the use of astringents.
Electricity may be of use if the trouble lies primarily in the muscles
or if it can be made to assist absorption of a tumor, as is sometimes the
case. General hygienic and therapeutic measures are to be carried out
as for superior laryngeal paralysis.
Paralysis of the Abductors. — When the posterior crico-arytenoids
are paralyzed, the vocal cords are brought into approximation, as in
phonation. Much theorizing has been done as to the cause of this
paralysis, but, since it is a frequent accompaniment of diseases having
their origin in brain lesions, particularly locomotor ataxia, it is highly
probable that many cases are of central origin. Still others may be
produced by pressure on the nerv^e-trunk or by peripheral lesions. In
bilateral paralysis during the inspiratory act the vocal cords are drawn
close together, symptoms of dyspnea become very urgent, and the vocal
cords cannot be drawn far apart under any circumstances. During
expiration the cords are forced up in a vaulted manner, separating as
634 SURGICAL DIAGNOSIS AND TREATMENT.
they rise, so that the column of air has free exit. The abductor muscles
from protracted non-use may undergo degeneration and atrophy.
Unilateral paralj'sis is apt to be due to pressure ; disease of the
bilateral variety is likely to have a central origin. Local irritation or
injury has been known to produce it, but such a cause is more likely to
be followed by bilateral paralysis.
Dyspnea is not urgent if it exists at all, and the lar)'ngoscope
reveals pathological conditions on one side only. It may remain
unilateral indefinitely or may merge into bilateral paralysis. Trache-
otomy is never a necessity for unilateral paralysis of the abductors.
Symptoms. — The one distinctive symptom is inspiratory dyspnea,
with at times great inspiratory stridor, not particularly noticeable at
first, but increasing in severity and frequency of the attacks as time
goes on. Other symptoms are those of the disease that produces the
paralysis, and whatever concomitant symptoms it may produce in other
nerves or in other parts of the body.
On laryngoscopical examination the cords are seen to approach
each other very closely and to be lifted apart during expiration ; they
assume a normal position during phonation, for the voice is not affected,
except that it suffers interruption in utterance from the stridulous in-
spiration.
Prognosis depends upon the cause. It is good if the cause is merely
local, not bad if due to pressure of a benign tumor, and very bad if due
to pressure of malignant growth, aneurysm, or to central nervous
affections.
Increasing unrelieved dyspnea is always of grave import, but trache-
otomy may come to the rescue for this condition.
Treatment. — Tracheotomy is to be performed when the dyspnea
demands it. Otherwise treatment is the same as for paralysis of the
superior laryngeal nerve.
Paralysis of the Adductors. — In this disease, when bilateral, the
lateral crico-arytenoids are drawn far back against the wall of the
larynx, leaving the rima glottidis as wide as possible. In unilateral
disease one muscle retreats to the laryngeal wall. It is probably not
of central origin, but generally of local causation, although diphtheria,
lead-poisoning, and occasionally typhoid fever may produce it.
Bilateral adductor paralysis is so rare as to raise a question as to
whether it really exists, or whether the so-called cases were not hys-
terical semblances of such a condition.
In unilateral paralysis the cord on the unimpaired side passes the
median line, somewhat toward the immovable fellow of the opposite
side, and its arytenoid passes in front of the other, these positions
making an oblique rima glottidis.
Aphonia is the symptom. Laryngoscopic examination makes clear
the diagnosis.
The prognosis is excellent.
Treatment. — Local treatment for the local condition and absolute
discontinuance of all attempts to use the voice are absolute require-
ments. General tonics and the best hygienic living are indicated. Elec-
tricity, preferably the faradic current, and strychnin are also valuable.
Aphonia is a symptom easily counterfeited by dishonest persons,
INJURIES AND DISEASES OF THE RESPIRATORY SYSTEM. 635
and either hysteria or dissimulation may call it to their aid. The dis-
tinguishing characteristic is this, that whereas paralysis of the adductors
is rarely or never bilateral, hysterical aphonia is always so, and dis-
simulation is simply silence with perfectly normal laryngeal muscles.
In either case anesthesia or surprising the patient when he is " off
guard " will clear up the doubtful features of the case.
Paralysis of the Internal Tensors. — No form of laryngeal paraly-
sis is more common, because of the frequency of chronic laryngitis and
straining of the voice from over-use. When included in some local
inflammation the thyroid muscle fails to contract as it should. The
voice, though still audible, loses its modulatory power, is weak and
unable to make the higher notes heard, and is hardly under the control
of the patient. It is usually unilateral, giving the " Indian-bow " image
of the glottis in the laryngoscope during phonation, but it may be
bilateral when the image is an ellipse. Paralysis of the arytenoideus
often accompanies tensor paralysis, and then in the laryngoscopic image
the vocal processes are approximated, shortening in front the " Indian
bow " or elliptical opening in the glottis during phonation, and show-
ing posterior to the vocal process a half ellipse, its point toward the
front, its base posteriorly.
If paralysis of the arytenoideus occur alone, the vocal cords during
phonation are properly approximated in front of the vocal processes,
leaving behind them a triangular opening. Complete restoration is the
rule in these cases, and local treatment with tonics, strychnin, and
possibly electricity constitutes efficient treatment.
Spasm of the Glottis. — Certain diseases, as croup or diphtheria,
may create or closely simulate this condition, but here is considered
only that form of laryngisuins stridulus which is simply of nervous
origin. It may be due to spasmodic contraction of the muscles, which
coapt the vocal bands, the ventricular bands, or of those which close
the glottis. Both adults and children are subject to it, but particularly
infants of delicate health — the scrofulous, anemic, rickety, those who
are in their first dentition, who are suffering from gastro-intestinal ail-
ments, from whooping-cough, or in whom enlarged glands press upon
the laryngeal nerves, or in whom the meninges are irritated by caries
of cervical vertebrae.
In adults the immediate cause is a reflex nervous excitability from
a variety of causes, as food or drink " going the wrong way " into the
larynx, the entrance of foreign bodies into the air-passages, etc.
Quite frequently there is some existing disease of the larjnix that
favors the occurrence of such accidents, as tuberculosis, syphilis, or
tumors, either benign or malignant, either internal or external, pressing
upon one of the nerves. Severe affections of the pharynx and esoph-
agus, causing painful deglutition, predispose to spasm of the glottis,
because then food and drink are apt to get into the larynx.
Some diseases of central origin, as epilepsy and locomotor ataxia,
afford frequent examples of it, and a condition of generally uneven
nervous poise is said to be predisposed toward it.
Symptoms. — The symptom of distinctive character is the paroxysmal
stridulous inspiration which occurs at intervals and lasts a few seconds.
The intervals between the spasmodic attacks may be hours or days,
636 SURGICAL DIAGNOSIS AND TREATMENT.
but if the system is in a condition predisposing to the occurrence of
spasm, they usually increase in severity and frequency, particularly in
the case of children, and also with them the attack usually comes on
at night. With adults the disease is rarely, if ever, feital. In the case
of children eclampsia and death often follow severe attacks, and may
occur after convalescence has apparently become established.
Diagnosis. — In the case of children croup would first suggest itself, but
the absence of fever and cough and the natural tones of the voice would
suffice to exclude croup. The generally ill-nourished condition of the
little patient, inflamed gums, the whooping-cough that is present, or
gastro-intestinal troubles will afford data for the cause of laryngismus
stridulus. If laryngoscopic examination is attempted, the placing of
the instrument is apt to excite spasm, and then the contracted muscles
are seen in the case of adults, and may even be provoked to establish
the diagnosis.
Bilateral paralysis of the abductors may cause spasm, but is more
chronic, less severe, lasts longer, and a study of the laryngoscopic
image will show total absence of action in the abduction, the glottis is
less rigid, and there is a marked absence of the convulsive movements
that attend spasm of the glottis.
Prognosis. — Because of its reflex origin it is not fatal in adults.
When it seems as if suffocation were imminent, relaxation allows of
inspiration, probably because of the sedative effects of carbonic acid
which is in excess in the system, but tracheotomy may be desirable to
ensure comfort. In children the prognosis is unfavorable, the degree
of danger depending upon the cause and severity of the attack.
Trcatnioit. — The causative disease must be treated, sedatives given
for the excessively neurotic condition, and the general health brought
to the highest possible point by tonics, nutritious diet, exercise, cold
baths, massage, and whatever other measures may be possible.
With children the immediate convulsion demands fresh air, ammonia
to the nose, hot water to the feet, cold to the head, flagellation, holding
of the nose, loosening of clothing, examination to see if there is an
impacted glottis and perhaps a hasty tracheotomy.
If the spasms tend to repeat themselves, preparations should be
made by the attendants for rapid treatment. In addition to the meas-
ures mentioned, morphin may be used, preferably hypodermically,
amyl nitrite may be kept at hand for instant inhalation.
During the interval between the attacks the cause should be re-
moved as rapidly as possible, and the system built up by dietary and
hygienic measures.
V. STRICTURE AND STENOSIS OF THE LARYNX AND TRACHEA.
Stenosis of the larynx and of the trachea are so frequently asso-
ciated clinically, and the causes producing the affection in the one are
so nearly identical with the causes in the case of the other, that it is not
less scientific than convenient to treat of the two together. Either or
both structures may be the seat of stenosis, and there may be one or
more points of constriction, though usually in such a case the multiple
points of constriction have the same causes, or causes operating at
INJURIES AND DISEASES OF THE RESPIRATORY SYSTEM 637
widely different times may be chargeable with the clinical condition.
The cause of stricture may be wholly external to the organ (compres-
sion-stenosis) or within its cavity, or it may be in the walls of it {occhi-
sion-steiwsis).
Compression-stenosis may be caused by aneurysmal tumors,
enlarged thyroids, thymus, or lymphatic glands, cicatricial tissue, cervi-
cal abscess, a foreign body, and by a diseased cervical vertebra, ster-
num, or clavicle. In this kind of stricture the integrity and character
of the walls of the organ are unimpaired, but they undergo involution
from the pressure.
Occlusion-stenosis is caused by cicatricial connective tissue, by
warping or distention of the tube itself, usually from congenital mal-
formations, by tumors, foreign bodies, edema, inflammation of mucous
and submucous tissue, submucous hemorrhage, paralysis of dilator
muscles or spasm of constricting muscles of the larynx, by adhesion
of the vocal bands, ventricular bands, or ar>^tenoid cartilages, or by the
presence of false membranes.
Injuries, especially gunshot wounds and cuts inflicted with suicidal
intent, are productive, in the process of healing, of connective tissue
which ultimately contracts, producing stenosis.
Stenosis varies between extreme limits. It may be a scarcely
appreciable diminution in the caliber of the organ or a complete ob-
literation of it. It is commonest and most important at the glottis, for
here the lumen is narrowed, and to all other causes operating in other
parts of the canal is added the contraction of the laryngeal process.
Under long-existing pressure degenerative changes may take place
in the tracheal walls. The cartilaginous rings may atrophy or become
wholly absorbed, so that perforation occurs.
According to the cause stricture is permanent or temporary.
Symptoms. — Whatever the cause and wherever the lesion, the symp-
toms are practically the same. The chief symptom is dyspnea on exer-
tion. It may take months or years to develop, but when due to false
membrane it may reach its height in a few hours. In any case, if un-
relieved, the stridor increases and the stenosis threatens suffocation.
The face is pale, livid, drawn, and anxious, and the pulse becomes
weak and fluttering. Sensations of tightness and discomfort are felt
in the chest. Cough is not always present, but when it is it is hard
and metallic. The voice weakens as the disease progresses, though in
chronic cases it may not be observed at first. In acute cases, where
false membrane is present, deglutition may be difficult or impossible.
Physical examination reveals an altered respiratory murmur. It is
harsh and strident, and in extreme cases may be heard across the room,
and on auscultation seems to pervade the entire chest. When the
larynx is the seat of the constriction, it descends during inspiration — a
symptom wholly absent when the constriction is in the trachea.
Diagnosis depends upon the symptoms, the history of the case,
and laryngoscopic examination. It must not be overlooked that a
slowly-developing stenosis is a far different thing, so far as prognosis
and treatment are concerned, from the rapidly-developing stenosis due
to recent cuts or gunshot wounds, to edema, or to the false membranes
of croup, diphtheria, and scarlet fever, or to the paralysis or spasm of
638 SURGICAL DIAGNOSIS AND TREATMENT.
the glottis resulting from those diseases. The laryngoscope is most
important in both classes of cases in order to determine where trache-
otomy shall be performed if symptoms become urgent.
Prognosis depends upon the cause. It is unfavorable in aneurysm,
mediastinal tumors, malignant tumor, external or internal, in some
forms of hypertrophy of the thyroid gland, and in many acute cases
where false membrane is formed.
It is favorable when there is occlusion by benign tumors, especially
in those so high that they may be reached through the mouth. The
prognosis is more favorable in all cases when it is so high that trache-
otomy can be performed below the obstruction.
Stenosis from paralysis or spasm of the laryngeal muscles may be
hopeful under long-continued treatment if a tracheotomy be performed
to ensure comfort and safety to the patient.
Treatment. — Foreign bodies must be removed either through the
mouth or external incision. Benign tumors can be removed by the
methods described ; malign tumors are sometimes removable.
Compression can be relieved only by treatment of the cause.
Tracheotomy must often be performed for false membrane or for the
resulting spasm or paralysis of acute diseases. Adhesions must be
carefully separated. The case may even call for laryngectomy. But
the treatment applicable to the greater number of cases is dilatation,
because the large majority of chronic cases are those resulting from
the contraction of cicatricial tissue after syphilitic ulceration. Dilata-
tion is generally a slow process, requiring a year or two of persistent
treatment, and tracheotomy, with the wearing of a cannula, is pre-
liminary to its successful carrying out. The common way is to place
in the canal a bougie as large as will enter the stricture and let it
remain for a few minutes. Gradually larger ones are borne for a
longer time. Various ingenious contrivances for inserting and retain-
ing them have been made, and patients readily learn to use these in-
struments themselves. Metal dilators, of two or three blades for more
rapid work, are sometimes used, but because they irritate the parts are
little to be recommended.
VI. MALFORMATIONS OF THE LARYNX AND TRACHEA.
In the examination of the trachea and larynx of infants that have
breathed but a short time or not at all a double trachea is sometimes
found, as if the bronchial tubes had extended themselves up to the
larynx. Sometimes the trachea is divided in part of its course by a
septum ; it may contain diverticula ; it may be dilated in some parts
and constricted in others ; it may open into the esophagus, or it may
be entirely absent.
A more common congenital fault is an external opening through the
integument — a fistula. This is supposed to be due to non-closure in
fetal development of the third or fourth branchial fissure, in which case
it is most commonly unilateral near the sterno-cleido-mastoid muscle,
or it may be accounted for by non-union of the third or fourth branchial
arch, when the fistula then opens in the middle line. Sometimes there
are bilateral fistulae, one near each sterno-mastoid muscle, though only
INJURIES AND DISEASES OF THE RESPIRATORY SYSTEM. 639
a few such cases have been reported. The opening upon the integu-
ment is usually very small, though often internally it may be seen by
laryngoscopic examination. Occasionally the track between the inter-
nal and external openings is very circuitous. Sometimes there is no
external opening, and the internal opening may manifest itself by an
emphysematous condition of the cervical cellular tissue. That such a
condition is not constant is explained by the supposition that the open-
ing is stopped by secretion. From the integumentary opening a drop
or two of muco-pus exudes from day to day, and air on forced expi-
ration.
Treatment is by caustics, electrolysis, or plastic operation.
Tumors of the Trachea. — All sorts of tumors, benign and
malignant, have been found in the trachea. Their characters do not
vary from such growths in the larynx, and are more common toward
the laryngeal extremity and upon the membranous than the cartilagi-
nous portion. They occur most frequently in adult males. They are
usually secondary, and quite frequently are associated with similar
growths in the contiguous structures, the larynx, esophagus, and
bronchial tubes.
Sometimes, in tracheotomy, the cannula injures the tissues, or there
is a subsequent attrition of the mucous membrane, and on the site of
such injuries fungoid excrescences appear. Also after the wound from
such an operation has cicatrized there appear similar vegetoid growths
upon the scar. The symptoms are the same as for growths not caused
by operation.
As compared with similar growths in the larynx, sarcoma of the
trachea is relatively common. Carcinoma is generally secondary.
Symptoms. — These are substantially the same as for laryngeal
neoplasms — dyspnea, loss of voice, harsh cough, and pain — when the
growth is a carcinoma. It is said that carr>'ing the head forward les-
sens, and lying down increases, the intensity of the symptoms.
Diagnosis is made from the symptoms and by the exclusion of
laryngeal disease by laryngoscopic examination or by inspection
through an external incision. It is not, however, impossible to view
the trachea well toward its bifurcation if laiyngeal tumors do not
obscure the field. Involution of the trachea from external pressure
must not be taken for neoplastic growths.
Prognosis for benign tumor is good, for malignant very bad.
Treatment. — Unless situated very high in the trachea, treatment
through the mouth is impracticable. Tracheotomy is performed,
and the growth removed by the instrument suited to the case. After
removal the site of the growth is cauterized. In most cases if, after
tracheotomy, a carcinoma is discovered, it were better not to attempt
removal, but to insert a cannula, and make the patient as comfortable
as possible by sedative drugs. The presence of carcinoma in other
parts and cachexia would prevent any doubt as to the character of the
growth, even before tracheotomy.
Tracheocele is a hernia of a portion of the mucous membrane of
the trachea between the rings of the trachea or through fistula. It may
be the size of a pea or as large as an &^^. It is filled with air and en-
larges on forced expiration. It may be almost or wholly negative as
640 SURGICAL DIAGNOSIS AND TREATMENT.
to symptoms, or may cause dyspnea, weakened voice, or the voice may
be temporarily lost. Pressure will usually remove it temporarily, and
may do so permanently, though occasionally radical treatment must be
employed to effect a cure.
VII. BRONCHIAL TUBES.
Injuries to the bronchial tubes are of external origin, and are dis-
cussed more properly under the general Surgeiy of the Chest.
Tumors are generally malign, and, as a rule, are secondary to the
disease in the lungs, and, on the whole, rare.
Stenosis of the bronchial tubes is not rare, and is caused by sub-
stances within the lumen, changes in the walls themselves, or by pres-
sure outside of the tubes. A small foreign substance, as a pea or bean,
may find its way into the bronchial tubes. Chronic inflammation may
thicken the walls, but, of all agencies producing alterations in the sub-
stance of the bronchial walls themselves, infiltration from chronic syph-
ilis is the most common. Syphilitic granulomatous deposits occasion-
ally diminish the lumen of the bronchial tube.
Mediastinal tumors, carcinoma of the lungs and lymphatic glands,
more frequently than anything else, cause stenosis of bronchial tubes.
Symptoms are not especially distinctive, and are apt to be masked
by those of the disease that causes the stenosis. Dyspnea, cough, and
stridor are the chief symptoms.
Treatment. — If syphilis is the cause, administration of iodid of potas-
sium must be pushed. Nothing can be done for carcinoma except to
relieve pain. Unless there is a definite history, a small foreign body
could not be diagnosed ; it could not well be removed, but might be
coughed up.
Tracheotomy. — The term " tracheotomy " is used, with less than
the customary professional accuracy, to indicate any operation that is
performed to admit air to the lungs when for any reason respiration
through the natural channels is impeded by certain operations above
the trachea. It includes laryngotomy, crico-thyroid laryngotomy, thy-
roid laryngotomy, laryngo-tracheotomy, and tracheotomy proper. The
two operations inexactly indicated by the word are usually spoken of
as the high and the low operation. By the " high operation " is meant
incision above the thyroid gland through the crico-thyroid membrane
and the first ring of the trachea — strictly a crico-tracheotomy or a
laryngo-tracheotomy. The " low operation " is below the thyroid
gland, and is through the fourth and fifth rings of the trachea, and
on down to within an inch of the sternum — a tracheotomy proper.
Sometimes incision through the thyroid gland cannot be avoided, and,
since it lies on the second and third rings of the trachea, this is also,
correctly speaking, a tracheotomy. Occasionally in opening into the
lar)mx the thyroid cartilage alone is incised, constituting a thyroidot-
omy, a thyro-laryngotomy, or a laryngotomy, any of the three terms
correctly describing the location of the incision.
In cases of croup and diphtheria, and when time and little hemor-
rhage are the desiderata, the high operation is chosen by most sur-
geons. Where the operation may proceed in a leisurely manner and
INJURIES AND DISEASES OF THE RESPIRATORY SYSTEM. 64 1
where permanency of opening is desired, the low operation is selected.
Generally, since it is a highly vascular structure, the thyroid gland is
avoided. If for any reason it is desirable to make the incision at that
portion of the trachea, the second and third rings, where its isthmus
lies, then two ligatures should be passed around it, one on each side
of the median line, and securely tied.
The reasons for performing tracheotomy are numerous and generally
imperative. It is done as a precautionary measure to secure free respi-
ration and to prevent the entrance of blood into the air-passages when
a long and bloody operation is to be done in the mouth or pharynx or
naso-pharynx. It is done when a foreign body is in the larynx, some-
times to give access to air and sometimes to effect the removal of the
foreign body ; in syphilitic and tubercular ulceration and in malignant
stenosis of the larynx, to afford rest to that organ ; in certain paralytic
and spasmodic affections of the laryngeal muscles threatening suffoca-
tive dyspnea ; in croup, diphtheria, and acute inflammations of the
larynx that greatly diminish the lumen ; and in edema of the glottis.
So frequently has it been mentioned in discussion of diseases of the
larynx and trachea that the student is already familiar with the indica-
tions for its employment.
Sometimes the necessity for tracheotomy is so urgent that the sur-
geon has opportunity for choice neither of instruments nor site. A
sharp penknife may be used, and the shape of the neck, and even the
attitude of the patient, may determine the location of the operation.
If, as is often the case with children, the neck is fat and short, the high
operation or that through the thyroid gland will be the only possible
one. If the neck is long and thin, the incision may be made close to
the sternum, always in the median line if possible, for there hemorrhage
is least and the tissues most easily separated. If, in the hasty operation
with a life at stake, a plexus of veins or an artery is found crossing the
middle line, the risk must be taken with confidence in stopping the
hemorrhage after the immediate danger is past. If the more leisurely
operation is possible, such vessels may be pushed aside or divided
between two ligatures.
Operation. — Unless the patient is already unconscious, an anesthetic
should be given or cocain injected locally. A firm pillow or sand-bag
is placed under the back of the neck and shoulder so as to stretch the
trachea and make it more prominent. An incision is made in the mid-
dle line, beginning at the level of the cricoid cartilage and proceeding
downward for a distance of five to seven centimeters. The skin, sub-
cutaneous tissue, and platysma are divided ; the remaining muscles in
front of the trachea can be separated by the handle of the knife. The
left hand of the operator now steadies the trachea while the remaining
tissues are dissected through and the rings of the trachea exposed.
All hemorrhage having been arrested, a sharp hook or tenaculum is
now inserted into the trachea to bring it forward and hold it steady
while it is being opened. The rings of the trachea are easily felt by the
point of the finger, and cannot be mistaken for anything else. A sharp-
pointed knife is the best for making the opening, and it should be
pushed through the wall of the trachea with a sharp, quick thrust, as
this prevents the mucous membrane from being stripped off and carried
41
642
SURGICAL DIAGNOSIS AND TREATMENT.
before the point of tlie knife. Two or three rings arc divided or the
cricoid cartilage and one ring. As soon as the windpipe is opened air
rushes in, and blood, air, mucus, and perhaps false membrane are driven
out with each expiration.
If the operator is acting in an emergency and has no tubes at hand,
all he has to do is to pass a silk thread through the edge of the tracheal
wound and the skin on either side. The thread can be secured to a piece
of elastic passing behind the neck. Thus the tracheal wound can be
kept wide open.
Tubes made of aluminum are the lightest, and in that respect the
best. Those made of hard rubber or silver are also used. They are
Fig. 267. — Gendron's split cannula, silver.
Fig. 268. — Little's aluminum trachea-tube.
Fig. 269. — Trachea-cannula, hard rubber.
graduated to suit the size of the windpipe, and are made double to al-
low of the inner tube being withdrawn and cleansed (Figs. 267, 268,
269). Selecting the largest tube
which the trachea can conveni-
ently receive, the tracheal w^ound
is held open either by the silk
threads already mentioned or by
the handle of the knife held trans-
versely, and the tube slipped into
position.
The after-treatment requires the
utmost care. The air of the room
should be kept moist and main-
tained at a temperature of about
80° F. A few folds of sterilized gauze should lie loosely over the
front of the neck to filter the air as it enters the tube. The tube is
to be kept clear of mucus by passing a damp feather through it from
time to time, and once or twice a day the inner portion should be taken
out, thoroughly cleansed, and returned. In cases of diphtheria five to
ten days is a sufficient time to retain it. If the operation has been
resorted to for the removal of a foreign body, one or two days will
suffice. In cancer of the lar}mx or other permanent obstruction the
tube must be retained permanently.
Intubation of the I^arynx. — Thanks to Dr. O'Dwyer of New
York, we have a device which can be employed without a cutting ope-
ration, and which in a large proportion of cases answers all the purposes
of tracheotomy.
INJURIES AND DISEASES OF THE RESPIRATORY SYSTEM. 643
Intubation of the larynx is indicated in diphtheria and croup, in some
cases of dyspnea caused by burns and scalds, and in pressure upon the
larynx from tumors. The instruments necessary for the operation are
made in sets, and consist of tubes of sizes suitable for patients from
early infancy up to twelve years of age (Fig. 270). The proper tube
for each case is found by consulting the scale B, which indicates the
length of the tube and the age for which it is suitable. No i is proper
for a child up to eighteen months old ; No. 2, between eighteen months
and three years ; No. 3, for the fourth year ; No. 4 from five to seven
years; and No. 5, from eight to twelve years. When the tube is to be
inserted a silk thread is passed through a small hole near the anterior
angle of its upper opening. Should the tube be placed in a wrong
position, it can be withdrawn by means of this thread. The obturator
is next screwed into the introducing handle and slipped into the tube.
The nurse holds the child upright on her lap with its arms controlled
by a sheet. An assistant controls the little patient's head, and at the
8-12 —
5-7 —
Fig. 270. — O'Dwyer's intubation instruments: A, tube; B, scale; C mouth-gag; D, intro-
ducer; E, tube-extractor.
proper moment inclines it backward. The operator, seated in front,
inserts the gag {C) and opens the mouth as widely as possible. The
introducer is taken in the right hand with the silk thread looped around
the little finger. The index finger of the left hand is passed in to the
epiglottis. The epiglottis is raised, leaving the glottis uncovered and
ready to receive the tube. At the same instant the tube is passed
back to the end of the left finger, and by it is guided into the glottis.
This is the only difficult part of the operation. The end of the tube
must be kept exactly in the middle line ; it must keep in close contact
with the under surface of the epiglottis, now held upright by the finger;
the finger must guide it to the opening, and then move to one side to
let the tube pass ; the other end of the handle is now sharply raised,
and the left finger feels that the posterior wall of the larjmx is behind
the tube. The tube is then pushed on to its position, and by a move-
644 SURGICAL DIAGNOSIS AND TREATMENT.
ment of the sliding thumb-piece on the handle quickly disconnected and
the handle and finger withdrawn from the mouth. If breathing goes
on satisfactorily through the tube, the thread is withdrawn, the index
finger again being used to press upon the upper end of the tube and
prevent its withdrawal while the thread is pulled out.
The removal of the tube after it has served its purpose requires a
little skill. The patient is held as before. The operator, taking the
extractor {E^ in his right hand, introduces his left index finger, and,
guided by it, the end of the closed extractor is inserted into the open-
ing in the tube ; by the aid of the thumb-piece the blades are sprung
apart and the tube withdrawn.
Skill in the use of these instruments can be secured by practice on
the cadaver, and it is a dut}' which the student owes himself and his
patients to obtain this dexterit>' before attempting the operation on the
living.
lyaryngectomy. — When the larynx is the seat of a sarcoma or a
carcinoma which does not involve the neighboring tissues or glands,
the operation of lar>'ngectomy is indicated. It has also been resorted
to for the relief of stenosis and of lupous, syphilitic, and tuberculous
diseases. Some ver>' satisfactor}' cases have been reported.
Operation. — If there is sufficient time, a preliminar>^ tracheotomy
should be made one or two weeks before the major operation, and
when practicable the tracheal opening should be high up, so that it will
be included in the subsequent incision.
First Step : The Incision. — This should extend from a little below
the chin to within an inch of the sternum, keeping exactly in the middle
line throughout. The superficial tissues are divided and the deep mus-
cles separated until the lar>mx proper, as well as the membranes above
and below it, is exposed. The isthmus of the thyroid gland is divided
between ligatures. Divided vessels are secured by forceps and afterward
ligated. The lar>mx is next freed from the muscles and other tissues
which are attached to it, provided they are free from disease ; otherwise
the dissection must go beyond the growth, so that the diseased parts
can be removed with the larynx.
Second Step : Removal of the Larynx. — The esophagus is separated
from the first ring of the trachea and from the posterior surface of the
cricoid cartilage. The esophagus ends at the upper border of the
cricoid cartilage, and is divided here when the lar>'nx is removed. The
patient is breathing through the tracheal cannula, and it is of great im-
portance that no blood be allowed to enter by the side of the instru-
ment. ]\Iichaers device for this purpose is very simple. He perforates
a cylindrical piece of sea-sponge, moistens it, and then runs the cannula
through it. The sponge is now allowed to dr>% and is surrounded by
a water-tight membrane which is secured tightly by tying it to the
cannula at the top and bottom. It is then covered with a solution of
gutta-percha. After its insertion the sponge is moistened with an anti-
septic lotion injected into it by a hypodermic syringe. The lar>'nx is
now separated from the trachea, and to further guard against the intake
of blood the divided end of the trachea is plugged as far down as the
cannula. The upper and lateral attachments of the lar>^nx are now
quickly divided and the lar>-nx lifted out of its position. A careful
INJURIES AND DISEASES OF THE RESPIRATORY SYSTEM. 645
search is made for diseased tissue, and if any remain it is thoroughly
removed. The tracheal tube is left in its former position or it may be
inserted into the upper end of the trachea.
Third Step : Care of the J Found. — It is best not to close the wound,
but to allow it to heal by granulation, which it does with great rapidity.
Packing with strips of iodoform gauze and careful tamponade of the
tracheal tube are all that is required. The esophagus having of neces-
sity been opened, the packing must be so arranged that should the
patient vomit the whole of the dressing need not be removed. At the
end of two days the patient is fed by introducing the end of a stomach-
tube into the esophageal opening, and this will have to be continued
for about three weeks, when the tube can be passed by the mouth.
Much improvement to the patient's condition is obtained by the use
of an artificial larynx made of light metal. Indeed, ingenuity has gone
so far that the new larynx is provided with vocal cords, by means of
which the patient can speak so as to be heard and understood at a
reasonable distance. The successful cases in this operation are 25 or
30 per cent.
Unilateral laryngectomy, by which is meant the removal of a lateral
half of the larynx, is performed exactly on the same principles as the
complete operation. It is less hazardous, but, on account of ,the
limited space, more difficult of performance.
VIII. THE CHEST.
Wounds occur chiefly as stabs or as bullet-wounds, and their most
serious aspect is the internal hemorrhage which they produce. Wounds
of the heart have already been considered. When one of the great
vessels is opened, the result is generally speedy death. A wound of
the lung is recognized by the patient expectorating blood. Collapse
of the lung on one side or the entrance of air into the wound would
indicate that the pleura was perforated. Paralysis of the diaphragm
points to division of the phrenic nerve. Sudden collapse and death
would indicate the severance of a large vessel or a wound of the heart.
Profuse external hemorrhage is probably due to a wound of an inter-
costal or the internal mammary arter>^
Treatment. — A wound of the chest should not be probed, for no
additional information can be gained thereby, and a clot may be broken
up which was doing good service in arresting hemorrhage. The inter-
costal arteries are not difficult to reach, and can be ligated. The inter-
nal mammary lies about half an inch from the edge of the sternum,
and can be secured by passing a curved needle around it carrjang a
ligature. In most cases patients who survive the immediate effect
of a wound will hav'e to be treated on the expectant plan and kept
at rest.
Effusions into the Pleural Cavity. — One or both pleural cavities
may be more or less filled with collections of blood, serum, or pus.
Blood as an effusion is, as a rule, the result of a stab-wound or a trau-
matism sufficient to fracture a rib and drive the fragments into the lung,
thus producing hemorrhage. When the collection of blood is moder-
ately large, coagulation takes place and the serum is separated from the
646 SURGICAL DIAGNOSIS AND TREATMENT.
clot. In the course of three or four days the serum is absorbed. If,
however, septic germs gain an entrance, suppuration is the result and
the serous effusion becomes a collection of pus (empyema).
Much more frequently the cause both of serous and purulent collec-
tions in the pleural cavity is pleurisy, and when the ordinary resources
of medical treatment prove unavailing, the surgeon is called upon to
reliev^e the condition by operation.
The signs of a collection of fluid in the pleural cavity are the same
whether the fluid be blood, scrum, or pus. The symptoms are differ-
ent ; if the signs of an effusion come on within a few hours or even a
day or two after traumatism, the effusion must be blood ; if the signs
of effusion are preceded by an attack of pleurisy, the fluid is at first
probably serum, and later pus. The signs of effusion are as follows :
There is a history of pleurisy or of a traumatism ; the patient has a
tendency to lie on the affected side ; that side of the chest is fuller than
the other side, because it is distended with the fluid ; consequently it
measures more. Place the end of a tape on the spinous processes be-
hind and bring it around to the middle line of the sternum, and you
will find a difference of an inch or more between the two sides. The
fluid bulges out the intercostal spaces and separates the ribs farther
from one another. The fluid pushes the heart to one side, and it is not
uncommon to find it on the right side of the chest when the left pleural
cavity is filled with fluid. Even the large, heavy liver is displaced, and
of course that displacement is downward. On percussion the area oc-
cupied by the fluid is as dull as a board, and on palpation there is no
friction or vocal fremitus. What do you hear on auscultation ? Abso-
lutely nothing. In many cases the level of the fluid changes with the
position of the patient, just as happens in ascites. Sometimes there is
so much fluid that there is dulness up to the lev^el of the clavicle. No
wonder that the patient wishes to lie on the affected side, so as to allow
the fluid to find its lowest level, instead of pressing over against the
healthy lung and interfering with his respiration. The well lung has
more to do than it had before, consequently there is exaggerated ve-
sicular resonance heard on auscultation. If in spite of all these signs
the surgeon is an unbelieving Thomas, he can thrust his hypodermic
needle into the side and settle the question definitely. Edema of
the chest-wall is considered an indication that the contained fluid is
pus.
Treatment. — The presence of a considerable quantity of fluid causes
compression of the lung, and the longer this pressure continues the less
likely is the lung to return to its normal position. If the fluid be pus,
the patient becomes emaciated and falls into that train of symptoms which
we if necessary sum up in the one word — hectic. For the simple re-
moval of fluid the operation of paracentesis thoracis is resorted to. This
was formerly done by a simple trocar and cannula, but Dr. Bowditch
greatly improved upon this method by the invention of the syringe
which bears his name and which has led to the various forms of aspi-
rators. In the withdrawal of fluid the two points to be kept in view are
to get rid of the fluid as thoroughly as possible and to prevent the en-
trance of septic germs, either on the needle or by the entrance of air.
The aspirating needle and the skin over a considerable area should be
INJURIES AND DISEASES OF THE RESPIRATORY SYSTEM. 647
as carefully sterilized as for a laparotomy. The opening made by the
needle should afterward be closed by iodoformized collodion and ab-
sorbent cotton. The most suitable place to insert the needle is just
below the lower angle of the scapula or at the side of the chest just in
front of the latissimus dorsi muscle. If the fluid is found to be serous,
the prospect of its not returning is fairly good ; if it is purulent, further
operative procedures will almost surely be required.
Thoracotomy. — An empyema, like a collection of pus anywhere
else, should be treated by incision and drainage. The simplest opera-
tion consists in making an incision about two inches in length over the
eighth or the seventh, or even as high as the sixth, intercostal space and
just in front of the latissimus dorsi muscle. The skin is drawn upward,
so that the opening will be valvular. Dissecting through the thoracic
wall, the pleura is reached, and to be on the safe side an aspirating
needle is thrust into it. If pus escape, the pleura is then incised to the
length of about an inch. Two drainage-tubes are inserted side by side.
When necessary the pleural cavity can be washed through these tubes.
It often happens that the ribs are close together and compress the
rubber drainage-tubes, rendering them useless. The proper thing to
do under these circumstances is to resect a piece of the rib (about an
inch), and the seventh is generally the one chosen.
Thoracoplasty, or Estlander's Operation. — In favorable cases the
pus-cavity is drained away, and the lung, expanding to its former posi-
tion, fills the pleural cavity once more. It often happens that our hopes
in this respect are disappointed ; the empyema continues and the lung
remains collapsed. It then comes to be a question of Mohammed going
to the mountain, since the mountain refuses to come to the prophet.
Estlander's operation is designed to
cause the chest-wall to fall in to meet
the lung.
In the simpler class of cases it is only
necessary to make an incision from the
axilla downward and remove pieces from
the third to the eighth rib. In the more
obstinate cases it is necessary to make
an incision both in front and behind, re-
moving so much of the ribs as is requi-
site to cause the required " staving in."
In old intractable cases Schede has
devised a still more radical operation.
He made an incision from the level of
the axilla in front, sweeping downward
in the form of an ellipse to the lower
limb of the pleura and ending at the
second rib behind (Fig. 271). The flap
is dissected upward and the scapula
lifted from the trunk. The ribs, the
entire muscular wall, and the pleura
are removed from the second rib down-
ward, the line of section being in front at the cartilage and posteriorly
at the tubercles. The cavity is then curetted and the flaps replaced.
Fig. 271. — Incision for Schede's ope-
ration of thoracoplasty (Esmarch and
Kowalzig).
648
SURGICAL DIAGNOSIS AND TREATMENT.
This is a serious operation. In a case requirini^ less surface of chest-
wall I make a less extensive incision, as seen in Fig. 272.
f'iG. 272. — Result of thoracoplastic operation.
CHAPTER XII.
THE DIAGNOSIS AND TREATMENT OF SYPHILIS.
Modes of Transmission. — Syphilis is an hereditary disease, but it
does not by any means follow that all the children of parents who are
one or both tainted with syphilis shall be syphilitic. According to the
law of Profeta (sometimes called Profeta's immunity), the children of
such parents may be born healthy, remain healthy, and be all their
lives proof against syphilis as if they had at one time suffered from
the disease. This immunity is explained on the ground that the tissue-
products of the virus pass into the fetal blood and protect the system
against future contamination ; just as vaccine virus protects against
small-pox. The mother of syphilitic children, who have inherited the
disease from a tainted father, may herself remain free from the disease.
This is known as Colles' immunity, and is accounted for by assuming
that the tissue-products of the virus have passed from the fetal into the
maternal circulation and protected the mother.
As a general rule, syphilis is contracted by impure sexual inter-
course, but it must not be forgotten that the disease is frequently
acquired or transferred by other avenues. It may be contracted by
kissing, by smoking an unclean pipe, or by drinking out of a contam-
inated vessel. The surgeon, accoucheur, or nurse runs a risk in the
THE DIAGNOSIS AND TREATMENT OF SYPHILIS. 649
discharge of professional duties, and there is danger every time an
abraded surface comes in contact with instruments or other articles
contaminated with the syphilitic virus.
The diagnosis of syphilis is greatly simplified by dividing the disease
into stages, as follows :
1. The stage of incubation. This is the period which intervenes
between the time of exposure to the virus and the first appearance of
the initial sore.
2. The period of primary symptoms, in which chancre and affections
of the adjacent glands appear.
3. This is a period of repose. It lasts about six weeks, and during
this time the virus is incubating for the secondary symptoms. It is
sometimes called the period of secondaiy incubation.
4. Secondary symptoms, characterized by mucous patches, erythem-
atous, pustular, papular, and tubercular affections of the skin. This
period may last from one to three years.
5. The secondary symptoms may subside, and under proper treat-
ment the patient may be apparently cured, but it is by no means cer-
tain that the varus is entirely exhausted. He must be kept under ob-
servation for a period varying from two to four years. During this
time his children, if any are born to him, are likely to be syphilitic.
At the end of the fourth year one of two points is settled — either that
he has been cured or that he has entered upon another stage of the
disease — viz. the period of tertiary syphilis, which is unlimited in dura-
tion. The bones now suffer, and we find periostitis, osteitis, nodes, etc.
Gummata are found in one or more parts of the body, and there are
tuberculo-ulcerous syphilides of the skin.
No two cases of syphilis are exactly alike, and yet the family like-
ness is marked in all. The whole category of syphilitic manifestations,
protean in their form and irregular in their clinical history, possess cer-
tain peculiarities that belong to no other class of eruptive diseases.
When called upon to differentiate the lesions peculiar to the secondary
or tertiary stage of this malady, no part of the body should escape
inspection. The closest scrutiny should be made of old scars, alopecia,
enlarged glands, gummata, mucous patches, condylomata of the genital
and anal regions, ulceration of the phar\mx, iritis, and macular eruptions.
The Primary Sore — Hard Chancre. — At the end of the period
of incubation, which is never before the tenth day and may be pro-
longed to or beyond the thirtieth, the " initial lesion," " primary sore,"
or " hard chancre " begins to appear. It is an abrasion, an erosion, or
a papule that subsequently breaks down and ulcerates. Its shape is
round or oval. Its edges are slanting and adherent to the tissue
beneath them. The discharge is scanty and serous unless the sore has
been irritated. Its base is indurated, but it must be borne in mind that
the peculiar induration which has earned for it the name of " hard
chancre " is caused by cell-proliferation, and is not fully developed
before the tenth to the fourteenth day. The chancre is painless.
Within a week the glands become indurated. The inflammation is
indolent, and there is no tendency to suppurate. The sore is usually
solitary ; if several lesions appear, they come simultaneously.
The dias:nosis between " hard " and " soft " chancre is of the utmost
650 SURGICAL DIAGNOSIS AND TREATMENT.
importance. A soft chancre or chancroid has a short period of incu-
bation ; it appears /// from tzvciity-four Jioiirs to eight days. Chancroid
makes its appearance as a pustule. Its shape is round or oval ; its
edges present the appearance of having been punched out and under-
mined; the discharge is creamy and puriform ; its base is soft and
supple, tender, and at times exquisitely painful upon pressure. The
ulcer follows the natural anatomical lines or folds of the integument.
It is frequently complicated with bubo and inclined to suppurate.
The following table presents the differential diagnosis between
chancre and chancroid :
Chancre. Chancroid.
Cause. — Syphilitic germ or virus. Inoculation by the secretion of chancroid.
Incitbation. — Ten to thirty days ; average First symptom makes its appearance in three
three weeks. to seven days. Sometimes within twenty-
four hours.
Nzcmber of Lesions. — Usually solitary ; when Usually more than one after appearing sue-
more than one, all appear at the same time. cessively, by auto-inoculation.
Color. — Dull, sometimes red or dirty white ; Dirty yellowish color, like wet chamois skin,
secretion serous and scanty, frequently Secretion purulent and profuse, not inclined
scales. to the formation of scales ; the surface is
always moist.
Subjective Syviptonis. — Pain usually absent ; Exquisitely tender, especially on pressure,
not much tenderness on pressure.
Indta-ation. — Base of ulcer hard and inelastic Base of ulcer pliable ; no induration,
by the tenth day.
Edges. — Sloping and adherent. Present the appearance of having been
punched out ; frequently undermined.
Glands. — Both sides indolent; not inclined More often one side affected and inclined to
to suppurate. suppurate. In about one-third of all cases
a bubo is present.
Treatment. — Apart from cleanliness, local Local applications the all-important treatment,
treatment is of no importance. Internal medication is of no use.
The chancre must be differentiated from herpes progenitalis,
balanitis, venereal warts, epithelioma, and chancroid.
The herpetic lesion differs from that of syphilis in its multiplicity
and in its vesicular and transitory nature, and, like balanitis, in yielding
quickly to treatment ; also, as in balanitis, there is no ulceration, no
induration, and no glandular complications.
Venereal warts differ from chancres in that they are more indurated,
seldom ulcerate, are not accompanied by adenopathy, and are more
persistent. They are rarely found in other than the progenital region.
Epithelioma usually occurs after middle life in both sexes, whereas
syphilis is more often observed in young adults, and the lesion of epi-
thelioma is usually far more persistent than that of syphilis, and is gen-
erally found in the glans penis, presenting the appearance of a flattened
papule, a shallow erosion, or a warty elevation. It may be accompanied
by induration and adenopathy, but is usually inactive and only affects
the glands in the advanced stage of the disease.
Treatment of CJiancroid. — There are two methods of treatment. The
first relies upon cleanliness and the local application of antiseptic rem-
edies. This is frequently all that is required to arrest the destructive
action of the peculiar microbe and the further progress of the lesion.
Many surgeons never omit, in any case, to adopt the second method,
cauterization, which aims to destroy at once the germs and convert the
THE DIAGNOSIS AND TREATMENT OF SYPHILIS. 65 1
chancroid into a healthy sore. It is quite necessary that all irregular
habits of life should be duly corrected, and when the lesion is serious
and other complications threaten, the recumbent position should be rig-
idly enforced. In simple cases, occurring in patients otherwise healthy
and robust, no internal medication is required. In other cases, that are
weakened by excesses or disease, it will be proper to administer tonics
and direct attention to all the details that will improve the general
health.
The antiseptic treatment of the disease consists in keeping the ulcer
thoroughly clean by washing it with soap and warm water, followed by
an irrigation of dilute peroxid of hydrogen, sublimate solution (i : 2000),
carbolic acid (i : 40), or the application of lint which has been previously
wet in either of the latter two. The ulcer should be completely cov-
ered, and in no case must it be allowed to lie in contact with the healthy
mucous membrane or skin, as the parts are sure to become infected and
new lesions are certain to appear. This precaution must be carefully
observed in females : the walls of the vagina and vulva should at all
times be separated by the interposition of lint or absorbent cotton pre-
viously wet with one of the above solutions. These should be changed
at intervals of two or three hours.
Many surgeons prefer to keep the ulcer thoroughly cleansed by fre-
quent ablutions of antiseptic solutions and apply to it a powder, consti-
tuting a dry method as opposed to the wet or moist dressing. For this
purpose iodoform, hydronaphthol, aristol, acetanilid, and calomel are val-
uable. Iodoform undoubtedly occupies the first place as the most potent
agent that can be applied ; its power to overcome the microbe of chan-
croid is second to none ; its chief objection is its odor : if, however, care
be taken in its application to prevent its falling on the clothing, scarcely
any odor will be noticed. A very good plan is to make an ethereal
solution and spray it on the ulcer ; the ether will speedily evaporate,
leaving a thin film. Care must be taken that the undermined edges are
thoroughly reached. When the floor of the chancroid loses its dirty
yellowish appearance and becomes red and filled with healthy granula-
tions, the application of iodoform may be omitted, and the use of mild
odorless antiseptics substituted.
For the purpose of cauterization the actual cautery or chemical
agents may be employed. The actual cautery is preferable if it is con-
venient ; if not, nitric acid or carbolic acid can be used. The ulcer
should be thoroughly cleansed and carefully dried ; a 4 to 8 per cent,
solution of cocain is then applied to the surface of the ulcer or a few
drops may be injected subcutaneously beneath the base. Care must
be observed that every part of the lesion is brought in contact with the
cautery. After cauterization, lead-water dressings are applied, and the
patient put to bed until the reaction has subsided. Cauterization is
becoming less frequently used than formerly ; it often fails to arrest the
progress of the lesion ; the sore assumes a fierce and obstinate aspect,
and the pain and soreness are greatly increased. Cauterization, there-
fore, as a routine practice should be condemned. In all cases where
the ulcer is intractable with pain, swelling, phimosis, and paraphimosis,
the parts should be submerged in hot boric-acid water for hours at a
time. In the female the vagina should be frequently and repeatedly
652 SURGICAL DIAGNOSIS AND TREATMENT.
irrigated with a saturated solution of boric acid as hot as can be borne.
In the treatment of phagedena, phimosis, and paraphimosis no more
potent and effectual remedy can be adopted than hot water ; hot sitz-
baths may be employed, the patient spending the greater part of his
time in the bath. The vitality of tlie microbe is destroyed by the per-
sistent use of water at a moderately high temperature.
Some authorities advise incision of the prepuce for the relief of phi-
mosis or paraphimosis. This procedure should not be adopted until
the measures already mentioned have been tried, as it is almost im-
possible with the greatest attention to antisepsis to prevent the infec-
tion of the wounds. Should an incision be made, the chancroid
should previously be cauterized, as also the wounds as soon as they
are made.
Bubo not infrequently complicates chancroid. It may be of an in-
dolent, non-suppurating character or it may assume the virulent type.
It is well to emplo)' the usual remedies to combat suppuration, as pres-
sure with a spica bandage, rest in the recumbent position, iodin exter-
nally or a solution of iodoform in collodion frequently applied to the
swelling. The proper strength is iodoform 13, collodion 15. Injec-
tions of various antiseptics into the bubo itself have been followed by
dangerous results, and are not usually effectual. When it becomes
obvious that suppuration has taken place or when further intervention
is ineffectual, free incision should be made with careful antiseptic pre-
cautions, all glandular tissue wholly or in part involved should be re-
moved, the parts curetted if necessary, washed with hot boric-acid solu-
tion, and dressed with iodoform gauze.
Treatment of chancre consists in cleanliness ; in the majority of cases
no other treatment is necessary. Small pieces of lint made moist by
dipping them in solutions of sublimate and frequently changed, calomel
lightly dusted upon the ulcer, unguentum hydrargyri, aristol, and iodo-
form are all appropriate. In women the labia should be well separated
by pledgets of lint. Buboes complicating chancres are best treated by
frequent ablutions of hot water, followed by the inunction of mercurial
ointment. The habits of the patient should be regulated to comply
with the strictest rules of hygiene. In general, it is best to withhold
specific medication until the appearance of secondary manifestations,
since the early exhibition of these remedies has a tendency to retard to
a remarkable degree the appearance of these lesions.
Syphilis has no respect for any of the tissues of the body : the in-
tegument, the bones, the viscera, and connective tissue are all liable to
become invaded.
The Secondary Stage. — We have seen that the period of primary
incubation occupies from ten to thirty days or more. The chancre and
its attendant glandular swellings have taken their course, and the period
of secondary incubation is going on. There is no stated period at which
the chancre disappears. It may persist until after the evolvement of
systemic symptoms or terminate earlier. It terminates in simple reso-
lution except in those cases which ulcerate, and in these a characteristic
scar remains.
The invasion of the different tissues of the body by the syphilitic
virus is very slow and insidious, and during the early part of the sec-
THE DIAGNOSIS AND TREATMENT OF SYPHILIS. 653
ondary incubation giv^es no evidence of its presence. During the latter
part, however, within a week or two before the eruption, the patient
exhibits not infrequently a sallow complexion, and still later a marked
degree of pallor. He complains of malaise and lassitude, loss of sleep
and appetite, and a depression of mind and body. He has pains in the
muscles and bones, and perhaps effusion into the knee- and elbow-joints.
Just preceding the eruption there is an elevation of temperature ; this
is the syphilitic fever. The temperature is rarely high unless the erup-
tion is to be of a pustular nature. It ranges from 101° to 103° F., some-
times 104° or 105° F. This fever endures for several days, possibly
for weeks. A short time before the eruption the superficial glands
become enlarged and constitute an important element in diagnosis.
The extent and general involvement of these glands are in proportion
to the severity or malignancy of the disease, and also to the suscepti-
bility of the patient to the influence of the poison. The glands most
frequently involved and conspicuous are the submaxillary, submental,
occipital, femoral, and the anterior and posterior auricular. These vary
in size from a pea to a small hickory-nut ; they are movable, indolent,
and painless. Within a few days a rash appears, usually, though not
always, in the form of roseola, and is frequently so mild that it is over-
looked by the patient and even by the medical attendant.
The lesions of secondary syphilis are inclined to be superficial and
confined to the integument; they are somewhat rapid in their develop-
ment and progress as compared with lesions of the tertiary stage. They
are also more symmetrical, show a more benign disposition, and are
more easily influenced by specific medication. This stage includes
those lesions of the skin that are described as erythematous, papular,
pustular, and vesicular syphilis.
The syphiloderm may be confounded with all other known affec-
tions of the skin. While they are not confined to any particular por-
tion of the integument, the different forms of eruptions exhibit a marked
preference for certain localities. On account of their close resemblance
to the non-specific affections of the skin they demand careful study and
consideration.
The following points should be observed : their color, situation, pig-
mentation, polymorphism, absence of subjective symptoms, grouping
and shape of lesion. No single case of syphilis will be likely to in-
clude all of these distinctive features, and neither of them, taken singly,
would justify a diagnosis of syphilis ; taken together, they constitute a
complete index to the character of the malady in question. They are
essentially chronic, and are not generally accompanied by even a mod-
erate degree of inflammation.
Color. — In their early stages they are of a bright-pink or pinkish-
red tint, but not so red as is common in exanthemata. The older they
become the more they fade, until they assume a brownish-red, copper,
or raw-ham color. Pressure upon the early lesions causes them to
disappear, but later, when they have acquired the copper color, it be-
comes permanent. It should, however, be remarked that the natural
complexion of the patient modifies to a great extent the appearance of
the lesion. In the blonde it is red, in the brunette it is brownish red,
and in persons who are broken down, pallid, and cachectic there is
654 SURGICAL DIAGNOSIS AND TREATMENT.
more of a li\'icl purple hue. Upon the lower limbs in nearly all cases
the color is darker than upon the trunk and upper extremities.
Location. — Syphilitic eruptions show a preference for certain parts
of the body where non-specific eruptions do not often develop. They
are common upon the scalp about its junction with the forehead, at the
angles of the mouth, upon the nose, about the anus and genitals, upon
the palms and soles, and in the groin.
Po/ftnorphisJii. — In non-specific eruptions of the skin there is usually
a uniformity in the type of the eruption. In syphilis it is quite common
to find er>'thematous, papular, and pustular lesions on different parts
of the body at the same time.
S?di/a-tirc Sjii/ptouis. — The lesions, owing to their indolent, chronic,
and non-inflammatory character, do not excite much distress. Pain
and itching are usually absent.
Mucous Patches. — On mucous membranes syphilis assumes a form
which is very characteristic. When a papule — that is, an inflammatory
swelling of the corium and papillae — occurs upon a mucous surface and
is subjected to constant moisture and warmth, the epithelium becomes
macerated and disappears. The surface occupied by the papule be-
comes broader and its color changes. Sometimes, as on the palate or
lips, the mucous patch has a whitish appearance, as if it had been
touched with nitrate of silver. In the skin it is red and shining. The
shape is circular or oval and the epidermis is thickened. The appear-
ance of mucous patches is such that when once seen they cannot be
mistaken for anything else.
The nails should always be examined in syphilis. Inflammation
around them occurs in two forms, the dry and the moist, and occasion-
ally results in their dropping off
Irregularity in the Evolution of Syphilis. — In many cases the
course, character, and duration are extremely mild ; the secondary
manifestations are so simple and yield so readily to treatment that this
form has been called " benign syphilis." In other cases from the com-
mencement of the initial lesion the progress of the disease is rapid, the
lesions develop precociously, the secondary stage is wanting, and the
tertiary stage appears instead. It is fierce and intractable ; its ravages
are frightful and hideous to observe. All efforts to arrest its onward
march are unav^ailing, and the unfortunate victim yields the palm to the
Mephisto of all diseases that afflict mankind.
Syphilides appear in two forms, the dry and the moist. In diagno-
sis the most common source of error is between syphilitic tubercles and
lupus vulgaris. The following table, from A)i American Text-Book of
Surgery, is valuable :
Tubercular Syphilide. Lupus Vulgaris.
Occurs chiefly among adults ; considerable Occurs commonly in young persons ; when in
infiltration of skin. adults there is often history of a similar
eruption in childhood.
Tubercles opaque and of deep brownish-red Not so marked. Tubercles often translucent
color. and lighter in color.
The characteristic ulcer produced in a month The same amount of ulceration would require
or two. several months, or even years, for its devel-
opment.
THE DIAGNOSIS AND TREATMENT OF SYPHILIS. 655
Tubercular Syphilide. Lupus Vulgaris.
Ulcers usually distinct. Ulcers apt to be confluent.
Ulcers deep and extensive. More superficial and involving smaller area.
Ulcers small, circular, and punched out. No regular form or perpendicular edges.
Secretion copious and sometimes oftensive. Secretion slight and inofiensive.
Crusts bulky and greenish. Crusts thin and dark-colored.
Scales irregular in shape and attachment. Scales arranged more regularly, attached in
the center and loosened at the edges.
Cicatrices soft, white, circular. Cicatrices distorted, irregular, puckered.
History and concomitant symptoms of syph- No history except as a coincidence.
ills.
Local treatment ineffective ; internal specific Eruption disappears only under very active
treatment effects a cure. lucal treatment, as curetting, or under the
influence of tuberculin.
The Tertiary Stage. — Tertiary lesions do not manifest them-
selves, as a rule, before the third or fourth year, and in a large pro-
portion of cases do not develop at all. Their early appearance
signifies a severe type of the malady. This stage includes those
lesions that are usually termed tubercular, bullous, ulcerative, and
gummatous syphilides. They are slow and indolent in their develop-
ment and course, deep-seated, intractable to treatment, show a lack of
symmetry, are scantily distributed, and are often terribly distinctive.
The lesions of the secondary stage are found to be superficial ; those
of the tertiary period are deep. To give them in detail would be
beyond the scope of this work, for they involve almost every organ
and tissue in the body, and have been referred to as these organs have
been discussed. A brief summary is all that can be given :
\. Tiibcratlm' syphilides are large and greatly hypertrophied papules,
and stand upon the borderland between the secondary and tertiary
stages. They are flattened pimples attended with a thickening of all
the tissues of the skin. They occur singly or in groups.
2. Giunniata are almost identical with tubercles, but have these dis-
tinctions : they go beyond the skin and involve the subcutaneous cellu-
lar tissue ; they make their appearance at any time between the first
and the thirtieth year after the appearance of the initial sore ; they
pass through four stages — viz. formation, softening, ulceration, and
repair.
3. Lesions of the Bones. — The forms of bone-disease comprise peri-
ostitis, osteo-periostitis, and osteo-myeiitis. The characteristics of syph-
ilitic bone-lesions are the following : they are painful ; the pain is worse
at night and the affected part is exquisitely sensitive to touch ; the dis-
ease responds readily to iodid of potassium. The bones commonly
affected are the tibia, ribs, sternum, clavicle, skull, and face-bones. The
disease most likely to be confounded with it is tubercular osteitis.
Syphilitic Osteitis. Tubercular Osteitis.
Location. — Common in the bones of the skull. Seldom attacks these bones.
History. — History of chancre and evidences History of tuberculosis, and manifestations in
of syphilis in other tissues. lungs, glands, or other organs.
Effects of Treatment. — Yields to antisyphi- Affected by no treatment except removal or
litics. injection with iodoform.
Course. — Seldom suppurates. Generally ends in suppuration.
4. Syphilis in the Testicles. — In the genitals of men we frequently
have the chancre, followed by gummatous deposits in the epididymis
656
SURGICAL DIAGNOSIS AND TREATMENT.
and core of one or both testes, the distinctly circumscribed indurated
mass being readily recognized by palpation. Syphilitic epididymitis is
to be differentiated from gonorrheal epididymitis by remembering that
syphilis usually attacks the globus major, while gonorrhea affects the
globus minor, and also from the history of a chancre in one and dis-
charge in the other. Sometimes in cases of urethral chancre it is hard
to get a correct historj^ as there would be a discharge from both, which
might, however, be differentiated by the microscope.
Tuberculosis of the testicle usually follows involvement of the pros-
tate, and tuberculous subjects are rarely syphilized. Syphilitic deposits
may sometimes be found in the corpora cavernosa, urethra, or base of
of the penis, but they are rare in these localities. Syphilitic orchitis is
a not infrequent accompaniment of late syphilis, and, as it comes on
insidiously, is often present without the patient's knowledge.
In the female syphilitic gummata are sometimes observed in the
vulva, and deposits or ulcers may be discovered in any part of the
genital tract, but are rarely found in the uterus, tubes, or ovaries.
The main points of difference between syphilitic orchitis, encephaloid
carcinoma of the testicle, and tubercular orchitis are brought out in the
following table, from An American Text-Book of Siirgciy :
Syphilitic Orchitis.
Syphilitic history.
Usually occurs at about twen-
ty-five or thirty years of
age.
Begins in the testicle.
Is situated primarily in the
connective tissue.
Tends to fibrous overgrowth.
Slow in its progress.
Skin of the scrotum rarely
involved.
Ulceration or suppuration
rare.
Fistulge uncommon.
A feeling of great weight,
with only such pain as re-
sults from dragging on the
cord.
Tumor very hard, uniform.
Skin of scrotum purplish, but
unaffected.
Of moderate size ; rarely ex-
ceeds twice its normal di-
ameter.
Painless on pressure.
Both testicles often affected.
Fungus rare.
Encephaloid Carcinoma
OF Testicle.
Tubercular Orchitis.
No history of any special con- Tubercular history.
dition.
Any age. Not often seen after thirty.
Begins in the body of the
organ.
Begins by the deposit of small
nodules in the seminiferous
tubules.
Tends to formation of patches
of softened, white, pulta-
ceous material.
Rapid in its course.
Skin of the scrotum finally
involved.
Ulceration and fungus com-
mon.
Fistuls; common.
Pain severe and lancinating
in advanced stages.
Begins in the epididymis.
Exists primarily in the tub-
ules.
Tends to fatty, caseous, or
purulent degeneration.
Slow in its progress.
Skin involved only just be-
fore the formation of ab-
scess.
Suppuration common.
Fistulse common.
Little pain.
Soft and fluctuating. At first hard, knotty, irregu-
lar.
Network of large veins over Skin congested, but otherwise
surface of tumor. unaffected.
Attains great size. Of moderate size.
Painless on pressure. Often painful on pressure.
Generally only one testicle Often both testicles affected.
affected.
Fungus always present in ad- Fungus common.
vanced stages.
THE DIAGNOSIS AND TREATMENT OF SYPHILIS. 6^/
Syphilitic Orchitis. ^'"''^Z'^T^.^.Sr'''"'^ Tubercular Orchitis.
No discharge or bleeding. Bleeds freely ; offensive dis- Not so apt to bleed ; discharge
charge. not so offensive.
Lasts many years, Rarely extends beyond twenty Lasts several years.
months.
Curable. Usually fatal. Generally incurable.
No involvement of inguinal Inguinal, iliac, and lumbar Usually no inflammation of
glands as a rule. glands and cord affected. glands.
Trcatvicnt. — It is better to wait in all cases until the appearance of
the secondary lesions before tr>'ing to administer specific treatment.
Although many excellent authorities advise the administration of mer-
cury as soon as the diagnosis is fully established, at the present day the
majority of authorities advise delay. Early treatment postpones the
appearance of the lesions, but does not modify their general character,
and it is thought that in some cases it increases their severity. The
experience of the past three or four centuries places mercury at the
head of the list of remedies on account of its potency in controlling
and subduing the ravages of this malady. From time to time many
medicines, mineral and vegetable, have been lauded as possessing supe-
rior efficacy, yet none of them have acquired the confidence of the
medical profession that mercury possesses.
At the beginning of treatment all hygienic measures should be
adopted to improve the general health and condition of the patient.
The use of tobacco, both smoking and chewing, should be interdicted,
as the habit seems to invite the development of lesions of the mucous
membrane of the mouth and throat. The teeth should receive careful
attention, and be placed in perfect condition by removing all accumula-
tions of tartar, filling cavities that may exist, and smoothing down rough
and jagged edges and points that may irritate the tongue and mucous
membrane of the cheeks.
All habits of intemperance and excess must be abandoned, and the
daily life of the patient made to correspond with the most advanced
rules contributory to health. Mercury may be introduced into the
system through different channels and by different methods — by hypo-
dermic injections, by the mouth, by inunction, or by fumigation.
Different preparations of the drug and different modes of adminis-
tration are advocated by individual authorities. Whatever method is
observed, it should be remembered that it is neither to be administered
too lavishly on the one hand, nor too niggardly on the other, and
always with careful observations as to its effects upon the system of
the patient and upon the lesions of the disease. Among the prepara-
tions of mercury that are employed are corrosive sublimate, calomel,
yellow and red oxide, biniodid, mercurial ointment, oleate, salicylate,
and many others. lodid of potassium is chiefly applicable to the later
stages of syphilis, and is not surpassed by mercury in its power and
efficacy to dissipate and resolve gummatous lesions. The iodids are
often extremely valuable in the treatment of syphilis when the patient
does not seem to tolerate the use of mercury. lodid of potassium is
more often used by the inexperienced in the treatment of the early
lesions, but in the hands of the expert it is reserved for the later trouble.
42
658 SURGICAL DIAGNOSIS AND TREATMENT.
In its administration it is well to prepare a solution of i ounce of the
drug to I ounce of water. The dosage must be regulated in accord-
ance with the severity of the demands of the case and the degree of
tolerance manifested by the patient. It is better to commence its use
by prescribing from 5 to 8 drops of this solution, well diluted, after
meals, gradually increasing the dosage by the addition of i drop a day
until 30, 40, or even 60 drops have been reached. If serious symptoms of
iodism ensue, its use must be abandoned or rather the dose diminished.
In urgent attacks of cephalalgia and meningitis and in osteo-periostitis
the dose must often be large, but abandoned or greatly diminished as
soon as relief is obtained.
The iodids are capable of producing the most satisfactory results in
properly selected cases. They often disagree with many patients, but
by careful administration of a graduated dose and by keeping the diet
bland and unirritating there are but {<:i\\ cases that cannot be coaxed
into tolerance. Their beneficent effect will well repay the patient and
gratify the surgeon for all the details and painstaking care that have
been observed in their exhibition. They will occasionally produce the
symptoms of iodism. The toxic effects of the iodids are frequently mani-
fested by a pronounced metallic taste in the mouth, all the symptoms
of acute coryza, eruptions on the skin resembling acne and urticaria,
-distention of the abdomen with gas, pain, and constipation. With
abandonment of the drug the toxic effects rapidly disappear. There
are, no doubt, rare and isolated cases that are so peculiarly susceptible
to the influence of iodids that their use must be avoided and some
preparation of mercury substituted.
Mercury may be introduced into the system by either the exter-
nal or the internal micthod. The external method employs inunction
and fumigation ; the internal method consists in the administration of
the drug by the mouth or its subcutaneous injection with the hypo-
dermic syringe. The method of internal use has been modified by many
syphilographers into different systems styled " continuous," continuous
tonic, and interrupted. The matter may be greatly simplified by ob-
serving the following directions, which if carefully followed will prevent
the development of any toxic effects. Calomel is not used very much
at the present time for internal administration, but is a ver>' excellent
preparation to be employed in fumigation, etc. Corrosive sublimate,
protoiodid, and the tannate are undoubtedly as suitable as anything that
can be selected. The " auld lang syne " doses are no longer in vogue.
The bichlorid may be given in doses of ^^ to |- gr. ; protoiodid, -^ to
\ gr. ; tannate, \ to i gr. As the malady to be treated is essentially a
chronic disease, it is obvious that the exhibition of remedies must be
prolonged ; therefore it is not proper to see how large a dose of mer-
cury the patient will tolerate at a given time, but to carefully determine
how large a dose he can take continuously and not affect his general
health, and at the same time prove curative. The student should be
impressed with the fact that he is treating an individual and not syph-
ilis alone, and that each individual is a law unto himself If the ad-
ministration of mercury by the mouth seems to disagree with the pa-
tient in doses that are sufficient to control the progress of the malady,
or if the case develops stomatitis or gastro-enteritis, it will be neces-
THE DIAGNOSIS AND TREATMENT OF SYPHILIS. 659
sary to resort to inunction, hypodermic injection of mercurials, or
fumigation.
When the disease has existed for several months, and just presents
itself for treatment, it is better to commence the use of inunction or
fumigation at once. Inunction consists in rubbing into the skin metal-
lic mercury or some form of it mixed with a fatty substance. It is
the oldest of all known methods, and is very potent in its results.
It relieves the alimentary tract from the frequent disagreeable effects
of mercury. The officinal blue ointment is a very reliable form ; the
dose to be employed should correspond to the size, weight, and general
condition of the patient; the patient should be directed to properly
cleanse the skin with warm water and soap ; from i to 3 scruples should
be rubbed in until it has disappeared. Any region of the body may be
selected. Should a dermatitis develop on the surface to which the in-
unction has been applied, another part may be selected. While this
process is being followed the diet should be generous and nourishing.
Iron, quinin, and strychnin may be given with very beneficial effects,
and especially in those cases that are prone to take on the anemia,
pallor, and weakness peculiar to the condition known as syphilitic
cachexia.
Fumigation is, without doubt, the most speedy and efficacious
method that can be employed in cases of emergency. It must be
used with considerable care. The elaborate apparatus found in bath-
houses is by no means necessary. All that is essential is a spirit
lamp ; directly over the flame a metallic plate of tin or copper is placed,
holding upon its surface from 40 to 60 grains of calomel and cin-
nabar in the proportion of 20 parts of the former to 40 of the latter ;
a kettleful of boiling hot water is placed by its side ; the patient is
stripped of all clothing and placed upon a chair in an improvised tent
made of a blanket or of bed-ticking, which is made to fit the neck
closely, leaving the head exposed. About half an hour is usually
necessary for a bath, and it should not be repeated oftener than every
second or third day. The effect of the bath in some cases is to pro-
duce great weakness, and a temporary resort to alcoholic stimulants
may become necessary to avert a profound feeling of faintness. The
bath should never be giv^en immediately after eating, but preferably
before retiring at night. Some patients do not seem to tolerate the
baths ; the depressing effect is often caused by using too much of the
steam vapor. From ten to twenty baths are usually necessar}^ to pro-
duce satisfactory results.
Hypodermic injections of the soluble and insoluble salts of mercury
are recommended by some authorities. The advocates of this method
claim for it rapidity of effect : it relieves the stomach and digestive
tract ; it admits of more perfect accuracy in dose ; it can be employed
in all stages of the malady ; it is followed by but few relapses ; it is
very simple, cleanly, and inexpensive. The injections are made every
second or third day, and of the following solution : Hydrarg. chlor. cor-
ros., gr. j ; glycerin, aqua dest., aa. oj. Of this inject 10 minims. The
toxic effects of the drug are often speedily developed, and saliv^ation
may be produced at the second or third injection. Abscesses, boils,
nodes, and sloughing of the tissues frequently follow this form of treat-
66o SURGICAL DIAGNOSIS AND TREATMENT.
mcnt. The strictest antiseptic precautions in all details must be ob-
served in adopting this method.
Finally, syphilis is a disease that requires prolonged treatment. If
it is treated as it should be, the patient must be under the medical
attendant's care for two and a half or three years. As soon as a diag-
nosis has been made at the beginning of treatment, the patient should
be made acquainted with the seriousness of his trouble. It is usually
not necessary to say much regarding the horrors of syphilis : he
has undoubtedly already an exaggerated opinion as to the rav-
ages that are alDout to overwhelm him. No class of cases requires
so much good judgment and discretion in their treatment as the vene-
real affections, and especially sj^philis. While we are warranted in en-
couraging the patient with hope and a satisfactory prognosis in the
great majority of cases, we must not forget to impress upon his mind
that it not infrequently exhibits a very irregular course, and cases that
are apparently simple and mild, if neglected or abandoned, may manifest
the severest features of the disease. He should be informed that he is
not to marry for six months after the disappearance of the lesions, and
only then if he has at the same time been under specific treatment for
two or three years.
Hereditary Syphilis. — In the great majority of cases the disease
is ifliherited from the mother. Women who have contracted syphilis,
and while passing through its early and active stages have become preg-
nant, are rarely able to carry the products of conception to full term ;
every pregnancy results in abortion until the disease wanes in its sever-
ity. The virus loses its intensity and potency, and becomes so attenu-
ated as to exert no longer its influence upon the viability of the fetus. A
\Qry large percentage of the infants of syphilitic mothers are dead, or
if viable at birth die soon afterward. Some live on to early childhood,
a few beyond the age of puberty. As a general rule, it may be regarded
as a fatal disease. At birth an infant may present the manifestations
of syphilis and speedily succumb to its deadly influence. In other
cases the infarrt at birth may look as plump, fresh, and vigorous as
babies usually do, but between the first and third month it begins to
show signs of failing health ; its appetite fails, it loses flesh, the skin
becomes sallow ; it is restless, loses sleep, and is feverish. Following
these symptoms there appears a rash, the syphilitic roseola ; it may be
only a mild efflorescence that is mistaken for " red gum " or " undue
heat," and it may be overlooked, or may develop an unmistakable form
of eruption, the macular syphilides, the lesions being bright and red
with tendency to desquamate. The color of the eruption is often a dirty
brown. At this time also coryza develops : the discharge is at first of
a serous nature, but becomes purulent and bloody ; it is offensive in its
odor, excoriates the lip and nostrils, interferes with breathing, and con-
stitutes the " snuffles." The early manifestations of hereditary syphilis
are usually confined to the skin, and consist of the erythematous, papu-
lar, pustular, and sometimes tubercular forms. Bullous lesions quite
often appear, and are described as syphilitic pemphigus ; they always
indicate a very serious and grave condition, and rarely if ever improve
under treatment. Papules of a moist character are found at the cor-
ners of the mouth, upon the genitalia and anal region. Gummatous
THE DIAGNOSIS AND TREATMENT OF SYPHILIS. 66 1
deposits, ulcers, furuncles, and abscesses are frequent. Should the in-
fant survive the early stage and live to attain childhood, the bones may
become involved. Those most frequently attacked are the tibia, ulna,
radius, femur, and bones of the skull. There is in the early months
often a swelling of the phalanges and the metatarsal and metacarpal
bones, constituting dactylitis syphilitica. Children who possess the
syphilitic taint are liable to attacks of interstitial keratitis, purulent
discharges from the ear persistent and intractable. The teeth of sec-
ond dentition present singular markings that were first pointed out by
Mr. Hutchinson as presenting conclusive evidence of the disease. The
upper central incisors are the test teeth. When first cut they are short,
narrow, and very thin. After a time a crescentic portion from the
edges breaks away, leaving a broad, shallow notch. The two teeth
often stand widely apart, but sometimes converge. While he regards
the markings of the teeth as of great value in the late manifestations
of the disease, there are other signs which greatly aid in establishing a
diagnosis — viz. sunken bridge of the nose, prominent frontal eminences,
scars at the corners of the mouth, silky softness of the skin with ab-
sence of color, and a history of past attacks of interstitial keratitis.
This disease usually affects tjoth eyes and causes very great impair-
ment of sight, lasting over several months. It then clears away, leav-
ing the corneae a little cloudy ; afterward there remains a steel-gray
luster on the iris. A peculiar form of phagedenic ulceration, some-
times erroneously called lupus, may affect any part, but is often seen
upon the nose. The disease shows itself in the bones in the form of
periosteal nodes. Mucous patches, as in acquired syphilis, affect the
mouth and throat ; the nails are frequently affected, and there may be
alopecia, both transient and permanent. Care must be taken in the
diagnosis of syphilitic bone-disease that it is not confounded with
rickets. In rickets the shafts of the bones become thin and are not
enlarged as in syphilis ; there are not the characteristic nodes ; the fon-
tanelles are open and are not prematurely closed by the development
of osteophytes. In rickets the bones are more flexible than in syphilis.
Should the patient surviv^e the period of infancy, there may be a
complete absence of syphilitic manifestations until the age of puberty,
when they suddenly reappear.
Hereditary syphilis produces arrest of development : the patients
look younger than they really are, and generally these subjects are
far below the average in physical and mental power. In females there
is little or no development of the mammae, menstruation is delayed,
the hair in the axilla and on the mons veneris is very scanty ; the joints,
nervous system, and viscera are frequently affected. To present a
typical picture of a patient afflicted with hereditary syphilis the words
of Cauganeux are to the point : " Had I in a few words to present the
ideal clinical type of late hereditary syphilis, I should select a young
girl eighteen or twenty years old, whose eyes should present traces of
interstitial keratitis ; the teeth should be eroded and crescentically
notched, at the same time they should be small and irregular; the
hearing should be partially or totally lost in consequence of frequent
attacks of otorrhea ; the genitals, possessing all the attributes of vir-
ginity, should be small, the mons veneris and axillae smooth, the
662 SURGICAL DIAGNOSIS AND TREATMENT.
mammjE without prominence, and menstruation scarcely established.
Add to these all the tertiary lesions you please and you will have
before you a complete picture of hereditary syphilis. To the triology
of Hutchinson, keratitis, defective incisors, otorrhea, I propose to add
two other signs — general congenital atrophy and general arrest of
development."
Treatment of Hereditary Syphilis. — The treatment of hereditary
syphilis should not begin /;/ ntero, as indicated by some writers. Only
when the diagnosis has been actually and undeniably established is it
quite proper to administer specific treatment to the mother, and thus
modify the intensity of the virus as it relates to the fetus. For this
purpose it is better to rely upon inunction. When the child is born
and is known to be affected inunction may also be adopted. The skin
of the infant is very sensitive, and care must be observed that dermatitis
does not develop. The flannel binder that is applied to the belly may
be used for the purpose of inunction. From lo to 20 grains of the
officinal mercurial ointment, with one or two scruples of vaselin, may
be smeared upon the bandage ; the natural movements of the child
will produce the necessary friction. Baths may be ordered daily of
corrosive sublimate, 10 grains to a pailful of warm water, allowing the
infant to remain in the bath from ten to fifteen minutes, after which it
is carefully wiped and dried. Should there be present in the folds of
the neck or about the genitals and anus moist papules, they may be
dusted with equal parts of calomel and boric acid. Especial care
should be observed that the skin is kept scrupulously clean.
Keyes advises the use of corrosive sublimate internally, h grain to
6 ounces of water ; of this a teaspoonful may be given hourly for the
first day, the second day every two hours, the third day every three
hours, or at longer intervals should it seem to disagree. Should the
babe maintain its weight and seem to thrive, the treatment may be con-
tinued under careful observation ; if it emaciates and grows pale, the
mercurial treatment must be diminished or withheld for a time. lodid
of potassium should not be administered to a young infant, as it will
inevitably disagree with the function of digestion and interfere with
nutrition. Later on, during the manifestations of the disease in child-
hood, it will exert a beneficent influence if prescribed in judicious doses
and with the ordinary care that should always be observed in the ad-
ministration of this drug. Local lesions should receive the topical
applications that are advised in the acquired form. The nutrition of
the infant or child should be maintained by the selection of proper food
that can be easily digested and thoroughly assimilated. Infants will not
do well when bottle-fed, and the mother's breast is always to be recom-
mended in preference to any other means of nourishment.
THE DIAGNOSIS AND TREATMENT OF TUMORS. 663
CHAPTER XIII.
THE DIAGNOSIS AND TREATMENT OF TUMORS.
It is perfectly natural for the patient and surgeon to divide all
tumors into two great classes — benign and malignant. The one class
means simple inconvenience ; the other means terrible and prolonged
suffering. One implies hope, the other despair. A benign or inno-
cent tumor has the following characteristics : It does not produce pain
except by pressure ; it generally has a capsule beyond which it does
not spread, and if it is diffuse it never infiltrates the surrounding tissues ;
it never spreads to the lymphatic glands ; if once removed, it never
returns ; it never endangers life except when by its size it presses upon
vital organs.
A malignant tumor is very different. While the benign or innocent
growth is attended with little or no pain, the malignant tumor, as a rule,
condemns its victim to a life of anguish ; it is not confined within a
capsule, but infiltrates the surrounding tissues ; it affects the lymphatic
glands ; it disseminates — that is, breaks out in distant organs ; it is
almost sure to return after removal ; except in the rare cases in which the
disease can be totally removed by operation the termination is death.
In the examination of a given tumor the first inquiry will relate to
the history of the growth. Is it congenital or acquired ? Is it growing,
receding, or stationary? Is it idiopathic or the result of an injury?
After obtaining a history the tumor may be examined by inspection
and palpation. The position of the growth should be noted, and the
structure to which it is attached, as skin, fascia, muscle, periosteum, or
bone. Is it movable or fixed ? Is its outline sharply defined, or does
it gradually shade off into the neighboring parts ? What is its con-
sistence ? Is it either hard, soft, firm, gelatinous, or fluctuating? Is it
smooth or lobulated ? The condition of the neighboring lymphatic
glands should next receive attention, and any enlargement should be
carefully noted.
Many tumors have already been considered under the special organs ;
what follows is a brief account of the more common growths and their
characteristics. It is often impossible to decide the nature of a neoplasm
before its removal ; all we can undertake to say is that the growth is one
which should be removed by operation, leaving its histological cha-
racters to be afterward determined by the use of the microscope.
Connective-tissue Tumors. — Of benign tumors the most com-
mon are lipomata, fibromata, myxomata, chondromata, osteomata,
gliomata, neuromata, angeiomata, lymphangeiomata, and myomata.
Lipomata, or fatty tumors, are found, as a rule, upon the trunk and
the parts of the limbs nearest to the trunk. They are made up of fat, and
are the most common of all neoplasms. Middle life is the period most
liable, as in most persons at that time the body shows a tendency to
the formation of fat. Fatty tumors are classified according to the posi-
tions they occupy as subcutaneous, subserous, submucous, subsynovial,
intermuscular, intramuscular, periosteal, and meningeal. Lipomata by
their weight frequently change their position. Fig. 273 represents a
664
SURGICAL DIAGNOSIS AND TREATMENT.
growth which began a httlc to the right of the umbihcus, but grad-
ually sank to the scrotum, distending the latter enormously ; the mass
hung down to a point midway between the knees and ankles. It was
successfully removed by Dr. Phelps of Hawarden, Iowa, to whom the
writer is indebted for a photograph of the case.
The subcutaneous lipomata are easily recognized by their being
lobulated, diffuse, and closely connected with the skin. When the
skin overlying the tumor is raised it becomes dimpled, owing to the
fasciculi of connective tissue which pass between it and the tumor. The
deeper tumors are most difficult of
recognition. A fatty tumor con-
nected with the periosteum of a
long bone closely resembles a sar-
coma. It grows more slowly, how-
ever, and if circumscribed has few
of the characters of sarcoma. In
the groin it may simulate abscess or
hernia. Abscess is preceded by a
history of suppuration, and hernia
has its characteristic positions and
an impulse on coughing. In the ab-
dominal cavity all we can say is that
a tumor is present, but its real cha-
racter must be determined after re-
moval.
Treatment. — The removal of fatty
tumors is attended with littledifficulty
or risk except when the growth is in
the abdomen.
Fibromata, or fibrous tumors,
are composed of fully-developed
fibrous tissue and form dense cir-
cumscribed masses, sometimes lobu-
lated, sometimes uniform in outline
(Fig. 274). When connected with
mucous membrane they constitute
a large proportion of the polypoid
growths usually met with. These
tumors occur wherever connective
tissue is found, and may therefore be
met with in any part of the body.
They are hard, freely movable, elas-
tic, and heavy. Their most common situations are the uterus, skin,
fascia, capsules of the joints, the synovial fringes, periosteum, nose,
gums, and nerves. The simple fibroma is composed of bundles of
wavy fibrous tissue ; the fibers are long and fully developed. In the
growing points the immature cells may be seen undergoing transfor-
mation into fibers. In fibro-sarcomata the cell-elements predominate,
and they do not become fully developed into perfect fibers.
A peculiar form of fibroma which is met with in the corium or
subcutaneous tissue is known as subcutaneous painful tubercle. It is
Fig. 273. — Lipoma commencing to the
right of umbilicus and gradually changing
its position by gravitation (from a photo-
graph in the collection of Dr. Phelps, Ha-
warden, Iowa).
THE DIAGNOSIS AND TREATMENT OF TUMORS. 665
commonly met with in the lower extremities, and more frequently in
women than in men. It is sometimes exceedingly painful, but in size
is seldom larger than a pea.
Molluscum fibrosum is a remarkable condition in which the skin
and subcutaneous tissue become the seat of enormous fibrous growths,
causing either numerous small tumors or a diffuse neoplasm which
hangs in folds about the body. Its cause is obscure.
Chondxomata, or cartilage-tumors, and osteoraata, have been con-
sidered in connection with Diseases of Bone.
Myxomata are tumors in which mucin is the preponderating ele-
ment, and consist of connective tissue as a framework in the meshes
of which a fluid is contained that is almost identical with Wharton's
jelly of the umbilical cord. These growths occur as nasal and aural,
rectal, and some forms of uterine polypi, cutaneous myxomata, and
neuro-myxomata ; their appearance is so characteristic that diagnosis
is not difficult.
Myo-fibromata are morbid growths composed of muscular and
Fig. 274. — Fibroma (from a photograph in the collection of l>r. Strickler).
fibrous tissue combined. The muscle-fibers are of the unstriped
variety and occur in closely interlacing bundles. Many uterine tumors
fall under this class.
Angeiomata, or vascular tumors, are composed of arteries, veins,
or capillaries, or of cavernous spaces containing blood.
Gliomata are tumors having about the same consistence as the
cortical substance of the brain, and are found in the central nervous
system only. They have no characteristic diagnostic symptoms apart
from other brain or spinal tumors.
Neuromata are composed of nerve-filaments or tissue, but the term
is often applied to neoplasms growing upon nerves, no matter what
their histological characters may be. A common form of neuroma is
the bulb which forms upon a divided nerve after amputation, and which
is often exceedingly painful. It seems to be produced by the nerve-
fibers doubhng back upon themselves and forming a tortuous mass.
666 SURGICAL DIAGNOSIS AND TREATMENT.
In the treatment care should be taken to form a flap of the nerve-
sheath so as to cover in the divided end of the nerve after cutting away
the tumor.
Sarcomata are composed of embryonic connective tissue, the cell-
elements largely preponderating over the intercellular substance. A
convenient classification of sarcomatous tumors is based upon the
shape and disposition of the cells, and is as follows: i. Round-celled
sarcoma ; 2. Lymph-sarcoma (resembling lymphatic glands) ; 3. Spin-
dle-celled sarcoma ; 4. Myeloid sarcoma (resembling the red marrow
of bones); 5. Alveolar sarcoma; 6. Melano-sarcoma.
Sarcomata are found wherever there is connective tissue ; hence we
look for them in connection with fascia, subcutaneous cellular tissue,
periosteum, intermuscular septa, marrow of bone, the ovary, the testi-
cles, occasionally in the brain, and rarely in the spinal cord and nerves.
They first make their appearance as nodules, single or multiple ; they
are usually firm, but may be soft. They have one remarkable cha-
racteristic, and that is the rapidity of their growth, and this dis-
tinguishes them from all other tumors. They are frequently observed
after injuries. It is not uncommon to see the disease occurring in a
strong young man who several months previously had received a blow
or fractured a bone. Cicatrices are sometimes the seat of these tumors.
They are rarest in children, rare between ten and twenty years, most
frequent in middle life, and rarer, again, in old age. Except when located
in or on a nerve-trunk sarcomata are usually painless until they begin to
ulcerate. As a rule, the softer the tumor the more rapid is its growth
and the worse the prognosis. Sarcomata, except in their early stages,
have no capsule. They rapidly infiltrate the fibrous tissue with which
they are connected, and give the tumor a diffuse character. In addi-
tion to spreading by infiltration, they are liable at any time to reproduce
themselves in distant organs, especially the lung. They do not spread
to neighboring lymphatic glands, and this constitutes one of the main
differences between them and carcinomatous tumors.
The treatment is complete extirpation when this is possible. If there
is not a reasonable prospect of getting away the whole of the diseased
structure, it is useless to operate.
Bpithelial Tumors. — In this type of tumors epithelium is the
distinguishing and essential feature, as connective tissue is in the
growths we have been considering.
"Warts. — The simplest form of epithelial growth is the wart or
papilloma. It is an outgrowth from an epithelial surface, and is com-
posed of an axis of fibrous tissue surmounted by epithelium and con-
taining blood-vessels. Warts are common on the hands — especially of
children, who do not keep their skin as clean as they should — the
anus, the glans penis, the labia, and other parts which are subjected to
irritating discharges, such as gonorrhea.
Villous papillomata are warty growths arising from mucous mem-
brane, and especially that of the bladder.
Intra-cystic Papillomata. — Warty growths are found upon the
lining membrane of certain cysts — e. g. cysts of the mammary gland
and cysts of the paraoophoron and Gartner's duct, and in cysts of the
thyroid glands.
THE DIAGNOSIS AND TREATMENT OF TUMORS.
667
Psammomata are warts found only in the pia mater of the brain
and spinal cord.
Epithelioma. — As long as the epithelium is limited by the base-
ment-membrane the growth falls within the category of warts ; when
the epithelium passes beyond this and infiltrates the subjacent con-
nective tissue, it is an epithelioma. The most common situation of this
variety of morbid growths is at the junction of skin and mucous mem-
brane ; hence we find them on the lip, at the verge of the anus, and on
the prepuce. They may also occur on any part of the skin, and are
more apt to appear upon scar-tissue. The first appearance of an epi-
thelioma is a fissure, a wart, or a nodule on the cutaneous or mucous
surface.
The disease may remain stationary for months or even years, but
sooner or later ulceration takes place and may involve a considerable
area (Fig. 275). The characters of the ulcer must be closely studied.
Fig. 275. — Epithelioma of the knee (from a photograph in the collection of Dr. Strickler, New
Ulm, Minn.).
Its base and margins are indurated, and may stand up as a per-
pendicular wall ; the surrounding skin is not inflamed ; the surface of
the ulcer is warty or like a cauliflower or excavated ; it has a foul, fetid
discharge containing sloughs of tissue. The lymphatic glands in the
neighborhood sooner or later become enlarged. In some cases a
tumor of considerable size is formed. A typical epithelioma, and the
668
SIRGICAL DIAGNOSIS AND TREATMENT.
most common of all, is that found in the lower lip of men (see Epithe-
lioma of the Lip). Epithelioma is very rare under thirty years of
age, the great majority of cases occurring between forty and seventy.
Adenomata. — These tumors are composed of gland-tissue, but dif-
fer from normal gland-structure by their failure to produce the secre-
tion peculiar to the gland which they resemble. The ovary, mamma,
and thyroid are the glands most commonly affected. In the intestine
a small adenoma may cause intussusception. They are not encapsuled,
do not invade the surrounding tissues, do not affect the neighboring
lymphatic glands, nor produce secondary deposits. They occur in
young persons, and are always found in connection with a secreting
gland. Upon these characteristics we must rely to differentiate ade-
nomata from other tumors. They are not dangerous to life, and usually
call for removal on account of the pressure-symptoms to which they
gi\'e rise.
Carcinomata, or cancers, are tumors of pronounced malignancy
(Fig. 276). They have no capsules, but infiltrate the neighboring
Fig. 276. — Medullary cancer : recurrence six months after removal of the eye (from a photo-
graph in the collection of Dr. Lincoln).
tissues, and at a comparatively early period spread to neighboring
lymphatic glands. Every part of the body which has secreting
glands is liable to carcinoma. The most common situations are the
mammae, the glands of the cervix utero, the prostate. It is rare before
the age of twenty-five, increasing in frequency with each decade there-
after.
Although the division of cancer into scirrhus, encephaloid, and col-
DISEASES AND INJURIES OF THE NECK.
669
loid is not a good classification from a pathological standpoint, it is
convenient clinically.
The differential diagnosis between encephaloid, scirrhus, and sar-
coma is thus summarized by Gross :
Encephaloid.
The tumor is soft and elastic,
but not uniformly.
It grows rapidly, and soon
acquires a large bulk, per-
haps ultimately attaining the
volume of an adult's head.
The pain is slight and eiTatic
until ulceration begins,
when it becomes more
severe and fixed.
There is always marked en-
largement of the subcutane-
ous veins.
The ulcer is foul and fungous,
with thin, undermined, and
livid edges, and is subject
to frequent and copious
hemorrhage.
There is generally early lym-
phatic involvement.
Occurs at all periods of life.
Is most frequent in the eye,
testicle, mamma, lymphatic
glands, bones, skin, and
cellular tissue.
The disease usually terminates
fatally in from nine to twelve
months.
Scirrhus.
Uniformly hard and inelastic,
feeling like a marble be-
neath the skin.
Growth is slow and bulk com-
paratively small, the tumor
rarely, even in the worst
cases, exceeding the vol-
ume of a large fist.
The pain begins early, is dis-
tinctly localized, and is of a
sharp, darting, burning, or
lancinating character.
In scirrhus these vessels re-
tain their natural size or
are only slightly enlarged.
The ulcer is encrusted with
spoiled lymph, and has
steep, abrupt edges, look-
ing as if it had been scooped
out of the part ; bleeding
little and seldom.
Usually not until late, or
shortly before ulceration
occurs.
Seldom before the
forty-five.
ige
of
Never occurs in the eye and
testicle, and rarely in the
bones, skin, and lymphatic
glands.
Seldom sooner than eighteen
months or two years.
Sarcoma.
May be firm, tense, and elas-
tic ; generally uniformly soft
and apparently fluctuating.
May remain stationary or
nearly so for many years;
awakened into activity, it
progresses more rapidly
than encephaloid, and may
attain an enormous volume
in a short time.
No pain until ulceration sets
in, and even then usually
insignificant.
The subcutaneous veins only
slightly, if at all, enlarged.
Tendency to ulcerate slight
and late in the disease, the
sore being superficial and
not subject to hemorrhage.
Singularly free from lymph-
atic involvement, or, if the
glands are affected at all,
they become so quite late.
Generally before forty, and
most commonly between
that age and twenty.
Always begins in the connec-
tive tissues, particularly sar-
coma of the extremities;
most common in skin, peri-
osteum, and bone ; infre-
quent in lymphatic and se-
creting glandular organs.
No reliable data ; patients,
however, often survive
many years, even after
repeated extirpation.
CHAPTER XIV.
DISEASES AND INJURIES OF THE NECK.
Congenital Malformations. — These, though not very common,
are seen from time to time, and include cysts and fistula; due to imper-
fect development of the branchial clefts.
Branchial cysts may be situated at the base of the tongue, con-
stituting one kind of ranula.
Branchial cysts in the neck may be divided into four groups :
{(I) dermoid cysts, {b) cystic hygroma, (<:) simple cyst or hydrocele of
the neck, and [d) malignant cyst.
6/0 SURGICAL DIAGNOSIS AND TREATMENT.
The dermoid cysts are usually smaller and firmer, and are to be
distinguished from the other varieties by the absence of fluctuation.
Cystic hygroma is a collection of cysts in a bed of fibrous tissue.
This cystic tumor often attains a large size and has a very irregular
outline. The irregular surface is the main diagnostic feature.
Simple cysts also often attain a large size. They have a smooth
surface, and if tense feel almost solid ; otherwise fluctuation ma)' be
elicited.
Malig-nant cysts are extremely difficult to diagnose, and are gen-
erally mistaken for abscesses ; e\-en after operation the diagnosis is
often doubtful. The manner in which the wound breaks down and the
rapid infiltration of surrounding tissues soon render painfull}' evident
what the surgeon has to deal with.
Treatment. — Dermoid c}'sts should be removed in toto, and, as a
rule, this can be done without difficulty. The complete removal of
simple cysts or cystic hygromata is usually a somewhat serious under-
taking on account of their thin walls and intimate relation to surround-
ing structures. Incision and drainage are preferable. Operations on
malignant cysts are usually hopeless, as they almost constantly recur.
However, their removal has sometimes to be undertaken for relief of
pain, and is exceedingly difficult on account of the manner in which
they surround and infiltrate the sheaths of the vessels and nerves.
Branchial fistulse are situated along the edges of the sterno-
mastoid muscles and may communicate with the pharynx. Their
situation serves to distinguish them from tracheal fistula;, which are
situated mesially.
Treatment^ when desirable, must be directed to exciting granulation
and consequent adhesion at the distal extremity of the fistula, avoiding
mere occlusion of the external orifice.
Cellulitis of the neck may prove a most serious condition,
depending on its position with regard to the layers of fascia, and also
on the extent to which it spreads. For instance, if deep enough it
may produce dangerous dyspnea by pressure on the trachea, or it may
produce dangerous pressure on the other important structures in the
neck, or it may extend to the mediastinum or axilla. A special form
of cellulitis of the neck is the submaxillar}- form, better known as
Ludwig's angina. In this condition the swelling around the submax-
illary gland encroaches so much on the floor of the mouth that there is
great difficulty in swallowing or breathing. As in other forms of an-
gina, there is great depression. The disease often proves fatal, some-
times gradually, sometimes from edema of the glottis, suddenly.
Ti'catnicnt. — Incision is of course the correct procedure in every
case, and even when there is so much induration that the diagnosis is
not absolutely certain, one will err on the safe side in making a diag-
nostic opening. The incision should not be deep, and should be per-
formed after the method of Hilton ; that is, make a small opening and
burrow in the cellular tissue w'ith a pair of closed forceps, and when
pus is found exuding alongside the blades, the}^ can be opened to allow
admission of the exploring finger. After evacuation of the pus a
counter-opening may be made if necessar}' to establish drainage.
Abscesses of the neck may arise in connection with carious
DISEASES AND INJURIES OF THE NECK. 67 1
teeth, as a periadenitis in connection with scrofulous glands or in con-
nection with necrosis of the lower jaw or cartilage of the larynx.
These abscesses are to be treated on general principles.
Cicatrices the result of burns, producing one form of wry-neck, are
to be treated as cicatrices elsewhere.
Injuries of the Neck.
Contusions of the neck may cause spasm of the glottis, which
may result in death unless tracheotomy be performed, or there may be
fracture of the hyoid bone or cartilage of the larynx, and subsequent
subcutaneous emphysema or injuries to the floor of the mouth, with
difficult respiration and deglutition.
The treatment consists in keeping the parts at rest as far as possible
by forbidding the patient to talk and by the use of the nasal tubes.
Evaporating lotions may also be applied to the neck.
Wounds of the Neck. — Cut-throat may serve as an example of
wounds of the neck. Unless the individual is left-handed the cut will
be found to extend obliquely from above downward and from left to
right across the middle line. The wound may extend into any part
of the larynx or trachea, and even to the esophagus, without injuring
the carotids, which lie somewhat deeply and are protected by the
sterno-mastoid muscles.
The dangers resulting from cut-throat are hemorrhage, entrance of
air into veins, septic pneumonia, and septicemia.
Treatment. — In every case the patient must be carefully watched
during treatment, lest he renew his attempts at self-destruction. All
hemorrhage must be carefully arrested, and if there appears to be
dyspnea, it will be well to ensure safety by the introduction of a trache-
otomy-tube. Divided structures should be sutured where necessary.
If the patient is much collapsed from hemorrhage, transfusion of nor-
mal saline solution will be indicated. If the skin-wound be allowed to
close before the tracheal wound, we will have emphysema of the neck.
The remedy is obvious : keep the skin-wound open till the trachea has
been closed by nature or by art.
Tumors of the Neck.
Tumors of the neck, if they reach any considerable size, are apt to
produce serious symptoms from pressure on the many important struc-
tures in the region, and if malignant the danger is increased immensely,
for the difficulty of removing them without injury to the structures is
great, and in many cases cannot be overcome.
Glandular Tumors. — These are by far the most common of all
tumors of the neck. They may be divided into {a) syphilitic, {b) tuber-
cular, and (c) malignant gland-disease.
Syphilitic enlarg-ement of the glands of the neck, especially of the
glandulae concatenat^e under the posterior edge of the sterno-mastoid
muscles, is very common in secondary syphilis, and one of its most
distinctive features. Glands thus affected seldom or never suppurate,
and may be treated by mercury given internally or by inunction.
Tubercular glands are very common, and have usually as an
672
SURGICAL DIAGNOSIS AND TREATMENT.
exciting cause irritation cxtendini^ from some other part ; for example,
from a carious tooth or from eczema of the scalp. At first they are
firm and hard, freely movable, and can easily be shelled out, but later
periadenitis develops, and their removal is rendered more difficult, or
they may caseate or suppurate and give rise to an abscess.
The treatment is removal, and this is one of the most common and
often most difficult operations in surgery, frequently involving a tedious
dissection and exposure of the carotid sheath. The complexity and num-
ber of the veins in this region also add considerably to the difficulty
and danger. Even though a divided vein be ligatured, embolism following
detachment of a thrombus is a danger which must not be overlooked.
When the glands have become adherent it is well to scrape the
capsule in addition. Abscesses should be opened and scraped.
The malignant glandular enlargement may be primary, as in
Hodgkin's disease and some rare cases of carcinoma, but it is
generally secondary to some primary deposit about the lips, tongue,
pharynx, esophagus, or mammae.
Hodgkin's disease, or malignant lymphoma, is a progressive
Fig. 277. — Hodgkin's disease (from a patient of Dr. J. E. Moore).
enlargement of glands accompanied by anemia. Its surgical interest
depends mainly on the difficulty of diagnosis in the early stages of the
disease from tubercular gland disease, and also to a certain extent from
syphilitic enlargements. From syphilis the diagnosis must be made by
a careful inquiry as to the presence of other secondary symptoms or
DISEASES AND INJURIES OF THE NECK. 673
the former existence of a chancre. The differentiation from tubercular
glands is more difficult, but the following points may be of service :
Tuberculosis of the glands most frequently affects the submaxillary
group, while in this disease the glands along the sterno-mastoid mus-
cles are more frequently affected (Fig. 277). The age of the patient
is important, Hodgkin's disease being more common in young adults.
The extension of the disease to glands in other parts of the body and
the progressive anemia will settle the point ultimately. Again, tuber-
cular glands tend to suppurate. This is not observed in malignant
lymphona. Tubercular glands, owing to periadenitis, coalesce into
masses, while in Hodgkin's disease the glands remain separate from
one another. Possibly a microscopic examination for tubercle bacilli
may be a valuable aid to diagnosis at an early stage.
Treatment. — Surgical interference, except for relief of pressure-
symptoms, is, as a rule, useless. Some glands might be excised at an
early stage to admit of examination microscopically. Arsenic, phos-
phorus, and other drugs have been employed by physicians in the
treatment of this disease without satisfactory results.
Actinomycosis and leprosy may also affect the glands of the neck,
but do not call for special attention in this section.
Other tumors of the neck are lipomata, simple sebaceous cysts,
and cysts in connection with the bursa above the thyroid cartilage, but
they do not call for any comment apart from that made in the intro-
duction to this subject.
The treatment is the sa^me as for the condition occurring in other
parts of the body.
Diseases of the Parotid Gland.
Parotiditis, or mumps, is an acute infective inflammation of the
parotid gland, and is attended by the usual febrile symptoms, with the
local addition of pain in swallowing. The disease sometimes assumes
the proportions of an epidemic, and whole families and even schools
may be laid up. In a small percentage of cases a curious complication
of orchitis in boys and mastitis or ov^aritis in girls arises. The inflamma-
tion usually resolves spontaneously, but in a few cases suppuration
ensues.
Treatnient. — In a non-suppurative case relief of pain is the chief
objective, and this may be attained to a considerable extent by hot or
other anodyne applications, as lead and opium. Where suppuration
has occurred the abscess must be opened, and here care must be taken
to avoid injuring the facial nerve or Steno's duct by making the incision
parallel to these structures.
Tumors of the parotid include adenoma, chondroma, or fibro-
chondroma also sarcoma and carcinoma. The diagnosis between
simple and malignant tumors is often extremely difficult, and must
depend on the usual questions of age, rapidity of growth, and glandular
infection.
Treatment. — When the tumor is simple and placed superficially
removal may be comparatively easy, care being taken to avoid injury
to the facial nerve and Steno's duct by making the incision parallel to
4:5
6/4 SURGICAL DIAGNOSIS AND TREATMENT.
these structures. When the tumor is mahgnant or extends deeply the
dissection becomes much more difficult and dangerous, and involves
serious risk to the external carotid arter>^, which passes through the
gland, and also to the internal carotid artery and internal jugular vein,
which lie in contact with its deep surface.
Diseases of the Thyroid Gland.
The thyroid gland has had much attention directed to it of late
on account of the discovery that myxedema, a disease depending
on atrophy of the gland, can be cured by the administration of thy-
roid glands procured from some of the lower animals, especially the
sheep. Myxedema comes under the consideration of the physician
rather than the surgeon, but an artificial variety known as cachexia
strumapriva may be observed after complete removal of the gland.
Goiter, or Bronchocele. — The thyroid gland occasionally under-
goes enlargement, known as goiter or bronchocele. Goiter forms a
soft pulsatile swelling of uniform size. On auscultation over the
tumor a blowing murmur can be frequently heard, due to the increased
vascularity of the gland. It may cause danger to life by pressure on
the trachea, and the compression is generally lateral, causing the lumen
•of the tube to become triangular. Occasionally from sudden congestion
of a goiter the dyspnea may become urgent.
Several varieties may be distinguished :
1. Goiter depending on increased growth of tissues already existing
in the gland and called parenchymatous, fibrous, or cystic according to
the preponderating tissue.
2. Malignant goiter, depending on a malignant new growth in the
gland, either carcinomatous or sarcomatous.
3. Exophthalmic goiter, where the goiter is complicated by exoph-
thalmos or protrusion of the eyes and attended with rapidity of the
heart's action. This disease is also medical rather than surgical,
although operative measures have been occasionally resorted to in the
hope of obtaining relief.
Diagnosis. — Goiter may be easily distinguished by observing the
intimate relation of the swelling to the trachea, and also by noting the
fact that the tumor moves up and down on deglutition. Malignant
goiter will be distinguished by the rapidity of growth and the speedy
involvement of neighboring lymphatic glands.
Treatment. — The general condition of the patient should be attended
to, and for this purpose iron and other tonics are indicated. Local
applications may be tried, such as iodin or the iodid of mercury, which
has so great a reputation in India. To obtain the best results from the
use of iodin it is necessary to inject the tincture into the tumor.
Cysts should be incised and stuffed with gauze, and where the
dyspnea is becoming great the isthmus should be divided, and this
sometimes results in cure of the goiter. Total extirpation should be a
last resort, as the dangers of the operation are considerable from hemor-
rhage and interference with the recurrent laryngeal nerve, and there is
the risk of cachexia strumapriva resulting. This latter condition, how-
ever, may be overcome by the internal administration of thyroid extract.
IXJURIES AND DISEASES OF THE BREAST. 6y$
When there is sudden increase of the bulk of the goiter, causing
urgent dyspnea, ice should be applied, and, if this is ineffectual, there
must be no delay in the performance of tracheotomy.
CHAPTER XV.
INJURIES AND DISEASES OF THE BREAST.
Many changes in the condition of the breast are of a physiological
rather than of a pathological character. The breast of an infant a few
days after birth may become engorged, swollen, and tender. These
conditions soon subside, but under improper management inflammation,
suppuration, and abscess may result. At puberty, just before or just
after the first menstruation, the breasts of females show a rapid devel-
opment, increasing in size and presenting an areola around the nipple.
Should the enlargement be confined to one side, it may to a careless
observer simulate a tumor. The most critical time in the history of the
gland is when it assumes its highest function — viz. during pregnancy
and lactation. During pregnancy the acini increase in size, forming
rounded nodules, and these may be the starting-points of benign but not
of cancerous tumors. After delivery the breast becomes engorged in
a marked degree, and if at this period there should be a breach of sur-
face on the nipple by which pyogenic germs can gain an entrance, sup-
puration and abscess are almost sure to follow. Another critical period
for the breast is the menopause. The acini now become atrophied, and
during this period of involution carcinoma may begin.
Thus there are three critical periods in the life of the mammary
gland, and each has its special danger. During pregnancy a benign
tumor may begin to develop ; at the beginning of lactation suppuration
and abscess may occur ; at the menopause cancer may attack the gland.
^Examination of the Breast. — The patient should be seated or
should recline upon a couch, in a good light. The nipple is first exam-
ined. It varies greatly in shape, and may be prominent, flattened, or
retracted. A retracted nipple is a characteristic of cancer of the breast,
but it must be associated with other symptoms of cancer to be of any
value. According to Gross, it is present in a little over 50 per cent, of
the cases.
Other changes in its shape are unimportant. Cracks or fissures are
significant, especially after delivery, as they may prove to be portals of
infection for pyogenic germs.
A discharge from the nipple is observed under certain circumstances.
In infants of either sex such a discharge is perfectly harmless and
should be let alone. When suppuration takes place, it is usually due
to meddlesome manipulation of the nurse, who thereby causes irrita-
tion of the gland and infects the nipple with germs from the hand.
During menstruation a discharge from the nipple is sometimes seen.
A blood-stained serum is suspicious of cancer, and is sometimes one
^■j6 SURGICAL DIAGNOSIS AXD TREATMENT.
of the earliest symptoms. The diseases to be sought for in the nipple
are —
1. Eczema. — This may be a simple skin-disease, running a course
similar to eczema in any other part and yielding to the ordinary rem-
edies ; but there is always a risk of the disease running into that which
is known as Paget's disease.
2. Pagcfs Disease. — This disease is a chronic destructive inflamma-
tion of the papillary layer of the nipple and the areola surrounding it.
It is found in women between forty and sixty years of age. At first
the so-called eczema is dry and the epithelium is shed like scales of
bran ; later it has a watery discharge of a yellowish color and sticky.
The surface of the nipple or areola becomes raw, red, and irritable, and
this condition may spread until within its circumference is embraced a
good part of the skin of the chest. It is attended with a tingling, burn-
ing pain. Although Paget's disease is not a form of epithelioma, it no
doubt paves the way for that disease by its constant and long-continued
irritation. It usually heals under soothing applications. If it does not,
it should be excised. A chronic ulcer with thickened edges, an irregu-
lar hardened base, and a foul-smelling, ichorous discharge is almost sure
to be epithelioma. Enlargement of the glands in the axilla; would be
corroborative evidence.
Diseases of the Mammary Gland. — Inflammation of the
Breast ; Mastitis or Mammitis. — This is nearly ah\a)'s met with in
nursing women about the first or second week after delivery. The
septic infection is in nearly every case due to the existence of chapped
nipples. The early symptoms are a stiffness and uneasiness of the
breast followed by a chill and a rise of pulse and temperature. The
breast becomes hard, hot, painful, and swollen. The inflammation may
end in resolution or go on to suppuration and the formation of an ab-
scess. If suppuration takes place, the breast continues painful and
throbbing, the induration and swelling increase, and after a few days
fluctuation can be felt. There are three different positions in which
the pus may collect : {a) in front of the gland, {f) in the substance
or betw^een the lobules (interlobular), (r and the product of
curettement.
Eaidy pregnancy may be excluded by the history, by the persist-
ence of the menstrual flow, and by observing the progress in develop-
ment.
Carcinoma of the uterus may be distinguished by the age, history,
fetid discharge, cachexia, and the examination of the product of cu-
rettement.
Diseased adnexa may be diagnosed usually by a careful bimanual
examination with the patient under the influence of an anesthetic. The
uterus is not increased in size, metrorrhagia does not exist, and the
development is more rapid.
Displacements of the uterus are recognized by bimanual examination
and the uterine sound. It is not uncommon to find displacement and
fibroids coexisting.
4. Subperitoneal Fibroids. — No hemorrhage accompanies this
condition, and the uterine cavity is not enlarged. By bimanual, vagino-
abdominal, and rectal examination the tumor or tumors are outlined
and their location and relations to surrounding structures determined.
They may usually be distinguished from ovarian cysts by their density
and by the absence of fluctuation, yet fluctuation is not always elicited
in ovarian cysts, particularly fibro-cysts. A second point in the dif-
ferentiation is the rapidity of growth of ovarian cysts.
740
SURGICAL DIAGNOSIS AND TREATMENT.
Floating kidney is distinguished by its form and by replacing it in
its natural position.
In the i)itra-ligai)ic7itous fibromata the tumors grow and wedge
themselves between the layers of the broad ligament, crowding into
the iliac fossa,\ and are closely connected with the uterus. They are
to be differentiated from parovarian cysts, which have no direct com-
munication with the uterus and which fluctuate.
A tube distended zvith pus, blood, or sej'ous fi?iid, when closely adhe-
rent to the uterus, may give rise to confusion, but doubt may be dis-
pelled by a carefully-taken history and by the aid of the sound.
These tumors usually increase slowly up to the time of the meno-
FlG. 309. — Multiple fibroma of uterus complicated with triplet pregnancy : i, pedunculated
subserous fibroid (myoma), diameter 6 inches ; 2, myoma, diameter 4^ inches ; 3, myoma,
diameter 4 inches ; 4, dilated cervix at seat of amputation (from a photograph in the collection
of Dr. Jepson, Sioux City).
pause, when retardation in their growth generally takes place. Inter-
stitial tumors are of slow growth. When multiple, they may crowd
upon each other and interfere with their own nutrition, first making
a rapid increase in the size of the uterus. Spontaneous enucleation
and expulsion may take place in either the submucous or subserous
variety ; gangrenous degeneration may precede the expulsion of the
tumor. When a subperitoneal fibroid is expelled into the peritoneal
cavity, it becomes either absorbed or mummified ; in rare instances it
may suppurate or become calcified. Death may result from peritonitis
or from the anemia consequent upon the frequent hemorrhage. Less
frequent causes of death are malnutrition from pressure, uremia, septi-
cemia, and heart-complications.
DISEASES AND INJURIES OF FEMAIE GENERATIVE ORGANS. 74 1
Pregnancy coexisting with fibroid tumors presents a very serious
complication and renders diagnosis difficult. By a strange coincidence
these tumors grow with increased rapidity during gestation. In Fig.
309 are represented the uterus pregnant with triplets and numerous
fibroids, twelve of which measured an inch and more in diameter.
Hysterectomy at the third month was followed by recovery. The
triplets contained in the uterus are represented in Fig. 310. When the
tumors are subserous, and especially if pedunculated, they can some-
times be pushed upward out of the true pelvis or they spontaneously
take this position, and thus interfere with natural labor to only a slight
extent. If serious interference with delivery is inevitable, operative
Bt ^ . V- . 1
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Fig. 310. — Triplets removed with uterus and fibroid tumors (from a photograph in the
collection of Dr. Jepson, Sioux City).
procedures must be considered with the view of saving, if possible,
both mother and child. Cesarian section, immediately followed by
removal of the tumor, is in many cases the operation of choice. In
others Porro's operation is the most suitable, especially if the tumors
are confined to the lower portions of the uterus.
Treatniejit. — Alterative treatment has no remedial effect, and should
be condemned as irrational and injurious to the patient.
Ergot in carefully selected cases is of service in controlling hemor-
rhage, in stimulating uterine contractions, thus aiding in the expulsion
of polypoid and submucous fibroids, less frequently interstitial fibroids.
It may serve to tide the patient over to the menopause, and sometimes
promotes atrophy of interstitial and subserous growths.
742 SURGICAL DIAGNOSIS AND TREATMENT.
Curettage, followed by uterine tamponade, will check the hemor-
rhage for a considerable time and will retard the growth of the tumor.
By this means time may be gained and the patient sustained till the
menopause brings about retrogressive processes.
Electricity tends to contract the uterus, to lessen hemorrhage, and
to decrease the size of submucous and interstitial fibroids. The
intra-uterine positive electrode causes atrophy, but only affects the
immediate vicinity which it touches. The negative electrode liquefies
the tumor superficially. Superitoneal tumors are but little affected.
The use and abuse of electricity are responsible for the development
of firm adhesions which seriously complicate subsequent operative
procedures.
Surgical Treatment. — i. Removal of the uterine appendages will
bring about the usual changes of the menopause, and has been advo-
cated for all varieties of uterine fibroids. Small interstitial tumors are
markedly affected, but the operation has very little influence, if any,
upon large tumors. The best results are obtained in medium-sized
hard fibroids where hemorrhage is severe.
2. Ligation of tJie Uterine Arteries. — The technique consists in pre-
paring the vagina as in all vaginal operations. A transverse incision is
made in the cul-de-sac of Douglas. The finger is introduced into the
incision and the uterine artery located ; a strong ligature is then passed
through the lower portion of the broad ligament above the uterine
artery and tightly tied. This method is of no service in large tumors
or in the subserous variety.
3. Morcellation. — In submucous tumors or in the interstitial variety
which has been forced to protrude into the cavity of the uterus, com-
plete enucleation should be done if the size of the growth is sufficient
to permit of its extraction through the dilated or incised cervix. If the
tumor cannot be extracted en masse, the cervix should be dilated to the
extreme degree, and, if this does not suffice, lateral incisions are made
in the cervix. Much advantage is gained by administering ergot for
some days prior to the removal of the growth. By this means the
cervix will be more efficiently dilated by the protruding mass. The
tumor is grasped with a volsellum forceps and traction made. With
the knife or scissors a section is taken from the tumor, and this process
is continued until the entire growth is removed. Hemorrhage is con-
trolled by packing with iodoform gauze.
4. Vaginal hysterectomy is indicated where enucleation and morcel-
lation cannot be performed and hemorrhage is severe. The tumor must
not exceed, in size, the fetal head. The technique will be described
under Vaginal Hysterectomy for Carcinoma of the Cervix.
5. Myomectomy is indicated in subserous growths and in interstitial
tumors where the uterine cavity is not entered. The abdominal cavity
is opened in the usual manner, the tumor is delivered through the ab-
dominal incision, the capsule is incised, and the growth enucleated. The
wound is then closed with sutures. The abdominal wound is closed
without drainage (Fig. 311)-
6. Abdominal Hysterectomy. — The incision should be made large
enough to deliver the tumor. Adhesions when existing are broken by
the fing-er. The broad ligaments are tied off on each side — two and
DISEASES AND INJURIES OF FEMALE GENERATIVE ORGANS. 743
possibly three ligatures will be required for each broad ligament ; the
last should be made to include the uterine artery, and the first should
Fig. 311. — Subperitoneal nodular fibroid tumor of the uterus (Baldy).
include the ovarian artery (Fig. 312). The broad ligament should be
severed close to the uterus as far as the reflection of the peritoneum to
Fig. 312. — Method of removal of a subserous uterine fibroid : stitches in place ready for tving
(Baldy).
the bladder. A circular incision through the peritoneum is then made
at this point, passing completely around the cervix. A V-shaped
wedge with the base upward is taken . from the cervix and the mass
744
SURGICAL DIAGNOSIS AND TREATMENT.
removed. The stump of the cervix is closed by buried catgut sutures,
and the peritoneal cuff stitched over the stump by separate interrupted
or continuous sutures ; thus the stump becomes extra-peritoneal. The
Trendelenburg position is almost indispensable. The patient is slowly
lowered to the horizontal position before closing the abdominal cavity,
and all bleeding points are controlled. If no great oozing occurs from
breaking up adhesions and pus does not escape into the peritoneal
cavit\-, the abdomen is closed without drainagfe.
Fig. 313. — Supravaginal amputation of the uterus : A, first step, position of second ligature
shown ; B, cervix amputated by wedge-shaped incision (Baldy).
Fig. 314. — Supravaginal amputation of the uterus : A, cervical canal being closed by su-
tures which are buried by subsequent sutures ; B, peritoneal edges of the stump in process of
being whipped together, the lower stump being buried under the peritoneum (Baldy).
The operation of supravaginal hysterectomy, as described by Dr.
Baer, is as follow^s :
"After the required abdominal incision is made all existing adhe-
sions of omentum, intestines, etc. are separated in the usual way, and
the tumor lifted out of the abdominal cavity. If the incision has been
an unusually lengthy one, several sutures are then placed at its upper
end for the better protection of the intestines. The patient may now
be elevated to the Trendelenburg posture if deemed best, and the parts
thoroughly studied, so that a clear idea as to the character and loca-
tion of the tumors and pedicle may be obtained before the ligation and
separation are begun. The first step in the operation is the passing of
a sincjle silk lia;ature through the broad ligament near the cervix. This
DISEASES AND INJURIES OF FEMALE GENERATIVE ORGANS. 745
ligature is again made to transfix the broad ligament near the outer
edge, to prevent slipping ; it is then tied. A stout pedicle-forceps is
next placed under the Fallopian tube and ovary and made to grasp the
broad ligament for the purpose of preventing reflux from the uterus
(Figs. 313, 314). The ligament is now severed just below the forceps,
the incision being carried close to the tissues of the tumor. If deemed
necessary another ligature is now passed through the broad ligament
farther down along the side of the cervix. This ligation and cutting
are now repeated on the opposite side. The knife is then run lightly
around the tumor an inch or two above the peritoneal reflection of the
bladder in front, probably a little lower behind, and the severed edge
of the peritoneum stripped down with the handle of the scalpel for the
purpose of making peritoneal flaps. The next step is a most important
one : it is the ligation of the uterine arteries. This is done in the broad
ligaments, outside of, but close to, the cervix. Care must be taken to
avoid the ureter on the one hand and the cervical tissue on the other.
The ligature may either be placed within the folds of the severed liga-
ments, or, which is preferable, made to encircle the double fold of the
ligament and artery in one sweep ; action here will depend upon the
size of the pedicle and the consequent separation of these folds. The
constant traction which is made upon the pedicle by the assistant who
is holding the tumor serves to draw out and elongate the cervix after
the peritoneal covering has been incised, and thereby to permit deeper
incision into the neck, which is next amputated with the knife by a
wedge-shaped incision. The stump is now grasped with a small vol-
sella forceps, and further trimmed and reduced, if necessary, so that
the entire supravaginal portion is removed before it is dropped back
into the pelvis. The cervix being now released, it immediately recedes,
and by the retractive and elastic properties of the vagina is drawn
deeply into the pelvis, where it is buried out of sight by the peritoneal
flaps covering it. These flaps have been rendered so taut by the liga-
tures which have been placed that usually as the cervix recedes into
the pelvis they close over it like elastic bands. The cervix is now in
its natural position and without a ligature or suture in its tissues. The
operation is finished by infolding the edges of the peritoneal flaps,
which may be secured by Lembert sutures if necessary. I have not
found this necessary if the ligatures which secured the uterine arteries
had also grasped the severed folds of the broad ligaments, for this so
tightens them that the sides are brought forcibly together when the
cervix is drawn under. The bladder and surrounding tissues aid also
in closing the pelvic cavity. Nothing whatever is done to the cervical
canal. The portion of the broad ligament embraced in the first ligature
is the same structure that forms the ordinary ovarian pedicle, minus
the Fallopian tube. The other ligatures close the opened broad liga-
ment, as a rule. If any other vessels are found spurting, they are of
course ligated. I have not found it necessary to employ the temporary
elastic ligature. The steps of the operation vary somewhat to suit the
complications which may be present in the individual case, but the gen-
eral direction and conclusion are practically the same in all cases."
Extra-pcritoncal Treatment of the Stump. — This method should be
selected only when great haste is demanded because of the patient's
746 SURGICAL DIAGNOSIS AND TREATMENT.
condition. The same steps are followed as in the intra-peritoneal treat-
ment of the stump to the point of amputatin' solution i : 2000. The instruments required
are to be sterilized by boiling them for ten minutes or longer in soda
solution, and are then placed upon a table at a convenient distance
from the operator in the tray in which they have been boiled. The
buttocks, thighs, and mons veneris are guarded by a broad strip of
antiseptic gauze having a slit corresponding to the vulvar orifice. The
cervix is exposed by a perineal retractor and the labia held apart by
assistants. The cervix is then seized in the grasp of a double tenaculum
or volsellum forceps and traction applied, the womb being drawn down
as far as the elasticity of the uterine ligaments will permit. A circular
incision is made from one-half to one centimeter beyond the margin of
the diseased vaginal mucous membrane. There may be considerable
hemorrhage from the divided vaginal arteries which will require the
application of hemostats and ligatures. After the hemorrhage has been
controlled it is easy with the finger to separate the cervix from the
tissues front and back, traction being made upon the cervix all the
while. The connective tissue here contains no large vessels and is
easily separated. The cervix is then drawn strongly to one side,
rendering tense the parametric connective tissue on the opposite side,
which contains the uterine vessels. This tense tissue, being easily
recognized by the touch, is surrounded by a ligature, as in the ope-
ration for total extirpation. The maneuver is best carried out by a
half-blunt staphylorrhaphy or aneur>^sm needle. After tightly tying the
ligature the included tissue is divided with scissors between the ligature
and the cervix. This ligation should include the uterine artery. A
ligature is similarly placed on the opposite side, and the tissues divided
between it and the cervix. Frequently the tightly-stretched sacro-
uterine ligaments interfere with the drawing down of the uterus. They
may be included in a ligature and severed, when the uterus will readily
descend. The ligatures should be applied as far from the cervix later-
ally as possible, so that the division of the tissues does not occur close
to the cervix. The cervix is now transversely separated from the body
DISEASES AND INJURIES OF FEMALE GENERATIVE ORGANS. 753
of the uterus anteriorly as far as the cervical canal, and a stitch passed
through the vaginal wall, the connective tissue, and the divided cervical
wall and brought out in the cervical canal. This, being tightly tied,
provides the means for safely holding down the stump after complete
separation of the cervix. Should there be any hemorrhage at this
stage, it may be controlled by several similar sutures. The posterior
wall of the cervix is now cut through, and sutures passed as before
around its circumference, uniting the mucous membrane of the vagina
to that of the womb. As the upper end of the opened vaginal tube is
much larger than that of the womb, the vaginal mucous membrane is
thrown into folds by the sutures. On either side are openings in which
the ligature strands lie ; these require each a stitch to effect closure. If
the ligatures include the uterine vessels and are tightly tied, there
should be very little bleeding in this operation. The lower segment
of the womb may be removed by this method if desired. Douglas's
cul-de-sac is frequently opened ; the author has opened it several times,
but this misadventure did not increase the danger of the operation.
The wound in Douglas's pouch should be immediately closed by a con-
tinued suture of fine silk or catgut. The vagina is to be carefully
cleansed with boiled water and tamponed with iodoform gauze. The
tampons are removed and renewed, and the vagina douched at intervals
of twenty-four hours. In from five to eight days the tampons ma\' be
discontinued, but the daily douches are persisted in. On the tenth or
twelfth day the patient may leave her bed. The early removal of the
stitches is a matter of no importance, and the longer they remain the
easier is their removal. Usually they are removed on the eighth day.
If catgut be used throughout, there is no need of paying any attention
to them whatever, as the loop is absorbed and the knot then falls off"
Carcinoma of the Body of the Uterus. — Cancer of the body of
the uterus presents itself either in the form of a diffuse infiltration or as
polypoid excrescences. The origin in either case is the endometrium.
Necrosis follows upon infiltration, surrounding structures become in-
volved, particularly the rectum, bladder, and peritoneum, adhesions
about the uterus are formed, and metastasis involves the distant organs
and tissues.
Symptoms. — A watery, fetid, and blood-tinged secretion is the cha-
racteristic symptom, though the blood and the odor are not constant.
Pain is not a constant, but is a characteristic, symptom. It is refer-
able to the uterine contractions in their effort to expel the contents of
the uterus, and hence are of a colicky nature, or to the peritoneum,
where a chronic peritonitis is set up, giving rise to the sharp, lanci-
nating pains. The pains may recur at certain intervals and at certain
hours. In this respect they are characteristic. Bimanual palpation
will reveal a uterus more or less enlarged, possibly adherent, and tender
to the touch. If the os is patulous or dilated, carcinomatous nodules
and infiltration may be detected by the examining finger.
The general effect upon the health is often not pronounced until
late in the course of the disease.
Diagnosis. — When hemorrhages recur frequently after the meno-
pause, and the usual causes, such as polypi, are excluded, and when
the discharge becomes fetid, it is highly suspicious of carcinoma. Little
48
754 SURGICAL DIAGNOSIS AXD TREATMENT.
doubt can remain if the body of the uterus is found enlarged, adherent,
and nodular growths are felt on its surfaces. The uterine sound will
aid in detecting the sloughing, irregular surface. A positive diagnosis
is made by examining the product of curettement by the microscope.
TrcatDicnt. — Operative treatment can only be undertaken when the
infiltration has not advanced beyond the uterine tissues. Nothing short
of a total extirpation will suffice, either by the abdominal or vaginal
route. Statistics show that hysterectomy done for carcinoma of the
uterus is successful as to immediate and remote results in 33 to 50 per
cent, of cases — a showing far superior to that of carcinoma in any other
portion of the body. Hence the injunction is imj)erative to operate at
the earliest possible moment before surrounding structures are involved,
and in all cases to remove the entire uterus, tubes, and ovaries. Where
the size of the uterus will permit the vaginal route should be selected,
and only in the rare cases where the body of the uterus is too large to
be removed through the vagina should the abdominal route be selected.
TccJiniquc of I \Tigiiial Hystcrcctoiiiy. — Many American gynecologists
prefer to secure the broad ligament by clamps because of the ease and
rapidity with which it is done. The use of clamps is open to a number
of serious objections: i. The danger of clamping a ureter; 2. Serious
hemorrhage from slipping of the clamps ; 3. Pressure of the forceps
upon the bladder and rectum ; 4. Interference with the operative pro-
cedures by crowding the space; 5. Preventing the closure of the peri-
toneal cavity, and thus permitting adhesions of the gut to the raw sur-
face and free access of infection to the peritoneal cavity.
The preparatory treatment consists in evacuating the bowels and
sterilizing the field of operation in the usual manner.
Where the cervix is completely degenerated, so that traction cannot
be made with forceps, the mass is curetted or dissected away with scis-
sors, the vaginal mucous membrane grasped with volsellum forceps
immediately in front of the cervix and incised at a safe distance. The
bladder is then carefully dissected up till a sufficient portion of the cer-
vix is exposed to afford a firm grasp with the forceps. The cul-de-sac
of Douglas is then incised and the peritoneal fold stitched to the vagi-
nal mucous membrane. W^ith the index finger as a guide, a ligature
on a staff is passed through the base of the broad ligament on either
side, the Hgature including the uterine artery (Fig. 315). The Hgated
portion of the broad ligament is severed and the uterus drawn farther
into the vagina. The bladder is readily stripped from the uterus, and
the anterior cut margin of the vagina is stitched to the vesico-uterine
fold of the peritoneum by a continuous catgut suture. The broad liga-
ment is then ligated in section, step by step, on either side until the
uterus is free (Fig. 316). The tubes and ov^aries are to be removed
together with the uterus. Each ligature is passed through the anterior
vaginal mucous membrane for the purpose of preventing slipping of the
ligatures and to bring the stumps of the broad ligament outside the
peritoneal cavdty. Finally a ligature is passed through all the stumps
of the broad ligament and out through the anterior vaginal mucous
membrane; next the opening in the vagina is closed with sutures and
packed with iodoform gauze. The above technique is essentially that
advised by Herman J. Boldt.
DISEASES AND INJURIES OF FEMALE GENERATIVE ORGANS. 755
In place of ligatures, clamps may be used in dealing with the broad
ligaments. The steps of the operation are the same, except the base
Fig. 315. — Vaginal hysterectomy: opening the posterior cul-de-sac, and suturing the perito-
neum and the mucous membrane together to control bleeding (Martin).
of the broad ligament is clamped on either side and the ligament cut
inside the clamp. The uterus is then drawn down and a second clamp
Fig. 316. — \'aginal hysterectomy with the ligature: A, first step; B, second step (Baldy).
placed higher up, and a third which includes the remaining portion of
the ligament. The uterus is removed, the handles of the clamps are
756
SURGICAL DIAGNOSIS AND TREATMENT.
sccurcl)' tied with silk to prevent slippin<^, and the vagina is packed
with iodoform gauze. In twenty-four to forty-eight hours the clamps
are removed and the openings again loosely packed. This method is
not only reliable, but rapid, and where there is much pelvic induration,
involving the broad ligaments, it may be impossible to ligate. Conva-
lescence, however, is more protracted.
Fig. 317. — Hysterectomy for cancer of the uterus (Clark).
Abdominal Hysterectomy luith Removal of a Considerable Portion of
the Broad Ligament. — Dr. J. G. Clark of Baltimore suggests a method
of extirpating the uterus and a great part of the broad ligament without
injury to the ureters. Under cocain anesthesia he first passes bougies
into the ureters, causing them to bulge out like thick cords, as seen in
Fig. 317. The patient is then anesthetized and a free abdominal incision
made. Next the upper portions of the broad ligaments, with the
ovarian ligaments, are ligated. The bladder is separated, the uterine
arteries exposed and dissected out an inch beyond the vaginal branches.
DISEASES AND INJURIES OF FEMALE GENERATIVE ORGANS. 757
and here they are tied. The next step is to dissect the ureters free, and
to tie the remainder of the broad ligament at a point close to the iliac
Fig. 318. — Hysterectomy for cancer of the uterus (Clark).
vessels ; it is then divided at its pelvic attachment well below the
cancerous area. The vagina is perforated with scissors, tied in seg-
FlG. 319. — The uterus after vaginal hysterectomy (Clark).
ments, and divided. A strip of gauze is passed down into the vagina,
and the peritoneal flaps are sutured over the raw surface The pelvic
758
SURGICAL DIAGNOSIS AND TREATMENT.
"^-^Hiis^^
Fig. 320. — Uterus, broad ligaments, and part of vagina removed en masse (Clark).
cavity is irrigated and the abdominal cavity clo.sed without drainage.
Fig. 318 shows the peritoneum dissected off, affording a lateral view
Fig. 321. — Hysterectomy for cancer of the uterus (Clark).
of the uterus and bladder, with their relations to the uterine artery and
ureter, and the latter vessels to each other. In Fig. 319 is shown the
condition of the uterus after vaginal hysterectomy. No part of the broad
DISEASES AND EVJCKIES OF FEMALE GENERATIVE ORGANS. 759
ligaments or vagina is excised with the uterus. The advantages of Clark's
method are shown in Fig. 320, which represents the uterine artery dis-
sected out before the broad ligaments were freed from their pelvic
attachments. Observe that the greater part of the broad ligament and
a considerable cuff of the vagina have been excised with the uterus en
masse. Fig. 321 represents the operation as completed. The space left
by the removal of the uterus is filled with gauze from above, after
which the vesical and rectal peritoneum are closed with a continuous
suture.'
XIII. NEW GROWTHS OF THE TUBES, OVARIES, AND BROAD
LIGAMENTS.
New growths of the tubes are of very infrequent occurrence,
and rarely attain any considerable size. As with all new growths,
these neoplasms are classed as benign and malignant.
Benign tumors are, in order of their frequency, adenomata, fibro-
myomata, cysts, and lipomata.
Adenomata spring from the glandular structures of the tube, and
form a papillomatous mass which occludes the lumen of the tubes.
Histologically, they are composed of true gland-structures.
Fibro-myoinata are usually subserous and sessile or pedunculated.
They never attain any considerable size. They are identical with the
fibromata of the uterus, though with a predominance of muscle-fibers.
Cysts. — These are either subserous or interstitial, never grow beyond
the size of a hen's ^g,%, and are usually much smaller.
Lipomata are subserous and have been found in rare instances.
Malignant Growths. — Carcbiomata. — Cancer of the tube may be
primary or secondary, either from metastasis or direct extension from
the endometrium ; less frequently, indeed almost never, from the
ovary.
Medullary carcinomata have been described, but the usual form is
epithelioma, similar to that of the endometrium.
Sarcomata. — The sarcomata may be primary, but in almost every
instance are secondary, and rarely composed of sarcomatous cells
alone, the usual form being a fibro-sarcoma and myxo-sarcoma.
The symptoms do not suffice to make a diagnosis, and nothing but an
exploratory incision will reveal the condition.
Benign growths are harmless, with the exception of adenomata.
The malignant growths are almost invariably fatal, because, as a rule,
they denote the extension of the growth from the uterus to the sur-
rounding structures.
Treatment. — There is no indication for the removal of benign growths.
Malignant growths, together with the uterus, should be extirpated, pro-
vided the infiltration is limited.
New Growths of the Ovaries. — Benign. — Fibromata are of in-
frequent occurrence, and still more rarely exist without more or less
muscle-fibers. In gross and minute appearances they are identical with
the subserous fibromata of the uterus, and may attain enormous pro-
portions. They are sharply circumscribed, smooth, and lobulated.
1 Johns Hopkins Hospital Bulletin, cited in Annual of the Medical Sciences, 1S96.
760 SURGICAL DIAGNOSIS AND TREATMENT.
The secondary degenerations are myxomatous, calcareous, fatty, and
cystic. At any stage of their development sarcomatous tissue may
appear. The tumor may suppurate or become gangrenous, and hemor-
rhages may occur in the substance of the growth. Fibro-cystic tumors
develop from the distention of the lymph-channels by a clear lymph
fluid, which may be tinged with blood or become purulent from
secondary infection with pyogenic organisms.
Malignant tumors of the ovary are, in point of frequency —
{ti) Sarcomata, which are relatively frequent in childhood, and are
of the spindle-cell variety, though the small round-cell sarcoma is occa-
sionally seen. Rarely is the growth composed of sarcomatous cells
alone, the usual combination being fibro-sarcoma. The medullar)^
sarcoma may be confused with carcinoma and require a microscopic
examination. The degenerative changes are fatty, hemorrhagic, cystic,
and calcareous. The growth may attain the size of a fully-developed
fetal head, and is peculiar in frequently appearing simultaneously in
both ovaries. This fact, together with the age, which is usually early
womanhood, the effect upon the general system, and the rapidity of
the growth, will suffice to make the diagnosis highly probable.
{h) Carcinoniata may be primary or secondary, either by direct ex-
tension from the uterus and tubes or as a metastatic growth from the
breast or elsewhere. Cystic tumors of the ovary are prone to become
cancerous. They appear in both ovaries less frequently than do sar-
comata. The usual form is the medullary, which must be differentiated
from sarcomata by the microscope. As a rule, they appear later in life
than sarcomata. The usual forms of degeneration are fatty, cystic,
myxomatous, and colloid. Extension to neighboring structures occurs
early, and metastasis rapidly takes place ; conversely, cancer of the
breast may result in metastatic deposits in the ovary ; less frequently
the disease comes from other portions of the body.
Ovarian Cysts. — Cysts of the ovary are usually classed as unilocu-
lar, multilocular, and dermoid (Fig. 322). The unilocular cysts are in
reality simple retention-cysts formed by the distention of the Graafian
follicle with a clear serous fluid. Rarely do they exceed in size a wal-
nut, rarely do they assume a size sufficient to indicate surgical inter-
ference, and the rupture of their contents into the peritoneal cavity is
harmless.
Multilocular cysts are varied in their composition, and possibly in
their origin, though their exact mode of formation is still under debate.
Probably the simpler varieties arise as the result of an oophoritis ; the
follicles, becoming more and more distended with fluid, and the walls,
becoming thinned from pressure-atrophy, finally give way, and two or
more follicles are combined to form a large one. In this manner the
ovary assumes the size of an orange, rarely as large as an adult head,
and is composed of numerous spaces distended with fluid. The more
complex cysts probably arise in the same manner, differing only in the
additional involvement of the connective-tissue framework and gland-
tissue. The gland-tissue proliferates as does the interstitial tissue ; in
this manner papillary and adenomatous excrescences project into the
cyst-cavities, forming great cauliflower growths. Many authors em-
phasize the importance of a microscopic examination of the cyst-con-
DISEASES AND INJURIES OF FEMALE GENERATIVE ORGANS. 76 1
tents — the elements being a few blood- and pus-cells, cholesterin plates,
degenerate epithelium, and the " ovarian granular cells " of Drysdale,
which are not pathognomonic of ovarian cysts, but in reality are epi-
thelium which has undergone partial fatty degeneration.
Papillomatous cysts rarely attain any considerable size. Without
entering into a discussion of their origin and pathology, suffice it to say
they present the same external appearance as the former cysts, unless
the cyst-wall has been penetrated by the papillomatous growths.
Within the cyst-wall are numerous dendritic growths varying in size
Fig. 322. — Multilocular cvst (from a photograph in the collection of Dr. Andrews, Mankato,
Minn.).
up to that of an orange ; the fluid within the cysts is clear and watery,
varying but little from that of the simple ovarian cysts. These growths
are prone to cancerous degeneration — a clinical fact so often observ^ed
as to suggest the probability of all being malignant : this is not borne
out by pathological investigation.
Tubo-ovarian cysts probably arise from the catarrhal salpingitis result-
ing in adhesions of the fimbriated extremity of the tube to the ovary ;
the tube fills with fluid ; the wall between a distended Graafian
follicle and the lumen of the tube gives way, and the two are simul-
762 Si'KGICAL D/AGA'OSIS AXD TREATMENT.
taneously distended. The cyst is characteristic in shape ; the tube
broadens toward the fimbriated extremity and ends in a bulbous sac.
It is rarely large, yet has been known to contain as much as a quart
of fluid. It is usually bilateral.
Dermoid Cysts. — According to Johnstone, dermoid cysts arise from
the Graafian follicle through the faulty development of the ovum. They
occur at all ages from infancy to adolescence ; many attain the size of
an adult head. They are usually unilateral ; their development is slow,
and oftentimes they cease to grow for a long period of time.
Ovarian cysts in the infant are almost invariably dermoid. In three-
fourths of the cases they are unilateral. Adhesions bind them to ad-
jacent structures and degenerative changes are of frequent occurrence.
The external wall of the cyst is of darker color than the simple ovarian
cysts, and yellowish patches of fat are seen here and there through the
cyst-wall. The contents consist of hair, teeth, bones, cartilage, nerve,
muscle, and nails ; even well-formed organs, such as the mammae, are
occasionally found. The contents of the cysts vary from an oily liquid
to a thick caseous substance ; they are always unilocular.
Svniptoms of Ovarian Tujuors. — Ovarian tumors may attain a
considerable size before the attention of the patient is attracted to their
growth.
Pain in the region of the ovary occurs in a limited number of cases,
and is in no way directly proportionate to the size of the growth, being
more the result of the accompanying peritonitis. Associated with
ovarian tumors there is usually endometritis ; hence menorrhagia is an
almost constant symptom. Amenorrhea is not frequent, and points to
the existence of a tumor in each ovary when occurring early in the
development of the condition. Later it follows as the result of ex-
haustion and depletion. Sterility is due to the involvement of both
ovaries or to some complication, as endometritis : pregnancy not in-
frequently complicates ovarian tumors. Pressure-symptoms soon
develop if the growth remains in the pelvis, but if it rises in the abdo-
men the growth may assume immense proportions before causing
discomfort. These pressure-symptoms are constipation, tenesmus,
frequent urination, dysuria, pain in the regions supplied by the sacral
and sciatic nerves, backache, heavy sensation in the pelvis, edema of
the vulva and lower extremities, and hemorrhoids. When the tumor
has ascended into the abdominal cavity and developed to an enormous
size the distress from pressure and weight is pitiful.
Dyspnea becomes extreme ; the stomach is unable to retain food ;
the heart's action is embarrassed ; jaundice may supervene from pres-
sure upon the bile-ducts ; the skin becomes dry ; emaciation becomes
extreme, and the urine scanty and high-colored. Death from ex-
haustion ends the patient's suffering unless some complication super-
venes.
Diagnosis of Ovarian Tumors. — A small cyst is frequently dis-
covered by bimanual examination when no suspicion of its exist-
ence had been entertained. It will be recognized as a smooth,
globular, elastic, movable tumor, lying to one side or behind, very rarely
in front of, the uterus. If lying between the layers of the broad liga-
ment, the growth will be more fixed. In all cases it can be outlined
DISEASES AND INJURIES OF FEMALE GENERATIVE ORGANS. 763
separately from the uterus. When the cyst has grown to the size of a
fetal head fluctuation is elicited, providing the contents are fluid. If
gelatinous, the peculiar sensation to touch will be elicited. This fluc-
tuation may be masked by thickening of the cyst-wall from inflammatory
adhesions. Anesthesia will facilitate the examination in such cases.
An exploratory puncture with an aspirating needle may be made,
providing the tumor is found in the cul-de-sac or bulges into the vagina.
The cantents aspirated may be serous, bloody, or purulent, and, if
purulent, vaginal incision and drainage may be made at once. When
the tumor has grown to the size of an adult head, lying largely
within the abdominal cavity, it will be recognized on palpation by
its smooth, circumscribed, peculiar tense, elastic sensation. Fluctuation
may not be detected, and too much stress must not be placed upon
this sign. The tumor is more or less movable when manipulated, and
may also move with the change of the position of the patient. The
percussion-note over the tumor is dull or flat, and this area of dulness
does not change to the most dependent portion of the abdominal cavity
when the patient lies on one or the other side. The position and size
of the uterus should be outlined by vaginal examination ; the organ
will be found to be displaced by the tumor — possibly drawn upward by
the adhesions, but usually pushed to one side. The uterus will not be
increased in size. When the tumor is large inspection wall aid much in
the diagnosis. The abdomen will not be symmetrically distended,
being more prominent in the region of the tumor. The degree of
distention may be estimated by measuring the distance from the
umbilicus to either anterior superior spine of the ilium. If the dis-
tention is great, the superficial veins will be prominent on that side, and
the linea albicantia may appear as in pregnancy. Above, the limit of the
tumor may be outlined, but below, it is lost in the pelvis. In extreme
cases the upper border may be lost behind the arch of the thorax ; the
ribs bulge and the abdominal viscera are displaced. In determining
the variety of the cyst — that is, w^iether it is unilocular, multilocular,
colloid, or dermoid — the following general points may be of serv^ice :
In unilocular cysts the surface is smooth ; even fluctuation is dis-
cerned at all points with equal facility, and the growth compared with
the multilocular cysts is limited in size.
Multilocular cysts attain enormous proportions, are irregular in out-
line, resistance is not uniform, fluctuation may be limited to a portion
of the tumor.
A dermoid cyst may be suspected when the tumor appears early in
life, when it is of slow growth, accompanied with pain and exacerbations
of peritonitis. On palpation it imparts a doughy sensation. Of course
when portions of the cyst, as teeth, bone, and hair, are discharged
through a fistulous communication, the diagnosis is established. Very
rarely, indeed, are portions of the tumor palpated and recognized as
teeth and bone.
Differential Diagnosis. — Tympanites often leads to a misappre-
hension as to the existence of a tumor. In tympanitis the distention
is symmetrical and not constant, being aggravated shortly after meals,
and is associated with flatulence, passage of gas, and rumbling in the
bowel. The percussion-note is uniformly tympanitic ; no circum-
764 SURGICAL DIAGNOSIS AND TREATMENT.
scribed mass can be palpated, and auscultation will reveal gurgling
sounds at all points.
PluDitotii tumors in hysterical subjects are often misleading. Anes-
thesia A\-ill clear up the mj'stery. Thick, fat abdoiiiinal zoa/Is are dis-
tinguished by the great fat folds so prominent in the sitting posture ;
by the peculiar doughy feel, so diflerent from the tense, elastic resist-
ance of an ovarian cyst; by the deep resonance. The "fat-thrill" of
Godell may simulate the cyst-thrill in percussion, but may be muffled
by laying the hand of an assistant upon the surface between the
examiner's hands.
Ascites. — Here the history and the presence of a cause in the heart,
lung, or liver will facilitate the diagnosis of ascites. The abdomen is
distended symmetrically, bulging at the sides, and more flattened in
front than is the case when a cyst is present. Fluctuation is not con-
fined to the bulging area, which is dull on percussion at the dependent
portion, and changes with the position of the patient. This is not true
of a cyst. Above the line of dulness is tympany. Vaginal examina-
tion is negative ; the uterus is not displaced and no tumor is felt. Cir-
cumscribed collections of fluid due to peritonitis are difficult to distin-
guish from cysts, but there is usually a history of peritonitis, and the
tumor is more often in the middle line than to one side.
In the presence of a large accumulation of ascitic fluid small cysts
are not often discovered. When suspicion of their presence exists, it
would be well to tap the abdomen to draw off the ascitic fluid, and then
make a careful examination for the cyst. The examination of the fluid
will aid in the diagnosis. Ascitic fluid coagulates by heating ; it may
contain somQ blood-cells ; the cell-elements of cystic fluid are rarely
present ; and the fluid lacks the viscidity of cystic fluid. The specific
gravity is about 10 14, and the color is green and yellow.
Pyosalpinx and Pelvic Abscesses. — The history will often clear up the
diagnosis. Such collections of pus are usually associated with a history
of septic infection following labor and abortion or a gonorrheal infec-
tion. They are generally accompanied with chills, pain, fever, and
sweating. Physical examination will elicit tenderness and a mass which
is fixed and does not give the firm, elastic resistance of a cyst. Rarely
do they attain any considerable size. If bulging into the vagina, the
exploring needle will settle the diagnosis.
Hydrosalpinx will usually be readily distinguished by its elongated,
tortuous shape.
Pelvic hematocele, as a rule, is associated with a history of possible
pregnancy. It is recognized by its peculiar doughy feeling, by the
mass being fixed and not circumscribed ; fluctuation is indistinct, and
the aspirating needle withdraws blood.
Ectopic gestation must be thought of Before the rupture there will
be a growing tumor to one side or behind the uterus ; it will be boggy
to the touch and other evidences of pregnancy will be found. After
rupture there will be a history of sudden pain, collapse, and the appear-
ance of a hematocele, as described above.
Uterine fibroids are usually distinguished by their greater degree of
resistance.
Pancreatic cysts are usually found in the median line of the epigas-
DISEASES AND INJURIES OF FEMALE GENERATIVE ORGANS. 765
trium ; the fluid is alkaline, of low specific gravity, and contains fat-
droplets. The epithelial cells found in ovarian cysts are absent. The
stomach is displaced forward.
Displacement of the kidney may be detected by the shape of the
organ, by the ability to replace it, and by its consistency.
Tumors of the kidney are usually found in the young. They are
retroperitoneal, as demonstrated by inflating the colon over them. A
history of hematuria, pyuria, and renal colic is often given, and the
lessening in size of the tumor simultaneously with the appearance of
pus or increased amount of water in the urine. Catheterization of the
pelvis of the kidney will be valuable in the diagnosis of pyonephrosis
and hydronephrosis.
Enlarged spleen from malaria, tumors, or leukemia is recognized by
its tendency to grow downward and inward, by its peculiar shape, by
the detection of the notch upon the inner margin, by the examination
of the blood, and by the history relating to the case.
A distended bladder should not be mistaken for a cyst. Inquire
into the frequency and time of urination, the amount of urine voided ;
and the use of the catheter will prevent possible errors.
Impacted feces will be excluded by the use of enemata and cathar-
tics ; the tumor thus caused will be dull on percussion and doughy
on pressure, the indentation remaining persistent after the finger is
removed.
Treatment of Ovarian Tumors. — Medical treatment, tapping, electri-
city, injections with iodin and astringents, will only be mentioned to con-
demn them. It cannot be too strongly emphasized that the only justi-
fiable treatment is surgical interference. Tapping may be the only
resort when the patient suffers from pressure-symptoms and a surgical
operation is contraindicated.
Ovariotomy may be said to be indicated wherever there exists a
tumor of the ovary. The usual preparations for an abdominal section
are made. The Trendelenburg position will be found most advantage-
ous. The incision should be in the median line above the pubis, and
should be long enough to admit of ready manipulation and delivery
of the tumor after it has been emptied. The adhesions binding the
tumor to the parietal peritoneum are broken up with the fingers ; the
omentum when adherent is freed in a similar manner, or, if too
strongly attached, by amputating the adherent portion. Great care
should be exercised in separating adhesions to the intestines ; the
adherent gut should be brought plainly to view, with the sac well ex-
posed. A trocar is plunged into the cyst-cavity and the fluid allowed
to escape. The peritoneal cavity is protected by sponges. As the
cyst empties the sac is grasped with the cyst-forceps and traction made.
Thus the cyst is drawn out of the wound. The trocar is then removed
and the opening in the sac enlarged. The contents are allowed to
escape, and the hand is introduced inside the cyst. Secondary cysts
may be broken into and discharge their contents into the large cyst-
cavity. Traction upon the cyst is continued until it is drawn outside
the abdominal cavity. The pedicle is then ligatcd and removed close
to the uterus.
The stump is either cauterized with a Paquelin cautery or with car-
766 SURGICAL DIAGNOSIS AXD TREATMENT.
bolic acid. If the contents of the cyst are not purulent, there is no in-
dication for irrigation. If there is suppuration, irrigation and drainage
should be employed. Where the adhesions are extensive and there is
considerable oozing a drainage-tube should be inserted. Serous and
bloody fluid should be removed from the peritoneal cavity by sterilized
sponges. The wound is closed in the usual manner.
Occasionally it will be found impossible to remove the cyst en masse.
Such is sometimes the case when the adhesions are too firm, the bleed-
ing and shock too severe, or the collapse of the patient renders a hasty
operation imperative. In such a case the cyst is drawn out as far as
possible and the extruded portion excised. The margins of the remain-
ing portion of the cyst are stitched to the abdominal incision, and the
cavity drained by iodoform gauze or a glass drainage-tube.
XIV. EXTRA=UTERINE PREGNANCY.
Tubal Pregfnancy. — The normal site of impregnation is in the
uterus, but sometimes it occurs in the tube.
Etiology. — Little is known concerning the cause of tubal pregnancy.
Most frequent!}' it occurs after a long period of sterility, though it has
been known to happen as early as the age of twenty, and after repeated
normal pregnancies or closely following upon an abortion, miscarriage,
or labor at full term. Desquamative salpingitis is thought by many to
be the pathological condition most frequently responsible.
As a result of tubal pregnancy the tube becomes thickened, owing
to congestion and hypertrophy of the essential cell-elements. At times
there is a general or localized thinning of the walls of the tube. The
ovum becomes adherent to the mucous membrane by a new-formed
chorionic membrane ; later the greater portion of the villi become
atrophied while the remaining villi form the placenta. When this
fetal body is separated from its attachments hemorrhage into the
chorionic villi is a universal result, and there is developed from
the product of conception what is generally known as an apoplectic
ovum or fleshy mole. Early, it is seen as a dark coagulum of blood
which in a few days becomes of a yellow color, due to a deposit of
fibrin upon the surface. In the center is a cavity lined with a smooth
amniotic membrane containing a clear amniotic straw-colored fluid,
and at times the remains of an embryo. The presence of an embr>'o
is proof positive of the character of the clot, and the existence of cho-
rionic villi, as demonstrated by the microscope, is the next most essen-
tial point in diagnosis.
Rupture of the tube is an almost inevitable result, though in rare
instances the fetus is destroyed early in its development and remains
quiescent. Rupture of the tube may be primary or secondary, and may
be intra-peritoneal or extra-peritoneal.
Primary rupture is the term employed when the accident occurs
prior to the development of the placenta at the twelfth week. When
rupture takes place into the peritoneal cavity there is grave danger of
fatal hemorrhage, the danger being proportionate to the degree of
the development of the ovum. Peritonitis is of rare occurrence.
The blood tends to collect in the cul-de-sac of Douglas and to
DISEASES AND INJURIES OF FEMALE GENERATIVE ORGANS. '/6y
become walled off in the pelvis by the adherent omentum and intes-
tines above. Secondary hemorrhages may follow. Primary rup-
ture of the tube between the layers of the broad ligament, known as
extra-peritoneal rupture of the tubes, is of less serious consequence,
because the extra-ligamentous pressure soon checks the hemorrhage.
The ovum may become destroyed and no subsequent injur}- ensue, but
it may go on to development between the layers of the broad ligament,
and is then called " intra-ligamentous gestation " or " broad-ligament
pregnancy."
Tubal abortion is a term applied to those cases in which impreg-
nation develops in the outer third of the tube, and, the ostium abdom-
inalis not being closed, the ovum is expelled through it into the
abdominal cavity. The danger of such an event is directly propor-
tionate to the proximity of the ovum to the ampulla and to the patency
of the ostium abdominalis, which should close not later than the sixth
or eighth week. After the eighth week tubal abortion does not take
place, but the tube ruptures because of the closure of the ostium
abdominalis.
Together with tubal abortion there is more or less hemorrhage
into the peritoneal cavity. This may be so abundant as to result in
profound shock and death or peritonitis may dev^elop. Thus the vast
majority of hematoceles are occasioned. Coincident with the develop-
ment of the ovum in the tube is the development of a uterine decidua,
which is expelled accompanied by hemorrhage. When occurring early
the ovum is often not detected in the blood-clot.
Tubal Gestation. — The placenta is formed almost exclusively
from fetal tissue, the tubal mucous membrane entering but little into
its structure ; hence there is little or no thickening of the tube, but, on
the contrary, the walls become thinned and finally rupture. The
decidua forms in the uterine cavity and around the ovum, and is usually
discharged during pregnancy, with symptoms of miscarriage. Occa-
sionally it is expelled in fragments and unnoticed. The menstrual
membrane of membranous dysmenorrhea must not be mistaken for
the decidual membrane. The decidual membrane is larger, thickened,
and presents a shaggy external surface, and at its three angles are the
openings corresponding to the Fallopian tubes 'and the internal os.
The internal surface is dotted with the orifices of the uterine glands.
When the fetus lies above the placenta in the tube the placenta is crowded
down between the layers of the broad ligament, and when the fetus lies
below the attachment of the placenta the latter is crowded high
into the abdomen. These remarkable displacements not only result
in alteration of the placental structure and function, but have a jeop-
ardizing effect upon the life and health of the mother and fetus.
The danger to the mother is hemorrhage from the placental site into
the peritoneal cavity or gestation-sac. The fetus is usually ill-formed
or under-sized ; club-foot, spina bifida, hydrocephalus, and like de-
formities are frequently present. Rarely does the fetus live, but even
after its death the placenta may continue to grow and attain enormous
proportions. A dead fetus may become viuvnuificd ; in other cases it
becomes partially converted into a litJwpcdion by a deposit of lime salts
in the superficial structures. The fetal body and placenta may become
768 SURGICAL DIAGNOSIS AND TREATMENT.
gangrenous or suppurate, and death ensue from septic infection or
peritonitis.
Sccividary rupture of the gestation-sac may occur at any time after
the formation of the placenta at the twelfth week. If the placenta lies
above the fetus, crowding it into the pelvis, there is great danger of
rupture of the placenta with fatal intra-peritoneal hemorrhage. When
the fetus lies above the placenta, the latter may finally rupture into the
peritoneal cavity without dangerous hemorrhage, and the fetus con-
tinue to live and accommodate itself to its environments. Not always
does the sac rupture. Spurious labor may occur at the expected time,
the amniotic liquor become absorbed, and the fetus mummifies, only to
be accidentally discovered years afterward.
J. Bland Sutton says : " There is not such a thing as primary peri-
toneal pregnancy. All forms of cxtra-titcrinc pregnancy pass their
primary stages in the Fallopian tube."
Tubo -uterine pregnancy, or interstitial pregnancy, as it
is sometimes called, is a term applied to the condition in which
the fetus dev^elops in that portion of the Fallopian tube lying in
the uterine wall. In consequence of the structures of the walls the
sac does not become thinned, but greatly hypertrophied, just as does
the uterus ; hence rupture does not occur so early as in the other
forms, and the rupture may be intra-peritoneal or intra-uterine. Tubal
pregnancy must not be confused with pregnancy in a rudimentary horn
of the uterus. In tubal pregnancy the decidua is intra-uterine, and in
pregnancy of a rudimentary cornu the decidua lies within the cornu.
A few cases are on record in which there existed simultaneously an
intra-uterine and an extra-uterine fetus.
Symptoms of Tubal Pregnancy. — The usual signs of early preg-
nancy are not always present, but when discernible are valuable diag-
nostic points. The breasts may not undergo the usual development,
and there may be no amenorrhea. In such cases the diagnosis must
depend upon a physical exploration. The woman herself may not be
aware that she is pregnant.
Rupture of the tube manifests itself by a sudden pain or sense of
something having given way in that region ; then follow other symp-
toms referable to internal hemorrhage. If the rupture has occurred
through the placental site into the peritoneal cavit}% the loss of blood
may be enormous ; the patient becomes faint, pallor rapidly develops,
the respiration becomes sighing, the pulse weak and rapid, the extremi-
ties cold, and the temperature subnormal. Death ma}' follow in two or
more hours. If the rupture occurs between the layers of the broad
ligament, the extra-vascular soon equalizes the intra-vascular pressure,
and hemorrhage is checked without serious effect upon the patient.
Coincident with the rupture there are frequently hemorrhage from the
uterus through the vagina and the expulsion of the decidua oi masse
or in shreds.
After the third month tubal pregnancy gives the following signs
and symptoms :
1. The breasts are usually enlarged as in normal pregnancy, though
this is not a constant sign.
2. Amenorrhea is not constant. Hemorrhage from the uterus may
DISEASES AND EVJURIES OF FEMALE GENERATIVE ORGANS. 769
recur at irregular intervals, and, when accompanied by the expulsion
of shreds of decidua, is a most characteristic symptom.
3. The uterus enlarges as in normal pregnancy up to about the
third month, and the os is soft and patulous.
4. When pregnancy has been suspected and symptoms of internal
hemorrhage suddenly develop, it is altogether probable that the gesta-
tion-sac has ruptured. The fetus may be palpated as a soft, irregular
mass lying to one side and behind the uterus. When the fetus has
become developed it is sometimes possible to recognize the head and
extremities by palpation.
5. The pre-existence of salpingitis and a long period of sterility is
strongly indicative of ectopic gestation. In the experience of Dr. Joseph
Price rupture of ectopic gestation-cysts occurs with much greater
frequency during the summer months than during any other period of
the year, and with noteworthy frequency in women in whom lactation
is prolonged either for the purpose of averting pregnancy or from other
cause.
Ectopic gestation at term is manifested by characteristic labor-pains,
dilatation of the os, hemorrhage from the uterus, and often expulsion
of the decidual membrane. These pains may continue for several days,
and the breasts may secrete milk for two or three weeks. All these
symptoms may disappear and the tumor gradually diminish in size
from the absorption of the liquor amnii and mummification of the fetus.
Again, the fetus may macerate, suppurate, or become gangrenous, and
either cause general peritonitis, or its remains may be discharged
through the groin, vagina, bladder, or rectum.
Diagnosis. — Prior to the rupture of the pregnant tube there is often
nothing to suggest pregnancy. However, a diagnosis is sometimes
arrived at through an examination made because of the suspicion of
pregnancy on the part of the patient or because of pain in the iliac
fossae. When the tube is found distended and boggy we should alwa}-s
think of the possibility of ectopic gestation, and where there are irregu-
lar symptoms of pregnancy, with the uterus slightly enlarged and the
cervix soft, the presence of a distended tube is highly suspicious of
tubal pregnancy.
The expulsion of the decidua, accompanied by hemorrhage, is an
important symptom, and must be differentiated from an early uterine
abortion and from membranous dysmenorrhea. The diagnosis of rup-
ture of the tubal sac may be made where the previous history of
amenorrhea and more or less definite signs of pregnancy are followed
by the appearance of a sudden pain in the region of the tube, followed
by collapse. The diagnosis subsequent to the rupture will be made by
the above history, plus finding a pelvic hematocele or hematoma.
Differential Diagnosis. — Pelvic Jicmatocelc or hematoma due to
ectopic gestation, and that due to other causes, cannot be differentiated
unless the history points directly to this cause or the fetal remains can
be found in the blood-mass. So frequently is ectopic gestation the
cause of hematosalpinx that we are quite justified in ascribing it as the
cause where no other can be found.
Tubal pregnancy must be differentiated from a tube distended zvith
pus a?id serum. Prior to the rupture the symptoms and physical signs
49
770 SURGICAL DIAGNOSIS AND TREATMENT.
may be identical, as they also are at the time of the rupture. Here
the history of previous symptoms of pregnancy will often suffice to
make a diagnosis. After the effects of the rupture have subsided the
subsequent course differs more widely.
In ruptured tubal pregnancy the temperature is at first subnormal,
and then slowly rises, while in ruptured pyosalpinx the temperature
rises rapidly. In the former condition there are symptoms of internal
hemorrhage, the pain is of limited duration, and the general symptoms
of sepsis are not marked. In ruptured pyosalpinx there are no signs
of internal hemorrhage, the pain is prolonged, the pulse becomes rapid
and weak, and general symptoms of sepsis ensue.
Ovaria?i tinnors are to be excluded by the menstrual history and
the signs of pregnancy.
Subserous fibroids of the uterus are sometimes mistaken for a gesta-
tion-sac. The previous history of increased menstruation, the slow
development, the absence of signs of pregnancy, and the firm consist-
ency and close connection of the growth with the uterus will aid in
making a diagnosis.
Treatment. — Electricity has been recommended as a means of de-
stroying the life of the fetus before the tube has ruptured, with the
expectation that the fetus will be absorbed. This procedure must be
condemned. Nothing short of the remov^al of the gestation-sac is indi-
cated. At the time of rupture of the sac, unless there is every evidence
of extra-peritoneal hemorrhage, the indication is imperative for imme-
diate abdominal section.
After the gestation-sac has ruptured and the symptoms of shock
and internal hemorrhage have subsided the patient may survive and
the condition be palliated for days, weeks, and months without surgical
interference. The indication, however, is to operate on all intra-perito-
neal cases at the earliest possible moment by abdominal section,
removing all blood-clots, irrigating, removing the gestation-sac, and
draining.
Where the sac has ruptured between the broad ligaments the mass
is to be removed by way of the vagina ; the pelvic cavity is irrigated
and drained. This, however, can only be done in the early period of
gestation ; after the third month the abdominal route must be selected.
As late as the fourth month the embryo, tube, ovary, placenta, and
adjacent portions of the broad ligament can be removed in toto, but
later than the fourth month the placenta has assumed such proportions
and has become so firmly adherent to its point of attachment that it
must be dealt with separately from the gestation-sac. In the treatment
of the gestation-sac no attempt should be made to extirpate it, because
of the danger of bleeding and the injury to the bowel and ureters,
which are often firmly adherent. The sac should be opened and emp-
tied of its contents, then stitched to the abdominal incision, and packed
with gauze. J. Bland Sutton formulates the treatment of the placenta
as follows :
1. " When the placenta is situated above the fetus it is good practice
to attempt its removal with the fetus.
2. " In some instances the placenta becomes detached in the course
of the operation and leaves no choice.
THE X-RAYS IN SURGICAL DIAGNOSIS. JJl
3. " When the placenta is below the fetus it may be left.
4. " Should the placenta be left, the sac closed, and symptoms of
suppuration occur, then the wound must be reopened and the placenta
removed.
5. " If the fetus dies before the operation is attempted, the placenta
can be removed without risk of hemorrhage."
It is thus seen that the operation for tubal pregnancy after the fourth
month is fraught with great dangers. This emphasizes the importance
of early operative interference. No time should be lost in waiting for
the period of viability in case the child continues to live after the rup-
ture of the gestation-sac. The added hazards to the life of the mother
are too great to justify the almost hopeless endeavor to save the life of
the child. The indication is for immediate operative interference as
soon as the condition is recognized.
CHAPTER XVII.
THE X= (OR RONTQEN) RAYS IN SURGICAL DIAGNOSIS.
A NEW chapter in surgery was begun when, on the 8th da\' of De-
cember, 1895, Prof Rontgen of Wurzburg, Germany, announced his
discovery that certain rays of light could be made to pass through
objects hitherto considered opaque. For want of a name, he let x
represent this unknown quantity, this new manifestation of energy, and
to the present time it is known as the x- or Rontgen ray. The scientific
world was startled and amazed when photographs of the human hand
showed that light penetrated the soft parts, throwing only a faint
shadow, while the bones, resisting the passage of these mysterious
rays, stood out clear and definite, a perfect image of the bony skeleton.
Metallic substances were shown to be impervious to the rays, and when
it happened that bullets, needles, or buckshot were lodged in the tissues,
the photograph — or skiagraph, as it came to be called — showed the
dark shadow of the object and revealed its position with perfect
accuracy.
Like many other important discoveries, skiagraphy was arrived at
step by step. The first step was taken by Maxwell when he pro-
pounded his theory regarding light. The ether is the name applied to
the subtle fluid which pervades all bodies, liquid or solid, and occupies
the boundless space between the stars. Maxwell's theory is that waves
of light are identical with electro-magnetic disturbances in ether.
In 1879, William Crookes published the results of his wonderful
experiments upon what he called the radiant or fourth state of matter.
Three states of matter were familiar to every one — namely, solid,
liquid, and gaseous, but this fourth state was something new. Michael
Faraday had worked in the same direction, and had expressed his
belief that there existed a state of matter in which the molecules were
relatively as far apart as compared with those of a gas as the molecules
of a gas were as compared with those of a liquid. What Faraday
']'J2 SURGICAL DIAGNOSIS AND TREATMENT.
suggested, Crookes demonstrated by the aid of his now world-renowned
tubes.
The terms a)iodc and cathode were employed by Faraday to designate
the conductor terminals by which a current enters and leaves an elec-
trolytic cell — that is to say, a cell in which chemical changes in the
fluid are produced by the passage through it of an electric current.
The element from which the current passed into the electrolyte was
designated anode, while cathode was the name applied to the element
to which the current passed from the electrolyte. The effect of electric
discharges through rarefied gases was also studied by him, and Geiss-
ler, following up his researches, was at last able to produce from the
Geissler tubes the startling and beautiful effects now familiar to all.
The results observed at the anode in rarefied gases differed from those
seen at the cathode. At the cathode appeared a beautiful bluish light,
while the balance of the tube, including the space about the anode,
presented a general and diffusive glow. One of the effects of the
cathode was the production of fluorescence or phosphorescence, and it
was even further noticed that the influence from the cathode moved in
straight lines ; thus the term catJiodic rays came into use and the
cathode became a central point of interest (Morton and Hammer).
Crookes came to the conclusion that electrified particles were pro-
jected in straight lines from the cathode. In the air of the tube
exhausted to one-millionth of an atmosphere, and thus reduced to the
radiant or fourth state of matter, the molecules were so far apart that
these electrified particles were capable of passing with great .speed in a
straight line, and bombarded the opposite side of the tube. At the
same time the glass became fluorescent.
Hertz took the next step by proving that electro-magnetic dis-
turbances in ether possessed many of the properties of light, as refrac-
tion, reflection, dispersion, and polarization. He took a Crookes tube
— which is nothing more or less than a glass tube of any shape from
which the air has been exhausted — and found that the cathode rays in
passing through the tube were capable also of passing through opaque
substances tvithiii the tube. This was in 1891, and shortly afterward
Hertz died. Paul Lenard took up the investigation where Hertz, his
preceptor, laid it down, and two years afterward discovered that the
rays passed through opaque objects after leaving the tube, and in 1893
made the remarkable announcement that he had obtained photographs
through opaque substances by means of these rays. Strange to say,
his statement received little attention. The final step was taken when
Rontgen, on the 8th of November, 1895, while experimenting with a
Crookes tube covered with a shield of black cardboard, noticed that a
piece of barium-platinum-cyanide became phosphorescent. He worked
on, and found that the rays affected photographic plates in the same
way as light does, but, unlike light, these rays cannot be reflected, con-
centrated, or refracted outside the tube in which they have their origin.
In December, 1895, Rontgen laid his remarkable communication
before the Wurzburg Physico-medical Society in the following terms :
" I. If we pass the discharge from a large Ruhmkorff coil through a
Hittorf or a sufficiently exhau.sted Lenard, Crookes, or similar appa-
ratus, and cover the tube with a somewhat closely fitting mantle of thin
THE X-RAYS IN SURGICAL DIAGNOSIS. 773
black cardboard, we observe in a perfectly darkened room that a paper
screen washed with barium-platinum-cyanide lights up brilliantly, and
fluoresces equally well whether the treated side or the other be turned
toward the discharge-tube. Fluorescence is still observable two meters
away from the apparatus. It is easy to convince one's self that the
cause of the fluorescence is the discharge apparatus and nothing else.
" 2. The most striking feature of this phenomenon is that an influence
(Agens) capable of exciting brilliant fluorescence is able to pass through
the black cardboard cover, which transmits none of the ultra-violent
rays of the sun or of the electric arc ; and one immediately inquires
whether other bodies possess this property. It is soon discovered that
all bodies are transparent to this influence, but in very different degrees.
A few examples will suffice : Paper is very transparent ; the fluorescent
screen held behind a bound volume of 1000 pages still lighted up
brightly ; the printer's ink offered no perceptible obstacle. Fluorescence
was also noted behind two packs of cards ; a few cards held between
apparatus and screen made no perceptible difference. A single sheet
of tin-foil is scarcely noticeable ; only after several layers have been
laid on top of each other is a shadow clearly visible on the screen.
Thick blocks of wood are also transparent ; fir planks from 2 cm. to 3
cm. thick are but very slightly opaque. A film of aluminum about 15
mm. thick weakens the effect very considerably, though it does not
entirely destroy the fluorescence. Several centimeters of vulcanized
India rubber let the rays through. Glass plates of the same thickness
behave in a different way according as they contain lead (flint glass) or
not ; the former are much less transparent than the latter. If the hand
is held between the discharge-tube and the screen, the dark shadow of
the bones is visible within the slightly dark shadow of the hand. Water,
bisulphid of carbon, and various other liquids behave in this respect as
if they were very transparent. I was not able to determine whether
water was more transparent than air. Behind plates of copper, silver,
lead, gold, platinum, fluorescence is still clearly visible, but only when
the plates are not too thick. Platinum 0.2 mm. thick is transparent ;
silver and copper sheets may be decidedly thicker. Lead 1.5 thick is as
good as opaque, and was on this account often made use of. A wooden
rod 20 by 20 mm. cross-section, painted white with lead paint on one
side, behaves in a peculiar manner. When it is interposed between
apparatus and screen, it has almost no effect when the -t'-rays go
through the rod parallel to the painted side, but it throws a dark
shadow if the rays have to traverse the paint. Very similar to the
metals themselves are their salts, whether solid or in solution.
" 3. These experimental results and others lead to the conclusion
that the transparency of different substances of the same thickness is
mainly conditioned by their density ; no other property is in the least
comparable with this.
" The following experiments, however, show that density is not
altogether alone in its influence : I experimented on the transparency
of nearly the same thickness of glass, aluminum, calc-spar, and quartz.
The density of these substances is nearly the same, and yet it was
quite evident that the spar was decidedly less transparent than the
other bodies, which were very much like each other in their behavior.
774 SURGICAL DIAGNOSIS AXD TREATMENT.
I have not observed calc-spar fluoresce in a manner comparable with
glass.
"4. With increasing thickness all bodies become less transparent.
In order to find a law connecting transparency with thickness I made
some photographic observations, the photographic plate being partly
covered with an increasing number of sheets of tin-foil.
" 6. The fluorescence of barium-platino-cyanide is not the only
recognizable phenomenon due to ,i'-rays. It may be observed, first of
all, that other bodies fluoresce — for example, phosphorus, calcium
compounds, uranium glass, ordinary glass, calc-spar, rock salt, etc.
" Of especial interest in many ways is the fact that photographic dry
plates show themselves susceptible to x-rays. We are thus in a posi-
tion to corroborate many phenomena in which mistakes are ea.sy, and
I have, whenever possible, controlled each important occular observa-
tion on fluorescence by means of photography. Owing to the prop-
erty possessed by the rays of passing almost without any absorption
through thin sheets of wood, paper, or tin-foil, we take the impression
on the photographic plate inside the camera or paper cover whilst in a
well-lit room. In former days this property of the ray only showed
itself in the necessity under which we lay of not keeping undeveloped
plates, wrapped in the usual paper and board, for any length of time
in the vicinity of discharge-tubes. It is still open to question whether
the chemical effect on the silver salts of photographic plates is exer-
cised directly by the .r-rays. It is possible that this effect is due to the
fluorescent light, which, as mentioned above, may be generated on the
glass plate or perhaps on the layer of gelatin. ' Films ' may be used
just as well as glass plates.
" I have not as yet experimentally proved that the .;r-rays are able
to cause thermal effects, but we may very well take their existence as
probable, since it is proved that the fluorescent phenomenon alters the
properties of .I'-rays, and it is certain that all the incident x-rays do not
leave the bodies as such.
" The retina of the eye is not susceptible to these rays. An eye
brought close up to the discharge apparatus perceives nothing, although,
according to experiments made, the media contained in the eye are
fairly transparent.
" 7. As soon as I had determined the transparency of different sub-
stances of various thicknesses, I hastened to ascertain how the x-rays
behaved when passed through a prism — whether they were refracted
or not. Water and carbon disulphide in prisms of about 30° refractive
angle showed neither with the fluorescing screen nor with the photo-
graphic plates any sign of refraction. For purposes of comparison the
refraction of light-rays was observed under the same conditions ; the
refracted images on the plate were respectively about 10 mm. and 20
mm. from the non-refracted one. With an aluminum and a vulcanized
rubber prism of 30° angle I have obtained images on photographic
plates in which one may perhaps see refraction. But the matter is
very uncertain, and even if refraction exists it is so small that the
refractive index of the x-ray for the above materials can only be, at the
highest, 1.05. Using the fluorescent screen, I was unable to discover
THE X-RAYS IN SURGICAL DIAGNOSIS. TJl
any refraction at all in the case of the aluminum and the rubber
prism.
" Researches with prismas of denser metals have yielded, up to now,
no certain results, on account of the small transparency, and conse-
quently lessened intensity, of the transmitted ray.
" In view of this state of things, and the importance of the question
whether ;ir-rays are refracted on passing from one medium to another,
it is very satisfactory that this question can be attacked in another way
than by means of prisms. Finely powdered substances in sufficient
thicknesses only allow a very little of the incident light to pass through,
and that is dispersed by refraction and reflection. Now, powdered sub-
stances are quite as transparent to .f-rays as are solid bodies of equal
mass. Hence it is proved that refraction and regular reflection do not
exist to a noticeable degree. The experiments were carried out with
finely-powdered rock salt, with pulverulent electrolytic silver, and with
the zinc powder much used in chemical work. In no case was any
difference observed between the transparency of the powdered and solid
substance either when using the fluorescent screen or the photographic
plate.
" It follows from what has been said that the a'-rays cannot be con-
centrated by lenses ; a large vulcanized rubber and glass lens were
without influence. The shadow of a round rod is darker in the middle
than at the edge ; that of a tube filled with any substance more trans-
parent than the material of the tube is lighter in the middle than at
the edge.
" 8. The question of the reflection of the ,r-rays is settled in one's
mind by the preceding paragraphs, and no appreciable regular reflec-
tion of the rays from the substances experimented with need be looked
for. Other investigations, which I will describe here, lead to the same
result. Nevertheless, an observation must be mentioned which at first
sight appears to contradict the above statement. I exposed a photo-
graphic plate to the ,r-rays, protected against light rays by black paper,
the glass side being directed toward the discharge-tube. The sensitive
layer was nearly covered, star-fashion, with blanks of platinum, lead,
zinc, and aluminum. On developing the negative it was clearly notice-
able that the blackening under the platinum, lead, and especially under
the zinc, was greater than in other places. The aluminum had exer-
cised hardly any effect. It appeared, therefore, that the three above-
mentioned metals had reflected the rays. Nevertheless, other causes
for the greater blackening were thinkable, and in order to make sure
I made a second experiment, and laid a piece of thiri aluminum, which
is opaque to ultra-violent rays, though very transparent to ;r-rays,
. between the sensitive layers and the metal blanks. As again much the
same result was found, a reflection of A'-rays by the above-mentioned
metals was demonstrated. But if we connect these facts with the
observation that powders are quite as transparent as solid bodies, and
that, moreover, bodies with rough surfaces are, in regard to the trans-
mission of ,r-rays, as well as in the experiment just described, the same
as polished bodies, one comes to the conclusion that regular reflection,
as already stated, does not exist, but that the bodies behaved to the x-
rays as muddy media do to light.
776 SURGICAL DIAGNOSIS AND TREATMENT.
" Again, as I could discover no refraction at the point of passage
from one medium to another, it would seem as if the A'-rays went
through all substances at the same si)eed, and that in a medium which
is ever}'\vhere, and in which the material particles are imbedded ; the
particles obstructing the propagation of the a-rays in proportion to the
density of the bodies.
" 9. Hence it may be that the arrangement of the particles in the
bodies influences the transparenc}- — that, for example, equal thick-
nesses of calc-spar would exhibit different transparencies according as
the ra\-s were in the direction of the axis or at right angles to it.
Researches with calc-spar and quartz have yielded a negative result.
" 10. It is well known that Lenard, in his beautiful investigation on
Hittorf cathode rays passed through thin aluminum-foil, came to the
conclusion that these rays were actions in the ether and that they
passed diffusely through all bodies. I have been able to say the same
about my rays.
" In his last work Lenard has determined the absorption coefficient of
various bodies for cathode rays, and among other things for air, atmo-
spheric pressure at 4.1, 3.4, 3.1, per centimeter, and found it connected
Avith the exhaustion of the gas contained in the discharge apparatus.
In order to estimate the discharge pressure by the spark-gap method,
I used in my researches almost always the same exhaustion. I suc-
ceeded with a Weber photometer (I do not possess a better one) in
comparing the intensity of the light of my fluorescing screen at dis-
tances of about 100 mm. and 200 mm. from the discharge apparatus,
and found in the case of three tests agreeing well with one another
that it varied very nearly inversely as the square of the distance of the
screen from the discharge apparatus. Hence the air absorbs a very
much smaller fraction of the ;i"-rays than of the cathode rays. This
result is also quite in agreement with the result previously mentioned,
that the fluorescing light was still observable at a distance of two
meters from the discharge apparatus.
" Other bodies behave generally like air — that is to say, they are
more transparent for x-rays than for cathode rays.
"II. A further noteworthy difference in the behavior of cathode rays
and ,t--rays consists in the fact that, in spite of many attempts, I have
not succeeded, even with vtvy strong magnetic fields, in deflecting
;r-rays by a magnet. The magnetic deflection has been up to now a
characteristic mark of the cathode rays : it was, indeed, noticed by
Hertz and Lenard that there were different kinds of cathode rays,
' distinguishable from one another by their phosphorescing powers,
absorption, and magnetic deflection,' but a considerable deflection was
nevertheless observed in all cases, and I do not think this characteristic
will be given up without overwhelming evidence.
" 12. After experiments bearing specially upon this question it is
certain that the spot on the wall of the discharge apparatus which
fluoresces most decidedly must be regarded as the principal point of
the radiation of the ;r-rays in all directions. The ;i--rays thus start
from the point at which, according to the researches of different in-
vestigators, the cathode rays impinge upon the wall of the glass tube.
If one deflects the cathode rays within the apparatus by a magnet, it is
THE X-RAYS IN SURGICAL DIAGNOSIS. 'J'J'J
found that the x-rays are emitted from another spot — that is to say,
from the new termination of the cathode stream.
" On this account, also, the ,i'-rays, which are not deflected, cannot
merely be unaltered cathode rays passing through the glass wall. The
greater density of the glass outside the discharge-tube cannot, accord-
ing to Lenard, be made responsible for the great difference in the
' deflectability.'
" I therefore come to the conclusion that the .i--rays are not identical
with the cathode rays, but that they are generated by the cathode rays
at the glass wall of the discharge apparatus.
" 13. This excitation does not only take place in glass, but also in
aluminum, as I was able to ascertain with an apparatus closed by a
sheet of aluminum 2 mm. thick. Other substances will be studied
later on.
" 14. The justification for giving the name of ' rays ' to the influence
emanating from the wall of the discharge apparatus depends partly on the
very regular shadows which they form when one interposes more or less
transparent bodies between the apparatus and the fluorescing screen or
photographic plate. Many such shadow pictures, the formation of which
possesses a special charm, I have observed — some photographically.
For example, I possess photographs of the shadow of the profile of
the door separating the room in which was the discharge apparatus
from the room in which was the photographic plate ; also photographs
of the shadows of the bones of the hand, of the shadow of a wire
wound on a wooden spool, of a weight enclosed in a small box, of a
compass in which the magnetic needle is completely surrounded by
metal, of a piece of metal the lack of homogeneity of which was
brought out by the .:i'-rays, etc.
" To show the rectilinear propagation of the ;r-rays there is a pin-
hole photograph which I was able to take by means of the discharge
apparatus covered with black paper. The image is weak, but un-
mistakably correct.
"15. I looked very carefulU' for interference phenomena with ,r-rays,
but, unfortunately, perhaps only on account of the small intensity of
the rays, without success.
" 16. Researches to determine whether electrostatic forces affect
;i'-rays in any way have been begun, but are not completed.
" 17. If we ask what ,t'-rays, which certainly cannot be cathode rays,
really are, we are led at first sight, owing to their powerful fluorescing
and chemical properties, to think of ultra-violet light. But we im-
mediately encounter serious objections. If x-rays be in reality ultra-
violet light, this light must possess the following characteristics :
" {a) It must show no perceptible refraction on passing from air into
water, bisulphid of carbon, aluminum, rock salt, glass, zinc, etc.
" {b) It must not be regularly reflected to any appreciable extent
from the above bodies.
" {c) It must not be polarizable by the usual means.
" (^/) Its absorption must not be influenced by any of the properties
of substances to the same extent as it is by their density.
" In other words, we must assume that these ultra-violet rays behave
in quite a different manner to any infra-red visible or ultra-violent rays
JJ^ SURGICAL DIAGNOSIS AND TREATMENT.
hitherto known. 1 could not bring myself to this conclusion, and I
have therefore sought another explanation.
" There seems at least some connection between the new rays and
light-rays in the shadow pictures and in the fluorescing and chemical
activity of both kind of ra\'s. Now, it has been long known that,
besides the transverse light vibrations, longitudinal vibrations might
take place in the ether, and, according to the view of the different
physicists, must take place. Certainly their existence has not, up till
now, been made evident, and their properties have not on that account
been experimentally investigated.
" I\Iay not the new rays be due to longitudinal vibrations in the
ether ? I must admit that I have put more and more faith in this idea
in the course of my research, and it behooves me, therefore, to announce
my suspicion, although I know well that this explanation requires further
corroboration."
Apparatus required for a-^Ray Work.
The apparatus as at present employed consists of four parts :
1. The battery or electric machine. To supply the required electric
current any of the following may be utilized : {a) Static electrical
machines ; {p) induction coils whose primary circuits are supplied either
with continuous or alternating electrical currents ; (r) Telsa transformers,
utilizing oscillatory electrical currents.
2. The Crookes tube.
3. The fluoroscope.
Any person possessing a Holtz machine can easily connect it
with a Crookes tube at small expense and obtain satisfactory results
in .i--ray work. The positive and negative poles must first be deter-
mined in the following manner : Operate the machine in the dark and
observe the " combs " or " collectors " on each side of the revolving
glass disks. At those combs opposite one of the prime conductors a
brilliant " brush-light " discharge will be observed extending from the
combs along the surface of the glass. This " brush-discharge " is posi-
tive. The discharge at the negative combs appears as bright star-like
points of light. That prime conductor which is an extension of the
positive combs will be, by induction, a negative pole, while the other
prime conductor will be, by induction, a positive pole.
Having determined these polarities, the next thing is to connect to
each prime conductor a small condenser in the form of a Leyden jar.
The small jars are the best, as the larger ones are likely to crack the
glass of the Crookes tube.
The Leyden jars are connected to the prime conductors by the
internal armatures. The external armatures are connected to the
Crookes tube. The positive prime conductor, as previously deter-
mined, being connected to the internal armature of one Leyden jar, will
induce a negative charge in the external armature of the same jar.
This, therefore, becomes a negative pole or cathode, and the source of
the cathodic stream from which are produced the .r-rays. The exter-
nal armature of the other jar becomes the anode or positive pole.^
1 Morton and Hammer : The x-Ray, pp. 80, 81.
THE X-RAYS IN SURGICAL DIAGNOSIS.
779
Fig. -323 illustrates the manner of connecting a Crookes tube to a
Holtz machine.
By means of Tesla transformers ,i'-rays of great power may be ob-
tained, and by the more elaborate apparatus the photographic plate
has been affected at a distance of forty feet.
Up to the present time the formula of Tesla is the best that has
been introduced, and follows the principle that the highest efficacy of
the rays depends upon the three following factors : high voltage, low
amperage, and frequent oscillations. Dr. Trouton has estimated that the
duration of .r-radiation at each spark ranges from yo ^^ soo o^ ^
second. Spark coils or Holtz machines are objectionable as ray-
producers, since the period of the spark is much longer than the period
of radiation. In the apparatus constructed upon Telsa's formula by
the consumption of about three amperes and no volts a voltage of
about 3,000,000 can be obtained, and a frequency of about 400,000 a
Sccfion of
Ley den Jar
Fig. 323. — Manner of connecting a Crookes tube to a Holtz machine.
minute, or 66,666 a second. The time of exposure is also much
lessened by the use of Tesla's formula, being only eight or ten minutes
for any part of the body, instead of one or two hours, as formerly.
For the hands and feet the exposure is practically instantaneous.
For further information on this subject the reader is referred to The
x-Ray, or the Photography of the Invisible, by Dr. Morton and Mr.
Hammer.
The fluoroscope was invented by Edison, and is an invaluable in-
strument in ;r-ray examinations. Rontgen found that fluorescent sub-
jects were excited by the ,i--ray, and Salvioni devised a tube having at
one end a pasteboard cover coated with fine crystals of platino-cyanide
of barium, and at the other an eye-piece through which the operator
could view the shadow cast upon the fluorescent screen by the inter-
vention of the opaque object between it and the Crookes tube.
Edison, after experimenting with eighteen hundred different sub-
stances, found that tungstate of calcium had better fluorescent qualities
than platino-cyanide of barium, and adopted a large camera or dark
chamber in the form of a stereopticon, which allowed the operator to
use both eyes at a convenient distance from the screen.
By means of the fluoroscope the operator can determine whether
.r-rays are being produced or not in the Crookes tube. He can also
make a rapid inspection of the parts under examination, and from as
many different positions as necessary, before resorting to the photo-
graphic plate for a permanent record.
78o SURGICAL DIAGNOSIS AND TREATMENT.
Uses of the j^-Rays.
1. The Study of AnatoDiy. — The liuman skeleton, no matter how
carefully mounted, gives an imperfect idea of the true relations of the
bones to one another. Under the ,r-rays these relations are perfectly
represented; the junction of epiphysis with bone and the centers of
ossification are clearly shown. Fig. 324 shows the arteries of a dead
infant ; the vessels were injected with plaster of Paris through the
umbilical vein.
Prof Diakonof suggests that structures such as arteries, veins, and
bronchioles may be injected with mercury on account of the ease with
w^hich it can be manipulated, and the fact that the same injecting fluid
can be used over and over again. Two sets of vessels in the same
organ may be injected simultaneously — one set with mercury, and the
other with a material still more opaque. He recommends the follow-
ing mixtute : gypsum, cinnabar, and red lead, 20 parts each; flour, 10
parts ; add enough water to make the mixture sufficiently fluid to flow
into the smallest vessels. This shows a very dark shadow in the
skiagraph, in strong contrast to the shadow thrown by mercur>'.
2. F^'actiircs and Dislocations. — The position of the fragments in a
recent fracture, the condition of an ununited fracture, and the question
of the existence or non-existence of a dislocation can be settled by the
jr-rays.
3. Diseases of Bones. — In Fig. 325 is represented a tubercular focus
in the os calcis. In this case the ;i"-rays settled the diagnosis between
sarcoma and tubercular osteitis.
4. Tlie Detection of Foreign Bodies. — The first and most frequent
application of Rontgen's discovery was to the detection of foreign
bodies in the tissues. Fig. 326 represents the hand and wrist of a
colored girl w^ho seven years previously received a charge of buckshot.
In Fig. 327 is seen the knee of a man containing a bullet. This was
supposed to be a case of rheumatism until the radiograph was taken,
and then the fact was recalled that the patient had received a bullet in
the thigh seven months previously. The missile took a downward
course, and most unexpectedly found its way to the knee-joint, as
shown in the picture. A toy whistle in the esophagus of a little girl is
represented in Fig. 328. It had been in that position nine days when
Dr. Law removed it with esophageal forceps.
5. Mineral concretions, such as renal and vesical calculi, are im-
pervious to the .I'-rays, and with increased dexterity on the part of
examiners we may shortly expect much light in the diagnosis of these
bodies. Calcareous and atheromatous deposits in arteries can also be
determined with accuracy. Dr. Kiimmel of Hamburg has shown that
in arterial sclerosis the sclerosed arteries become visible as black stripes
on the skiagram. So far, gall-stones have not been seen by the a-rays.
Laurie and Leon by experiment hav^e shown that urinary calculi com-
posed of oxalate or phosphate of lime are more opaque than bone,
uric-acid calculi of almost the same opacity, and gall-stones very slightly
more opaque than flesh.
Potain and Cerbanisco claimed to make a differential diagnosis
between deposits of gout and rheumatism by the aid of -t'-rays. Ac-
Fig. 324.— Arteries of an infant (pliotograph by Dr. Artlnir Ayer Law).
Fig. 325.— Tubercular focus in the os calcis (photograpli by Dr. .Arthur .Vyer Law).
> ^
? p
I— I u
Fig. 328. — Toy whistle in the esophagus (photograpli by Dr. Artluir Ayer Law).
THE X-RA YS IN SURGICAL DIAGNOSIS. 78 1
cording to these observ^ers, the former show a translucent central part
limited by a narrow dark border, which is again enclosed in a wider
opaque area. This central clear portion is absent in rheumatic thicken-
ing. It is attributed to the greater permeabilit)- to the rays of urate
of soda as compared with rheumatic deposits, and also with the nor-
mal bone salts — a conclusion which they have confirmed by further
independent observations.
6. Under the fluoroscope the soft tissues can be studied. Thus, the
heart casting a darker shadow than the surrounding parts, its pulsations
can be observed as a wave of shadow changing shape, while another
shadow representing the liver is seen to rise and fall with respiration.
INDEX.
Abbe's operation, 198
rings, 248
Abdomen, contusions of, 207
diseases and injuries of, 201
enterectomy in wounds of, 213
examination of, 201
gunshot wounds of, 208
incised wounds of, 208
laparotomy in punctured wounds of, 21 1
non-penetrating wounds of, 208
omental grafting in wounds of, 214
penetrating wounds of, 209
search for perforations in, 212
stab-wounds of, 208
treatment after operation, 214
wounds of, 208
Abdominal aorta, aneurysm of, 43
cavity, irrigation of, 214
drainage, 214
hysterectomy, 742, 756
nephrectomy, 359
section, 206, 211, 732
adhesions found in, 247
after-treatment in, 214
arrest of hemorrhage, 212
closure and dressing of wound in,
214
for diagnosis, 206
for diseases of female generative or-
gans, 730
drainage in, 214
incision for, 212
preparation of patient in, 212
Abductors of larynx, paralysis of, 633
Abscess, of antrum, 589
appendicular, 274
of bone, 94
of brain, 487
initiatory stage, 488
operative treatment, 493
second stage, 489
third stage, 491
treatment of, 492
of breast, 676
cerebellar, 491, 494
cerebral, 487
from ear diseases, 486, 488, 494
Abscess, cold, 152
dorsal, 534
hepatic, 292
of hip-joint, 155
ischio-rectal, 332
of larynx, 617
of liver, 292
lumbar, 534
nephritic, 360
of pancreas, 315
perinephric, 360
peri nephritic, 360
perityphlitic, 274
of prostate, 417
psoas, 534
of rectum, 332
retropharyngeal, 195
treatment of, 196
spinal, 534
of spleen, 319
Acetabulum, fracture of, 116
Acromegaly, 105
Acromion process, fracture of, 65
Actinomycosis, 97
Adam's operation for Dupuytren's con-
traction, no
Adductors of larynx, paralysis of, 634
Adenitis, syphilitic, 671
tubercular, 671
Adenoma of breast, 678
Adenomata, 668
Adeno-sarcoma of breast, 679
Agraphia, 499
Air-passages, foreign bodies in, 605
Alexander's operation, 712
Alexia, 471, 499
Amenorrhea, 704
Amputation after injury, 88
indications for, 88
Anastomosis, intestinal, 247
Anderson's method of tendon-lengthen-
ing, 107
Anel's operation in aneurysm, 34
Anesthesia in aneurysm, 40
Aneurysm, 30
abdominal, 43
Anel's operation for, 34
7S3
784
INDEX.
Aneurysm, Antyllus's operation for, 35
aortic, 35
of arch of aorta, 35
ascending, 36
descending, 38
transverse, 37
arterio-venous, 48
axillary, 42
Brasdor's operation foi', 35
of carotid artery, 41
causes of, 30
cirsoid, 48
classification of, 30
compression in, 34
diagnosis of, 32
dissecting, 31
Esmarch's bandage in, 34
false, 31
femoral, 46
fusiform, 31
galvano-puncture in, 40
Hunterian operation for, 34
idiopathic, 30
iliac, 44
innominate, 39
Macevven's method in, 40
orbital or ophthalmic, 41
popliteal, 46
sacculated, 31
subclavian, 42
symptoms of, 32
traumatic, 30, 47
treatment of, 34
true sacculated, 31
varicose, 48
vertebral, 41
Wardrop's operation for, 35
Aneurysmal varix, 48
Angeiomata, 665
Ankle, examination of, 140
Ankle-joint disease, 162
tuberculosis of, 162
Anosmia, 606
Antrum of Highmore, 588
abscess of, 589
diseases of, 588
foreign growths in, 591
injuries of, 588
Antyllus, method of, in aneurysm, 35
Anus, artificial, 245
fissure of, 337
imperforate, 347
prolapse of, 327
pruritus of, 329
Aorta, abdominal, aneurysm of, 43
Aphasia, 471
Apoplexy, differential diagnosis of, 472
Appendicitis, 273
after-treatment of, 280
causes of, 274
classification of, 278
diagnosis of, 276
etiology of, 274
indications for operation in, 279
McBurney's plan of incising abdomi-
nal wall in, 280
obliterans, 279
perforating, 278
surgical treatment of, 279
symptoms of, 275
Apraxia, 471
Areas of brain, 456
Arm, cerebral center for, 458
Arteries, atheroma of, 29
calcification of, 30
compression of, 27
examination of, 27
inflammation of, 29
ligation of, 28
rupture of coats of, 27
special, arrest of hemorrhage in, 27
compression of, 28
wounds of, 27
Arteritis, 29
Artery of cerebral hemorrhage, 472
Artery and arteries, laceration of, in frac-
ture, 56
lenticulo-striate, 472
middle meningeal, hemorrhage from,
472
wounds of, 27
Arthritis, 148
causes of, 148
chronic rheumatoid, 164
gonorrheal, 164
gouty, 165
neuropathic, 165
pyemic, 151
rheumatic, 164
septic, 1 50
suppurative, 150
tubercular, 152
Arthrotomy, 83
Ascites, 203, 764
Aspiration in over-distention of ven-
tricles, 22
in paracentesis thoracis, 23
Atheroma, 29
Atony of bladder, 381
Atrophy of tongue, 180
INDEX.
785
Balanitis, 426
Barker's operation for fractured patella,
83
Bavarian splint, 85
Bichat, fissure of, 459
Bigelow's method of reducing disloca-
tions, 135
Bladder, atony of, 381
carcinoma of, 405
congenital deformities of, 427
diseases and injuries of, 375
examination of, 375
exstrophy of, 407
fibromata of, 405
hernia of, 409
inflammation of, 383
myomata of, 405
papillomata of, 404
rupture of, 378
sacculation of, 384
sarcomata of, 403
stone in, 386
tumors of, 404
wounds of, 377
Bodies, loose, in joints, 142
Bone, chondromata of, 99
diseases of, 89
fibromata of, 100
inflammation of, 89
chronic, 93
septic, 91
overgrowth of, 98
sarcomata of, loi
tuberculosis of, 94
tumors of, 98
malignant, loi
Bone-chips, decalcified, 247
Bone-plates, Senn's decalcified, 247
Bougies a boule, 435
filiform whalebone, 439
Brain, abscess of, 478
color of, 477
compression of, 470
concussion of, 469
examination of, 477
faradization of, for determining motor
centers, 477
foreign bodies in, 478
gunshot wounds of, 478
and membranes, injuries of, 469
motor areas of, 458
operations on, 478
pulsation of, 477
topography of, 455
treatment of, after operation, 478
50
Brain, wounds of, 478
Branchial cysts, 669
Breast, adeno-fibroma of, 678
adeno-sarcoma of, 679
cancer of, 679
cancer en cuirasse, 682
carcinoma of, 679
medullary, 681
scirrhous, 680
operation for, 681
contraindications for, 681
Halsted's, 682
soft, 681
cysts of, 678
diseases and injuries of, 675
examination of, 675
inflammation of, 676
neuroses of, 677
sarcoma of, 679
tumors of, 681
malignant, 679
treatment of, 681
Broca's centre of speech, 459
Bronchial tubes, 640
injuries of, 640
Bronchocele, 674
Buck's extension apparatus, 80
Bursae, affections of, no
Bursitis, no
Cachexia, 681
Calcification of arteries, 30
Calculus of prostate, 419
renal, 354
salivary, 179
of ureter, 373
vesical, 386
measuring, 392
operative treatment of, 393
preparatory treatment for operation
in, 396
sounding for, 388
symptoms of, 387
treatment of, 393
Cancer of breast, 679
chimney-sweep's, 447
en cuirasse, 682
Cancerous cachexia, 681
Caput succedaneum, 462
Carcinoma of brain, 496
of breast, 679
scirrhous, 680
retraction of nipple in, 680
soft, 681
of cervix uteri, 720
786
INDEX.
Carcinoma, diagnosis of, 669
of intestine, 234
of larynx, 629
diagnosis of, 630
of nose, 564
of ovary, 760
of pancreas, 316
of prostate, 413
of stomacli, 220
of uterus, 753
cause of, 749
of cerv^ix, 749
palliative treatment of advanced
cases, 751
Carcinomata, 668
Caries, 91
Cartilages, semilunar, dislocation of, 144
Castration, 450
for hypertrophied prostate, 415
Catarrh, 572
nasal, 572
atrophic, 575
hypertrophic, 572
Celiotomy for acute obstruction, 245
Center, cerebral, for arm, 458
for face, 458
for hearing, 460
for leg, 458
for smell, 460
for speech, 459
auditory, 459
visual, 459
for vision, 460
Cephalhematoma, 462
Cerebral topography, 455
Cervicitis, 719
Cervix uteri, amputation of, 722
carcinoma of, 749
lacerations of, 735
tuberculosis of, 734
Chancre, diagnosis of, 649
differential diagnosis of, 650
hard, 649
soft, or chancroid, 650
of tongue, 182
Chancroid, 649
treatment of, 650
Chapped lips, 172
Charcot's disease, 165
Chest, contusions of, 645
effusion into pleural cavity, 645
wounds of, 645
Chiene's method for finding Rolandic fis-
sure, 460
Chimney-sweep's cancer, 447
Cholecystectomy, 313
Cholecyst-enterostomy, 310
Cholecystotomy, 308
Cholelithotomy in two stages, 310
Chondritis, 617
Chondromata, 665
Chorditis tuberosa, 614
Claw-hand, 554
Cleft-palate, 174
Cloaca, 93
Cold in head, 570
Colon, distention of, with fluids, 245
tubage of, 245
Colostomy, 345
Compound fractures, 88
Compression for aneurysm, 34
of brain, 470
local, 471
total, 470
Concretions of tonsils, 194
Concussion of brain, 469
Contre-coup, fractures by, 52
Contusions of joints, 11 1
of kidney, 349
Coryza, acute, 572
Cracked lips, 172
Cracked-pot sound in fissured fracture of
skull, 466
Curvature of spine, 525
anterior, 530
lateral, 525
posterior, 529
Cyrtometer, Horsley's, 461
Cystitis, 383
treatment of, 385
Cystocele, 409
Cystoscope Leiter's, 391
Cysts of breast, 678
hydatid, of liver, 296
of kidney, 366
of liver, 296
multilocular, 760
of ovary, 760
dermoid, 760
of pancreas, 315
papillomatous, 761
of tubes, 759
tubo-ovarian, 761
unilocular, 760
Deformity, silver-fork, 74
Digestive tract, injuries and diseases of,
166
Dilatation of stomach, 231
of urethra, 437
nVDEX.
7^7
Diplopia from paralysis of fourth nerve,
481
Dislocations, 114
of ankle, 140
of astragalus, 142
of carpal bones from radius, 130
carpo-metacarpal, 131
causes of, 114
classification of, 114
of clavicle, 120
complications of, 116
compound, 117
congenital, 114
differential diagnosis of, 112
of elbow, 127
old unreduced, 130
etiology of, 114
examination of, 115
of femur, 134
backward, on dorsum ilii, 134
forward, 136
into sciatic notch, 134
of hip, 134
congenital, 138
diagnosis, 138
of humerus, 123
incomplete, 114
of lower jaw, 118
of knee, 139
metacarpal phalangeal, 131
methods of reduction of, 116
old, reduction of, 117
of patella, 140
pathological, 114
of phalanges, 131
of radius alone, 127
of radius and ulna, 127
reduction of, by manipulation, 117
of semilunar cartilages, 144
of shoulder, 123
luxatio erecta, 127
old unreduced, treatment of, 117
reduction of, by Kocher's method,
124
treatment of, 124
of sternum, 122
subastragaloid, 142
symptoms of, 115
traumatic, 114
treatment of, 1 16
of ulna alone, 130
of wrist, 130
Diverticula of esophagus, 196
Dugas's test, 67
Duplay's operation for hypospadias, 443
Dupuytren's contraction of fingers, 109
splint, 87
Dural separator, Horsley's, 477
Dysmenorrhea, 706
ECCHYMOSIS, 53
Echinococcus, 296
Edema of larynx, 614
Elbow, examination of, 120
Elbow-joint, diseases of, 163
dislocation of, 127
tuberculosis of, 163
Elephantiasis of nose, 556
Enchondroma of larynx, 625
Enchondromata, 99
Endocervicitis, 719
Endometritis, 718
Enterectomy, 252
in wounds of abdomen, 213
Enterocele, 258
Enterostomy, 244
Enterotomy, 244
Epididymitis, 429
Epilepsy, 504
idiopathic, 504
Jacksonian, 504
traumatic, 505
trephining for, 506
Epiphysis of humerus, separation of, 68
lower, 71
upper, 54
Epiplocele, 258
Epispadias, 445
Epistaxis, 564
Epithelioma, 667
of nose, 567
of tongue, 182
Epulis, 187
Esmarch's bandage in aneurysm, 34
Esophageal bougies, 198
Esophagectomy, 199
Esophagoscope, 198
Esophagotomy, 199
Esophagus, dilatation of, 198
diseases and injuries of, 196
gastrotomy in, 199
malformations of, 196
operations on, 189
sacculation of, 196
stricture of, 196
malignant, treatment of, 198
Esthesiometer, 538
Estlander's operation, 647
Ethmoidal sinuses, 594
Examination of patients, 19
788
INDEX.
Exostoses, 98
Exstrophy of bladder, 437
Extension apparatus, 116
External genitalia, 691
Extra-uterine pregnancy, 727
Extravasation of urine, 439
Face, cerebral centre for, 458
Fallopian tube, anomalies of, 698
tuberculosis of, 734
False passages, 422
Fat-embolism, 55
Fatty tumors of scalp, 463
Fecal impaction, 255
obstruction, 255
Female generative organs, 767
Fenger's method in ureteral stricture, 375
Fever after fracture, 55
Fibroids, uterine, 738
interstitial, 739
submucous, 739
subperitoneal, 739
Fibromata, 664
Fibromyomata, electrolysis in, 742
ergot in, 741
extirpation through abdominal incision,
742
morcellation in, 742
removal of uterine appendages for,
742
through vagina, 742
submucous, 739
subserous, of tubes, 759
Filiform whalebone bougies, 439
Fingers, Dupuytren's contraction of, 109
Fissure of anus, 337
of Bichat, 460
method of finding, 460
of Rolando, 460
Chiene's method of finding, 460
of Sylvius, 461
Fistula in ano, 333
blind, 335
complete, 334
gastric, 219
horseshoe, 336
incomplete, 334
and phthisis, 337
Floating kidney, 355
liver, 298
Fluhrer's aluminum probe, 483
Foreign bodies in air-passages, 596
in urethra, 423
Fracture or fractures, 49
of acromion process, 65
Fracture of astragalus, 87
Barton's, 75
classification of, 50
of clavicle, 60
of coccyx, 76
CoUes', 74
comminuted, 52
complete, 51
complications and consequences of,
55
compound, 52, 88
by contre-coup, 52
of coracoid process, 72
of coronoid process, 72
crepitus in, 53
deformity in, 53
diagnosis of, 52
displacements in, 53
evidence of, 52
of femur, 77
extra-capsular, 77
intra-capsular, 'j'j
lower end of, 81
neck of, 77
shaft of, 79
of fibula, 86
of great trochanter, 77
green-stick, 72
of hip, measurement in, 52, 78
of humerus, 65
lower end of, 68
shaft of, 65
upper end of, 66
with dislocation, 67
of hyoid bone, 62
of ilium, 77
immediate causes of, 52
incomplete, 50
by indirect violence, 52
of inferior maxilla, 60
intercondyloid, 51
intra-articular, 51
intra-capsular, 51
of ischium, "]"]
of leg, 84
of lower jaw, 60
of malar bone, 59
of malleolus, 87
of metacarpal bones, 75
mobility abnormal in, 53
by muscular action, 52
of nasal bones, 58
of olecranon, 71
of patella, 82
operative measures for, 82
INDEX.
789
Fracture, pathological, 80
of pelvis, 75
of phalanges, 75
Pott's, 86
of pubes, 76
of radius, lower end of, 74
shaft of, 73
and ulna, 72
upper end of, 73
of ribs, 63
of sacrum, 76
of scapula, 64
simple, 50
of skull, 465
base of, 467
compound, 465, 467
by contre-coup, 465
fissure of vault, 465
inner table of, 466
punctured, 467
simple, 466
vault of, 465
of sternum, 63
of superior maxilla, 5y
symptoms of, 53
T-shaped, 69, 81
of tibia, 85
toothed, 51
transverse, 51
of ulna, shaft of, V-shaped, 51
Fragilitas ossium, 96
Frontal sinus, diseases of, 592
tumors of, 593
sinuses, foreign bodies in, 593
inflammation of, 592
injuries of, 591
Gall-bladder, anatomy of, 298, 314
diagnosis of position of, 303
diseases and injuries of, 298
ducts of, 309
empyema of, 314
wounds of, 313
Gall-stones, 298
diagnosis of, 303
pathological changes produced by, 304
surgical treatment of, 307
Galvano-puncture in aneurysm, 40
Ganglion, 109
compound, log
Gastrectasia, 231
Gastric fistula, 219
Gastro-enterostomy, 231
Gastroscopy, 227
Gastrostomy, 199
Gastrostomy, Ssabanejew-Frank's opera-
tion, igq
Witzel's method of performing, 199
Generative organs, anomalies of, 695
diseases of, 685
methods of examination of, 685
positions for examination, 686
Girdner's telephonic probe, 483
Gleet, 433
treatment of, 433
Glioma, 496
Glottis, spasm of, 635
Goiter, 674
Gonorrhea, 425
abortive, 430
catarrhal, 429
complications of, 426
chronic, 433
irritative, 430
symptoms and complications of first
stage, 426
second stage, 428
third stage, 429
treatment of, 430
Gonorrheal rheumatism, 429
Gouty arthritis, 165
Hare-lip, 166
Head, diseases and injuries of, 455
gunshot wounds of, 482
Hearing, cerebral centre for, 459
Heart, diseases of, 22
injuries of, 24
over-distention of ventricles, 22
rupture of, 24
tapping cavity of, 22
wounds of, 24
Hematocele, 453
traumatic, 453
Hematosalpinx, 726
Hematuria in genito-urinary diseases, 376
Hemianopsia, 460
Hemorrhage, 27
in abdominal section, arrest of, 28, 206
into brain-substance, 473
cerebral, artery of, 472
extra-dural, 472
intra-cranial, 472
treatment of, 473
local treatment of, 28
from middle meningeal, 472
pancreatic, 315
subarachnoid, 473
subdural, 472
Hemorrhoids, 323
790
INDEX.
Hemorrhoids, arterial, 324
capillary, 324
cutaneous, 323
external, 323
internal, 324
treatment of, 326
venous, 323
Hepatotomy, 295
Heredity, 18
Hermaphrodism, 695
Hernia, 255
Bassini's method of radical cure of, 268
of bladder, 409
causes of, 256
Championniere's method of radical
cure of, 265
congenital, radical cure of, 261
diagnosis of, 259
diaphragmatic, 273
femoral, 259
Halsted's operation for, 268
incarcerated, 260
inguinal, 257
irreducible, 259
of Littre, treatment of, 261
lumbar, 273
Macewen's operation for, 267
obturator, 273
palliative treatment of, 270
perineal, 273
radical cure of, 263
strangulated, 260
differential diagnosis of, 261
umbilical, 271
varieties of, 257
ventral, 272
Herniotomy, 262
Hip-joint, disease of, 153
symptoms of first stage, 1 53
of second stage, 153
of third stage, 155
treatment of, 156
examination of, 131
tuberculosis of, 1 53
Hodgen's splint, 81
Hodgkin's disease, 672
Hoffa's appliance for curvature, 529
Horsley's cyrtometer, 461
dural separator, 477
Housemaid's knee, 1 10
Hunterian operation for aneurysm, 34
Hydrated testicle, 450
Hydrocele, 451
of cord, 453
incision of, 452
Hydrocele, symptoms of, 451
tapping of, 452
treatment of, 452
Hydrogen gas in intestinal perforation,
210
Hydrogen-test in intestinal injuries, 210
Hydronephrosis, 363
Hydrops ventriculorum, 496
Hydrosalpinx, 725
Hyperosmia, 596
Hypertrophy of lips, 172
of prostate, 410
Hypospadias, 443
treatment of, 443
Hysterectomy, abdominal, 74?, 756
supravaginal, partial, 744
total, 746
vaginal, 754
Hysterorrhaphy, 712
Imperforate anus, 347
Implantation of ureters, 371
Indian method of rhinoplasty, 582
Inflammation of bladder, 383
of bone, 89
of breast, 676
of veins, 25
Information obtained from patient, 18
Internal tensors of larynx, paralysis of,
635
Intestinal anastomosis, 247
obstruction, 237
acute, 237
chronic, 253
diagnosis of, 240
from intussusception, 237
operative treatment of, 244
surgical treatment of, 242
Intestine and intestines, carcinoma of,
234
diseases and injuries of, 233
examination of, 233
palpation of, 233
percussion of, 234
resection of, 252
strangulation of, by bands or divertic-
ula, 253
suturing of wounds of, 251
Intra-cranial hemorrhage, 472
Intussusception, 237
Intussusceptum, 237
Intussuscipiens, 237
Invagination of bowel, 237
Irrigation of joints, 114
Irritable ulcer, 338
INDEX.
791
Ischio-rectal abscess, 332
Ischochymia, 226
Jacksonian epilepsy, 504
Jaw and jaws, ankylosis of, 192
Esmarch's operation for, 193
carcinoma of, 189
closure of, 193
deformities of, 186
diseases of, 186
enchondroma of, 189
epithelioma of, 189
fibroma of, 188
lower operations on, 192
necrosis of, 187
osteomata of, 189
periostitis of, 187
phosphorus-necrosis of, 187
sarcoma of, 190
tumors of, 187
Joints, contusions of, in
examination of, 145
loose bodies in, 142
sprains of, in
tuberculosis of, 1 53
wounds and injuries of, n2, 113
Jury-mast, 540
Kangaroo tendon for deep sutures, 266
Keyes' operation for varicocele, 455
Kidney, cysts of, 366
diseases of, 347
examination of, 351
floating, 352
hydatid cysts of, 365, 749
injuries of, 349
movable, 352
sarcoma of, 366
surgical, 361
anatomy of, 347
tuberculosis of, 365
tumors of, 366
wounds of, 350
Knee-joint disease, 161
housemaid's, no
tuberculosis of, 161
Kocher's method of reducing dislocations
of shoulder, 123
operation for removal of entire tongue,
184
Kraske's operation for cancer of the in-
testine, 236
Laparotomy in abdominal wounds, 211
Laryngectomy, 644
Laryngitis, 608
acute infantile, 609
catarrhal, 608
chronic, 611
chorditis tuberosa, 614
diphtheritic, 604
sicca, 613
subglottic, chronic, 613
Laryngoscope, 588
Laryngoscopy, 588
Larynx, 588
abscess of, 617
burns and scalds of, 601
cancer of, 629
chondritis and perichondritis of, 617
contusions of, 593
diseases of, 608
dislocation of cartilages of, 584
edema of, 614
gunshot wounds of, 603
incised wounds, 603
intubation of, 642
malformations of, 638
malignant tumors of, 629
neuralgia of, 631
neuroses of, 631
paralysis of, 631
stenosis of, 637
strictures of, 636
syphilis of, 623
trachoma of, 614
tuberculosis of, 619
tumors of 623
ulcers of, 619 ^
wounds and injuries of, 600
external, 602
treatment of, 604
Lavage of stomach, 233
Lawn-tennis arm, 105
Leg, cerebral center for, 458
Leiter's cystoscope, 391
Leonard's trephine, 476
Leptomeningitis, 490
Ligature for internal piles, 327
Lilienthal's bullet probe, 484
Lip, cysts of, 171
epithelioma of 173
nevi of, 171
Lips, affections of, 166
chapped, 172
cracked, 172
hypertrophy of, 172
inflammation of, 172
tumors of, 171
wounds of, 172
792
INDEX.
Litholapaxy, 394
Lithotomy, lateral, 393, 399, 400
median, 393, 401
perineal, 393, 400
suprapubic, 393, 403
Lithotritcs, 395
Lithotrity, 395
perineal, 402
Littre's hernia, 261
Liver, abscess of, 292
dermoid cysts of, 291
diagnosis of, 293
diseases and injuries of, 290
examination of, 291
floating, 298
hydatid cysts of, 296
rupture of, 291
wounds of, 291
Loose bodies in joints, 142
Lordosis, 525
Loreta's operation, 230
Lupus of nose, 567
and syphilis, differential diagnosis of,
567
Luxatio erecta, 527
Macewen's method in aneurysm, 40
of compressing aorta, 29
charts, 489
operation for the radical cure of hernia,
267
Macroglossia, 180
Macrostoma, 170
Main en griffe, 554
Massage in sprains, 113
Mastitis, 676
Mastoid disease, incision of cells in, 494
Maxillary sinus, 599
McBurney's point, 275
Meatus, urinary, stricture of, 437
Meckel's ganghon, removal of, 546
Meningitis, 486
differential diagnosis of, 486
Menorrhagia, 705
Menstruation, disorders of, 704
Meteorismus peritonei, 281
Metritis, 718
Microstoma, 170
Mind-blindness, 471
Morbus coxae, 153
coxarius, 153
Morton's fluid, 223
Mother's mark, 27
Motor areas of brain, 456
paralysis of, 454
Mouth, diseases and injuries of, 179
Mucocele in frontal sinus, 605
Murphy's button, 268
Muscle, contractures of, 107
diseases and injuries of, 105
obturator internus, 133
ossification of, 107
rupture of, 105
wounds of, 106
Myalgia, 106
Myo-fibroma, 665
Myositis, 106
ossificans, 107
suppurative, 106
Myxomata, 665
Neck, abscess of, 670
cellulitis of, 670
contusions of, 671
cysts of, 669
diseases and injuries of, 669
malformations of, 669
tumors of, 671
wounds of, 671
Necrosis, 92
Nelaton's line, 138
Nephrectomy, 354, 358
Nephro-lithotomy, 357
Nephrorrhaphy, 358
Nerve or nerves, contusions and com-
pression of, 547
cranial, 479
extra-cranial lesions of, 550
intra-cranial lesions of, 481
facial, diagnosis of lesions of, 481, 550
fifth, diagnosis of lesions of, 481
methods of reaching, 546
glosso-pharyngeal, 482
great sciatic, diagnosis of lesions of, 555
inflammation of, 543
injuries and diseases of, 543
remote effects following, treatment
of. 549
median, diagnosis of lesions of, 553
musculo-spiral, diagnosis of lesions of,
553
olfactory, diagnosis of lesions of, 479
optic, diagnosis of lesions of, 480
pneumogastric, diagnosis of lesions of,
482
of posterior cervical muscles, division
of, for wry neck, 537
radial, diagnosis of lesions of, 553
recurrent laryngeal, diagnosis of lesions
of, 553
INDEX.
793
Nerve, sixth, diagnosis of lesions of, 481
special, diagnosis of lesions of, 550
spinal accessory, 482
ulnar, diagnosis of lesions of, 553
wounds of, 547
immediate effects of, 548
remote effects of, 549
treatment of, 549
Neuralgia, 544
epileptiform, 546
of scars, surgical treatment of, 546
treatment of, 546
Neuritis, 543
multiple, 544
Neuroses of larynx, 631
of nasal passages, 594
Nevi of lips, 171
of tongue, 185
Nevus, 27
Nose, abscess of, 580
accessory sinuses of, diseases and in-
juries of, 588
adenomata of, 563
angeiomata of, 563
asymmetry of, 576
atrophic catarrh of, 575
congenital malformations of, 58 1
deformities of, 580
enchondromata of, 563
exostoses and osteomata of, 563
fibromata of, 561
foreign bodies in, 557
hypertrophic catarrh of, 572
injuries of, 556
malignant growths in, 563
parasites in, 558
plugging of, 565
polypi of, 559
rhinoliths in, 558
septum of, diseases and displacements
of, 577
ulcers of, 566
Nose-bleed, 564
Obstruction, intestinal, 237
acute, 237
chronic, 253
diagnosis of, 231
operative treatment of, 244
surgical treatment of, 242
treatment of, 241
Omentum, sarcoma of, 289
Orchitis, 448
syphilitic, 448
differential diagnosis of, 448
Orchitis, tubercular, 449
Osseous system, injuries and diseases of,
49
Osteitis, syphilitic, 95
tubercular, 94
Osteo-malacia, 97
Osteo-myelitis, 91
Osteo-periostitis, 90
Ovarian cyst, 760
diagnosis of, 762
cystomata, 766
dermoids, 762
tumors, 759
Ovaries, anomalies of, 698
inflammation of, 727
removal of, 765
Ovariotomy, 765
Ovaritis, 727
Ovary, cysts of, 760
dermoid cysts of, 762
new growths in, benign, 756
malignant, 760
tuberculosis of, 734
tumors of, 762
Ozena, 576
Facet's disease, 676
Pain in injury and disease of abdomen,
202
Palate, cleft, 174
syphilis of, 179
tumors of, 179
ulceration of, 179
Palpation, bimanual, 689
Pancreas, abscess of, 315
cancer of, 316
cysts of, 315
diseases and injuries of, 314
Pancreatic hemorrhage, 315
Papillomata, 666
of bladder, 404
of rectum, 340
Paracentesis pericardii, 23
of right auricle, 22
thoracis, 646
Paralysis from injuries to brain, 471
of laryngeal nerve, 631
Paraphimosis, 445
Parotid gland, diseases of, 673
tumors of, 673
Parotitis, 673
Parturition, injuries due to, 698
Patella, fracture of, 82
treatment of, 82
Patients, examination of, 19
794
INDEX.
Patients, position of, 19
Pelvic abscess, 764
cellulitis, 728
hematocele, 453
inflammations, 724, 729
peritonitis, 728
treatment of, 730
Penis, amputation of, 446
diseases and injuries of, 443
epithelioma of, 445
and urethra, relative sizes of, 436
Pericardium, effusion into, 23
Perinephric abscess, 360
Perinephritic abscess, 360
Perineum, injuries of, 698
repair of, 699
rupture of, 698
complete, 700
incomplete, 700
surgery of, 698
Periproctitis, 332
Peritoneum, 281
carcinoma of, 288
examination of, 281
injuries and diseases of, 28 1
rupture of, 289
tumors of, 289
Peritonitis, 282
pelvic, 728
plastic, 282
septic, 283
suppurative, 285
tubercular, 286
Perityphlitic abscess, 274
Petit's triangle, 273
Pharynx, diseases of, 195
tumors of, 196
Phimosis, 427, 445
treatment of, 427
Phonendoscope, 205, 234
Piles. (See I-Jei>wrrhoids?)
Pleural cavity, effusions into, 645
Pneumatocele, 464
Polypus, nasal, 559
of rectum, 339
of uterus, 746
Pott's disease of spine, 530
differenual diagnosis of, 536
treatment of, 537
Iracture, 86
Pregnancy coexisting with fibroids, 741
extra-uterine, 766
Probe, Fliihrer's aluminum, 483
improvised, 485
Lilienthal's, 484
Probe, telephonic, of Girdner, 483
Proctitis, 330
Prolapse of anus, 327
of rectum, 328
of uterus, 713
Prostate gland, anatomy of, 409
atrophy of, 411
calculus of, 413, 419
carcinoma of, 413, 419
diseases of, 409
examination of, 412
hypertrophy of, 410
diagnosis of, 413
double castration for, 415
symptoms of, 41 1
treatment of, 413
injuries of, 409
sarcoma of, 419
tuberculosis of, 413
wounds of, 420
Prostatectomy, 415
Prostatic disease, 410
Prostatitis, 417
acute, 417
chronic, 417
follicular, acute, 417
chronic, 417
gouty, 418
parenchymatous, 418
tubercular, 419
Pruritus ani, 329
Psammoma, 667
Psoas abscess, 534
Ptosis, 481
Puffy tumor, 464
Pyloroplasty, 230
Pylorus, cicatricial stricture of, 233
digital divulsion of, 230
Pyonephrosis, 364
Pyosalpinx, 726, 764
Rachitis, 96
Ranula, 180
Rectum, cancer of, 236
diagnosis of, 235
condylomata of, 341
congenital malformations of, 345
examination of, 320
foreign bodies in, 320
inflammatory diseases of, 330
injuries and diseases of, 320
manual exploration of, 321
papillomata of, 340
polypus of, 339
prolapse of, 328
INDEX.
795
Rectum, stricture of, 341
syphilitic ulceration of, 331
tubercular ulceration of, 331
tumors of, 339
warty growths of, 340
wounds of, 322
Renal calculus, 354
Resection of ankle, 163
Respiratory tract, diseases and injuries
of. 556
Retention of urine, 380
Retro-pharyngeal abscess, 195
treatment of, 196
tumors, 196
Rhinitis, 570
purulent, 577
Rhinoliths, 558
Rhinoscleroma, 556
Rhinoscopy, 584
anterior, 585
posterior, 585
Rickets, 96
Rings, Abbe's, 248
Rolando, fissure of, 460
Chiene's method of fixing, 460
Rontgen rays in surgery, 771
Rupture of bladder, 378
of muscle, 105
of stomach, 217
Sacro-iliac joint disease, 158
tuberculosis of, 1 58
diagnosis of, 160
Salivary calculi, 179
Salpingitis, 724, 725
Saphenous vein, internal, varix of, 26
Sarcoma and sarcomata, 666
of bone, loi
diagnosis of, 104, 665
of ovary, 760
of skull, 496
of uterus, 748
diagnosis of, 749
Sayre's dressing for fractured clavicle, 61
jacket, 539
Scalp, contusions of, 463
diseases and injuries of, 462
fatty tumors of, 463
horns of, 464
sebaceous tumors of, 463
tumors of, 463
warts of, 464
wounds of, 462
Scars, neuralgia of, 546
Sciatica, 545
Sciatica, surgical treatment of 546
Scirrhous carcinoma of breast, 665
Scrotum, diseases of, 447
edema of, 447
elephantiasis of, 447
epithelioma of, 447
Senn's decalcified bone-plates, 247
Septic inflammation of bone, 91
treatment of, 92
Septum, nasal, abscess of, 580
deviation of, 577
hematoma of, 580
perforating ulcer of, 580
Sequestrotomy, 93
Sequestrum, 93
Shoulder, cerebral center for, 558
examination of, for injury, 119
Shoulder-joint disease, 163
tuberculosis of, 163
Silver-fork deformity, 74
Simple ulcer of tongue, 183
Sims' position, 687
Singer's node, 614
Skin, examination of, 20
Skull, injuries of, 464
Smith, Nathan R., anterior splint of, 81
Sounding for urinary calculus, 388
indications for, 388
Specula, 691
bivalve, 692
cylindrical, 692
examination with, 691
Sims', 692
Speech, Broca's center for. 459
Spermatic cord, diseases of. 453
hydrocele of, diffused, 453
encysted, 454
Sphenoidal sinus, 594
Sphincter ani, spasm of, 339
Sphincterismus, 339
Spina bifida, 521
Spinal cord, compression of, 510
concussion of, 510
hemorrhage into, 510
locahzation of injury of, 514
meningocele, 522
meningo-myelocele, 522
reflexes, 517
wounds of, 520
Spine, 506
abscess of, treatment of, 540
curvature of, anterior, 524
lateral, 625
posterior, 529
curvatures of, treatment of, 527
796
INDEX.
Spine, deformities of, 521
dislocations of, 520
examination of, 507
excurvation of, 529
extra-medullary, hemorrhage of, 510
fractures of, 512
diagnosis of position of, 513
intra-meduUary, hemorrhage of, 510
kyphosis of, 529
Pott's disease of, 530
railway, 508
sprains of, 508
surgical anatomy of, 506
operations on, 1 19
tuberculosis of, 530
tumors of, 525
Spleen, abscess of, 319
cysts of, 320
diagnosis of, 320
examination of, for injury, 317
rupture of, 320
tumors of, 320
wounds of, 317, 319
Splenectomy, 318
Spondylitis, 530
Sprains, 1 1 1
Squint, convergent, 481
Stomach, carcinoma of, 220
dilatation of, 231
diseases and injuries of, 216
examination of, 215
foreign bodies in, 217
irrigation of, 233
lavage of, 233
mechanical fixation of, 218
operations on, 231
rupture of, 217
ulcer of, 218
Stomach-contents, examination of, 222
Stone in the bladder, 386
Strabismus from paralysis of third nerve,
481
Strangulation of intestine by bands or
diverticula, 253
Stricture of esophagus, 196, 229
of pylorus, 229
of rectum, 341
of ureter, 374
of urethra, 434
Student's elbow, no
Suppurative inflammation of muscles,
106
teno-synovitis, 107
Suprameatal triangle, 494
Supravaginal hysterectomy, 744
Surgical kidney, 361
Suture, continuous, 213
Czerny-Lembert, 212
interrupted, 213
Lembert, 212
Sylvius, fissure of, 461
Syme's staff, 440
Synovitis, 145
Syphilides, 654
Syphilis, 648
hereditary, 660
of larynx, 622
methods of transmission of, 648
mucous patches in, 654
of nasal cavities, 568
of palate, 179
primary sore of, 649
stage of, 649
secondary stage of, 652
treatment of, 662
Syphilitic orchitis, 448
differential diagnosis of, 656
ulcers of palate, 179
Syphiloderm, 653
Talipes valgus, 112
Telangiectasis, 27
Telephone probe, 483
Temperature, value of, in diagnosis, 21
Teno-synovitis, 107
chronic tubercular, 108
suppurative, 108
Tenotomy, 107
Testicle and testicles, carcinoma of, 449
differential diagnosis of, 449
cystic, 451
hydrated, 450
inflammation of, 448
malignant, disease of, 449
retained, 451
sarcoma of, 449
syphilis of, 448
tuberculosis of, 449
tumors of, benign, 451
Thecitis, 107
Thermesthesiometer, 548
Thomas's splint, 157
Thoracoplasty, 647
Thoracotomy, 647
Thrombosis, 25
of lateral sinus, 492
Thyroid body, 674
Tobold's laryngoscope, 588
Tongue, atrophy of, 180
cancer of, 182
INDEX.
797
Tongue, chancre of, 182
epithelioma of, 182
hypertrophy of, 180
inflammation of, 181
injuries of, i8i
malformations of, 180
nevi of, 185
removal of, entire, 184
partial, 183
syphilis of, 181
tuberculosis of, 181
tumors of, 185
ulcer of, 181
wounds of, 181
Tongue-tie, 181
Tonsil and tonsils, calcareous concretions
of, 194
carcinoma of, 195
caseous concretions of, 194
hypertrophy of, 194
sarcoma of, 195
tumors, malignant, of, 195
Tonsillitis, 193
Tourniquet, Esmarch's, 28
Trachea, burns and scalds of, 639
malformations of, 638
tumors of, 639
Tracheocele, 639
Tracheotomy, 640
Trachoma of larynx, 614
Traumatic aneurysm, 30
dislocations, 114
Trendelenburg's position, 688
Trephining, operation of, 475
Tubal pregnancy, 766
diagnosis of, 766
Tuberculosis of ankle-joint, 162
of brain, 496
of elbow-joint, 163
of female genital tract, 733
of hip-joint, 153
of joints, 152
of knee-joint, 161
of sacro iliac-joint, 158
of shoulder-joint, 163
of spine, 530
of wrist-joint, 164
Tubes, new growths in, 759
Tufnell's method in aneurysm, 39
Tumors, 663
of bladder, 404
of bone, 98
of brain, 497, 500
differential diagnosis of, 497
general symptoms of, 497
Tumors of brain, prognosis of, 503
treatment of, 503
cartilaginous, 99, 665
of cerebellum, 503
classification of, 663
of connective tissue, 663
epithelial, 666
fatty, 463
intestinal, 234
of jaws, 187
of kidney, 366
of lips, 171
malignant, of bone, loi
of neck, 673
of nose, external, 556
ovarian, 762
of ovary, diagnosis of, 762
treatment of, 765
of parotid, 673
of rectum, 339
retro-pharyngeal, 196
of scalp, 463
of tongue, 185
Ulcer of nose, 566
siinple, of tongue, 183
of stomach, 218
syphilitic, of tongue, 183
tubercular, of tongue, 183
varicose, 26
Ureter, rupture of, 369
stricture of, 374
Ureteral calculus, 373
Ureterotomy, 371
Ureters, diseases of, 368
examination of, in female, 694
inflammation of, 373
injuries of, 368
methods of catheterizing, 694
surgical anatomy of, 368
Urethra, calculus lodged in, 423
diseases and injuries of, 420
foreign bodies in, 423
and penis, relative sizes of, 435
rupture of, 421
stricture of, 434
annular, 435
behind bulbo-membranous junction,
438
deep impassable, 439
permeable only to filiform bougies,
437
inflammatory, 434
of large caliber, 437
hnear, 435
798
INDEX.
Urethra, stricture of pendulous portion, 437
of meatus and fossa navicularis, 437
spasmodic, 434
tortuous, 435
Urethral fistula, 439
injections in early stage of gonorrhea,
432
Urethritis, 425
gonorrheal, 425
simple, 425
Urethrotomy, external, 440
internal, 438
without guide, 441
Urinary calculus, 386
pouches, 442
Urine, extravasation of, 439
retention of, 380
Uterine polypi, 747
sound, 693
Uterus, anomalies of, 697
anteflexion of, 708
artificial dilatation of, 693
gradual, 693
carcinoma of, 639, 753
displacement of, 708, 739
examination of, and bladder, 694
fibro-myomata of, 738
inflammations of, 717, 723
inversion of, 714
myomata of, 738
polypoid growths in, 738
interstitial, 739
submucous, 739
subperitoneal, 739
prolapse of, 713
reposition of, 709
retroflexion of, 709
retroversion of, 709
sarcoma of, 768
tumors of, 738
fibroid, 741
Vagina, injuries of, 698
Vaginal examination, 688
Vaginitis, 716
Varicocele, 454
Varicose veins, 25
Varix, 25
aneurysmal, 48
arterial, 48
of internal saphenous vein, 25
Vascular system, examination of, 22
Veins, diseases of, 24
varicose, 25
wounds of, 24
Velpeau's bandage, 61
dressing for dislocation, 121
for fracture of clavicle, 61
Ventricles, over-distention of, 22
Villous tumors of bladder, 405
Volvulus, 253
Vulva, inflammation of, 915
injuries of, 698
Wardrop's operation for aneurysms,
35
Warts on scalp, 464
Wens, 463
Wharton's duct, calculi in, 179
Wheelhouse's method of perinealsection,
441
Whitehead's operation for excision of
piles, 327
for removal of entire tongue, 185
Witzel's method of performing gastros-
tomy, 199
Word-blindness, 471
Word-deafness, 491
Wounds of abdomen, 208
after-treatment of. 214
arrest of hemorrhage in, 212
enterectomy in, 213
incision in, 212
non-penetrating, 208
omental grafting in, 214
penetrating, 209
diagnosis of, 209
preparation of patient for operation
in, 212
search for perforation in, 212
symptoms of, 209
treatment after operation, 214
of back, 51 1
gunshot, probing of, in head, 483 .
of intestine, suturing of, 212
of muscle, 106
of skull, 482
of tongue, 181
Wry neck, 537
X- or Rontgen rays, 771
Zinc-glue bandages for varicose veins,
26
CATALOGUE
OF THE
MEDICAL PUBLICATIONS
OF
W. B. SAUNDERS,
No, 925 WALNUT STREET, PHILADELPHIA.
Arranged Alphabetically and Classified under Subjects.
* I ^riE books advertised in this Catalogue as being sold by subscription are usually to be
obtained from traveling solicitors, b«t they will be sent direct from the office of pub-
lication (charges of shipment prepaid) upon receipt of the prices given. AU the other
books advertised are commonly for sale by booksellers in all parts of the United States j
but any book will be sent by the publisher to any address, carriage prepaid, on receipt o£
the published price.
Money may be sent at the risk of the publisher in either of the following ways r
A post-office money order, an express money order, a bank check, and in a registered
ktter. Money sent in any other way is at the risk of the sender.
See pages 30, 31, for a List of Contents classified according to subjects.
LATEST PUBLICATIONS.
Amer. Text-Book of Genito-Urinary and Skin Diseases. Page 4.
Macdonald^s Surgical Diagnosis, just Ready. See page 16.
Anders' Practice of Medicine — Revised Edition. See page 6.
Moore's Orthopedic Surgery, just Ready. See page 17.
Penrose's Diseases of Women. See page 18.
Mallory and Wright's Pathological Technique. See page 16.
Van Valzah and Nisbet's Diseases of the Stomach. See page 28.
American Year-Book of Medicine and Surgery. See page 6.
Senn's Genito-Urinary Tuberculosis. See page 25.
Sutton and Giles' Diseases of Women. See page 28.
Stoney's Nursing — Revised Edition. See page 27.
Garrigues' Diseases of Women — Revised Edition. See page ii.
Keen's Surgical Complications of Typhoid Fever. See page I5.
Gould and Pyle's Curiosities of Medicine. See page n.
De Schweinitz' Diseases of the Eye — Revised Edition. Page lo.
Chapin's Compendium of Insanity, just Ready. See page 8.
Church and Peterson's Nervous and Mental Diseases. Page 9.
Saunders' Medical Hand-Atlases. See page 2.
DaCosta's Surgery — Revised and Enlarged Edition. See page lo.
SPECIAL ANNOUNCEMENT.
Mr. Saunders is pleased to announce that arrangements have been completed for the
publication of an English edition of the world-famous
Lehmann medicinische Handatlanten.
For scientific accuracy, pictorial beauty, compactness, and cheapness these books
surpass any similar volumes ever published. Each volume contains from
50 to 100 Colored Plates,
besides numerous other illustrations in the text. These colored plates have been executed
by the most skilful German lithographers, in some cases twenty or more impressions being
required to obtain the desired result. There is a full and appropriate description of each
plate (printed, for convenience, opposite the plate), together with a condensed outline of
the subject to which the book is devoted.
The same careful and competent editorial supervision will be secured in the
English edition as in the originals. The translations will be directed and edited by the
leading American specialists in the different sul^jects.
The great advantage of natural pictorial representation is indisputable. For lasting and
practical knowledge, one accurate illustration is better than several pages of dry
description.
These Atlases offer a ready and satisfactory substitute for clinical observation, avail-
able only to the residents of large medical centers ; and with such persons the requisite
variety is seen only after long years of routine hospital service.
By reason of their projected universal translation and reproduction, affording inter-
national 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
cflfer them at a price heretofore unapproached in cheapness. The success of the under-
taking is demonstrated by the fact that volumes have already appeared in German, English,
French, Italian, Russian, Spanish, Danish, Swedish, and Hungarian.
While appreciating the value of such colored plates, the profession has heretofore been
practically debarred from purchasing similar works because of their extremely high price,
made necessary by the limited sale and the enormous expense of production. The very
low price of these Atlases will place them within the reach of even the novice in practice.
NOW READY.
Atlas of Internal Medicine and Clinical Diagnosis. By Dr. Chr. Jakob, of Erlangen. Edited
by Augustus A. Eshner, M.D., Professor of Clinical Medicine in the Philadelphia Polyclinic; At-
tending Physician to the Philadelphia Hospital. 68 colored plates, and 64 illustrations in the text.
Cloth, S3. 00 net.
Atlas of Legal IMedicine. By Dr. E. R. von Hofmann, of Vienna. Edited by Frederick Peter-
son, M.D., Clinical Professor of Mental Diseases, Woman's Medical College, New York; Chief
of Clinic, Nervous Dept., College of Physicians and Surgeons, New York. With 120 colored fig-
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Atlas of Diseases of the Larynx. By Dr. L. Grunwald, of Munich. Edited by Charles P.
Grayson, M.D., Lecturer on Laryngology and Rhinology in the University of Pennsylvania;
Physiclan-in-Charge, Throat and Nose Department, Hospital of the University of Pennsylvania.
With 10/ colored figures on 44 plates, and 25 text-illustrations. Cloth, I2.50 net.
Atlas of Operativ Surgery. By Dr. O. Zuckf.rkandl, of Vienna. Edited by J. Chalmers
DaCosta, M.D., Clinical Professor of Surgery, Jelilerson Medical College, Philadelphia ; Surgeon
to the Philadelphia Hospital. With 24 colored plates, and 217 text illustrations. Cloth, I3.00 net.
Atlas of Syphilis and the Venereal Diseases. By Prof. Dr. Franz Mracek, of Vienna. Edited
by L. Bolton Bangs, M.D., late Professor of Genito-Urinary and Venereal Diseases, New York
Post-Graduate Medical School and Hospital. With 71 colored plates from original water-colors,
and 16 black-and-white illustrations. Cloth, ^3.50 net.
IN PREPARATION.
Atlas of External Diseases of the Eye. By Dr. O. Haab, of Zurich. Edited by G. E.
DE ScHWEiNiTZ, M.D., Professor of Ophthalmology, Jefl!"erson Medical College, Philadelphia.
With 100 colored illustrations.
Atlas of Skin Diseases. By Prof. Dr. Franz Mracek, of Vienna. With 80 colored plates from
original water-colors.
Atlas of Pathological Histology. Atlas of Operative Gynecology.
Atlas of Orthopedic Surgery. Atlas of Psychiatry.
Atlas of General Surgery, Atlas of Diseases of the Ear.
THE AMERICAN TEXT-BOOK SERIES.
AN AMERICAN TEXT=BOOK OF APPLIED THERAPEUTICS.
By 43 Distinguished Practitioners and Teachers. Edited by James C.
Wilson, M.D., Professor of the Practice of Medicine and of Clinical
Medicine in the Jefferson Medical College, Philadelphia. One hand-
some imperial octavo volume of 1326 pages. Illustrated. Cloth,
$7.00 net; Sheep or Half Morocco, $8.00 net. Soid by Subscription.
" As a work either for study or reference it will be of great value to the practitioner, as
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with this one in practical value to the working physician." — Chicago Clinical Review.
"■ The whole field of medicine has been well covered. The work is thoroughly prac-
tical, and while it is intended for practitioners and students, it is a better book for the general
practitioner than for the student. The young practitioner especially will find it extremely
suggestive and helpful." — The Indian Lancet.
AN AMERICAN TEXT=BOOK OF THE DISEASES OF CHILDREN.
By 61 Eminent Contributors. Edited by Louis Starr, M.D. , Physi-
cian to the Children's Hospital, Philadelphia, etc.; assisted by
Thompson S. Westcott, M.D., Attending Physician to the Dispen-
sary for Diseases of Children, Hospital of the University of Pennsyl-
vania. In one handsome imperial octavo volume of 1190 pages,
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"This is far and away the best text-book on children's diseases ever published in the
English language, and is certainly the one which is best adapted to American readers.
We congratulate the editor upon the result of his work, and heartily commend it to the
attention of ever)' student and practitioner. ' ' — Americati Journal of the Medical Sciences.
AN AMERICAN TEXT=BOOK OF DISEASES OF THE EYE, EAR,
NOSE, AND THROAT.
By 58 Prominent Specialists. Edited by G. E. de Schweinitz, M.D.,
Professor of Ophthalmology in the Jefferson Medical College, Phila-
delphia ; and B. Alexander Randall, M.D., Professor of Diseases
of the Ear in the University of Pennsylvania and in the Philadelphia
Polyclinic. Ready soon.
Illustrated Catalogue of the ** American Text-Books" sent free upon application*
4 Medical Publications of W. B. Saunders.
AN AMERICAN TEXT-BOOK OF GENITO=URINARY AND SKIN
DISEASES.
By 47 Eminent Specialists and Teachers. Edited by L. Bolton
Ban(;s, M.D., Late Professor of Genito-Urinary and Venereal Diseases,
New York Post-Graduate Medical School and Hospital ; and W.
A. Hardaway, M.D., Professor of Diseases of the Skin, Missouri
Medical College. Cloth, $7.00 net; Sheep or Half Morocco, $8.00 net.
This latest addition to the series of " American Text-Books " it is confidently believed will meet
the requirements of both students and practitioners, giving, as it does, a comprehensive and detailed
presentation of tile 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 in regard to the particular views set
forth, but have offered every facility lor 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 concerned.
AN AMERICAN TEXT=BOOK OF GYNECOLOGY, MEDICAL AND
SURGICAL.
By 10 of the Leading Gynecologists of America. Edited by J. M.
Baldy, M.D., Professor of Gynecology in the Philadelphia Polyclinic,
etc. Handsome imperial octavo volume of over 700 pages, with 360
illustrations in the text, and 37 colored and half-tone plates. Cloth,
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" It is practical from beginnimg to end. Its descriptions of conditions, its recommen-
dations for treatment, and above all the necessary technique of different operations, are
clearly and admirably presented. . . . It is well up to the most advanced views of the
day, and embodies all the essential points of advanced American gynecology. It is destined
to make and hold a place in gynecological literature which will be peculiarly its own." —
Medical Record, New York.
AN AMERICAN TEXT=BOOK OF LEGAL MEDICINE AND TOXI-
COLOGY.
Edited by Frederick Peterson, M.D., Clinical Professor of Mental
Diseases in the Woman's Medical College, New York; Chief of Clinic,
Nervous Department, College of Physicians and Surgeons, New York ;
and Walter S. Haines, M.D., Professor of Chemistry, Pharmacy,
and Toxicology in Rush Medical College, Chicago. In Preparation.
AN AMERICAN TEXT=BOOK OF OBSTETRICS.
By 15 Eminent American Obstetricians. Edited by Richard C. Nor-
Ris, M.D.; Art Editor, Robert L. Dickinson, M.D. One handsome
imperial octavo volume of over 1000 pages, with nearly 900 beautiful
colored and half-tone illustrations. Cloth, $7.00 net; Sheep or Half
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J. C. Skene, Professor of Gynecology in the Long Island College Hospital, Brooklyn, N. V.
" This is the most sumptuously illustrated work on midwifery that has yet appeared. In
the number, the excellence, and the beauty of production of the illustrations it far surpasses
every other book upon the subject. This feature alone makes it a work which no medical
library should omit to purchase." — British Medical Journal.
" As an authority, as a book of reference, as a ' working book ' for the student or prac-
titioner, we commend it because we believe there is no better." — A7nerica7i Journal of the
Medical Sciences.
Illustrated Catalogue of the ^'American Text-Books " sent free upon application.
Medical Publications of W. B, Saunders. 5
AN AMERICAN TEXT=BOOK OF PATHOLOGY.
Edited by John Guiteras, M.D., Professor of General Pathology and
of Morbid Anatomy in the University of Pennsylvania ; and David
RiESMAN, M.D., Demonstrator of Pathological Histology in the
University of Pennsylvania. In Prepai-ation.
AN AMERICAN TEXT=BOOK OF PHYSIOLOGY.
By I o of the Leading Physiologists of America. Edited by William
H. Howell, Ph.D., M.D., Professor of Physiology in the Johns Hop-
kins University, Baltimore, Md. One handsome imperial octavo
volume of 1052 pages. Illustrated. Cloth, $6.00 net ; Sheep or Half
Morocco, $7.00 net. Sold by Subscription.
" We can commend it most heartily, not only to all students of physiology, but to every
physician and pathologist, as a valuable and comprehensive work of reference, written by
men who are of eminent authority in their own special subjects." — London Lancet.
" To the practitioner of medicine and to the advanced student this volume constitutes,
we believe, the best exposition of the present status of the science of physiology in the
English language." — American Journal of tlie A/edical Sciences.
AN AMERICAN TEXT=BOOK OF SURGERY. Second Edition.
By 13 Eminent Professors of Surgery. Edited by William W. Keen,
M.D., LL.D., and J. William White, M.D., Ph.D. Handsome
imperial octavo volume of 1250 pages, with 500 wood-cuts in the text,
and 39 colored and half-tone plates. Thoroughly revised and enlarged,
with a section devoted to " The Use of the Rontgen Rays in Surgery."
Cloth, $7.00 net; Sheep or Half Morocco, $8.00 net. Sold by Sub-
scription.
" Personally, I should not mind it being called THE Text-Book (instead of A Text-
Book), for I know of no single volume which contains so readable and complete an account
of the science and art of Surgery as this does." — EDMUND Owen, F.R.C.S., Member of
the Board of Examitiers of the Royal College of Stirgeotis, England.
" If this text-book is a fair reflex of the present position of American surgery, we must
admit it is of a very high order of merit, and that English surgeons will have to look very
carefully to their laurels if they are to preserve a position in the van of surgical practice." —
London Lancet.
AN AMERICAN TEXT=BOOK OF THE THEORY AND PRACTICE
OF MEDICINE.
By 12 Distinguished American Practitioners. Edited by William
Pepper, M.D., LL.D., Professor of the Theory and Practice of Medi-
cine and of Clinical Medicine in the University of Pennsylvania. Two
handsome imperial octavo volumes of about 1000 pages each. Illus-
trated. Prices per volume : Cloth, $5.00 net ; Sheep or Half Morocco,
g6.oo net. Sold by Subscription.
" I am quite sure it will commend itself both to practitioners and students of medicine,
and become one of our most popular text-books." — Alfred Loomis, M.D., LL.D., Pro-
fessor of Pathology and Pt-actice of Medicine, University of the City of New York.
" We reviewed the first volume of this work, and said : ' It is undoubtedly one of the
best text-books on the practice of medicine which we possess.' A consideration of the
second and last volume leads us to modify that verdict and to say that the completed work
is in our opinion the best o{ its kind it has ever been our fortune to see." — A^ew York Medical
Journal.
Illtfstrated Catalogue of the "American Text-Books'* sent free upon application.
6 Medical Publications of W. B. Saunders.
AN AMERICAN YEAR-BOOK OF MEDICINE AND SURGERY.
A Yearly Digest of Scientific Progress and Autlioritative 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 Georcie M. Gould, M.D. One handsome imperial
octavo volume of about 1200 pages. Uniform in style, size, and
general make-up with the "American Text-Book" Series. Cloth,
$6.50 net ; Half Morocco, ^7.50 net. So/t/ by Subscription.
" It is difficult to know wliich to admire most — the research and industry of the distin-
guished band of experts whom Dr. Gould has enlisted in the service of the Year-Book, or the
wealth and abundance of the contributions to every department of science that have been
deemed worthy of analysis. . . . It is much more than a mere compilation of abstracts,
for, as each section is entrusted to experienced and able contributors, the reader has the
advantage of certain critical commentaries and expositions . . . proceeding from writers
fully qualified to perform these tasks. . . . It is emphatically a book which should find
a place in every medical library, and is in several respects more useful than the famous
'Jahrbiicher' of Gemiany." — London Lancet.
ANDERS' PRACTICE OF MEDICINE. Second Edition.
A Text-Book of the Practice of Medicine. By James M. Anders,
M.D., Ph.D., LL.D., Professor of the Practice of Medicine and of
Clinical Medicine, Medico-Chirurgical College, Philadelphia. In one
handsome octavo volume of 1287 pages, fully illustrated. Cloth,
$^.^0 net; Sheep or Half Morocco, $6.50 net.
" It is an excellent book, — concise, comprehensive, thorough, and up to date. It is a
credit to you ; but, more than that, it is a credit to the profession of Philadelphia — to us."
James C. Wilson, Professor of the Practice of Medicine and Clinical Medicine, Jefferson
Medical College, Philadelphia.
" I consider Dr. Anders' book not only the best late work on Medical Practice, but by
far the best that has ever been published. It is concise, systematic, thorough, and fully up
to date in everything. I consider it a great credit to both the author and the publisher." —
A. C. COWPERTHWAITE, President of ihe Illinois Homeopathic Medical Association.
ASHTON'S obstetrics. Fourth Edition, Revised.
Essentials of Obstetrics. By W. Easterly Ashton, M.D., Pro-
fessor of Gynecology in the Medico-Chirurgical College, Philadelphia.
Crowm octavo, 252 pages; 75 illustrations. Cloth, $1.00; interleaved
for notes, $1.25.
[See Saunders^ Quesiioti-Conipends, page 21.]
<' Embodies the whole subject in a nut-shell. We cordially recommend it to our read-
ers." — Chicago Medical Times.
BALL'S BACTERIOLOGY. Third Edition, Revised.
Essentials of Bacteriology ; a Concise and Systematic Introduction
to the Study of Micro-organisms. By M. V. Ball, M.D., Bacteriol-
ogist to St. Agnes' Hospital, Philadelphia, etc. Crown octavo, 218
pages; 82 illustrations, some in colors, and 5 plates. Cloth, ^i.oo;
interleaved for notes, $1.25.
[See Saunders' Question- Compends, page 21.]
" The student or practitioner can readily obtain a knowledge of the subject from a perusal
of this book. The illustrations are clear and satisfactory." — Medical Record, New York.
Medical Publications of W. B. Saunders. 7
BASTIN'S BOTANY.
Laboratory Exercises in Botany. By Edson S. Bastin, M.A.,
late Professor of Materia Medica and Botany, Philadelphia College of
Pharmacy. Octavo volume of 536 pages, with 87 plates. Cloth, $2.50.
"It is unquestionably the best text-book on the subject that has yet appeared. The
work is eminently a practical one. We regard the issuance of this book as an important
event in the history of pharmaceutical teaching in this country, and predict for it an unquali-
fied success." — Alutiini Report to the Philadelphia College of Phartnacy.
"There is no work like it in the pharmaceutical or botanical literature of this country,
and we predict for it a wide circulation." — American Journal of Pharmacy.
BECK'S SURGICAL ASEPSIS.
A Manual of Surgical Asepsis. By Carl Beck, M.D., Surgeon to
St. Mark's Hospital and the New York German Poliklinik, etc. 306
pages; 65 text-illustrations, and 12 full-page plates. Cloth, $1.25 net.
" An excellent exposition of the ' very latest ' in the treatment of wounds as practised
by leading German and American surgeons." — Birmingha7n (Eng.) Medical Review.
"This little volume can be recommended to any who are desirous of learning the details
of asepsis in surgery, for it will serve as a trustworthy guide." — London Lancet.
BOISLINIERE'S OBSTETRIC ACCIDENTS, EMERGENCIES, AND
OPERATIONS.
Obstetric Accidents, Emergencies, and Operations. By L. Ch.
BoiSLiNiERE, M.D., late Emeritus Professor of Obstetrics, St. Louis
Medical College. 381 pages, handsomely illustrated. Cloth, ^2.00 net.
" It is clearly and concisely written, and is evidently the work of a teacher and practi-
tioner of large experience." — Bt-itish Medical Journal.
" A manual so useful to the student or the general practitioner has not been brought to
our notice in a long time. The field embraced in the title is covered in a terse, interesting
way." — Vale Medical Journal.
BROCKWAY'S MEDICAL PHYSICS. Second Edition, Revised.
Essentials of Medical Physics. By Fred J. Brockway, M.D,,
Assistant Demonstrator of Anatomy in the College of Physicians and
Surgeons, New York. Crown octavo, 330 pages ; 155 fine illustrations.
Cloth, $1.00 net ; interleaved for notes, ^1.25 net.
[See Samiders' Question- Compends, page 21.]
" The student who is well versed in these pages will certainly prove qualified to com-
prehend with ease and pleasure the great majority of questions involving physical principles
likely to be met with in his medical studies." — American Practitioner and News.
"We know of no manual that affords the medical student a better or more concise
exposition of physics, and the book may be commended as a most satisfactory presentation
of those essentials that are requisite in a course in medicine." — Nezv York Medical Journal.
*' It contains all that one need know on the subject, is well written, and is copiously
illustrated." — Medical Record, New York.
BURR ON NERVOUS DISEASES.
A Manual of Nervous Diseases. By Charles W, Burr, M.D.,
Clinical Professor of Nervous Diseases, Medico-Chirurgical College,
Philadelphia ; Pathologist to the Orthopedic Hospital and Infirmary
for Nervous Diseases; Visiting Physician to St. Joseph's Hospital, etc.
Jn Preparation.
8 Medical Publications of W. B. Saunders.
BUTLER'S MATERIA MEDICA, THERAPEUTICS, AND PHAR-
MACOLOGY.
A Text-Book of Materia Medica, Therapeutics, and Pharma-
cology. By George ¥. 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 Theraj^eutics,
Northwestern University, Woman's Medical School, etc. Octavo, 858
pages, illustrated. Cloth, $4.00 net; Sheep, $5.00 net.
" Taken as a whole, the book may fairly be considered as one of the most satisfactory
of any single-volume works on materia medica in the market." — Journal of the American
Medical Association.
" The work is executed in a clear, concise, and practical manner, and should meet with
a hearty endorsement from the students of our up-to-date colleges. The book will l^e found
a valuable work of reference for the practitioner." — Americati j\Iedico-Surgical Bulletin.
CASSELBERRY ON THE NOSE AND THROAT.
Diseases of the Nose and Throat. By W. E. Casselberry, Pro-
fessor of Laryngology and Rhinology in the Northwestern University
Medical School, Chicago. In Preparation.
CERNA ON THE NEWER REMEDIES. Second Edition, Revised.
Notes on the Newer Remedies, their Therapeutic Applications
and Modes of Administration. By David Cerna, M.D., Ph.D.,
formerly Demonstrator of and Lecturer on Experimental Therapeutics
in the University of Pennsylvania ; Demonstrator of Physiology in the
Medical Department of the University of Texas. Rewritten and
greatly enlarged. Post-octavo, 253 pages. Cloth, $1.25.
"These ' Notes ' will be found v&ry useful to practitioners who take an interest in the
many newer remedies of the present day." — Edinburgh Medical Journal.
" The appearance of this new edition of Dr. Cerna's verj' valuable work shows that it
is properly appreciated. The book ought to be in the possession of every practising physi-
cian." — N'ew York Aledical Journal.
CHAPIN ON INSANITY.
A Compendium of Insanity. By John B. Chapin, M.D., LL.D.,
Physician-in-Chief, Pennsylvania Hospital for the Insane; late Physi-
cian-Superintendent of the Willard State Hospital, New York ; Hon-
orary Member of the Medico-Psychological Society of Great Britain,
of the Society of Mental Medicine of Belgium. 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. The work will also
prove valuable to members of the legal profession and to those who, in their relations to the
insane and to those supposed to be insane, often desire to acquire .some practical knowledge
of insanity presented in a form that may be understood by the non -professional reader.
CHAPMAN'S MEDICAL JURISPRUDENCE AND TOXICOLOGY.
Second Edition, Revised.
Medical Jurisprudence and Toxicology. By Henry C. Chapman,
M.D., Professor of Institutes of Medicine and Medical Jurisprudence
in the Jefferson Medical College of Philadelphia. 254 pages, with 55
illustrations and 3 full-page plates in colors. Cloth, ^1.50 net.
"The best book of its class for the undergraduate that we know of." — A^eiv York
Medical Times.
Medical Publications of W. B. Saunders. 9
CHURCH AND PETERSON'S NERVOUS AND MENTAL DISEASES.
Nervous and Mental Diseases. By Archibald Church, M.D.,
Professor of Mental Diseases and Medical Jurisprudence in the North-
western University Medical School, Chicago ; and Frederick Peter-
son, M.D., Clinical Professor of Mental Dis^^ases in the Woman's
Medical College, New York ; Chief of Clinic, Nervous Department,
College of Physicians and Surgeons, New York. In Preparation.
CLARKSON'S HISTOLOGY.
A Text=Book of Histology, Descriptive and Practical. By
Arthur Clarkson, M.B., C.M. Edin., formerly Demonstrator of
Physiology in the Owen's College, Manchester; late Demonstrator of
Physiology in Yorkshire College, Leeds. Large octavo, 554 pages;
22 engravings in the text, and 174 beautifully colored original illustra-
tions. Cloth, strongly bound, $6.00 net.
" The work must be considered a valuable addition to the list of available text books,
and is to be highly recommended." — A^ew York Medical Journal.
" This is one of the best works for students we have ever noticed. We predict that the
book will attain a well-deserved popularity among our students." — Chicago Medical Recorder.
"The volume is a most valuable addition to the armamentarium of the teacher." —
Brooklyn Medical Journal.
CLIMATOLOGY.
Transactions of the Eighth Annual Meeting of the American
Climatological Association, held in Washington, September 22-25,
1 89 1. Forming a handsome octavo volume of 276 pages, uniform with
remainder of series. (A limited quantity only.) Cloth, $1.50.
COHEN AND ESHNER'S DIAGNOSIS.
Essentials of Diagnosis. By Solomon Solis-Cohen, M.D., Pro-
fessor of Clinical Medicine and Applied Therapeutics in the Philadel-
phia Polyclinic ; and Augustus A. Eshner, M.D., Professor of Clinical
Medicine in the Philadelphia Polyclinic. Post-octavo, 382 pages; 55
illustrations. Cloth, $1.50 net.
[See Saunders' Question- Compends, page 21.]
"We can heartily commend the book to all those who contemplate purchasing a 'com-
pend.' It is modern and complete, and will give more satisfaction than many other works
which are perhaps too prolix as well as behind the times." — Medical Review, St. Louis.
CORWIN'S PHYSICAL DIAGNOSIS.
Essentials of Physical Diagnosis of the Thorax. By Arthur
AL Corwin, A.]\L, M.D., Demonstrator of Physical Diagnosis in Rush
Medical College, Chicago ; Attending Physician to Central Free Dis-
pensary, Department of Rhinology, Laryngology, and Diseases of the
Chest, Chicago. 200 pages, illustrated. Cloth, flexible covers, $1.25 net.
" It is excellent. The student who shall use it as his guide to the careful study of
physical exploration upon normal and abnormal subjects can scarcely fail to acquire a good
working knowledge of the subject." — Philadelphia Polyclinic.
"A most excellent little work. It brightens the memory of the differential diagnostic
signs, and it arranges orderly and in sequence the various objective phenomena to logical
solution of a careful diagnosis." — Journal of Nervous and Mental Diseases.
10 Medical Publications of W. B. Saunders.
CRAGIN'S QYN/CCOLOQY. Fourth Edition, Revised.
Essentials of Qynzecology. liy Edwin ]]. Cragin, M.D., Attend-
ing (iyn;x;cologist, Roosevelt Hospital, Out-Patients' Department, New
York, etc. Crown octavo, 200 pages; 62 fine illustrations. Cloth,
$1.00; interleaved for notes, $1.25.
[See Saunders^ Question- Compe7ids, page 21.]
" A handy volume, and a distinct improvement on students' compends in general. No
autlior wlio was not himself a practical gynecologist could have consulted the student's needs
so thoroughly as Dr. Cragin has done." — Medical Record, New York.
CROOKSHANK'S BACTERIOLOGY.
A Text=Book of Bacteriology. By Edgar M. Crookshank, M.B.,
Professor of Comparative Pathology and Bacteriology, King's College,
London. Octavo volume of 700 pages, with 273 engravings and 22
original colored plates. Cloth, ^6.50 net; Half Morocco, ^7.50 net.
" To the student who wishes to obtain a good resume of what has been done in bacteri-
olog}', or who wishes an accurate account of the various methods of research, the book mav
be recommended with confidence that he will find there what he requires." — Lotidon Lancet.
Da COSTA'S SURGERY. Second Ed., Revised and Greatly Enlarged.
Modern Surgery, General and Operative. By John Chalmers
DaCosta, M.D., Clinical Professor of Surgery, Jefferson Medical
College, Philadelphia ; Surgeon to the Philadelphia Hospital, etc.
Handsome octavo volume of 900 pages, profusely illustrated. Cloth,
$4.00 net; Half Morocco, ^5.00 net.
"We know of no small work on surgery in the English language which so well fulfils
the requirements of the modern student." — Medico-Chirurgical Journal, Bristol, England.
DE SCHWEINITZ ON DISEASES OF THE EYE. Second Edition,
Revised.
Diseases of the Eye, A Handbook of Ophthalmic Practice.
By G. E. DE ScHWEiNiTZ, M.D., Professor of Ophthalmology in the
Jefferson Medical College, Philadelphia, etc. Handsome royal octavo
volume of 679 pages, with 256 fine illustrations and 2 chromo-litho-
graphic plates. Cloth, ^4.00 net; Sheep or Half Morocco, ^5.00 net.
" A clearly written, comprehensive manual. One which we can commend to students
as a reliable text-book, written with an evident knowledge of the wants of those entering
upon the study of this special branch of medical science." — British Medical Journal.
" A work that will meet the requirements not only of the specialist, but of the general
practitioner in a rare degree. I am satisfied that unusual success awaits it." — William
Pepper, M.D., Professor of the Theory and Practice of Medicine and Clinical Medicine,
University of Pennsylvania.
DORLAND'S OBSTETRICS.
A Manual of Obstetrics. By W. A. Newman Borland, M.D.,
Assistant Demonstrator of Obstetrics, LTniversity of Pennsylvania;
Instructor in Gynecology in the Philadelphia Polyclinic. 760 pages;
163 illustrations in the text, and 6 full-page plates. Cloth, $2.50 net.
" By far the best book on this subject that has ever come to our notice." — American
Medical Review.
" It has rarely been our duty to review a book which has given us more pleasure in its
perusal and more satisfaction in its criticism. It is a veritable encyclopedia of knowledge,
a gold mine of practical, concise thoughts." — American Medico-Surgical Bulletin.
Medical Publications of W. B. Saunders. 11
FROTHINQHAM'S GUIDE FOR THE BACTERIOLOGIST.
Laboratory Guide for the Bacteriologist. By Langdon Froth-
INGHAM, M.D.V., Assistant in Bacteriology and Veterinary Science,
Sheffield Scientific Schoo], Yale University. Illustrated. Cloth, 75 cts.
" It is a convenient and useful little work, and will more than repay the outlay neces-
sary for its purchase in the saving of time which would otherwise be consumed in looking
up the various points of technique so clearly and concisely laid down in its pages." — Ameri-
can Medico- Sia-gical BtiUetin.
GARRIGUES' DISEASES OF WOMEN. Second Edition, Revised.
Diseases of Women. By Henry J. Garrigues, A.M., M.D., Pro-
fessor of Gynecology in the New York School of Clinical Medicine;
Gynecologist to St. Mark's Hospital and to the German Dispensary,
New York City, etc. Handsome octavo volume of 728 pages, illus-
trated by 335 engravings and colored plates. Cloth, $4.00 net;
Sheep or Half Morocco, $5.00 net.
" One of the best text-books for students and practitioners which has been published in
the English language ; it is condensed, clear, and comprehensive. The profound learning
and great clinical experience of the distinguished author find expression in this book in a
most attractive and instructive form. Young practitioners to whom experienced consultants
may not be available will find in this book invaluable counsel and help." — Thad. A.
Reamy, M.D., LL.D., Professor of Clinical Gynecology, Medical College of Ohio.
GLEASON'S DISEASES OF THE EAR. Second Edition, Revised.
Essentials of Diseases of the Ear. By E. B. Gleason, S.B.,
M.D., Clinical Professor of Otology, Medico-Chirurgical College,
Philadelphia ; Surgeon-in-Charge of the Nose, Throat, and Ear Depart-
ment of the Northern Dispensary, Philadelphia. 208 pages, with
114 illustrations. Cloth, $1.00; interleaved for notes, ^1.25.
[See Saunders' Question- Compends, page 21.]
" It is just the book to put into the hands of a student, and cannot fail to give him a
useful introduction to ear-affections ; while the style of question and answer which is adopted
throughout the book is, we believe, the best method of impressing facts permanently on the
mind. ' ' — Liverpool Medico- Chirurgical Journal.
GOULD AND PYLE'S CURIOSITIES OF MEDICINE.
Anomalies and Curiosities of Medicine. By George M. Gould,
M.D., and Walter L. Pyle, M.D. An encyclopedic collection of
rare and extraordinary cases and of the most striking instances of
abnormality in all branches of Medicine and Surgery, derived from an
exhaustive research of medical literature from its origin to the present
day, abstracted, classified, annotated, and indexed. Handsome im-
perial octavo volume of 968 pages, with 295 engravings in the text,
and 12 full-page plates. Cloth, $6.00 net; Half Morocco, $7.00 net.
Sold by Subscription.
" One of the most valuable contributions ever made to medical literature. It is, so far
as we know, absolutely unique, and every page is as fascinating as a novel. Not alone for
the medical profession has this volume value: it will serve as a book of reference for all who
are interested in general scientific, sociologic, or medico-legal topics." — Brooklyn Medical
Journal.
"This is certainly a most remarkable and interesting volume. It stands alone among
medical literature, an anomaly on anomalies, in that there is nothing like it elsewhere in
medical literature. It is a book full of revelations from its first to its last page, and cannot
but interest and sometimes almost horrify its readers." — American Afedico- Surgical Bulletin.
12 Medical Publications of W. B. Saunders.
GRIFFIN'S MATERIA MEDICA AND THERAPEUTICS.
Manual of Materia Medica and Therapeutics. By Hi.nry A.
Griffin, A. 15., M.l)., Assistant I'hysician to the Roosevelt Hospital,
Out-Patient Department, New York City. /;/ Preparation.
GRIFFITH ON THE BABY.
The Care of the Baby. By J. P. Crozer Griffith, M.D., Clini-
cal Professor of Diseases of Children, University of Pennsylvania;
Physician to the Children's Hospital, Philadelphia, etc. i2mo, 392
pages, with 67 illustrations in the text, and 5 jilates. Cloth, $1.50.
" The best book for the use of the young mother with which we are acquainted. . . .
There are very few general practitioners who could not read the book througli with advan-
tage. ' ' — Archives of Pediatrics.
"The whole book is characterized by rare good sense, and is evidently written by a
master hand. It can be read with benefit not only by mothers but by medical students and
by any practitioners who have not had large opportunities for observing children." — Anieri-
cati Journal of Obstetrics.
GRIFFITH'S WEIGHT CHART.
Infant's Weight Chart. Designed by J. P. Crozer Griffith, M. D. ,
Clinical Professor of Diseases of Children in the University of Penn-
sylvania, etc. 25 charts in each pad. Per pad, 50 cents net.
A convenient blank for keeping a record of the child's weight during the first two years
of life. Printed on each chart is a curve representing the average weight of a healthy infant,
so that any deviation from the normal can readily be detected.
GROSS, SAMUEL D., AUTOBIOGRAPHY OF.
Autobiography of Samuel D. Gross, M.D., Emeritus Professor of
Surgery in the Jefferson Medical College, Philadelphia, with Remi-
niscences of His Times and Contemporaries. Edited by his Sons,
Samuel W. Gross, M.D., LL.D., late Professor of Principles of Sur-
gery and of Clinical Surgery in the Jefferson Medical College, and
A. Haller Gross, A.M., of the Philadelphia Bar. Preceded by a
Memoir of Dr. Gross, by the late Austin Flint, M.D., LL.D. In
two handsome volumes, each containing over 400 pages, demy octavo,
extra cloth, gilt tops, with fine Frontispiece engraved on steel. Price
per volume, $2.50 net.
" Dr. Gross was perhaps the most eminent exponent of medical science that America
has yet produced. His Autobiography, related as it is with a fulness and completeness
seldom to be found in such works, is an interesting and valuable book. He comments on
many things, especially, of course, on medical men and medical practice, in a very interest-
ing way." — The Spectator, London, England.
HAMPTON'S NURSING.
Nursing: Its Principles and Practice. By Isabel Adamg Hamp-
ton, 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.
i2mo, 484 pages, profusely illustrated. Cloth, $2.00 net.
" Seldom have we perused a book upon the subject that has given us so much pleasure
as the one before us. We would strongly urge upon the members of our own profession the
need of a book like this, for it will enable each of us to become a training school in him-
self. ' ' — Ontario Medical Journal.
Mediciil Publications of W. B. Saunders. 13
HARE'S PHYSIOLOGY. Third Edition, Revised.
Essentials of Physiology. By H. A. Hare, M.D., Professor of
Therapeutics and Materia Medica in the Jefferson Medical College of
Philadelphia; Physician to the Jefferson Medical College Hospital.
Containing a series of handsome illustrations from the celebrated
**Icones Nervorum Capitis" of Arnold. Crown octavo, 239 pages.
Cloth, $1.00 net; interleaved for notes, $1.25 net.
[See Saufiders^ Question- Compends, page 21.]
" The best condensation of physiological knowledge we have yet seen." — Medical
Record, New York.
HART'S DIET IN SICKNESS AND IN HEALTH.
Diet in Sickness and in Health. By Mrs. Ernest Hart, formerly
Student of the Faculty of Medicine of Paris and of the London School
of Medicine for Women ; with an Introduction by Sir Henry
Thompson, F.R.C.S., M.D., London. 220 pages ; illustrated. Cloth,
$1.50.
" We recommend it cordially to the attention of all practitioners ; both to them and to
their patients it may be of the greatest service." — Nezu York Medical Journal.
HAYNES' ANATOMY.
A Manual of Anatomy. By Irving S. Haynes, M.D., Adjunct
Professor of Anatomy and Demonstrator of Anatomy, Medical Depart-
ment of the New York University, etc. 680 pages, illustrated with 42
diagrams in the text, and 134 full-page half-tone illustrations from
original photographs of the author's dissections. Cloth, $2.50 net.
" This book is the work of a practical in.structor — one who knows by experience the
requirements of the average student, and is able to meet these requirements in a very satis-
factory way. The book is one that can be commended." — Medical Record, New York.
HEISLER'S EMBRYOLOGY.
A Text=Book of Embryology. By John C. Heisler, M.D., Pro-
fessor of Anatomy in the Medico-Chirurgical College, Philadelphia.
In Preparation.
HIRST'S OBSTETRICS.
A Text=Book of Obstetrics. By Barton Cooke Hirst, M.D.,
Professor of Obstetrics in the University of Pennsylvania, In Prepa-
ration.
HYDE AND MONTGOMERY ON SYPHILIS AND THE VENEREAL
DISEASES.
Syphilis and the Venereal Diseases. By James Nevins Hyde,
M.D., Professor of Skin and Venereal Diseases, and Frank H. Mont-
gomery, M.D., Lecturer on Dermatology and Genito-Urinary Diseases
in Rush Medical College, Chicago, 111. 618 pages, profusely illustrated.
Cloth, $2.50 net.
" We can commend this manual to the student as a help to him in his study of venereal
diseases. ' ' — Liverpool Medico- Chiriirgical Journal.
"The best student's manual which has appeared on the subject." — St. Louis Medical
and Surgical Journal.
14 Medical Publications of W. B. Saunders.
JACKSON AND GLEASON'S DISEASES OF THE EYE, NOSE, AND
THROAT. Second Edition, Revised.
Essentials of Refraction and Diseases of the Eye. By Edward
Jackson, A.M., M.D., Professor of Diseases of the Eye in the Phila-
delphia Polyclinic and College for Graduates in Medicine ; and —
Essentials of Diseases of the Nose and Throat. By E. Bald-
win Glkason, M.D.. Surgeon-in-Charge of the Nose, Throat, and
Ear Department of the Northern Dispensary of Philadeljihia. Two
volumes in one. Crown octavo, 290 pages; 124 illustrations. Cloth,
$1.00; interleaved for notes, $1.25.
[See Saunders'' Question- Compends, page 21.]
" Of great value to the beginner in these branches. The authors are both capable men,
and know what a student most needs." — Medical Record, New York.
KEATINQ'S DICTIONARY. Second Edition, Revised.
A New Pronouncing Dictionary of Medicine, with Phonetic
Pronunciation, Accentuation, Etymology, etc. By John M.
Keating, M.D., LL. D., Fellow of the College of Physicians of Phila-
delphia; Vice-President of the American Paediatric Society; Editor
"Cyclopaedia of the Diseases of Children," etc.; and Henry
Hamilton, Author of '-'A New Translation of Virgil's ^neid into
English Rhyme," etc.; with the collaboration of J. Chalmers Da-
Costa, M.D., and Frederick A. Packard, M.D. With an Appendix
containing Tables of Bacilli, Micrococci, Leucomai'nes, Ptomaines;
Drugs and Materials used in Antiseptic Surgery ; Poisons and their
Antidotes ; Weights and Measures ; Thermometric Scales ; New
Official and Unofficial Drugs, etc. One volume of over 800 pages.
Prices, with Denison's Patent Ready-Reference Index: Cloth, $5.00
net; Sheep or Half Morocco, g6.oo net; Half Russia, $6.50 net.
Without Patent Index: Cloth, $4.00 net; Sheep or Half Morocco,
$5.00 net.
" I am much pleased with Keating's Dictionary, and shall take pleasure in recommend-
ing it to my classes." — Henry M. Lyman, M.D., Professor of the Frinciples and Fj-actice
of Medicine, Rusk Medical College, Chicago, III.
" I am convinced that it will be a very valuable adjunct to my study-table, convenient
in size and sufficiently full for ordinary use." — C. A. Lindsley, M.D., Professor of the
Theory and Practice of Medicine, Medical Dept. Yale University .
KEATINQ'S LIFE INSURANCE.
How to Examine for Life Insurance. By John M. Keating,
M.D., Fellow of the College of Physicians of Philadelphia; Vice-
President of the American Paediatric Society ; Ex-President of the
Association of Life Insurance Medical Directors. Royal octavo, 211
pages ; with two large half-tone illustrations, and a plate prepared by
Dr. McClellan from special dissections; also, numerous other illustra-
tions. Cloth, ^2.00 net.
" This is by far the most useful book which has yet appeared on insurance examination,
a subject of growing interest and importance. Not the least valuable portion of the volume
is Part II, which consists of instructions issued to their examining physicians by twenty-four
representative companies of this country. If for these alone, the book should be at the right
hand of every physician interested in this special branch of medical science." — The Medical
News.
Medical Publications of W. B. Saunders. 15
KEEN ON THE SURGERY OF TYPHOID FEVER.
The Surgical Complications and Sequels of Typhoid Fever.
By Wm. W. Keen, M.D., LL.D., Professor of the Principles of Sur-
gery and of Clinical Surgery, Jefferson Medical College, Philadelphia;
Corresponding ^Member of the Societe de Chirurgie, Paris ; Honorary
Member of the Societe Beige de Chirurgie, etc. Octavo volume of
386 pages, illustrated. Cloth, $3.00 net.
This monograph is the only one in any language covering the entire subject of the
Surgical Complications and Sequels of Typhoid P'ever. It will prove to be of importance
and interest not only to the general surgeon and physician, but also to many specialists — laryn-
gologists, gynecologists, pathologists, and bacteriologists.
KEEN'S OPERATION BLANK. Second Edition, Revised Form.
An Operation Blank, with Lists of Instruments, etc. Required
in Various Operations. Prepared by W. W. Keen, M.D., LL.D.,
Professor of the Principles of Surgery in Jefferson Medical College,
Philadelphia. Price per pad, containing blanks for fifty operations,
50 cents net.
KYLE ON THE NOSE AND THROAT.
Diseases of the Nose and Throat. By D. Braden Kyle, M.D.,
Clinical Professor of Laryngology and Rhinology, Jefferson Medical
College, Philadelphia; Consulting Laryngologist, Rhinologist, and
Otologist, St. Agnes' Hospital ; Bacteriologist to the Philadelphia
Orthopedic Hospital. In Preparatio7i.
LAINE'S TEMPERATURE CHART.
Temperature Chart. Prepared by D. T. Laine, M.D. Size 8 x i2^Y2,
inches. A conveniently arranged Chart for recording Temperature,
with columns for daily amounts of Urinary and Fecal Excretions,
Food, Remarks, etc. On the back of each chart is given in full the
method of Brand in the treatment of Typhoid Fever. Price, per pad
of 25 charts, 50 cents net.
" To the busy practitioner this chart will be found of great value in fever cases, and
especially for cases of typhoid." — Indian Lancet, Calcutta.
lockwood's practice of medicine.
A Manual of the Practice of Medicine. By George Roe Lock-
WOOD, M.D., Professor of Practice in the Woman's Medical College
of the New York Infirmary, etc. 935 pages, with 75 illustrations in
the text, and 22 full-page plates. Cloth, ^2.50 net.
" Gives in a most concise manner the points essential to treatment usually enumerated
in the most elaborate works." — Massachusetts Medical Journal.
LONG'S SYLLABUS OF GYNECOLOGY.
A Syllabus of Gynecology, arranged in Conformity with •• An
American Text=Book of Gynecology." By J. W. Long, I\LD.,
Professor of Diseases of Women and Children, Medical College of
Virginia, etc. Cloth, interleaved, $1.00 net.
" The book is certainly an admirable risume of what every gynecological student and
practitioner should know, and will prove of value not only to those who have the ' American
Text-Book of Gynecology,' but to others as well." — Brooklyn Medical Journal.
16 Medical Publications of W. B. Saunders.
MACDONALD'S SURGICAL DIAGNOSIS AND TREATMENT.
Surgical Diagnosis and Treatment. By J. W. Macdonald, M.D.
Edin., L.R.C.S., Edin., Professor of the Practice of Surgery and of
Clinical Surgery in Hamline University ; Visiting Surgeon to St.
Barnabas' Hospital, Minneapolis, etc. Handsome octavo volume of
800 pages, profusely illustrated. Cloth, $5.00 net; Half Morocco,
$6. CO net.
" A thorough and complete work on surgical diagnosis and treatment, free from pad-
ding, full of valuable material, and in accord with the surgical teaching of the day." — JVie
Medical News, New York.
"The work is brimful of just the kind of practical information that is useful alike to
students and practitioners. It is a pleasure to commend the book because of its intrinsic
value to the medical practitioner." — Cincinnati Lancet-Clinic.
MALLORY AND WRIGHT'S PATHOLOGICAL TECHNIQUE.
Pathological Technique. A Practical Manual for Laboratory Work
in Pathology, Bacteriology, and Morbid Anatomy, with chapters on
Post-Mortem Technique and the Performance of Autopsies. By Frank
B. Mallory, A.m., M.D., Assistant Professor of Pathology, Harvard
University Medical School, Boston; and James H. Wright, A.M.,
M.D., Instructor in Pathology, Harvard University Medical School,
Boston. Octavo volume of 396 pages, handsomely illustrated. Cloth,
$2.50 net.
" I have been looking forward to the publication of this book, and I am glad to say that
I find it to be a most useful laboratory and post-mortem guide, full of practical information,
and well up to date." — William H. Welch, Professor of Pathology, Johns Hopkins Uni-
versity, Baltimore, Md.
MARTIN'S MINOR SURGERY, BANDAGING, AND VENEREAL
DISEASES. Second Edition, Revised.
Essentials of Minor Surgery, Bandaging, and Venereal
Diseases. By Edward Martin, A.M., M.D., Clinical Professor of
Genito-Urinary Diseases, University of Pennsylvania, etc. Crown
octavo, 166 pages, with 78 illustrations. Cloth, $1.00 ; interleaved for
notes, $1.25.
[See Saunders' Question- Compends, page 21.]
"A very practical and systematic study of the subjects, and shows the author's famil-
iarity with the needs of students." — Therapeutic Gazette.
MARTIN'S SURGERY. Sixth Edition, Revised.
Essentials of Surgery. Containing also Venereal Diseases, Surgi-
cal Landmarks, Minor and Operative Surgery, and a complete de-
scription, with illustrations, of the Handkerchief and Roller Bandages.
By Edward Martin, A.M., M.D., Clinical Professor of Genito-
Urinary Diseases, University of Pennsylvania, etc. Crown octavo, 338
pages, illustrated. With an Appendix containing full directions for the
preparation of the materials used in Antiseptic Surgery, etc. Cloth,
$1.00; interleaved for notes, $1.25.
[See Saunders'' Question- Compends, page 21.]
" Contains all necessary essentials of modern surgery in a comparatively small space.
Its s'yle is interesting, and its illustrations are admirable. " — Medical and Surgical Reporter. Kjf
Medical Publications of W. B. Saunders. 17
MCFARLAND'S PATHOGENIC BACTERIA.
Text=Book upon the Pathogenic Bacteria. Specially written
for Students of Medicine. By Joseph McFarland, M.D., Pro-
fessor of Pathology and Bacteriology in the Medico-Chirurgical College
of Philadelphia, etc. Octavo volume of 359 pages, finely illustrated.
Cloth, $2.50 net.
" Dr. McFarland has treated the subject in a systematic manner, and has succeeded in
presenting in a concise and readable form the essentials of bacteriology up to date. Alto
gether, the book is a satisfactory one, and I shall take pleasure in recommending it to the
students of Trinity College." — H. B. Anderson, M.D. , Professor of Pathology and Bac-
teriology, Trinity Medical College, Toronto.
MEIGS ON FEEDING IN INFANCY.
Feeding in Early Infancy. By Arthur V. Meigs, M.D. Bound
in limp cloth, flush edges, 25 cents net.
" This pamphlet is worth many times over its price to the physician. The author's
experiments and conclusions are original, and have been the means of doing much good." —
Medical Bulletin.
MOORE'S ORTHOPEDIC SURGERY.
A Manual of Orthopedic Surgery. By James E. Moore, M.D.,
Professor of Orthopedics and Adjunct Professor of Clinical Surgery,
University of Minnesota, College of Medicine and Surgery. Octavo
volume of 356 pages, handsomely illustrated. Cloth, $2.50 net.
A 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.
MORRIS'S MATERIA MEDICA AND THERAPEUTICS. Fourth
Edition, Revised.
Essentials of Materia Medica, Therapeutics, and Prescription=
Writing. By Henry Morris, M.D., late Demonstrator of Thera-
peutics, Jefferson Medical College, Philadelphia, Fellow of the College
of Physicians, Philadelphia, etc. Crown octavo, 250 pages. Cloth,
^i.oo; interleaved for notes, $1.25.
[See Saunders' Question- Compends, page 21.]
" This work, already excellent in the old edition, has been largely improved by revi
sion. " — American Practitioner and jVews.
MORRIS, WOLFF, AND POWELL'S PRACTICE OF MEDICINE.
Third Edition, Revised.
Essentials of the Practice of Medicine. By Henry Morris, M. D.,
late Demonstrator of Therapeutics, Jefferson Medical College, Phila-
delphia ; with an Appendi.x on the Clinical and Microscopic Examina-
tion of Urine, by Lawrence Wolff, M.D. , Demonstrator of Chemistry,
Jefferson Medical College, Philadelphia. Enlarged by some 300 essen-
tial formulae collected and arranged by William M. Powell, M.D.
Post-octavo, 488 pages. Cloth, $2.00.
[See Saunders' Question- Compends, page 21.]
" The teaching is sound, the presentation graphic ; matter full as can be desired, and
style attractive." — American Practitioner and jVews.
2
18 Medical Publications of W, B. Saunders.
MORTEN'S NURSE'S DICTIONARY.
Nurse's Dictionary of Medical Terms and Nursing Treat-
ment. Containing Definitions of the Principal Medical and Nursing
Terms and Al)l)reviations ; of the Instruments, Drugs, Diseases, Acci-
dents, Treatments, Operations, Foods, Aj)pliances, etc. encountered
in the ward or in the sick-room. By Honnor Morten, author of
" How to Become a Nurse," etc. i6mo, 140 pages. Cloth, $1.00.
" \ handy, compact little volume, containing a large amount of general information, all
of which is arranged in dictionary or encyclopedic form, thus facilitating quick reference.
It is certainly of value to those for whose use it is published." — C/iica^o Clinical Review.
NANCREDE'S ANATOMY. Fifth Edition.
Essentials of Anatomy, including the Anatomy of the Viscera.
By Charles B. Nancrede, M.D., Professor of Surgery and of Clini-
cal Surgery in the University of Michigan, Ann Arbor. Crown octavo,
388 pages; 180 illustrations. With an Appendix containing over 60
illustrations of the osteology of the human body. Based upon Gray' s
Anatomy. Cloth, $1.00; interleaved for notes, $1.25.
[See Saunders Question- Co7tipends, page 21.]
" For self-quizzing and keeping fresh in mind the knowledge of anatomy gained at
school, it would not be easy to speak of it in terms too favorable." — American Practitioner.
NANCREDE'S ANATOMY AND DISSECTION. Fourth Edition.
Essentials of Anatomy and Manual of Practical Dissection.
By Charles B. Nancrede, M.D., Professor of Surgery and of Clinical
Surgery, University of Michigan, Ann Arbor. Post-octavo; 500 pages,
with full-page lithographic plates in colors, and nearly 200 illustrations.
Extra Cloth (or Oilcloth for the dissection-room), ^2.00 net.
" It may in many respects be considered an epitome of Gray's popular work on general
anatomy, at the same time having some distinguishing characteristics ot its own to commend
it. The plates are of more than ordinary excellence, and are of especial value to students
in their work in the dissecting room." — Journal of the American Medical Association.
NORRIS'S SYLLABUS OF OBSTETRICS. Third Edition, Revised.
Syllabus of Obstetrical Lectures in the Medical Department
of the University of Pennsylvania. By Richard C. Norris,
A.M., M.D., Demonstrator of Obstetrics, University of Pennsylvania.
Crown octavo, 222 pages. Cloth, interleaved for notes, $2.00 net.
"This work is so far superior to others on the same subject that we take pleasure in
calling attention briefly to its excellent features. It covers the subject thoroughly, and will
prove invaluable both to the student and the practitioner." — Medical Record, New York.
PENROSE'S DISEASES OF WOMEN. Second Edition, Revised.
A Text=Book of Diseases of Women. By Charles B. Penrose,
M.D., Ph.D., Professor of Gynecology in the University of Pennsyl-
vania; Surgeon to the Gynecean Hospital, Philadelphia. Octavo
volume of 529 pages, handsomely illustrated. Cloth, $3.50 net.
"I shall value very highly the copy of Penrose's 'Diseases of Women' received.
I have already recommended it to my class as THE BEST book." — Howard A. Kelly,
Professor of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, Md.
" 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.
Medical Publications of W. B. Saunders. 19
POWELL'S DISEASES OF CHILDREN. Second Edition.
Essentials of Diseases of Children. By William M. Powell,
M.D., Attending Physician to the Mercer House for Invalid Women
at Atlantic City, N. j. ; late Physician to the Clinic for the Diseases of
Children in the Hospital of the University of Pennsylvania. Crown
octavo, 222 pages. Cloth, $i.oo; interleaved for notes, $1.25.
[See Saiinders' Question- Compends, page 21.]
"Contains the gist of all the best works in the department to which it relates." —
American Practitioner and A'ews.
PRINQLE'S SKIN DISEASES AND SYPHILITIC AFFECTIONS.
Pictorial Atlas of Skin Diseases and Syphilitic Affections
(American Edition). Translation from the French. Edited by
1. J. Pringle, M.B., F.R.C.P., Assistant Physician to the Middlesex
Hospital, London. Photo-lithochromes from the famous models in
the Museum of the Saint-Louis Hospital, Paris, with explanatory wood-
cuts and text. In 12 Parts. Price per Part, $3.00. Complete in
one volume, Half Morocco binding, $40.00 net.
" I strongly recommend this Atlas. The plates are exceedingly well executed, and
will be of great'value to all studying dermatology." — STEPHEN Mackenzie, M.D.
"The introduction of explanatory wood-cuts in the text is a novel and most important
feature which greatly furthers the easier understanding of the excellent plates, than which
nothing, we venture to say, has iieen seen better in point of correctness, beauty, and general
merit." — Nezu York Medical Journal.
PYE'S BANDAGING.
Elementary Bandaging and Surgical Dressing. With Direc-
tions concerning the Immediate Treatment of Cases of Emergency.
For the use of Dressers and Nurses. By Walter Pye, F.R.C.S., late
Surgeon to St. Mary's Hospital, London. Small i2mo, with over 80
illustrations. Cloth, flexible covers, 75 cents net.
" The directions are clear and the illustrations are good.'' ^— ^London Lancet.
"The author writes well, the diagrams are clear, and the book itself is small and port-
able, although the paper and type are good." — British Medical Journal.
RAYMOND'S PHYSIOLOGY.
A Manual of Physiology. By Joseph H. Raymond, A.M., M.D.,
Professor of Physiology and Hygiene and Lecturer on Gynecology in
the Long Island College Hospital ; Director of Physiology in the
Hoagland Laboratory, etc. 382 pages, with 102 illustrations in the
text, and 4 full -page colored plates. Cloth, $1.25 net.
" Extremely well gotten up, and the illustrations have been selected with care. The
text is fully abreast with modern physiology." — British Medical Journal.
RONTGEN RAYS.
Archives of the Rontgen Ray (Formerly Archives of Clinical
Skiagraphy). Edited by Sydney Rowland, M.A., M.R.C.S., and
W. S. Hedley, M.D., M.R.C.S. A series of collotype illustrations,
with descriptive text, illustrating the applications of the new photo-
graphy to INIedicine and Surgery. Price per Part, $1.00. Now ready:
Vol. I., Parts I. to IV.; Vol. II., Parts I., II.
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Each book is of convenient size (5x7 inches), containing on an average 250 pages,
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Although there are numerous other Quizzes, Manuals, Aids, etc. in the market, none of
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Saunders Series, in our opinion, bears oft" the pahn at present."— AVzt/ Yo7k Medical Record.
1. ESSENTIALS OF PHYSIOLOGY. By H. A. Hare, ]M.D. Third edition,
revised and enlarged. (Si-oo net.)
2. ESSENTIALS OF SURGERY. By Edward Martin, ]\I.D. Sixth edition.
revised, with an Appendi.\ on Antiseptic Surgery.
3. ESSENTIALS OF ANATOMY. By Charles B. Nancrede, M.D. Fifth
edition, with an Appendix.
4. ESSENTIALS OF MEDICAL CHEMISTRY, ORGANIC AND INORGANIC.
By Lawrence Wolff, M.D. Fourth edition, revised, with an Appendix.
5. ESSENTIALS OF OBSTETRICS. By W. E.\sterly Ashton, M.D. Fourth
edition, revised and enlarged.
6. ESSENTIALS OF PATHOLOGY AND MORBID ANATOMY. By C. E.
Ar>ljlND Semple, M.D.
7. ESSENTIALS OF MATERIA MEDICA, THERAPEUTICS, AND PRE-
SCRIPTION=WRITING. By Henry Morris, M.D. Fourth edition, revised.
8. 9. ESSENTIALS OF PRACTICE OF MEDICINE. By Henry Morris,
^LD. An Appendix on Ukine E.xamination. By Lawrence Wolff, M.D.
Third edition, enlarged by some 300 Essential Formula;, selected from eminent
authorities, by Wm. I\L Powell, M.D. (Double number, S2.00.)
10. ESSENTIALS OF GYN/ECOLOGY. By Edwin B. Cr.\gin, M.D. Fourth
edition, revised.
11. ESSENTIALS OF DISEASES OF THE SKIN. By Henry W. Stelwagon,
M.D. Third edition, revised and enlarged. (Si. 00 net.)
12. ESSENTIALS OF MINOR SURGERY, BANDAGING, AND VENEREAL
DISEASES. By Edward ^L\RTIN, ^LD. Second ed., revised and enlarged.
13. ESSENTIALS OF LEGAL MEDICINE, TOXICOLOGY, AND HYGIENE.
By C. E. Armand Semple, jM.D.
14. ESSENTIALS OF DISEASES OF THE EYE, NOSE, AND THROAT.
By Edward Jackson, ^LD. , and E. B. Gleason, M.D. Second ed., revised.
15. ESSENTIALS OF DISEASES OF CHILDREN. By William M. Powell,
^LD. Second edition.
16. ESSENTIALS OF EXAMINATION OF URINE. By Lawrence Wolff,
I\LD. Colored " Vogel Scale." (75 cents. )
17. ESSENTIALS OF DIAGNOSIS. By S. Solis Cohen, M.D., and A. A. Eshner,
^LD. (Si. 50 net.)
18. ESSENTIALS OF PRACTICE OF PHARMACY. By Lucius E. Sayre.
Second edition, revised and enlarged.
20. ESSENTIALS OF BACTERIOLOGY. By M. V. Ball, I\LD. Third edition,
revised.
21. ESSENTIALS OF NERVOUS DISEASES AND INSANITY. By John C.
Shaw, ^LD. Third edition, revised.
22. ESSENTIALS OF MEDICAL PHYSICS. By Fred J. Brockway, M.D.
Second edition, revised. {Si. 00 net.)
23. ESSENTIALS OF MEDICAL ELECTRICITY. By David D. Stewart, M.D.,
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24. ESSENTIALS OF DISEASES OF THE EAR. By E. B. Gleason, M.D.
Second edition, revised and greatly enlarged.
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'T'HAT there exists a need for thoroughly reliable hand-books on the leading branches
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the SAUNDERS NE"^ SERIES OF MANUALS have been received by medical
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and practitioners, most of them being teachers in representative American colleges.
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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
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The SAUNDERS NEW SERIES OF MANUALS are conceded to be superior
to any similar books now on the market. No other manuals afford so much infor-
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standard attained by these books.
Any of these Manuals w^ill be mailed on receipt of price (see next page for List),
Saunders^ New Series of Manuals*
VOLUMES PUBLISHED.
PHYSIOLOGY. By Joseph Howard Raymond, A.M., M.D., Professor of Physiology
and Hygiene and Lecturer on Gynecology in the Long Island College Hospital ;
Director of Physiology in the Hoagland Laboratory, etc. Illustrated. Cloth, $1.25 net.
SURGERY, General and Operative. By John Chalmers DaCosta, M.D. , Clini-
cal Professor of Surgery, Jefferson Medical College, Philadelphia; Surgeon to the
Philadelphia Hospital, etc. Second edition, thoroughly revised and greatly enlarged.
(Jctavo, 900 pages, profusely illustrated. Cloth, $4.00 net ; Half Morocco, $5-°° '^^^•
DOSE=BOOK AND MANUAL OF PRESCRIPTI0N=WR1TING. By E. Q.
Thornton, M.D., Demonstrator of Therapeutics, Jefferson Medical College, Phila-
delphia. Illustrated. Cloth, ^1.25 net.
SURGICAL ASEPSIS. By Carl Beck, M.D., Surgeon to St. Mark's Hospital and
to the New York German Poliklinik, etc. Illustrated. Cloth, $1.25 net.
MEDICAL JURISPRUDENCE. By Henry C. Chapman, M.D. Professor of Insti-
tutes of Medicine and Medical Jurisprudence in the Jefferson Medical College of Phila-
delphia. Illustrated. Cloth, ;?i.50 net.
SYPHILIS AND THE VENEREAL DISEASES. By James Nevins Hyde, M.D.,
Professor of Skin and Venereal Diseases, and Frank H. MONTGOMERY, M.D.,
Lecturer on Dermatology and Genito-Urinary Diseases in Rush Medical College,
Chicago. Profusely illustrated. (Double number.) Cloth, $2.50 net.
PRACTICE OF MEDICINE. By George Roe Lockwood, M.D., Professor of
Practice in the Woman's Jvledical College of the New York Infirmary ; Instructor in
Physical Diagnosis in the Medical Department of Columbia College, etc. Illustrated.
(Double number.) Cloth, ^2. 50 net.
MANUAL OF ANATOMY. By Irving S. Haynes, M.D., Adjunct Professor of
Anatomy and Demonstrator of Anatomy, Medical Department of the New York
University, etc. Beautifully illustrated. (Double Number. ) Cloth, ^2.50 net.
MANUAL OF OBSTETRICS. By W. A. Newman Dorland, M.D., Assistant
Demonstrator of Obstetrics, University of Pennsylvania ; Chief of Gynecological Dis-
pensaiy, Pennsylvania Hospital, etc. Profusely illustrated. (Double number.) Cloth,
;^2.50 net.
DISEASES OF WOMEN. By J. Bland Sutton, F.R.C.S., Assistant Surgeon to
Middlesex Hospital and Surgeon to Chelsea Hospital, London ; and Arthur E.
Giles, M.D., B..Sc. Lond. , F.R.C.S. Edin., Assistant Surgeon to Chelsea Hospital,
London. Handsomely illustrated. (Double number.) Cloth, ^2.50 net.
VOLUMES IN PREPARATION.
NOSE AND THROAT. By D. Braden Kyle, M.D., Clinical Professor of Laryn-
gology and Rhinology, Jefferson Medical College, Philadelphia; Consulting Laryngolo-
gist, Rhinologist, and Otologist, St. Agnes' Hospital ; Bacteriologist to the Philadel-
phia Orthopedic Hospital and liifirmary for Nervous Diseases, etc.
NERVOUS DISEASES. By Charles W. Burr, M.D., Clinical Professor of Nervous
Diseases, Medico-Chirurgical College. Philadelphia ; Pathologist to the Orthopaedic
Hospital and Infirmary for Nervous Diseases ; Visiting Physician to the St. Joseph
Hospital, etc.
*** There will be published in the same series, at short intervals, carefully-prepared works
on various subjects by prominent specialists.
Pamphlet containing specimen pages^ etc. sent free upon application.
24 Medical Publications of W. B. Saunders.
SAUNDBY'S RENAL AND URINARY DISEASES.
Lectures on Renal and Urinary Diseases. By Robert Saundby,
M.D. Kclin., Fellow of the Royal College of Physicians, London, and
of the Royal Medico-Chirurgical Society ; Physician to the General
Hospital ; Consulting Physician to the Eye Hospital and to the Hos-
pital for Diseases of Women; Professor of Medicine in Mason College,
Birmingham, etc. Octavo volume of 434 pages, with numerous illus-
trations and 4 colored plates. Cloth, $2.50 net.
" The volume makes a favorable impression at once. The style is clear and succinct.
We cannot find any part of the subject in which the views expressed are not carefully thought
out and fortified by evidence drawn from the most recent sources. The book may be cordially
recommended." — British Medical Journal.
SAUNDERS' POCKET MEDICAL FORMULARY. Fourth Edition,
Revised.
By William M. Powell, M.D., Attending Physician to the Mercer
House for Invalid Women at Atlantic City, N. J. Containing 1750
formulae selected from the best-known authorities. With an Appen-
dix containing Posological Table, Formulae and Doses for Hypo-
dermic Medication, Poisons and their Antidotes, Diameters of the
Female Pelvis and Fcetal Head, Obstetrical Table, Diet List for Various
Diseases, Materials and Drugs used in Antiseptic Surgery, Treatment
of Asphyxia from Drowning, Surgical Remembrancer, Tables of
Incompatibles, Eruptive Fevers, Weights and Measures, etc. Hand-
somely bound in flexible morocco, with side index, wallet, and flap.
$1.75 net.
" This little book, that can be conveniently carried in the pocket, contains an immense
amount of material. It is very useful, and, as the name of the author of each prescription
is given, is unusually reliable." — Medical Record, New York.
SAUNDERS' POCKET MEDICAL LEXICON. Fourth Edition,
Revised.
A Dictionary of Terms and Words used in Medicine and
Surgery. By John M. Keating, M.D., Fellow of the College of
Physicians of Philadelphia; Editor of the "Cyclopaedia of Diseases
of Children," etc.; Author of the "New Pronouncing Dictionary of
Medicine;" and Henry Hamilton, Author of " A New Translation
of Virgil's yEneid into English Verse;" Co-Author of the "New
Pronouncing Dictionary of Medicine." 321110, 280 pages. Cloth,
75 cents; Leather Tucks, $1.00.
" Remarkably accurate in terminology, accentuation, and definition." — Journal of the
American Medical Association.
SAYRE'S PHARMACY. Second Edition, Revised.
Essentials of the Practice of Pharmacy. By Lucius E. Sayre,
M.D., Professor of Pharmacy and Materia Medica in the University of
Kansas. Crown octavo, 200 pages. Cloth, $1.00; interleaved for
notes, $1.25.
[See Saunders' Question- Cotnpends, page 21.]
" The topics are treated in a simple, practical manner, and the work forms a very useful
student's manual." — Boston Medical and Surgical Journal.
Medical Publications of W. B. Saunders. 25
SEMPLE'S LEGAL MEDICINE, TOXICOLOGY, AND HYGIENE.
Essentials of Legal Medicine, Toxicology, and Hygiene. By
C. E. Armand Semple, B. A., M. B. Cantab., M. R. C. P. Lond.,
Physician to the Northeastern Hospital for Children, Hackney, etc.
Crown octavo, 2 1 2 pages ; 130 illustrations. Cloth, $1.00; interleaved
for notes, S 1 . 2 5 .
[See Saunders' Question- Compends, page 21.]
" No general practitioner or student can afford to be without this valuable work. The
subjects are dealt with by a masterly hand." — London Hospital Gazette.
SEMPLE'S PATHOLOGY AND MORBID ANATOMY.
Essentials of Pathology and Morbid Anatomy. By C. E.
Armand Semple, B.A., M.B. Cantab., M.R. C.P. Lond., Physician to
the Northeastern Hospital for Children, Hackney, etc. Crown octavo,
174 pages; illustrated. Cloth, $1.00; interleaved for notes, $1.25.
[See Satinders' Question- Compends, page 21.]
" Should take its place among the standard volumes on the bookshelf of both student
and practitioner." — London Lfospital Gazette.
SENN'S GENITO=URINARY TUBERCULOSIS.
Tuberculosis of the Genito-Urinary Organs, Male and Female.
By Nicholas Senn, M.D., Ph.D., LL.D., Professor of the Practice of
Surgery and of Clinical Surgery, Rush Medical College, Chicago.
Handsome octavo volume of 320 pages, illustrated. Cloth, ^3.00 net.
" An important book upon an important subject, and written by a man of mature judg-
ment and wide experience. The author has given us an instructive book upon one of the
most important subjects of the day." — Clinical Reporter.
" A work which adds another to the many obligations the profession owes the talented
author." — Chicago ALedical Recorder.
SENN'S SYLLABUS OF SURGERY.
A Syllabus of Lectures on the Practice of Surgery, arranged
in conformity with " An American Text=Book of Surgery." By
Nicholas Senn, M.D., Ph.D., Professor of the Practice of Surgery and
of Clinical Surgery in Rush Medical College, Chicago. Cloth, $2.00.
" This syllabus will be found of service by the teacher as well as the student, the work
being superbly done. There is no praise too high for it. No surgeon should be without
it. " — Ne-iv York Medical Times.
SENN'S TUMORS.
Pathology and Surgical Treatment of Tumors. By N. Senn,
M.D., Ph.D., LL.D., Professor of Surgery and of Clinical Surgery,
Rush Medical College ; Professor of Surgery, Chicago Polyclinic ;
Attending Surgeon to Presbyterian Hospital ; Surgeon-in-Chief, St.
Joseph's Hospital, Chicago. Octavo volume of 710 pages, with 515
engravings, including full-page colored plates. Cloth, $6.00 net;
Half Morocco, $7.00 net.
" The most exhaustive of any recent book in English on this 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.
26 Medical Publications of W. B. Saunders.
SHAW'S NERVOUS DISEASES AND INSANITY. Third Edition,
Revised.
Essentials of Nervous Diseases and Insanity. By John C.
Shaw, M.D., Clinical Professor of Diseases of the Mind and Nervous
System, Long Island College Hospital Medical School ; Consulting
Neurologist to St. Catherine's Hospital and to the Long Island College
Hospital. Crown octavo, i86 pages; 48 original illustrations. Cloth,
$1.00 ; interleaved for notes, $1.25.
[See Saunders' Question- Compends, page 21.]
"Clearly and intelligently written." — Boston Aledical and Surgical Journal.
"There is a mass of valuable material crowded into this small compass." — American
3fedico- Surgical Bulletin.
STARR'S DIETS FOR INFANTS AND CHILDREN.
Diets for Infants and Children in Health and in Disease. By
Louis Starr, M.D., Editor of "An American Text-Book of the
Diseases of Children." 230 blanks (pocket-book size), perforated
and neatly bound in flexible morocco. $1.25 net.
The first series of blanks are prepared for the first seven months of infant life ; each
blank indicates the ingredients, but not the quantities, of the food, the latter directions being
left for the physician. After the seventh month, modifications being less necessary, the diet
lists are printed in full. Formulae for the preparation of diluents and foods are appended.
STELW AGON'S DISEASES OF THE SKIN. Third Edition, Revised.
Essentials of Diseases of the Skin. By Henry W. Stelwagon,
M.D., Clinical Professor of Dermatology in the Jefferson Medical
College, Philadelphia; Dermatologist to the Philadelphia Hospital;
Physician to the Skin Department of the Howard Hospital, etc.
Crown octavo, 270 pages; 86 illustrations. Cloth, $1.00 net; inter-
leaved for notes, $1.25 net.
[See Saunders' Question- Cotnpetids, page 21.]
" The best student's manual on skin diseases we have yet seen." — Times and Register.
STENGEL'S PATHOLOGY.
A Manual of Pathology. By Alfred Stengel, M.D., Physician
to the Philadelphia Hospital ; Professor of Clinical Medicine in the
Woinan's Medical College ; Physician to the Children's Hospital ;
late Pathologist to the German Hospital, Philadelphia, etc. In
Preparation.
STEVENS' MATERIA MEDICA AND THERAPEUTICS. Second
Edition, Revised.
A Manual of Materia Medica and Therapeutics. By A. A.
Stevens, A.M., M.D., Lecturer on Terminology and Instructor in
Physical Diagnosis in the University of Pennsylvania; Demonstrator
of Pathology in the Woman's Medical College of Philadelphia. Post-
octavo, 445 pages. Cloth, $2.25.
"The author has faithfully presented modern therapeutics in a comprehensive work,
and, while intended particularly for the use of students, it will be found a reliable guide and
sufficiently comprehensive for the physician in practice." — University Medical AJagazine.
Medical Publications of W. B. Saunders. 27
STEVENS' PRACTICE OF MEDICINE. Fourth Edition, Revised.
A Manual of the Practice of Medicine. By A. A. Stevens, A.M.,
M.D., Lecturer on Terminology and Instructor in Physical Diagnosis
in the University of Pennsylvania ; Demonstrator of Pathology in
the Woman's Medical College of Philadelphia. Specially intended
for students preparing for graduation and hospital examinations. Post-
octavo, 511 pages; illustrated. Flexible leather, $2.50.
"The frequency with which new editions of this manual are demanded bespeaivs its
popularity. It is an excellent condensation of the essentials of medical practice for the
student, and maybe found also an excellent reminder for the busy physician." — Buffalo
Medicixl Journal.
STEWART'S PHYSIOLOGY.
A Manual of Physiology, with Practical Exercises. For
Students and Practitioners. By G. N. Stewart, M.A., M.D.,
D.Sc, lately Examiner in Physiology, University of Aberdeen, and
of the New Museums, Cambridge University ; Professor of Physiology
in the Western Reserve University, Cleveland, Ohio. Octavo volume
of 800 pages; 278 illustrations in the text, and 5 colored plates.
Cloth, $3.50 net.
" It will make its way by sheer force of merit, and amply deserves to do so. It is one
of the very best English text-books on the subject." — London Lancet.
"Of the many text-books of physiology published, we do not know of one that so
nearly comes up to the ideal as does Prof. Stewart's volume." — British Medical Journal.
STEWART AND LAWRANCE'S MEDICAL ELECTRICITY.
Essentials of Medical Electricity. By D. D. Stewart, M.D.,
Demonstrator of Diseases of the Nervous System and Chief of the
Neurological Clinic in the Jefferson Medical College; and E. S.
Lawrance, M.D., Chief of the Electrical Clinic and Assistant Demon-
strator of Diseases of the Nervous System in the Jefferson Medical
College, etc. Crown octavo, 158 pages; 65 illustrations. Cloth,
$1.00 ; interleaved for notes, $1.25.
[See Saunders'' Qiiestion-Cotnpetids, page 21.]
" Throughout the whole brief space at their command the authors show a discriminating
knowledge of their subject." — Medical News.
STONEY'S NURSING. Second Edition, Revised.
Practical Points in Nursing. For Nurses in Private Practice.
By Emily A. M. Stoney, Graduate of the Training-School for Nurses,
Lawrence, Mass.; late Superintendent of the Training-School for
Nurses, Carney Hospital, South Boston, Mass. 456 pages, illustrated
with 73 engravings in the text, and 8 colored and half-tone plates.
Cloth, $1.75 net.
" There are few books intended for non-professional readers which can be so cordially
endorsed by a medical journal as can this one." — Therapeutic Gazette.
" This is a well-written, eminently practical volume, which covers the entire range of
private nursing as distinguished from hospital nursing, and instructs the nurse how best to
meet the various emergencies which may arise, and how to prepare everything ordinarily
needed in the illness of her patient." — American Jourjial of Obstetrics and Diseases of
Women and Children.
" It is a work that the physician can place in the hands of his private nurses with the
assurance of benefit." — Ohio Medical Journal.
28 Medical Piihlications of W. B. Saunders.
SUTTON AND GILES' DISEASES OF WOMEN.
Diseases of Women. By J. Bland Sutton, F.R.C.S., Assistant
Surgeon to Middlesex Hospital, and Surgeon to Chelsea Hospital,
London; and Arthur E. Giles, M.D., B.Sc. Lond., F.R.C.S. Edin.,
Assistant Surgeon to Chelsea Hospital, London. 436 pages, hand-
somely illustrated. Cloth, $2.50 net.
" The 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 day." — Journal of the
Aiiitiican Medical Assoiiation.
THOMAS'S DIET LISTS AND SICK=ROOM DIETARY.
Diet Lists and Sick=Rooni Dietary. By Jerome B. Thomas,
M.D., Visiting Physician to the Home for Friendless Women and
Children and to the Newsboys' Home ; Assistant Visiting Physician
to the Kings County Hospital. Cloth, $1.50. Send for sample sheet.
" The idea is good, and the lists are copious." — London Lancet.
"Its practical usefulness places it among the requirements of every practitioner." —
Chicago Medical Recorder.
THORNTON'S DOSE=BOOK AND PRESCRIPTION=WRITING.
Dose=Book and Manual of Prescription=Writing. By E. Q.
Thornton, M.D., Demonstrator of Therapeutics, Jefferson Medical
College, Philadelphia. 334 pages, illustrated. Cloth, ^1.25 net.
" Full of practical suggestions; will take its place in the front rank of works of this
sort." — Medical Record, New York.
VAN VALZAH AND NISBET'S DISEASES OF THE STOMACH.
Diseases of the Stomach. By William W. Van Valzah, M.D. ,
Professor of General Medicine and Diseases of the Digestive System
and the Blood, New York Polyclinic; and J. Douglas Nisbet, M.D.,
Adjunct Professor of General Medicine and Diseases of the Digestive
System and the Blood, New York Polyclinic. Octavo volume of 674
pages, illustrated. Cloth, $3.50 net.
VIERORDT'S MEDICAL DIAGNOSIS. Third Edition, Revised.
Medical Diagnosis. By Dr. Oswald Vierordt, Professor of Medi-
cine at the University of Heidelberg. Translated, with additions,
from the second enlarged German edition, with the author's permission,
by Francis H. Stuart, A.M., M.D. Handsome royal octavo volume
of 700 pages; 178 fine wood-cuts in te.xt, many of them in colors.
Cloth, $4.00 net; Sheep or Half Morocco, $5.00 net; Half Russia,
$5.50 net.
" A treasury of practical information which will be found of daily use to every busy
practitioner who will consult it." — C. A. LiNDSLEY, M.D., Professor of the Theory and
Practice of Medicine, Yale University.
" Rarely is a book published with which a reviewer can find so little fault as with the
volume before us. Each particular item in the consideration of an organ or apparatus, which
is necessary to determine a diagnosis of any disease of that organ, is mentioned; nothing
seems forgotten. The chapters on diseases of the circulatoiy and digestive apparatus and
nervous system are especially full and valuable. The reviewer would repeat that the book is
one of the best — probably the best — which has fallen into his hands." — University Aledical
Magazifie.
Medical Piihlications of W. B. Saunders. 29
WARREN'S SURGICAL PATHOLOGY AND THERAPEUTICS.
Surgical Pathology and Therapeutics. By John Collins Warren,
M.D., LL.D., Professor of Surgery, Medical Department Harvard
University; Surgeon to the Massachusetts General Hospital, etc.
Handsome octavo volume of 832 pages; 136 relief and lithographic
illustrations, 33 of which are printed in colors, and all of which were
drawn by William J. Kaula from original specimens. Cloth, $6.00
net; Half Morocco, $7.00 net.
"There is the work of Dr. Warren, which I think is the most creditable book on
Surgical Pathology, and the most beautiful medical illustration of the bookmaker's art, that
has ever been issued from the American press." — Dr. Roswell Park, zn the Harvard
Graduate Magazine.
" The handsomest specimen of bookmaking that has ever been issued from the American
medical press." — Atnerica^i Journal of the Medical Sciences.
"A most striking and very excellent feature of this book is its illustrations. Without
exception, from the point of accuracy and artistic merit, they are the best ever seen in a work
of this kind. Many of those representing microscopic pictures are so perfect in their coloring
and detail as almost to give the beholder the impression that he is looking down the barrel
of a microscope at a well-mounted section." — Annals of Surgery.
WEST'S NURSING.
An American Text=Book of Nursing. By American Teachers.
Edited by Roberta M. West, late Superintendent of Nurses in the
Hospital of the University of Pennsylvania. In Preparation.
WOLFF ON EXAMINATION OF URINE.
Essentials of Examination of Urine. By Lawrence Wolff, M.D.,
Demonstrator of Chemistry, Jefferson Medical College, Philadelphia,
etc. Colored (Vogel) urine scale and numerous illustrations. Crown
octavo. Cloth, 75 cents.
[See Saii?iders' Question- Compends, page 21.]
'* A very good work of its kind — very well suited to its purpose." — Times and Register.
WOLFF'S MEDICAL CHEMISTRY. Fourth Edition, Revised.
Essentials of Medical Chemistry, Organic and Inorganic.
Containing also Questions on Medical Physics, Chemical Physiology,
Analytical Processes, Urinalysis, and Toxicology. By Lawrence
Wolff, M.D., Demonstrator of Chemistry, Jefferson Medical College.
Philadelphia, etc. Crown octavo, 218 pages. Cloth, ^i.oo; intf
leaved for notes. Si. 25.
[See Saunders' Question- Compends, page 21.]
•'The scope of this work is certainly equal to that of the best course of lectures on
Medical Chemistry." — Phari/tacetttical Era.
CLASSIFIED LIST
Medical Publications
W. B. SAUNDERS,
925 Walnut Street, Philadelphia.
ANATOMY, EMBRYOLOGY,
HISTOLOGY.
Clarkson — A Text-Book of Histology, 9
Haynes — A Manual of Anatomy, . . . 13
Heisler — A 'i'ext-Rook of Embryology, 13
Nancrede — Essentials of Anatomy, . . 18
Nancrede — Essentials of Anatomy and
Manual of Practical Dissection, . . . 18
Semple — Essentials of Pathology and
Morbid Anatomy, 25
BACTERIOLOGY.
Ball — Essentials of Bacteriology, ... 6
Crookshank — A Text-Book of Bacteri-
ology, 10
Frothingham — Laboratory Guide, . . H
Mallory and Wright — Pathological
Technique, 16
McFarland — Pathogenic Bacteria, . . 17
CHARTS, DIET-LISTS, ETC.
Griffith — Infant's Weight Chart, ... 12
Hart — Diet in Sickness and in Health, . 13
Keen — Operation Blank, 15
Laine — Temperature Chart 15
Meigs — Feeding in Early Infancy, . . 17
Starr — Diets for Infants and Children, . 26
Thomas — Diet-Lists and Sick-Room
Dietary, 28
CHEMISTRY AND PHYSICS.
Brockway — Essentials of Medical Phys-
ics, 7
Wolff — Essentials of Medical Chemistry, 29
CHILDREN.
An American Text-Book of Diseases
of Children, . . 3
Griffith — Care of the Baby 12
Griffith — Infant's Weight Chart, ... 12
Meigs — Feeding in Early Infancy, . . 17
Powell — Essentials of Dis. of Children, 19
Siarr — Diets for Infants and Children, . 26
DIAGNOSIS.
Cohen and Eshner— Essentials of Di-
agnosis, . 9
Corwin — Physical Diagnosis, .... 9
Macdonald — Surgical Diagnosis and
Treatment, 16
Vierordt — Medical Diagnosis, .... 28
DICTIONARIES.
Keating — Pronouncing Dictionary, . . I4
Morten — Nurse's Dictionary, .... 18
Saunders' Pocket Medical Lexicon, . 24
EYE, EAR, NOSE, AND THROAT.
An American Text- Book of Diseases
of tlie Eye, Ear, Nose, and Throat, . 3
Casselberry — Dis. of Nose and Throat, 8
De Schweinitz — -Diseases of the Eye, . ID
Gleason — Essentials of Dis. of the Ear, il
Jackson and Gleason — Essentials of
Diseases of the Eye, Nose, and Throat, 14
Kyle — Diseases of the Nose and Throat, 15
GENITO=URINARY.
An American Text-Book of (Jenito-
Urinary and Skin Diseases, 4
Hyde and Montgomery — Syphilis and
the \'enereal Diseases, 13
Martin — Essentials of Minor Surgery.
Bandaging, and Venereal Diseases, . 16
Saundby — Renal and Urinary Diseases, 24
Senn — Genito-Urinary Tuberculosis, . 25
GYNECOLOGY.
American Text- Book of Gynecology, 4
Cragin — Essentials of Gynecology, . . 10
Garrigues — Diseases of Women, ... 11
Long — Syllabus of Gynecology, ... 15
Penrose — Diseases of Women, .... 18
Sutton and Giles — Diseases of Women, 28
MATERIA MEDICA, PHARMACOL-
OGY, AND THERAPEUTICS.
An American Text-Book of Applied
Therapeutics 3
Butler — Text-Book of Materia Medica,
Therapeutics and Pharmacology, ... 8
Cerna — Notes on the Newer Remedies, 8
Griffin — Materia Med. and Therapeutics, 12
Morris — Essentials of Materia Medica
and Therapeutics, . . 1 7
Saunders' Pocket Medical Formulary, 24
Sayre — Essentials of Pharmacy, . . 24
Stevens — Essentials of Materia Medica
and Therapeutics ... 26
Thornton — Dose-Book and Manual of
Prescription-Writing 28
\A^arren — Surgical Pathology and Ther-
apeutics, 29
MEDICAL JURISPRUDENCE AND
TOXICOLOGY.
An American Text-Book of Legal
Medicine and Toxicology, 4
Chapman — Medical Jurisprudence and
Toxicology, 8
Semple — Essentials of Legal Medicine,
Toxicology, and Hygiene, 25
Medical Publications of W. B. Saunders.
31
NERVOUS AND MENTAL
DISEASES, ETC.
Burr — Nervous Diseases, 7
Chapin — Compendium of Insanity, . . 8
Church and Peterson — Nervous and
Mental Diseases, 9
Shaw — Essentials of Nervous Diseases
and Insanity, 26
NURSING.
An American Text-Book of Nursing, 29
Griffith — The Care of the Baby, ... 12
Hampton — Nursing, 12
Hart — Diet in Sickness and in Health, 13
Meigs — Feeding in Early Infancy, . . 17
Morten — Nurse's Dictionary iS
Stoney — Practical Points in Nursing, . 27
OBSTETRICS.
An American Text-Book of Obstetrics, 4
Ashton — Essentials of Obstetrics, ... 6
Boisliniere — Obstetric Accidents, Emer-
gencies, and Operations, 7
Borland -Manual of Obstetrics, . . . lo
Hirst — Text-Book of Olistetrics, ... 13
Norris — Syllabus of Obstetrics, .... 18
PATHOLOGY.
An American Text-Book of Pathologj', 5
Mallory and Wright — Pathological
Technique, 16
Semple — Essentials of Pathology and
Morbid Anatomy, 25
Senn — Pathology and Surgical Treat-
ment of Tumors, 25
Stengel — Manual of Pathology, ... 26
Warren — Surgical Pathology and Thera-
peutics, 29
PHYSIOLOGY.
An American Text-Book of Physi-
ology, 5
Hare — Essentials of Physiology, ... 13
Raymond — Manual of Physiology, . . I9
Stewart — Manual of Physiology, ... 27
PRACTICE OF MEDICINE.
An American Text-Book of the The-
ory and Practice of Medicine, .... 5
An American Year-Book of Medicine
and Surgery, 6
Anders — Te.\t-Book of the Practice of
Medicine, .... 6
Lockwood — Manual of the Practice of
Medicine, . . .... 15
Morris — Essentials of the Practice of
Medicine, 17
Rowland and Hedley — Archives of
the Roentgen Ray, I9
Stevens — Manual of the Practice of
Medicine, 27
SKIN AND VENEREAL.
An American Text-Book of Genito-
urinary and Skin Diseases, 3
Hyde and Montgomery — Syphilis and
the \'enereal Diseases, 13
Martin — Essentials of Minor Surger}',
Bandaging, and Venereal Diseases, . 16
Pringle — Pictorial Atlas of Skin Dis-
eases and Syphilitic Affections, ... 19
Stelwagon — Essentials of Diseases of
the Skin 26
SURGERY.
An American Text-Book of Surgery, 5
An American Year-Book of Medicine
and Surgery, 6
Beck — Manual of Surgical Asepsis, . . 7
DaCosta — Manual of Surgery, .... 10
Keen— Operation Blank, ...... 15
Keen — The Surgical Complications and
-Sequels of Typhoid Fever, 15
Macdonald — Surgical Diagnosis and
Treatment, 16
Martin — Essentials of Minor Surgery,
Bandaging, and Venereal Diseases, . 16
Martin — Essentials of Surgery, .... 16
Moore^Orthopedic Surgery, 17
Pye — Elementary Bandaging and Surgi-
cal Dressing, ig
Rowland and Hedley— Archives of
the Roentgen Ray, 19
Senn — Genito-Urinary Tuberculosis, . 25
Senn — Syllabus of Surgery, 25
Senn — Pathology and Surgical Treat-
ment of Tumors, 25
Warren — Surgical Pathology and Ther-
apeutics, 29
URINE AND URINARY DISEASES.
Saundby — Renal and Urinary Diseases, 24
Wolff — Essentials of Examination of
Urine, 29
MISCELLANEOUS.
Bastin — Laboratory E.\ercises in Bot-
any, 7
Gould and Pyle — Anomalies and Curi-
osities of Medicine, 11
Keating — How to E.xamine for Life
Insurnnce, 14
Keen — Surgical Complicat'ons and Se-
quels of Ty]jhoid Fever, 15
Rowland and Hedley — Archives of
the Roentgen Ray, 19
Saunders' Medical Hand-Atlases, . . 2
Saunders' New Series of Manuals, 22, 23
Saunders' Pocket Medical Formulary, . 24
Saunders' Question-Compends, . . 20, 21
Senn — Pathology and Surgical Treat-
ment of Tumors, ... . -25
Stewart and Lawrance — Essentials of
Medical Electricity, 27
Thornton — Dose-Book and Manual of
Prescription-Writing 28
Van Valzah and Nisbet — Diseases of
the Stomach, 28
In Preparation for Early Publication.
AN AMERICAN TEXT-BOOK OF DISEASES OF THE EYE, EAR, NOSE,
AND THROAT.
Edited by G. E. DK Schweinitz, M.D. , Professor of Ophthalmology in the Jeffer-
son Medical College, I'liiladelphia ; and B. Alexander Randall, M.D., Professor
of Diseases of the Ear in the University of Pennsylvania and in the Philadelphia
Polyclinic.
AN AMERICAN TEXT=BOOK OF PATHOLOGY.
Edited by John GuixfeRAS, M.D., Professor of General Pathology and of Morbid
Anatomy in the University of Pennsylvania; and David Riesman, M. D., Demon-
strator of Pathological Histology in the University of Pennsylvania.
AN AMERICAN TEXT-BOOK OF LEGAL MEDICINE AND TOXICOLOGY.
Edited by Frederick Peterson, M.D., Clinical Professor of Mental Diseases in
the Woman's Medical College, New York ; Chief of Clinic, Nervous Department,
College of Physicians and Surgeons, Newr York; and Walter S. Haines, M.D.,
Professor of Chemistry, Pharmacy, and Toxicology in Rush Medical College, Chicago,
Illinois.
STENGEL'S PATHOLOGY.
A Manual of Pathology. By Alfred Stengel, ISI. D., Physician to the
Philadelphia Hospital ; Professor of Clinical Medicine in the Woman's Medical
College ; Physician to the Children's Hospital ; late Pathologist to the German
Hospital, Philadelphia, etc.
CHURCH AND PETERSON'S NERVOUS AND MENTAL DISEASES.
Nervous and Mental Diseases. By Archibald Church, M.D., Professor of
Mental Diseases and Medical Jurisprudence in the Northwestern University Medical
School, Chicago ; and Frederick Peterson, M.D. , Clinical Professor of Mental
Diseases in the Woman's Medical College, New York ; Chief of Clinic, Nervous
Department, College of Physicians and Surgeons, New York.
HEISLER'S EMBRYOLOGY.
A Text=Book of Embryology. By John C. Heisler, M.D., Professcnr of
Anatomy in the Medico-Chirurgical College, Philadelphia.
KYLE ON THE NOSE AND THROAT.
Diseases of the Nose and Throat. By D. Braden Kyle, M. D., Clinical Pro-
fessor of Laryngology and Rhinology. Jefferson Medical College, Philadelphia; Con-
sulting Earyngologist, Rhinologist, and Otologist, St. Agnes' Hospital ; Bacteriologist
to the Philadelphia Orthopedic Hospital and Infirmary for Nervous Diseases, etc.
HIRST'S OBSTETRICS.
A Text=Book of Obstetrics. By Barton Cooke Hirst, M.D., Professor of
Obstetrics in the University of Pennsylvania.
WEST'S NURSING.
An American Text-Book of Nursing. By American Teachers. Edited by
Roberta M. West, Late Superintendent of Nurses in the Hospital of the University
of Pennsylvania.
COLUMBIA UNIVERSITY LIBRARIES
This book Is due on "the date indicated below, or at the
expiration of a definite period after the date of borrowing, as
provided by the library rules or by special arrangement with
the Librarian in charge.
DATE BORROWED
DATE DUE
DATE BORROWED
DATE DUE
C28 (449; M50
AclinicaMpv. >. .' *'• '
2002108666
RD31
M14
1897
MacDonald
Clinical text-book of surgical
diagnosis and treatment.
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