COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD HX64060543 RD31 D11 A manual ol modem s RECAP n il ■ t i a wp w iii— iWM '•t'»^'rmm^mK^mi0fim iwm i i lutf I ^*«wh Sciences Ijfcfiry Digitized by the Internet Archive in 2010 with funding from Columbia University Libraries http://www.archive.org/details/manualofmodernsuOOdaco Frontispiece. Plate i. K - / 3. 'iv. . \ \ I. Bacillus of Tetanus, with Spores. 2. Gonococci in Gonorrhoeal Pus (aniline, methyl-violet). 3. Tubercle Bacilli in Sputum (Ziegler). 4. Hutchinson Teeth. 5, 6. Radial Pulse-tracings in Aneurysm of Right Brachial Artery : 5, left radial pulse ; 6, right radial pulse. Sauntrrrs' IMcto ^tti Scries A MANUAL OF MODERN SURGERY GENERAL AND OPERATIVE BY JOHN CHALMERS DaCOSTA, M.D., DEMONSTRATOR OF SURGERY, JEFFERSON MEDICAL COLLEGE, PHILADELPHIA; CHIEF ASSISTANT SURGEON, JEFFERSON MEDICAL COLLEGE HOSPITAL, ETC. WITH 188 ILLUSTRATIONS IN THE TEXT AND 13 FULL-PAGE PLATES IN COLORS AND TINTS, AGGREGATING 276 SEPARAXE FIGURES W. B. SAUNDERS 925 Walnut Street. 1894. ■P.i Copyright, 1894, by W. B. SAUNDERS EUECTROTYPED BY PRESS OF WESTCOTT & THOMSON, PHILADA. W. B. SAUNDERS, PHILADA. o -J CO 'Si- CD OS a. THIS VOLUME IS DEDICATED, WITH AFFECTIONATE REGARDS, TO DR. ORVILLE HORWITZ. THE FELLOW-STUDENT, THE HOSPITAL ASSOCIATE, AND THE TRUSTED FRIEND OF THE AUTHOR. PREFACE. The aim of this Manual is to present in clear terms and in concise form the fundamental principles, the chief operations; and the accepted methods of modern surgery. The work seeks to stand between the complete but cumbrous text-book and the incomplete but concentrated compend. Obsolete and unessential methods have been excluded in favor of the living and the essential. There has been no attempt to exploit fanciful theories nor to defend unprovable hypotheses, but rather the effort has been to present the sub- ject in a form useful alike to the student and to the busy practitioner. The opening chapter is devoted to Bacteriology because the author profoundly believes that without some knowledge of the vital principles of this branch of science the vast im- portance of its truths will be ill-appreciated, and there will be inevitable failure in the application of aseptic and anti- septic methods. Ophthalmology, gynecology, rhinology, otology, and lar- yngology have not been considered, because of the obvious fact that in the advanced state of specialized science only the specialist is competent to write upon each of these branches. In Orthopedic Surgery are discussed those conditions which must in the very nature of things often be cared for by the surgeon or the general practitioner (such as hip-joint disease, club-foot, Pott's disease of the spine, flat-foot, etc.). The limited space at command precluded the introduction of a special division on diseases of the female breast. A large amount of space has been devoted to Fractures and Dis- locations, the enormous practical importance of these sub- jects calling for their full discussion. Operative Surgery is 3 4 PREFACE. considered in separate sections, the most important pro- cedures being fully described, giving also the instruments necessary, and the positions assumed by patient and operator. This method has been adopted to fit the work for use in sur- gical laboratories. Many systems, manuals, monographs, lectures, and journal articles have been consulted, and credit has been given in the text for statements and quotations. Special acknowl- edgment is due to the American Text-Book of Surgery^ edited by Keen and White ; to the surgical works of Ashurst, Agnew, the elder Gross, Duplay and Reclus, Esmarch, Albert Koenig, Wyeth, and Bryant ; to the Man- ual of Surgery edited by Treves ; to the International En- cyclop(Bdia of Surgery edited by Ashurst ; to the Surgical Pathology of Billroth and of Bowlby ; to the Diagnosis of E. Pearce Gould ; to the Surgical Dictionary of Heath ; to the Rest and Pain of Hilton; to the works on operative sur- gery of Barker, Jacobson, Treves, Stephen Smith, and Joseph Bell ; to the Minor Surgery of Wharton ; to the dictionary of Foster and of Gould ; to the Principles of S^irgery of Senn; to the orthopedic writings of Sayre ; to the work on Diseases of the Male Generative Organs of Jacobson ; to the System of Genito-nrinary Diseases edited by Morrow ; and to the treatises on Fractures and Dislocations of Sir Astley Cooper, Malgaigne, Hamilton, Stimson, and T. Pickering Pick. The Author returns his thanks to the numerous writers who courteously authorized the reproduction of special illustrations, and particularly to Professors Keen and White for their free permission to draw upon the American Text- Book of Surgery, from which a number of pictures have been taken, distinctively those referring to Bandaging; to Mr. John Vansant for the great amount of labor so ably and cheerfully performed ; and to Dr. Howard De Honey for the preparation of the Index. 2050 Locust Street, Philadelphia, October, 1894. CONTENTS. PAGE I. Bacteriology 17 ^licro-orgaiiisms. Microbes, or Bacteria, 17: P'orms of Bacteria, 19; Multiplication of Bacteria, 21 ; Life Conditions of Bacteria, 22; Effect of Heat and Cold on Bacteria, 23 ; Chemical Germicides, 24 ; Distribu- tion of Microbes, 24 ; Koch's Circuit, 25 ; Toxalbumins and Toxines, 26; Ptomaines, 27 ; Leucomaines, 27; Antitoxines, 27; Phagocytes, 28 ; Protective and Preventive Inoculations, 29 ; Antagonistic Microbes, 30; Mixed Infection, 30; Placental Transmission, 30. Special Sur- gical Microbes, 31 : Other Surgical Microbes, 32. II. Inflammation 33 Definition, 33 ; Vascular and Circulatory Changes, -^t^ ; Active Hyper- semia, ^t^ ; Retardation of the Circulation, 34 ; Oscillation and Stagna- tion, 36 ; Exudation of Fluids, 36 ; Diapedesis or Migration, 37 ; Changes in the Perivascular Tissues, 38 ; Classification of Inflamma- tions, 39; Ejy^nsion of Inflammation, 40; Terminations of Inflam- mation, 41 ; Causes of Inflammation, 41 ; Symptoms of Inflammation, 42; Constitutional Symptoms of Inflammation, 47 ; Treatment of In- flammation, 47 ; Local Treatment of Inflammation, 48 ; Constitu- tional Treatment of Inflammation, 60. III. Repair 73 Healing by First Intention, 73; Healing by Second Intention, 74; Heal- ing by Third Intention, 75 ; Cell-division, 76. IV. Surgical Fevers 77 Types of Fever, 78 : Sthenic, 78 ; Asthenic, 78 ; Nervous, 79. Trau- matic Fevers, 80 : — Primaiy Wound-fever : a. Aseptic Fever, b. Traumatic or Surgical Fever, 80; Secondary ^Yound-fever : Sup- purative Fever, 81. V. Terminations of Inflammation 81 Effusion of Serum, 8i ; Effusion of Lymph, 82; Suppuration, 84; Forms of Pus, 85. Abscesses, 88 : Forms of Abscesses, 90; Acute Abscess, 91, VI. Ulceration and Fistula loi Necrosis, 102; Classification of Ulcers, 102; Acute Ulcer of the Leg, 103; Chronic Ulcer of the Leg, 104; Complications of Ulcers, 105; Ulcers in any Region, 1075 Fistula, 108; Sinus, 108, 5 6 CONTENTS. PAGE VII. Mortification or Gangrene 109 Classification, 109 ; Dry or Chronic Gangrene (Pott's Gangrene), iio; Senile Gangrene, iii; Moist or Acute Gangrene, 113. Septic Gaii- grene, 114: a. Traumatic Gangrene, 115, b. Hospital Gangrene, 115. Special Forms of Gangrene, 116: a, Symmetrical Gangrene, 116; b. Diabetic Gangrene, 117; c, Gangrene from Ergotism, 117; d, Gan- grene from Frost-bite, 118; e, Noma, or Cancrum Oris, 118; Slough- ing, 119; Phagedsena, 119; Decubital Gangrene, or Bed-sore (Decu- bitus), 1 20 5 Rules for Amputation in Gangrene, 121. VIII. Thrombosis and Embolism 122 IX. Septicaemia AND Pyaemia 125 Septicccniia, 125; Sapraemia, or Septic Intoxication, 125; Septic Infection, or True Septicaemia, 126. Pya:mia, 127. X. Erysipelas (St. Anthony's Fire) 129 Forms of Erysipelas, 130 ; Clinical Forms, 130; Cutaneous Erysipelas, 130; Cellulo-cutaneous or Phlegmonous Erysipelas, 131 ; CelluUtis, 132. XI. Tetanus, or Lockjaw 133 Acute, 133; Chronic, 134. XII. Tuberculosis and Scrofula 137 Bacillus of Tubercle, 138; Tubercular Infection, 140; Scrofula, 141 ; Tuberculous Abscess, 142; Tuberculosis of the Skin, 142; Anatomi- cal Tubercle, 142; Scrofulodermata, or Scrofulous Gummata, 142; Tuberculosis of Subcutaneous Connective Tissue, 143; Tuberculosis of the Alimentaiy Canal, 143; Intestinal Tuberculosis, 143; Peritoneal Tuberculosis, 144; Tuberculosis of the Brain, 144; Tuberculous Dis- ease of the Joints, 144; Tuberculosis of Lymphatic Glands, 144; Diagnosis, Prognosis, and Treatment of Tuberculosis, 145 ; Koch's Tuberculin, 146. XIII. Rickets i47 XIV. Contusions and Wounds 148 Contusions, 148 ; Wounds, 149 ; Local Phenomena of Wounds, 149 ; Con- stitutional Condition of Wounds, 150; Treatment of Wounds, 151 ; In- cised Wounds, 153; Lacerated and Contused Wounds, 153; Punctured Wounds, 154; Gunshot Wounds, 154; Poisoned Wounds, 156; Septic Wounds, 156; Dissection-wounds, 156; Malignant CEdema or Gan- grenous Emphysema, 157; Stings and Bites of Insects and Reptiles, 157; Anthrax, 160; Hydrophobia, Rabies, or Lyssa, 162; Glanders, Farcy, or Equinia, 163; Actinomycosis, 164. CONTENTS. 7 PAGE XV. Syphilis 165 Definition, 165; Transmission of Syphilis, 166; Syphilitic Stages, 167; Syphilitic Peiiods, 167; Primary Syphihs, 167; Initial Lesions, 168; Mixed Infection of Chancre and Chancroid, 168 ; Syphilitic Bubo, 171 ; General Syphilis, 172; Secondary Syphilis, 172. Syphilitic Skin Dis- eases, 172: Forms of Eruption, 173. Aftections of the Mucous Mem- branes, 175; Affections of the Hair, 176; Affections of the Nails, 176; Affections of the Ear, 176; Affections of the Bones and Joints, 176; Affections of the Eye, 177; Affections of the Testes, 177; Intermediate Period, 177; Tertiary Syphihs, 178; Treatment of Primary Stage, 180; Treatment of Secondary Stage, 181 ; Acute PtyaHsm, or Salivation, 184; Treatment of Tertiar>- Stage, 187; Hereditary Syphilis, 188. XVI. Tumors, or Morbid Growths 191 Neoplasms, 191 ; Classes of Tumors, 192; Causes, 193; Malignant and Innocent or Benign Tumors, 194; Classification, 195. Innocent Con- nective-tissue Tumors, 196: Lipomata, 196; Fibromata, 197; Chon- dromata, 199; Osteomata, 200; Odontomata, 201; Myxomata, 202; Lymphomata, 203 ; Myomata, 204 ; Neuromata, 207 ; Angeiomata, 208; Lymphangeiomata, 209. Malignant Comiective-tissue Tumors, or Sarcomata, 2IO. Injiocent Epithelial Tuviors, 215. Papillomata, or Warts, 2j^. Adenomata, 216. Malignant Epithelial Tumors, Carcinof?iata, or Cancers, 217- Epitheliomata, 219; Rodent Ulcer, 219; Spheroidal-celled Carcinomata, 220 ; Cylindrical-celled Carcino- mata, 221. Cysts, 222: Sebaceous Cysts, 222; Dermoid Cysts, 223 ; Hydatid Cysts, 223. XVII. Diseases and In7URIes of the Heart and Vessels .... 224 Heart and Pericardium^ 224: Wounds and Injuries, 224; Phlebitis, or Inflammation of a Vein, 225 ; Varicose Veins, or Varix, 225 ; Nsevus, 227; Arteritis, 227. Aneioysm, 229: Forms of Aneurysm, 230; Causes of Aneun,'sm, 233 ; Constituent Parts of xA.neurysm, 233 ; Symp- toms of Aneurysm, 234 ; Diagnosis of Aneur}-sm, 234 ; Treatment of Aneurysm, 235 Arterio-venous Aneurysm, 241. Citsoid Aneurysm, or Aneurysm by Anastomosis, 242. Wounds of Arteries, 243. (l) Hemorrhage, or Loss of Blood, 244 : Hemorrhagic Fever, 245 ; Hemostatic Agents, 246; Golden Rules for Procedure in Primary Hemorrhage, 249 ; Reactionary or Recurrent Hemorrhage, 258 ; Sec- ondary Hemorrhage 258. (2) Operations on the Vascular Sys- tem, 260: Paracentesis Auriculi, 260; Paracentesis Pericardii, 260; Operation for Varix of Leg, 260; Open Operation for Vancocele, 261 ; Subcutaneous Ligature for Varicocele, 261 ; Phlebotomy, or Venesec- tion, 262; Transfusion of Blood, 263. (3) Ligation of Arteries 8 CONTENTS. PAGE IN Continuity, 265 : Radial Artery, 268 ; Ulnar Artery, 271 ; Brachial Artery, 272; Axillary Artery, 274; Subclavian Artery, 277; Region of the Neck, 278 ; Common Carotid Artery, 280; External Carotid Artery, 283; Internal Carotid Artery, 284; Lingual Artery, 285; Dorsalis Pedis Artery, 285 ; Anterior Tibial Artery, 287 ; Posterior Tibial Artery, 289; Popliteal Artery, 290; Femoral Artery, 290; Iliac Arteries, 293. XVIII. Diseases and Injuries of Bones and Joints 295 (i) Diseases of the Bones, 295 : Atrophy of Bone, 295 ; Hypertrophy of Bone, 295 ; Osteitis, or Inflammation of Bone, 295 ; Chronic Periostitis, 298 ; Osteoplastic Periostitis, 298 ; Abscess of Bone, 298 ; Caries, 299 ; Necrosis, 301 ; Acute Diffuse Osteo-myelitis, 303 ; Acute Epiphysitis, 304; Chronic Osteo-myelitis, 305 ; Osteo-malacia, or Mollities Ossium, 305. (2) Fractures, 306: Definition, 306; Varieties, 306; Causes, 311 ; Symptoms, 314; Varieties of Displacement, 315 ; Diagnosis, 318; Complications and Consequences, 320; Repair of Fractures, 320; Non-union of Fractures, 322; Treatment of Fractures, 322. Special Fractures: Nasal Bones, 328. Superior Maxillary Fractures, 331. Fracture of Malar Bone, 333. Fracture of the Zygomatic Arch, 333. Fractures of Inferior Maxillary Bone, 333. Fractures of Hyoid Bone, 335, Fractui-e of Laryngeal Cartilages, 336. Fracture of the Ribs, 337 : Fracture of Costal Cartilages, 340. Fracture of Sternum, 341. Fractures of the Pelvis, 343: Fractures of False Pelvis, 343; Fractures of True Pelvis, 344. Fracture of Sacrum, 346. Fractures of Coccyx, 347. Fracture of Clavicle, 348 : Fractures of Shaft of Clavicle, 348; Fracture of Acromial End of Clavicle, 351; Fracture of Sternal End of Clavicle, 352. Fracture of Scapula, 352 : Frac- tures of Neck of Scapula, 353 ; Fractures of Glenoid Cavity of Scapula, 353 ; Fracture of Acromion Process of Scapula, 353 ; Fracture of Coracoid Process of Scapula, 354. Fractures of Humerus, 354 : Fracture of Anatomical Neck of Humerus, 354; Fractures of Surgical Neck of Humerus, 356; Longitudinal and Oblique Fracture of Head of Humerus, 357; Separation of Upper Epiphysis of Humerus, 358; Fracture of Shaft of Humerus, 359; Fractures of Lower Extremity of Humerus, 360; Fracture of External Condyle of Humerus, 360; Fracture of Inner Epicondyle of Humerus, 360; Fracture of Internal Condyle of Humerus, 361 ; Fracture at Base of Condyles of Humerus, 361 ; T-Fracture of Humerus, 361 ; Fractures in or near Elbow-joint, 361 ; Epiphyseal Separation of Humerus, 362. Fractures of Ulna, 363 : Fracture of Coronoid Process of Ulna, 363 ; Fracture of Olecranon Process of Ulna, 363 ; Fracture of Shaft of Ulna, 364 ; Fracture of Styloid Process of Ulna, 365. Fractures of Radius, 365: CONTENTS. 9 PAGE Fracture of Head of Radius, 365 ; Fracture of Neck of Radius, 366 ; Fracture of Shaft of Radius, 366 ; Fracture of Radius above Insertion of Pronator Radii Teres Muscle, 366; Fracture of Radius below In- sertion of Pronator Radii Teres Muscle, 367; Fracture of Shafts of both Bones of Forearm, 367 ; Fracture of Lower Extremity of Radius, 368 ; Fracture of Both Radius and Ulna near Wrist, 370 ; Separation of Lower Radial Epiphysis, 370. Fractures of Carpus, 371 : Fracture of Metacarpal Bones, 371 ; Fractures of Phalanges, 372. Fracture of Femur, 372: Fractures of Upper Extremity of Femur, 372; Intra- capsular Fracture of Femur, 372; Extracapsular Fracture of Femur, 379 ; Fracture of Great Trochanter, 380 ; Separation of Upper Epiphy- sis of Femoral Head, 381 ; Separation of Epiphysis of Great Tro- chanter, 381 ; Fractures of Shaft of Femur, 381 ; Fracture of Femur above Condyles, 383 ; Fracture of Femur Separating either Condyle, 384; Longitudinal Fractures of Femur, 385; Separation of Lower Epiphysis of Femur, 385. Fracture of Patella, 385: Fracture of Patella by Muscular Action, 385 ; Transverse Fractures of Patella, 386 ; Fractures of Patella by Direct Force, 387. Fractures of Tibia, 388: Fractures of Upper End of Tibia, 388; Separation of Upper Epiphysis of Tibia, 389 ; Fractures of Shaft of Tibia, 389 ; Fractures of Lower End of Tibia : Fracture of Inner Malleolus, 389 ; Separation of Lower Epiphysis of Tibia, 390. Fracture of Fibula, 390 : Fractures of Upper Two-thirds of Fibula, 390; Fractures of Lower Third of Fibula, 390; Pott's Fracture of Fibula, 391 ; Fracture of Both Bones of Leg, 392. Fractures of Bones of Foot, 393 : Fractures of Meta- tarsal Bones, 395 ; Fractures of Phalanges of Toes, 395. (3) Dis- eases OF THE Joints, 395 : Synovitis, 395 : Acute Synovitis, 395 ; Chronic Synovitis, 396. Arthritis, 397 : Tubercular Arthritis, 398. Tuberculosis of Special Joints, 400 : Hip-joint, 400; Knee-joint Dis- ease, 407; Ankle-joint Disease, 409; Shoulder-joint Disease, 409; Elbow-joint Disease, 410; Wrist-joint Disease, 410; Septic Arthritis, 411; Infective Arthritis, 411 ; Gonorrhoeal Arthritis, or Gonorrhoeal Rheumatism, 412; Rheumatic Arthritis, 414; Gouty Arthritis, 415; Arthritis Deformans, 416. Charcot's Disease, 419. Hysterical Joint, 420. Neuralgia of Joints, 421. Articular Wounds and Injuries, 422 : Sprains, 423. Ankylosis, 425 : False or Extra-articular Ankylosis, 428. Loose Bodies in Joints (Floating Cartilages), 428. (4) Luxations or Dislo- cations, 429 : Traumatic Dislocations, 430; Spontaneous, Pathological, and Consecutive Dislocations, 431 ; Congenital Dislocations, 431 ; Compound Traumatic Dislocations, 435 ; Old Traumatic Dislocations, 436. Special Trauviatic Dislocations : LoTver Jaiu, 436. Dislocation of the Clavicle: Sternal End, 438; Forward Dislocation of the lO CONTENTS. PAGE Clavicle, 438 ; Backward Dislocation of Clavicle, 439 ; Upward Dis- location of Clavicle, 439; Dislocation of Acromial End of Clavicle, 440. Dislocation of Lower Angle of Scapula, 440. Dislocations of Hiitnerus {^Shoulder-joint^, 441. Dislocation of Eliww-joint, 448: Dislocation of Both Bones of Elbow Forward, 449; Lateral Disloca- tions of Both Bones of Elbow, 449. Dislocation of Ulna, 450. Dis- location of Radius Forward, 450: Dislocation of Radius Backward, 45 1 ; Dislocation of Radius Outward, 45 1 ; Subluxation of Head of Radius, 451. Dislocations of Wrist, 452: Backward Dislocation of Wrist, 453 ; Forward Dislocation of Wrist, 453 ; Dislocation at Infe- rior Radio-ulnar Articulation, 453. Dislocations of Individual Carpal Bones, 454. Dislocations of Metacaipal Bones, 454 : Dislocation at Metacarpo-phalangeal Articulations, 454; Dislocation of Metacarpo- phalangeal Joint of Thumb, 454. Dislocations of Phalanges, 455. Dislocations of Ribs and Costal Cartilages, 456. Dislocations of Sternum, 456. Pelvic Dislocations, 456, Dislocations of Femur [Hip-joint), 457 : Dislocation of Femur on Dorsum of Ilium, 457 ; Dislocation of Femur into Sciatic Notch, 460; Dislocation of Femur Downward into Obturator Foramen, 461 ; Dislocation of Femur into Pubes, 462 ; Anomalous Dislocation of Hip, 462. Dislocations of Knee, 463 : Dislocation Forward of Knee-joint, 463 ; Dislocation Backward of Knee-joint, 463 ; Dislocation Outward of Knee-joint, 464 ; Dislocation Inward of Knee-joint, 464 ; Lateral Dislocations of Knee-joint, 464; Dislocation of Semilunar Cartilages of Knee, 464. Dislocations of Fibula : Dislocation at Superior Tibio-fibular Articula- tion, 465. Dislocations of Ankle-joint, 466 : Lateral Dislocations of Ankle-joint, 466 ; Antero-posterior Dislocations of Ankle-joint, 467 ; Dislocation Upward of Ankle-joint, 467. Dislocation of Astragalus, 468 : Dislocation of Astragalus Forward or Backward, 468 ; Lateral and Rotary Dislocations of Astragalus, 468 ; Sulmstragaloid Disloca- tion, 469. Dislocations of Other Tarsal Bones, 470. Dislocations of Metatarsal Bones, 470. Dislocations of Phalanges, 470. (5) Opera- tions ON Bones, 470: Osteotomy 470: Osteotomy for Genu Valgum, or Knock-knee (Macewen's Operation), 471 ; Osteotomy for Bent Tibia, 473 ; Osteotomy for Faulty Ankylosis of Hip-joint, 473 ; Oste- otomy through Neck of Femur, 473 ; Osteotomy of Shaft of Femur below Trochanters (Gant's Operation), 475 ; Osteotomy for Faulty Ankylosis of Knee-joint, 475 ; Osteotomy for Vicious Union of Frac- ture, 476 ; Osteotomy for Hallux Valgus, 476 ; Osteotomy for Talipes Equino-varus, 476; Osteotomy for Talipes Equinus 477; Bone-graft- ing, or Transplantation (see p. 303) ; Osteotomy and Wiring for Ununited Fracture, 477. Treves^ Operation for Caries of Lumbar CONTENTS. 1 1 PAGE and Last Dorsal Vertebnv, 479. Aspiration of Joints, 480. Ex- cision of Bones and Joints, 481 : Erosion, or Arthrectomy, 482; Ex- cision of Shoulder-joint, 483 ; Excision of Elbow-joint, 487 ; Excision of Wrist-joint, 488 ; Excision of Metacarpal Bones and of Phalanges, 490; Excision of Hip-joint, 491 ; Excision of Ankle-joint, 495; Excision of Os Calcis, 496 ; Excision of Astragalus, 497 ; Excision of Metatarso-phalangeal Articulation of Big Toe, 497 ; Excision of Meta- tarsal Bone of Big Toe, 498; Excision of Clavicle, 498; Excision of Scapula, 498 ; Excision of Rib, 499 ; Complete Excision of One-half of Upper Jaw, 500 ; Excision of One-half of Lower Jaw, 502. XIX. Diseases and Injuries of Muscles, Tendons, and Burs^ . . . 503 Myalgia, or Muscular Rheumatism, 503 ; Myositis, 505 ; Hypertrophy of Muscles, 505 ; Atrophy of Muscles, 505 ; Degeneration of Muscles, 506 ; Local Ossification and Myositis Ossificans, 506 ; Tumors of Muscles, 506; Syphilis, 506; Trichinosis, 506; Wounds and Contu- sions of Muscles, 507 ; Strains and Ruptures of Muscles, 508 ; Hernia of Muscles, 509; Contractions of Muscles, 509; Dislocation of Ten- dons, 509; Wounds of Tendons, 510; Rupture of Tendons, 510. Tkecitis, or Tenosynovitis, 510: Acute Thecitis, 510; Palmar Abscess, 511; Chronic Thecitis, 511. Ganglia, 512. Felon, WTiitlow, or Paronychia, 512. Bursitis, 513. Housemaid's Knee, 514. Bunion, 514. Operations on Tendons: Tenotomy, 515: Tenotomy of Tendo Achillis, 515 ; Tendon-suture and Tendon-lengthening, 516. XX. Orthopedic Surgery 517 Torticolhs, 518; Dupuytren's Contraction, 519 ; Syndactylism (Webbed Fingers), 520; Polydactylism (Supernumerar)^ Digits), 520; Genu Val- gum (Knock-knee), 520; Genu Varum (Bow-legs), 521; Talipes (Club-foot), 521; Pes Planus (Flat-foot), 523; Pes Cavus (Hollow- foot), 523; Hallux Valgus or Varus, 523; Hammer-toe, 523. XXI. Diseases and Injuries of Xerves 524 (i) Diseases of Nerves: Neuritis, or Inflammation of a Nerve, 524; Neuralgia, 525. (2) Wounds and Injuries of Nerves: Section of Nerves, 525; Pressure upon Nerves, 526; Contusions of Nerves, 527; Punctured Wounds of Nerves, 527. (3) Operations upon Nerves : Neurorrhaphy, or Nerve-suture, 527 ; Neurectasy, Neurotomy, and Neurectomy, 52S ; Stretching of Sciatic Nerve, 529; Neurectomy of Infraorbital Nerve, 529; Neurectomy of Supraorbital Nerv'e, 530. XXII. Diseases and Injuries of the Head 530 (i) Diseases of the Head: Anatomical Regions of Head, 530; Dis- eases of Scalp, 534; Diseases of Bones of Skull (see p. 295 et seq.); 1 2 CONTENTS. PAGE Microcephalus, 535. Diseases and A/n if or ma lions Involving Brain : Meningocele, 536; Encephalocele, 536; Hydrencephalocele, 536; Ilydroceplialus, 537; Acute Hydrocephalus, 537; Chronic Hydro- cephalus, 537. (2) Injuries of Head : Cephalhematoma, 537 ; Scalp- wounds, 537 ; Contusions of Head, 538; Concussion or Laceration of Brain, 538; Compression of Brain, 540. Intracranial Hemorrhage : I, Extradural Hemorrhage, 542; 2, Subdural Hemorrhage, 543; 3, Cerebral Hemorrhage, 543. Rupture of a Sinus, 544. Fractures of Skull, 544 : Fractures of Vault, 545 ; Fractures of Base, 546, Wounds of Brain, 549: Gunshot Wounds of Head, 550; Fungus Cerebri, 551 ; Traumatic Inflammation of Brain, 551 ; Pachymeningitis, 551 ; Pachy- meningitis Interna, 552; Leptomeningitis, 552; Tuberculous Menin- gitis, 553; Acute Traumatic Leptomeningitis, 554; Chronic Lepto- meningitis, 556 ; Abscess of Brain, 556 ; Brain Disease from Suppu- rative Ear Disease, 558; Cerebral Abscess from Ear Disease, 559; Extradural Abscess, 559; Infective Sinus Thrombosis, 559; Intra- cranial Tumors, 560; Operative Treatment of Epilepsy, 561. Opera- tions on the Skull and Brain : Trephining, 562 ; Technique of Brain- operations, 564; Operation for Mastoid Suppuration, 565. XXIII. Surgery of the Spine 566 Congenital Deformities, 566; Tumors of Spine, 567. Spinal Curvatures, 568: Lateral Curvature (Scoliosis), 569; Antero-posterior Cui-vature, 572 ; Angular Curvature, 573. Injuries of Spinal Ligaments and Muscles, 575 : Traumatic Hysteria, 577 ; Malingering, 578. Concus- sion of Spinal Cord, 579 ; Contusion of Spinal Cord, 579; Wounds of Spinal Cord, 579; Compression of Spinal Cord, 580; Fractures and Dislocations of Spine, 580. Operations on Spine : Treves' Operation for Vertebral Caries (see p. 479) ; Laminectomy, 582. XXIV. Surgery of Respiratory Organs 583 (i) Diseases and Injuries of Nose and Antrum: Foreign Bodies in Nose, 583 ; Inflammation and Abscess of Antrum of Highmore (Max- illary Antrum"), 583. (2) Diseases and Injuries of Larynx and Trachea: CEdema of Lar}^nx (CEdema of Glottis), 584; V^''ounds and Injuries of Larynx, 585 ; Foreign Bodies in Air-passages, 585. (3) Operations on Larynx and Trachea: Tracheotomy, 588; High Tracheotomy, 590; Quick Laryngotomy, 591; Intubation of Larynx (O'Dwyer's Operation), 592. (4) Diseases and Injuries OF Chest, Pleura, and Lungs : Pleuritic Eft'usion, 593 ; Empyema, 593; Contusions and Wounds of Chest, 594; Paracentesis Thoracis, 594 ; Thoracotomy, 595 ; Thoracoplasty, 596. CONTENTS. 13 PAGE XXV. Diseases and Injuries of the Digestive Tract 597 Diseases of Mouth, Tongue, and (Esophagics : Hare-lip and Cleft Palate, 597 ; Tongue-tie, 601 ; Ranula, 601 ; Excision of Tongue, 602 ; Stric- ture of CEsophagus, 603 ; Foreign Bodies in CEsophagus, 605. XXVI. Diseases and Injuries of the Abdomen 606 Contusion of the Abdominal Wall, 606 ; Rupture of Stomach without External Wound, 606; Rupture of Intestine without External Wound, 607; Wounds of Abdominal Wall, 610; Foreign Bodies in Alimentary Canal, 611 ; Cancer of Stomach, 61 1 ; Cicatricial Stenosis of Oritices of Stomach; 612. Intestinal Obstrtidion, 613 : Symptoms of Acute Intes- tinal Obstruction, 615; Diagnosis, 616; Prognosis, 618; Treatment, 619. Appendicitis, 620. Peritonitis, 626 : Plastic Peritonitis, 626; Sep- tic Peritonitis, 626 ; Fibrino-plastic Peritonitis, 627 ; Suppurative Perito- nitis, 627 ; Tubercular Peritonitis, 629. Operations upon the Abdofnen : Abdominal Section, 629 ; Enterorrhaphy, or Suture of Intestines, 632 ; Pylorectomy (Excision of Pylorus), 634; Gastrostomy, 635; Gastro- enterostomy, 636. Enterecfomy, or Resection of Intestine : Enterec- toniy with Circular Suturing, 636 ; Intestinal Anastomosis, 637 ; Ingui- nal Colostomy (Maydl's Operation), 639. Ahdoininal Hernia or Rtip- ture, 640 : Reducible Hernia, 641 ; Irreducible Hernia, 646 ; Incar- cerated or ^structed Hernia, 647 ; Inflamed Hernia, 647 ; Strangu- lated Hernia, 648 ; Herniotomy, 651. XXVII. Diseases and Injuries of the Rectum and Anus 654 Hemorrhoids, or Files, 654 ; External Flemorrhoids, 655 ; Internal Hem- orrhoids, 655. Prolapse of Rectum, 658; Ulcer of Rectum, 659; Stricture of Rectum, 660; Cancer of Rectum, 661 ; Foreign Bodies in Rectum, 662; Wounds of Rectum, 662; Ischio-rectal Abscesses, 662 ; Fistula in Ano, 662 ; Praritus of Anus, 665 ; Fissure of Anus, 665. XXyill. An.^:sthesia and An.^:sthetics 666 General Anaesthesia, 666; Administration of Chloroform, 668; Adminis- ti-ation of Ether, 669; Anaesthetic State from Ether or Chloroform, 670; Treatment of Comphcations, 671; Primary Anaesthesia, 673; Local Anaesthesia, 673 ; Cocaine Hydrochlorate, 674. XXIX. Burns and Scalds 675 Scalds of Glottis, 676; Effects of Cold, 677; Chilblain, or Pernio, 677. XXX. Diseases of the Skin and Xails 678 Dermatitis Venenata, 678; Furuncle, or Boil, 679; Carbuncle, 680; Clavus, or Corn, 681; Warts (see p, 215); Onychia, 682. 14 CONTENTS. XXXI. Diseases and Injuries of the Lymphatics 683 Lymphangitis, 683. Lymphadenitis, 683 : Acute Lymphadenitis, 683. Chronic Adenitis, 684 ; Lymphangiectasis, 684 ; Lymphangioma, 684 ; Elephantiasis, 684; Malignant Lymphoma, or Ilodgkin's Disease (see p. 203). XXXII. Bandages 685 Spiral Reversed Bandage of Upper Extremity, 686 ; Spiral Bandage of all the Fingers (Gauntlet), 686; Spiral Bandage of Palm or Dorsum of Hand (Demi-gauntlet), 686; Spica of Thumb, 687; Spiral Re- versed Bandage of Lower Extremity, 687; Bandage of Foot cover- ing Heel (American Bandage of Foot), 687; Bandage of Foot not covering Heel (French Method), 687 ; Spiral Bandage of Foot cover- ing Heel (Ribble's Bandage; Spica of Instep), 688; Crossed Bandage of Both Eyes, 688; Borsch's Eye-bandage, 688; Barton's Bandage (Figure-of-8 of Jaw), 689; Gibson's Bandage, 689; Crossed Bandage of Angle of Jaw (ObUque Bandage of Jaw), 689; Spica of Groin (Figure-of-8 of Thigh and Pelvis), 690; Spica of Shoulder, 690; Velpeau's Bandage, 690; Desault's Apparatus, 691 ; Recurrent Band- age of Head, 692 ; Recurrent Bandage of a Stump, 692 ; T-Bandage of Perineum, 692 ; Handkerchief Bandages, 692. Fixed Dressings : Plaster-of- Paris Bandage, 692 ; Silicate-of-Soda Dressing, 693. XXXIII. Plastic Surgery 693 Displacement, 693; Interpolation, 694; Retrenchment, 694. Skin- grafting, 694 : Reverdin's Method, 694 ; Thiersch's Method, 695. XXXIV. Diseases and Injuries of the Genito-urinary Organs . . 696 Haematuria, 696; Tests for Blood, 696; Bleeding from Kidney-substance, 697 ; Vesical Hemorrhage, including Hemorrhage from Prostate, 698 ; Urethral Hemorrhage, 698; Frequency of Micturition, 699; Mobile Kidney, 700. Injuries of Kidney : Laceration or Rupture, 702 ; Per- forating Wounds of Kidney, 703 ; Renal Calculus, 703 ; Abscess of Kidney, 705; Pyelitis and Pyelonephritis, 706; Perinephritis, 706; Perinephric Abscesses, 706; Hydronephrosis, 707; Pyonephrosis, or Surgical Kidney, 708 Operations on the Kidney : Nephrotomy, 709; Nephrolithotomy, 709; Nephrectomy, 710; Lumbar Nephrectomy, 710; Abdominal Nephrectomy, 710; Nephrorrhaphy, 711. Retention of Urine, 711. Injztries of the Bladder : Contusion of the Bladder, 714; Rupture of Bladder, 715 ; Atony of Bladder, 716 ; Vesical Calcu- lus, or Stone in Bladder, 717; Cystitis, 722; Tumors of Bladder, 725. Operations on Bladder : Lateral Lithotomy, 726 ; Suprapubic Lithot- omy, 728. Crushing of Vesical Calculi, 730. Litholapaxy (Bigelow's Operation), 730. Cystoto??iy, 735. Growths in Female Bladder, 736. CONTENTS. 1 5 XXXV. Diseases and Injuries of the Urethra, Penis, Testicles, Prostate, Spermatic Cord, and Tunica Vaginalis 736 Perineal Bruises, 736 ; Rupture of Urethra, 737 ; Foreign Bodies in the Urethra, 740. Urethritis, or Injlafjunatioii of the Urethra, 741 : Simple Urethritis, 741 ; Traumatic Urethritis, 742 ; Gouty Urethritis, 742; Eczematous Urethritis, 742; Tubercular Urethritis, 743. Gonor- rhoea, 743 : Subacute or Catarrhal Gonorrhoea, 744 ; Irritative or Abortive Gonorrhoea, 745. Chronic Urethral Discharges : Chronic Urethral Catarrh, 745 ; Chronic Gonorrhoea, 745 ; Gleet, 745. Gonor- rhcea in the Female, 749. Stricture of Urethra, 750. Epispadias, 752; Hypospadias, 752. Chancroid, 752. Phimosis, 754. Fracture of Penis, 754; Gangrene of Penis, 754; Cancer of Penis, 754; Amputa- tion of Penis, 755. Hypertrophy of Prostate Gland, 755 ; Retained Testicle, 757; Orchitis, 757; Castration, 758; Epididymitis, 758. Hydrocele, 758: Congenital Hydrocele, 759; Infantile Hydrocele, 759; Encysted Hydrocele of Cord, 759; Funicular Hydrocele, 760. Haematocele, 760. Varicocele, 760, XXXVI. Amputations 761 Methods of Amputating : Circular Method, 764; Modified Circular Method, 765; Elliptical Method, 765; Oval or Racket Method, 766; Flap Method^ 766. Special Amputatiojis : Fingers and Hand, 767 ; Disarticulation of a Metacarpo-phalangeal Joint, 768; Amputation of Thumb, 768; Amputation at Wrist-joint, 768; Amputation through Forearm, 769; Disarticulation of Elbow-joint, 769; Amputation of Arm, 770; Disarticulation at Shoulder-joint, 770; Amputation of Toes and Foot, 771; Amputation at Tarso-metatarsal Articulation, 771; Amputation through Middle Tarsal Joint, 773; Amputation at Ankle- joint, 773. Amputations of Leg, 774: Sedillot's Leg Amputation, 774; Modified Circular Amputation of Leg, 775 ; Amputation of Leg by a Long Postenor and a Short Anterior Flap, 775 ; Amputation just below Knee, 776; Disarticulation of Knee, 776; Amputation through Femoral Condyles, 776; Amputation of Thigh, 777; Disarticulation of Hip-joint, 777. Bronchocele, or Goitre, 778: Exophthalmic or Pulsating Goitre, 780. XXXVII. Asepsis and Antisepsis 780 Surgical Cleanliness, 780; Dry Antiseptic Method, 781. Preparations for an Operation, 781 : Disinfection of Instruments, 782; Antiseptic Preparation- of Patient, 782; Antiseptic Ligatures, 782; Antiseptic Dressings, 7S3. Preparation of Marine Sponges, 784; Cleansing Vagina and Rectum, 785 ; Senn's Decalcified Bone-chips, 785. A Manual of Surgery. I. BACTERIOLOGY. Bacte-riology is the science of micro-organisms. Though a science in the youth of its years, bacteriology has not only profoundly altered, but it has also revolutionized, pathology, and our views of surgery will be incomplete, misleading, and erroneous without its aid. Micro-orggsnisms, microbes, or bacteria are minute vegetable cells of the class fungi, many of them being vis- ible only by means of a highly powerful microscope after they have been brightly stained. The contents of these cells is protoplasm enclosed by a structure like cellulose. The protoplasm can be stained by aniline colors, and the cell- wall is more readily detected after treating it with water, which causes it to swell. Many of these organisms are col- ored, others are colorless. Some move (motile bacteria), others do not move ; among the motionless ones may be mentioned the bacilli of anthrax and tubercle. Definite knowledge of these minute bodies and of their actions dates from the study of fermentation by the cele- brated Frenchman, Pasteur, who in 1857 asserted that every fermentation has invariably its own specific ferment; that this ferment consists of living cells ; that these cells produce fermentation by absorbing the oxygen of the substance acted upon; that putrefaction is caused by an organized ferment; 2 17 1 8 A MANUAL OF SURGERY. that all organized ferments are carried about in the air ; and that to entirely exclude air prevents putrefaction or fermenta- tion. These statements, which were radical departures from accepted belief, inaugurated a bitter controversy, and in that controversy were born the microbic theory of disease, the doctrine of preventive inoculation, and antiseptic surgery. The word microbe, which signifies a small living being, was introduced in 1878 by the late Professor Sedillot of Paris. At that time the nature of these bodies was in doubt; some thought them animal, and called them inicrozoaria ; others thought them vegetable, and called them niicropJiyta ; the designation "microbe" does not commit us to either view. We now know them to be vegetable, but the term "microbe" has remained in use. The fiingi connected with disease in man are divided into three classes : 1. Yeasts, or Blastomycetes ; 2. Moulds, or Hyphomycetes ; 3. Bacteria, or Schizomycetes. Yeasts are small cells which multiply by gemmation, these cells often sticking together and forming branches, and con- taining spores when nourishment is insufficient. They are thought to be vegetative forms of higher fjingi (Green). The chief importance of these cells is that they cause fermenta- tions ; they never invade human tissues. Yeasts may dwell on mucous membranes, and even in the stomach. Oidinin albicans is an yeast-fungus whose growth upon the mucous membranes of the mouth, pharynx, and oesophagus causes the disease known as " thrush." Moulds consist of filaments, each filament being com- posed of a single row of cells arranged end to end, and all filaments springing from a germinal tube which grows from a germinating spore. Moulds are largely connected with processes of decay. Some of them can grow upon inflamed BACTERIOLOGY. 1 9 mucous membrane ; some invade the epidermis, producing certain skin diseases (favus, tinea tonsurans, tinea versic- olor, etc.). Actinomycosis and Madura-foot arise from the lodgment and growth of moulds (Fig. i). Actinomycosis is a disease seen in cattle, and occasionally in men, es- pecially in drovers. Cattle become infected through their food, the fungus entering by a hollow tooth or by a breach in continuity. The . . ^. , ^ ■' •' Fig. I. — Actinomj'ces (Ziegler). lower jaw is usually the seat of involvement (lumpy jaw). A tumor forms, which contains sero-pus, and after a time ruptures and discharges. The matter contains nodules of fungi. The bone may undergo extensive destruction. Other bones and various organs can be infected. Iodide of potassium will sometimes bring about a cure. Extensive operations may be demanded. Bacteria chiefly claim our attention. It is important to remember that the term " bacteria," though applied to the class schizoinycctcs, has also a more restricted application — that is, to a division of the class ; it may either mean schizo- niycetes in general, or rod-shaped schizoinycctcs, whose length is not more than twice their breadth. Some of the scJiizoniycctcs induce certain fermentations ; others are productive of putrefaction, and are called sapro- phytes ; still others, known as the pathogenic, cause various diseases. They vary much in shape, size, color, and arrange- ment. One form cannot be transformed into another, but each maintains its own specific identity. Every organism comes from a pre-existing organism, this being tru£ of all forms, and spontaneous generation is impossible. Forms of Bacteria. — The three chief forms of bacteria are — 20 A MANUAL OF SURGERY. 1. The Coccus — bcriy-sliaped or round bacterium (Fi<^. 2) ; 2. The Bacillus — rod-shaped bacterium (Fig. 3); 3. The Spirilliiin — corkscrew-shaped bacterium (Fig. 4). /— Fig. 2. — Micrococcus. Fig. 3. — Bacillus. Fig. 4. — Spirillum. De Bary compares these forms, respectively, with the biUiard-ball, the lead-pencil, and the corkscrew. Cocci. — We only have to do with cocci and bacilli. Cocci may be named according to their arrangement with one ••• <^^-; V B / \ Fig. 5. — Forms of Bacteria. Fig. 6.— Zoogloea (Ball). another, namely : in pairs they are called diplococci (Fig. 5 a); in a chain they are called streptococci (Fig. 5 c) ; in a cluster like a bunch of grapes they are called staphylococci (Fig. 5 b) ; and in an irregular mass, stuck together by a thick sub- stance, they constitute a zoogloea (Fig. 6). The cocci are often named according to their function, as, for example, " pyogenic," or pus-forming. The name may BACTERIOLOGY. 21 embody the form, arrangement, color, and function; for instance, staphylococcus pyogenes aureus signifies a round, golden-yellow micro-organism, which arranges itself with its fellows into the form of a bunch of grapes, and which pro- duces pus. Multiplication of Bacteria. — Bacteria multiply with great rapidity when placed under suitable conditions. They can multiply by fission or by spore-formation. Some bacteria multiply by both methods. In fission, or segmentation, the cell elongates and about its middle a constriction begins, wiiich deepens until the cell has divided into two parts. Fig. 7. — Divisions of a Micrococcus (after Mace). Fig. 8. — Divisions of a Bacillus (after Mace). each of which soon grows as large as its parent (Figs. 7, 8). All cocci and some bacilli multiply by this method. If segmentation of a single cell and the growth to maturity of its products require one hour (it really takes place in less time), a single cell in a single day will have sixteen million descendants (Cohn). Spores. — A sp07'e is a germ, and corresponds with the seed of a plant. Most of the bacilli multiply by spore- formation. When spore-formation is about to occur in a bacillus, points 22 A MANUAL OF SURGERY. Fig. 9. — Sporulation (after De Bary). of cloudiness appear in the protoplasm, the cell generally elongates, and in twenty-four hours the cell is found to con- sist of a series of segments like a necklace of beads, each segment containing a full- grovyn spore (Fig. 9). The wall of the cell now liquefies, the segments separate, the spores are set free, and each spore, under favorable con- ditions, becomes a bacillus. When the initial cloudiness appears in the middle of the cell, it is called an " endo- spore ;" when it appears at one or both extremities, it is christened an " endspore " or " endspores." When multiplication is by a single endospore, the bacillus does not elongate. Life-conditions of Bacteria. — In order to grow and to multiply, bacteria require suitable soil and the favoring influ- ences of heat and moisture. The soil demanded consists of highly-organized compounds rather than crude substances, and slight modifications in it may prove fatal to some forms of bacterial life, but highly advantageous to others. The fluids and tissues of the individual may or may not afford favorable soil for the germs of disease, or, in the same per- son, may afford it at one time, and not at another. Some individuals seem to possess indestructible immunity from, and others are especially prone to, certain contagious dis- eases. Impairment of health, by altering some subde condi- tion of the soil, may make a person liable who previously was exempt. All organisms require water. If dried, no form will multiply, and many forms will die. The presence of oxygen effects microbic growth. Most BACTERIOLOGY. 23 organisms thrive best when exposed to the oxygen of the air, and they are known as " aerobic." The term " anaerobic " is employed to designate organisms that can hve without free oxygen ; they require this gas, but are capable of extract- ino- it from its combinations in tissues. An organism which can grow indifferently where oxygen is plenty or where free oxygen is absent is called a " facultative-aerobic " bacterium. A sensitive organism which dies when the amount of oxygen is even slightly diminished is called an " obligate-aerobic " bacterium. Most microbic diseases in man are due to facultative-aerobic bacteria. Effect of Heat and Cold. — Most fungi grow best when at rest ; agitation retards the growth of some and kills others. Temperature is of importance to bacterial growth. Some organisms will only grow within narrow temperature limits, while others can sustain sweeping alterations, but most grow best between the limits of from 86° to 104° Fahrenheit. Freezing renders bacteria motionless and incapable of multi- plication, but it does not kill them : they again become active when the temperature is raised. The absurdity of employ- ing cold as a germicide is evident when the fact is known that a temperature of 200° F. below zero is not fatal to germ- life, its activities only being rendered dormant. High tem- peratures are fatal to bacteria; moist heat is more destructive than dry heat, and adult cells are more vulnerable than spores. A temperature less than 212° F. will kill many organisms, and boiling will kill every organism that does not form spores. Some spores are not destroyed after pro- longed boiling, and some will withstand a temperature of 120° C. As a practical fact, however, boiling water kills, in a few minutes, all cocci, most bacilli, and many spores; though the spores of anthrax, tetanus, and malignant oedema are not with certainty destroyed. Sunlight antagonizes some forms of bacterial growth. 24 A MANUAL OF SUKGEKY. Chemical Germicides. — Many chemical agents will kill bacteria, the most certain of them all being corrosive sub- limate. Koch showed that corrosive sublimate is an efficient germicide when present in the proportion of only I part to 50,000. It is used in surgery in strengths of i part of the salt to 1000, 2000, 3000 or more parts of water. Because of the fact that contact with albumin precipitates from a solution of corrosive sublimate an insoluble albuminate of mercury, in surgical operations by the wet method consider- able quantities must be used ; or the mercury is combined with tartaric acid in the proportion of i to 5, which com- bination prevents the insoluble albuminate from being formed. Carbolic acid is a valuable germicide in the strength of from I : 40 to I : 20. It is certainly fatal to pus-germs. Unfortunately, this acid attacks the hands of the surgeon ; consequently in the United States it is chiefly employed as an antiseptic medium in v/hich to place the operating-instru- ments. Iodoform is largely used; it is not truly a germi- cide, as bacteria will grow upon it, but it hinders the devel- opment of bacteria and directly antagonizes the toxic prod- ucts of germ-life. Kreolin, which is a preparation made from coal, is a germicide without irritant or toxic effects. It is less powerful than carbolic acid, and is used in an emulsion of a strength of from i to 5 per cent. Peroxide of hydrogen is a most admirable agent for the destruction of pus cocci. It comes in a 15-volume solution, which is diluted one-half or two-thirds. It probably destroys the albuminous element upon which the bacteria live. The per- oxide of hydrogen is not fatal to tetanus bacilli. Distribution. — Microbes are very widely distributed in nature. They are found in all water except that which comes from very deep springs ; in all soil to a depth of 3 feet ; and in air, except that of the desert, on the open sea, and on lofty mountains. BACTERIOLOGY. 25 Microbes may be useful. Some of them are scaveno-ers and clean the surface of the earth of its dead by the process known as " putrefaction," in which complex organic matter is reduced to harmless gases and to a mineral condition, the gases being taken up from the air by vegetables, and the mineral matter dissolving in rain-water and passing again into the soil from which it came, there again to be food for plants which become food for animals. Other organisms purify rivers ; others again cause bread to rise ; still others give rise to fermentation in liquors. Microbes may be harm- ful. They may poison rivers and soils ; they may be parasites on vegetable life ; they cause disease of the grape and wine ; they mould bread ; they poison sausage and canned foods; and they produce many diseases among men and the lower animals. With so universal a distribution of these fungi, man must constantly take them into his organism. They are upon the surface of his body, he inhales them with every breath, and he swallows them with his food and drink. Most of them, fortunately, are entirely harmless ; others cannot act on the living tissues ; but some are virulent, and these are generally destroyed by the cells of the human body. The alimentary canal always contains bacteria of putrefaction, which act only upon the dead food, and not upon the living body; but when a man dies these ors^anisms at once attack the tissues, and post-mortem putrefaction begins in the abdomen. Koch's Circuit. — To prove that a microbe is the cause of a disease it must fulfil Koch's circuit. It must always be found associated with the disease ; it must be capable of forming pure cultures outside the body ; these cultures must be capable of reproducing the disease ; and the microbe must again be found associated with the morbid process. When disease-producing organisms enter the body, they are usually rapidly destroyed ; they cannot dwell there 26 A MANUAL OF SURGERY. long without inducing disease, but spores can lie dormant in the system for years, only waking into activity when they come in contact with some damaged, weakened, or dis- eased part — a so-called point of least resistance (a locus minoris rcsistcntice) — which affords a nest for them to develop and to multiply, the cellular activities of the weakened part being unable to cope with the organism. Even large doses of pathogenic organisms may induce no trouble in a healthy man ; but let them reach a damaged spot, and mischief is apt to arise. Kocher established subcutaneous bone-injuries in dogs, and these injuries pursued a healthy course until the animal was fed upon putrid meat, whereupon suppura- tion took place. This experiment proves that an organism can reach a damaged area by means of the blood, and it enables us to understand how a knee-joint can suppurate when we merely break up adhesions, and how osteo-myelitis can follow trauma when the skin is intact. Toxalbumins and Toxines. — The action of pathogenic bacteria upon the tissues is of great importance. In the first place, they abstract from the blood, the lymph, and the cells certain elements necessary to the body — as water, oxy- gen, albumins, carbohydrates, etc. — and bring about body- wasting and exhaustion from want of food. In the second place, bacteria produce a series of compounds, some harm- less and others highly poisonous. These organisms contain and secrete ferments like pepsin or trypsin, and as albumoses are formed in the alimentary canal by the digestive ferments, which split up proteids, sugars, and starches, we have microbic albumoses. Just as the albumoses formed in digestion are poisonous when injected, so are the albumoses of microbic action, and they are called "toxalbumins." These albu- moses often operate as virulent poisons to the body-cells. Another assemblage of compounds formed by the microbic destruction of tissue is designated the group of " toxines." BA CTERIOL OGY. 2/ These toxines are poisonous alkaloids which are readily- diffusible and, many of them, very virulent. It is probable that every pathogenic organism has its own special toxine which produces its own characteristic effects. The absorp- tion of toxines may be very rapid ; for instance, the toxines of cholera may kill a man before the bacillus has migrated from the intestine. Ptomaines. — By many writers the term " ptomaine " is used to designate these toxines, but in reality a ptomaine is a form of toxine that is due to the action of saprophytic bacteria. A ptomaine is a putrefactive alkaloid, and a toxine is any poisonous alkaloid of microbic origin. Among these poisonous alkaloids may be mentioned tetanine, typhotoxine, sepsine, putrescine, muscarine, and spasmotoxine. Leucomaines must not be confounded with the above- mentioned bodies. Leucomaines are alkaloid substances existing newmally in the tissues, and arising from physio- logical fermentations or retrograde chemical changes. They are natural body-constituents, in contrast to toxines, which are morbid. Leucomaines are found in expired air, saliva, urine, various tissues, and the venom of serpents. If not excreted, these bodies can induce illness, and when injected can act as poisons. Ordinary colds and some fevers result from leucomaines ; they play a great part in uraemia, and when excretion is deficient and leucomaines are retained they make the system a hospitable host for pathogenic bacteria. Among leucomaines may be mentioned adenine, hypoxanthine, and xanthine, allied to uric acid, and other substances allied to creatine and creatinine. Antitoxines. — Another group of substances arising from microbic action are known as " antitoxines." It is a well- recognized fact in fermentation that after a time the process ceases, and the addition of more ferment is void of result. The same is true of specific maladies ; thus, if a person 28 A MANUAL OF SURGERY. recovers, the organisms disappear, and the injection of more of them produces no result; in other words, immunity exists toward the disease. This immunity was long believed to arise from the exhaustion of some unknown constituent of tissue necessary to the life of the bacteria. It is now believed to be due partly to the capacity of the amceboid cells to destroy germs, and partly to the production of anti- toxines which, when they have developed in sufficient amount, destroy the cells that made them. In other words, the fact seems to be established that bacteria not only produce poisons, but also the antidotes for them. Phag-ocytes. — The tendency of the white blood-cells and of the fixed tissue-cells to destroy organisms is undoubted. This process of destruction is known as " phagocytosis," and the destroying cells are called " phagocytes." These cells try to eat up and destroy the germs. A battle-royal occurs, Fig. io. — Phagocytosis : a, successful, b, unsuccessful (Senn). the microbe fighting the body-cells with most active ferments, the body-cells endeavoring to devour and engulf the bacteria (Fig. lo). In some cases the bacteria win absolutely and the patient dies. In other cases they win for a time and overwhelm the organism, but presently the body-cells, whose BA CTERIOL OGY. 2g movements were inhibited by poison, regain their activity and successfully recur to the attack. After the attack is over the body-cells have been educated to withstand this poison, and their descendants retain this capacity ; the weak cells were killed, the fittest survived, and the descendant cells of the survivors are born insusceptible. This is inwiu- iiity, and lasts for a varying period. Some persons seem, from birth, immune to certain maladies. The theory of phagocytosis immunity assumes an educated white corpuscle and body-cell. This view originated with Sternberg, but it is usually accredited to Metschnikoff Protective and Preventive Inoculations. — Our know- ledge of protective inoculations for contagious diseases dates from Jenner's discovery in 1768. Preventive inoculations with attenuated virus are due to the experiments of Pasteur. This observer discovered the cause of chicken-cholera, and he cultivated the micro-organism of this disease outside the body. He found that by keeping his cultures some time they became attenuated in virulence, and that these attenu- ated cultures, inoculated in fowls, caused a mild attack of the disease, which attack was protective, and rendered the fowl immune to the most virulent cultures. Cultures can be attenuated by keeping them for some time, by exposing them for a short period to a temperature just below that necessary to kill the organisms, and by treating them with certain antiseptics. It has further been shown that injection of the blood-serum of an animal rendered immune by inocu- lation is capable of making a susceptible animal also immune. A most important fact is that animals may be rendered immune by inoculating them with filtered cultures, the fil- trate containing microbic products, but not living microbes. By this method animals can be rendered immune to tetanus and diphtheria. Pasteur's protective inoculations against hydrophobia owe their power to microbic products, and 30 A MANUAL OF SURGERY. Koch's lymph contains them as its active ingredients. The chief feature in acquired immunity is the presence in the blood of elements which can neutralize the toxic products of bacteria. These elements are called " antitoxines," or defensive proteids. The present knowledge of them arose from the discovery of Nuttall and Buchncr that fresh blood- serum is germicidal, the power varying for different bacteria and being limited, for a fixed amount of serum is capable of destroying a small dose of bacteria only. It has been shown that in tetanus injections of the serum of an immune ani- mal can cure the disease. The above facts are of immense importance, for on these lines will be solved the prevention and treatment of microbic maladies. Antag-onistic Microbes. — Another observation of import- ance is that certain microbes are antagonistic to one another. The streptococcus of erysipelas attacks the organism of anthrax. We should note also that the growth of some microbes affects the soil favorably or otherwise for the growth of others, and the same may be true in the body. Mixed Infection. — A fact of practical importance to the surgeon is that an area infected by one form of pathogenic organism may be invaded by another form. This is known as a mixed infection, and consists of a primary infection with one organism, and a secondary infection with another. Koch found both bacilli and micrococci in the same lesion of tubercle. A soil filled with pneumococci is favorable to the growth of pus cocci and tubercle bacilli. Tuberculous and syphilitic lesions may be attacked by erysipelas. Chancre and chancroid can exist together. A syphilitic ulcer is a good culture for tubercle bacilli (Schnitzler). Suppuration in erysipelas or tuberculosis means a secondary infection with pus cocci. Placental Transmission. — The direct transmission of bac- teria from parents to foetus is a problem still in course of BACTERIOLOGY-. 31 solution. Certain it is that some diseases (as syphilis) are due to the direct carrying of the microbes by sperm-cell to germ-cell, or to the transmission of the micro-organism through the septum of separation between the circulations of the mother and child. In many other diseases the microbe is not directly transmitted (as in phthisis), but a patient born with weakened tissue-cells is prone to fall a prey to the latter malady. Special Surgical Microbes. — P21S microbes, or pyogenic microbes^ include the following forms : I. Staphylococcus pyogenes aureus (Fig. 11), which is the commonest form, is killed by a few minutes' boiling, by cor- rosive sublimate, or by carbolic acid. These microbes are very widely distributed in the soil, air, and water, in the Fig. II. — Staphylococcus Pyogenes Aureus in Pus (X 1000) (Frankel and Pfeiffer;. Fig. 12. — Streptococcus Pyogenes m Pus (X 1000) (Frankel and Pfeiffer). superficial layers of the skin, especially the axillae and the region of the perineum, and are found in the mouth, phar- ynx, alimentary canal, and under the nails. 2. Staphylococcus pyogenes albus. 3. StaphylococcJis pyogenics citretis. 4. Streptococcus pyogenes, which is found normally in the nose, saliva, vagina, and urethra (Fig. 12). 5. Bacillus pyocyaneus, which exists in blue pus. 32 A MANUAL OF SURGERY. These pyogenic cocci subsist in all acute abscesses. The staphylococci exist in circumscribed suppurations, as in boils and carbuncles; the streptococci, in spreading inflammations, as in erysipelas and cellulitis. Can suppuration exist without cocci ? It can, but prac- tically does not. The injection of irritants may form a thin fluid resembling pus, but containing no bacteria. The prod- ucts of bacterial action when injected will form pus. But practically in surgery to exclude cocci is to prevent the formation of pus. Cocci form pus by liquefying inflam- matory products or tissues. Cold abscesses are due to tubercle bacilli, and they do not contain pus cocci unless mixed infection exists. Other Surg-ical Microbes. — Streptococcus erysipclatis re- sembles streptococcus pyogenes, and they are thought by many to be identical. Their difference in action is consid- ered to be due to difference in virulence induced by external conditions and the state of the tissues. The gonococcus, or Neisser's bacillus, is a diplo- coccus, and is the specific or- ganism of gonorrhoea (PI. i, Fig. 2). The tetanus bacillus, or the bacillus of Nicolaier, exists chiefly in the soil of gar- dens, in manures about stables, and in masonry (PI. i, Fig. i). The bacillus tuberculosis, or Koch's bacillus, the cause of all tuberculous processes, exists particularly in air infected by the dried sputum of tuberculous subjects. This infected air is the chief means of its transmission. It is found also Fig. 13. — Anthrax Bacilli in Blood (Vierordtj. IN FLA MM A TION. 3 3 in the milk of tuberculous cows. Such milk can spread the disease (PI. i, Fig. 3). The bacillus ccdcmatis nialigiii gives rise to malignant oedema. The bacillus of syphilis, or Lustgarten's bacillus, is not definitely determined to be the cause of syphilis. The bacillus mallei is the bacillus of glanders. The bacillus anthracis is the bacillus of anthrax, splenic fever, wool-sorter's disease, or malignant pustule (Fig. 13). The j'ay fungus causes actinomycosis. Strepto- cocci are found in noma. No specific organism has been isolated for traumatic spreading gangrene or hospital gangrene; 'only pus cocci have been found. The bac- terium coli communis is the supposed cause of peritonitis {q. v.). 11. INFLAMMATION. Definition. — Inflammation is a nutritive disturbance aris- ing from tii^sue -damage, and is not an increase of nutrition. It is defined bv Burden-Sanderson as " the succession of changes which occur in a living tissue when it is injured, provided that the injury is not of such a degree as at once to destroy its structure and vitality." The changes alluded to in this definition comprise — (i) changes in the vessels and the circulation ; (2) exudation of fluids and solids from the vessels ; and (3) changes in the perivascular tissues. Vascular and Circulatory Chang-es are essential to in- flammation in both vascular and non-vascular tissues. In the former they occur in the tissues ; in the latter (cornea and cartilage) they are manifest in neighboring tissues from which the non- vascular area derives its nutritive material. Active Hyperaemia. — When an irritant is applied to tis- sue, there may be a momentary arterial contraction due to irritation of the nerves, but this contraction is transitory, and is not an inflammatory phenomenon. The first vascu- lar phenomenon is dilatation of all the vessels — capillaries, 3 34 A MANUAL OF SURGERY. venules, and arterioles — appearing first, and being most pro- nounced, in the small arteries. As a result of this dilatation there is increased rapidity of circulation and increased deter- mination of blood to the part. This condition of increased circulatory activity is known as "active hyperaemia" (Fig. i 5). Retardation. — During active hyperaemia the capillaries are crowded with corpuscles and the blood in the veins is of a much brighter red than in health. The red blood-cells are swept along the centre of the current (in the axial stream), the white blood-cells float lazily along near the vessel-wall. After a variable time the blood-current begins to slow down until it becomes more tardy than in health. Fig. 14. — Normal Vessels and Blood-stream : a, artery ; d, vein ; c, capillary (Landerer). This is known as " retardation of the circulation." Retarda- tion is first noted in the capillaries, next in the venules, JNFLAMMA TION. 35 < *n rt 3 55 M n > 32 •^ t; i.1 3 M V o\ C; 1 !/i V ^ ■J> ») o -*1 rt W «< o * ■ o