K^M Columbia Wini\}tx^itv intJjeCitpofi^etDi % department of burger? PuU ilemorial if und u^^-^ ^v^^^^II^^, A MANUAL MODERN SURGERY GENERAL AND OPERATIVE BY JOHN CHALMERS DaCOSTA, M.D. Clinical Professor of Surgery, Jefiferson Medical College, Philadelphia; Surgeon to the Philadelphia Hospital, etc. WITH 386 ILLUSTRATIONS PHILADELPHIA W. B. SAUNDERS 925 Walnut Street I 898 Copyright, 1898, by W. B. SAUNDERS. ELECTROTYPED BY PRESS OF WESTCOTT & THOMSON, PHILADA. W. B. SAUNDERS, PHILADA. 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 TO THE SECOND EDITION. In the preface to the first edition of this work it was stated tliat the purpose of the author was to make a book that would stand between the text-book and the compend. The very considerable success that has been accorded the effort seems to indicate that there was a distinct demand for such a book. In the new edition no attempt has been made to alter the character or to change the purpose of the Manual, although it has been practically rewritten, many entirely new articles added, and a majority of the old articles enlarged, restricted, or otherwise altered. Many of the changes and additions have been made in response to the suggestions of reviewers and of teachers of surgery. The changes are numerous, and it is impossible to enu- merate them in this place. Among them may be mentioned the following : Sections have been added upon the Surgery of the Liver and Gall-Bladder, the Spleen, the Pancreas, the Female Breast, Wounds Inflicted by Modern Projectiles, Electrical Injuries, and the Use of the Rontgen Rays. The following operations have been described : Resection of the Gasserian Ganglion ; Methods of Gastrostomy ; Schede's Operation of Thoracoplasty ; Use of the Murphy Button ; various new methods of Enterorrhaphy ; Bodine's Method of Colostomy ; Prevention of Hemorrhage in Hip-joint Amputation by Macewen's Method of Aortic Compression J Edmund Owen's Operation for Harelip; Senn's Method of Resection of the Shoulder-joint, etc. 11 12 PREFACE TO THE SECOND EDITION. As in the previous edition, the writings of other authors have been extensively quoted, and the endeavor has been always to give proper credit. The author desires to extend his cordial thanks to Mr. Thos. F. Dagney, of Mr. Saunders' editorial department, for much valuable aid rendered during the progress of the work through the press, and to Mr. R. W. Greene for making the index. 1629 Locust Street, Philadelphia, June, 1898. 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 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. 13 14 PREFACE. 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 StLvgery, edited by Keen and White ; to the surgical works of Ashhurst, 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- cyclopcedia of Surgery edited by Ashhurst; to the Surgical Pathology of Billroth and of Bovvlby ; 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 Surgery of Senn; to the orthopedic writings of Sayre ; to the work on Diseases of the Male Generative Orgajis of Jacobson ; to the System of Genito-tirinary 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 Americaji 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 Dehoney for the preparation of the Index, 2050 Locust Street, Philadelphia, October, 1894. CONTENTS. PAGE I. Bacteriology 17 II. Asepsis and Antisepsis 42 III. Inflammation 48 IV. Repair 82 V. Surgical Fevers 87 VI. Terminations of Inflammation . 90 VII. Ulceration and Fistula no VIII. Mortification or Gangrene 119 IX. Thrombosis and Embolism 132 X. Septicemia and Pyemia 136 XI. Erysipelas (St. Anthony's Fire) 140 XII. Tetanus or Lockjaw 144 XIII. Tuberculosis and Scrofula. 148 XIV. Rickets 158 XV. Contusions and Wounds 160 XVI. Syphilis 1S4 XVII. Tumors, or Morbid Growths 209 XVIII. Diseases and Injuries of the Heart and Vessels . . . 239 1. Hemorrhage or Loss of Blood 258 2. Operations on the Vascular System 274 3. Ligation of Arteries in Continuity 278 XIX. Diseases and Injuries of Bones and Joints 309 1. Diseases of the Bones 309 2. Fractures 321 3. Diseases of the Joints 406 4. Luxations or Dislocations 438 5. Operations upon Bones 475 XX. Diseases and Injuries of Muscles, Tendons, and Burs^ . . 504 Operations upon Muscles and Tendons 516 XXI. Orthopedic Surgery 519 XXII. Diseases and Injuries of Nerves 527 1. Diseases of Nerves 527 2. Wounds and Injuries of Nerves 528 3. Operations upon Nerves 530 15 1 6 CONTENTS. PAGE XXIII. Diseases and Injuries of the Head 535 1. Diseases of the Head 535 2. Injuries of the Head 543 XXIV. Surgery of the Spine 577 XXV. Surgery of the Respiratory Organs 596 1. Diseases and Injuries of the Nose and Antrum .... 596 2. Diseases and Injuries of the Larynx and Trachea . . . 59^ 3. Operations on the Larynx and Trachea 600 4. Diseases and Injuries of the Chest, Pleura, and Lungs . 605 XXVI. Diseases and Injuries of the Upper Digestive Tract 612 XXVII. Diseases and Injuries of the Abdomen 626 1. Stomach and Intestines 633 2. The Peritoneum 655 3. The Liver and Gall-bladder 658 4. The Pancreas 664 5. The Spleen •-.... 665 6. Operations upon the Abdomen . 666 XXVIII. Diseases and Injuries of the Rectum and Anus . . 713 XXIX. Anesthesia and Anesthetics 725 XXX. Burns and Scalds 73^ XXXI. Diseases of the Skin and Nails 739 XXXII. Diseases and Injuries of the Thyroid Gland .... 743 XXXIII. Diseases and Injuries of the Lymphatics 746 XXXIV. Bandages 748 XXXV. Plastic Surgery 759 XXXVI. Diseases and Injuries of the Genito-urinary Organs 763 1. Diseases and Injuries of the Kidney and Ureter ... 768 2. Diseases and Injuries of the Bladder 784 3. Diseases and Injuries of the Urethra, Penis, Testicles, Prostate, Seminal Vesicles, Prostatic Cord, and Tunica Vaginalis 810 XXXVII. Amputations 841 Special Amputations 847 XXXVIII. Diseases of the Breast 859 XXXIX. Skiagraphy, or the Employment of the RontCen Rays 871 XL. Injuries by Electricity 878 INDEX Modern Surgery. I. BACTERIOLOGY. Bacteriology 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-organisms, microbes, or bacteria, are minute vegetable cells of the class fniigi, 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 are protoplasm and nuclear chromatin enclosed by a structure containing cellulose. The protoplasm can be stained with anilin colors, and the cell-wall is more readily detected after treating it with water, which causes it to swell. Many or- ganisms are colored, others are colorless. Some move (mo- tile bacteria), others do not move (amotile bacteria) ; among the motionless ones may be mentioned the bacilli of anthrax and tubercle, and all cocci. Many bacteria can change from motile to amotile or from amotile to motile when sub- jected to changed conditions of life. The oscillations of cocci are physical and not vital in nature; they are Brun- onian movements, movements due to alterations in equilib- rium because of currents or changes of level in the fluid in which the organisms are held. Bacteria possess the power of attracting elements necessary for their nutrition and of repelling elements antagonistic to them (chemiotaxis or chemotaxis). Definite knowledge of these minute bodies and of their actions dates from the study of fermentation by the cele- brated Frenchman Pasteur, who in 1858 asserted that every fermentation has invariably its specific ferment ; that this ferment consists of living cells ; that these cells produce fer- mentation by absorbing the oxygen of the substance acted upon ; that putrefaction is caused by an organized ferment ; 2 17 l8 MODERN 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, antiseptic surgery, and serum-therapy. 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 microzoaria ; others thought them vegetable, and called them inicvophyta ; the designation " microbe " does not commit us to either view. We now know them to be vegetable, but the term " mi- crobe " has remained in use. The fungi connected with disease in man are divided into three classes : 1. Yeasts, Saccharomyces, or Blastomycetes ; 2. Moulds, or Hyphomycetes ; 3. Bacteria, or Schizomycetes. Yeasts include most of those fungi which can cause alco- holic fermentation in saccharine matter. They consist of small cells which multiply by gemmation and which can live with- out free oxygen. These cells often stick together and form branches, and contain spores when nourishment is insufficient. They are thought to be vegetative forms of higher fungi (Green). The chief importance of yeasts is that they cause fermentation ; they never invade human tissues, though they can dwell on mucous membranes, and even in the stomach. O'idium albicans is an yeast-fungus whose growth upon the mucous membrane of the mouth, pharynx, and esophagus causes the disease known as " thrush." Pekelharing says that pityriasis capitis is due to the saccharomyces capillitii. Moulds consist of filaments, each filament being composed of a single row of cells arranged end to end, and all filaments springing from a germinal tube which grows from a germi- nating spore. Moulds are largely connected with processes of decay. Some of them grow upon inflamed mucous mem- brane, and some invade the epidermis, producing certain skin diseases (favus, tinea tonsurans, tinea versicolor, etc.). Actinomycosis and Madura-foot arise from the lodgement and growth of moulds (Fig. i). Actinomycosis is a disease seen in cattle, and occasionally in men, especially in drovers. Cattle become infected usually through their food, the fun- gus entering by a hollow tooth or by a breach of continuity BACTERIOLOGY. 19 in mucous membrane. The lower jaw is usually the seat of involvement in cattle (lumpy jaw). A tumor forms, which con- tains sero-pus, and after a time ruptures and discharges mat- ter containing nodules composed of fungi. The bone may undergo extensive destruction. Other bones and various organs may be infected. Madura-foot or mycetoma is an endemic disease of India, which is probably due to infection with the Chionypha Carted. The foot swells and becomes covered with , , , Fig. I. — Actinomyces (Ziegler). pustules ; the pustules rupture and expose sinuses ; each sinus is lined with a firm membrane and is filled with material which looks like the roe of a fish. The bones are often extensively destroyed, and gangrene not un- commonly arises. Bacteria chiefly claim our attention. It is important to remember that the term " bacteria," though applied to the class scJiizoinycctcs, has also a more restricted application — that is, to a division of the class ; it may mean either schizo- viycctcs in general, or rod-shaped scliizoviycctcs, whose length is not more than twice their breadth. Some of the scJiizoinycctcs induce certain fermentations ; others grow upon dead organic matter, but are not able to invade living tissues, and are called sapropJiytcs or non- pathogenic bacteria ; still others, known as the pathogenic, cause various diseases. Parasitic bacteria can grow on or in the tissues of the body. Obligate parasites are those which have not been cultivated outside of the body (as the bacilli of leprosy). Facultative parasites usually live outside the body, but may enter into the body and produce disease. The schizomycetes vary much in shape, size, color, arrange- ment, mode of growth, and action upon the body. One form cannot be transformed into another, but each main- tains its specific identity. Every organism comes from a pre-existing organism, this being true of all forms, as spon- taneous generation is impossible. Forms of Bacteria. — The three chief forms of bacteria are — 1. The Coccus or Micrococcus — berry-shaped, oval, or round bacterium (Fig. 2) ; 2. The Bacillus — rod-shaped bacterium (Fig. 3) ; 3. The Spirillum — corkscrew-shaped or spiral bacterium (Fig. 4). A short spiral is called a comma bacillus. 20 MODERN SURGERY. De Baiy compares these forms, respectively, to the bil- liard-ball, the lead-pencil, and the corkscrew. Cocci and Bacilli. — We have to do only with cocci and bacilli. Cocci may be designated according to their arrange- ment with one another ; namely, when existing singly they Fig. 2. — Micrococcus. Fig. 3. — Bacillus. Fig. 4. — Spirillum. are called monococci ; in pairs they are called diplococci (Fig. 5, a); in a chain they are called streptococci (Fig. 5, c); in a cluster Hke a bunch of grapes they are called staphylococci . (Fig. 5, b) ; in groups of four they are called tetracocci ; m groups of eight they are called sarcina or wool-sack cocci. Irregular masses, resembling frog-spawn, constitute zooglea masses (Fig. 6). The gelatinous matter in such a mass is formed by a transformation in the walls of the bacteria. The term ascococci is applied to a group of cocci enclosed in a capsule (G. S. Woodhead). The cocci are often named according to their function, as. '>:^ .-<.••- r— •'•5 C<^': c Fig. 5.— Forms of cocci. Fig. 6.— Zooglea (Ball). for example, "pyogenic," or pus-forming. Cocci may be named according to the color of the culture. The name may embody the form, arrangement, color, and function ; for instance, staphylococc2is pyogenes aureus signifies a round, golden-yellow micro-organism, which arranges itself with its BACTERIOLOGY. 21 fellows into the form of a bunch of grapes, and which pro- duces pus. The bacilli are long, staff-shaped organisms. Long bacilli having a wavy outline are called leptothrix. Chain-like ba- cilli are called strepto-bacilli. Bacilli give origin to many surgical diseases. Multiplication of Bacteria.— Bacteria multiply with great rapidity when placed under suitable conditi(jns. 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, which deepens until the cell has divided into two parts, each of which soon grows as large as its parent (Figs. 7, 8), Fig. 7. — Divisions of a micrococcus (after Mace). Fig. 8. — Divisions of a bacillus (after Mace). 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, the cholera bacillus requiring but twenty minutes to divide), a single cell in a single day will have sixteen million descendants (Cohn). In order, however, for such enormous multiplication to occur conditions must be absolutely favor- able to the cells, and conditions are rarely absolutely favor- able. Were it otherwise all other forms of life would be destroyed. Spores. — A spore is a germ, and corresponds with the seed of a plant. Most of the bacilli multiply by spore- formation. Cocci do not undergo spore-formation after the manner of bacilli, though some observers maintain that cocci occasionally undergo an alteration that makes them very resistant to any destructive influences (arthrospores). When spore-formation is about to occur in a bacillus points MODERN 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 consist of a series of segments like a necklace of beads, each segment containing a full-grown spore (Fig. 9). The wall of the cell now liquefies, the segments separate, the spores are set free, and each spore under favorable conditions be- comes a bacillus. When ffl 1^ ^ \a) ^ m ^^^ initial cloudiness ap- '^' '^ ^ pears in the middle of the cell it is called an " endo- spore ;" when it appears at one or both extremities it is christened an " end- spore " or " endspores." When multiplication is by a single endospore the ba- cillus does not elongate. Organisms which when active multiply by fission take on spore-formation when subjected to certain conditions. Spore -formation tends to occur when bacilli are about to die for want of nourishment or when there is an excess of oxygen present. Each cell, as a rule, contains but one spore, but may contain several. The spore has a dense envelope or covering which is very resistant to destructive agents. So resistant is the covering that twice the amount of heat is necessary to kill a spore as to kill an active adult cell. Spores when placed under conditions unfavorable for devel- opment may remain inactive for an indefinite period, just as seeds remain inactive when unplanted. When spores en- counter favorable conditions they at once develop into adult cells, just as seeds develop when planted. It seems prob- able that spores occasionally remain dormant in the human body for long periods, and finally awaken into activity be- cause of injury or disease of the tissue in which they lie. lyife-conditions of Bacteria. — In order to grow and to multiply, bacteria require a suitable soil and the favoring influences of heat and moisture. The soil demanded con- sists of highly organized compounds rather than crude sub- stances, and slight modifications in it may prove fatal to some forms of bacterial life, but highly advantageous to others. Some organisms require albuminous matter, others need carbohydrates ; they all require water, carbon, nitrogen, oxygen, hydrogen, and certain inorganic materials, especially BACTERIOLOGY. 23 lime and potassium (Woodliead). All organisms require water. If dried, no form will multiply, and many forms will die. The fluids and tissues of the individual may or may not afford a favorable soil for the germs of a disease, or, in the same person, may afford it at one time, and not at an- other. Some individuals seem to possess indestructible im- munity from, and others are especially prone to, certain con- tagious diseases. Impairment of health, by altering some subtle condition of the soil, may make a person liable who previously was exempt. The presence of oxygen influences microbic growth. Most organisms thrive best when exposed to the oxygen of the air, and they are known as " aerobic." The term " anaero- bic " is employed to designate organisms that can grow and multiply and produce particular products only when air is absent, free oxygen being fatal to them. The tetanus bacil- lus and the bacillus of malignant edema are anaerobic. An organism which can grow indifferently where oxygen is abun- dant or where free oxygen is absent is called a " faculta- tive-aerobic " bacterium. It may need oxygen; but if it does, it is able to obtain it from the tissues when air is excluded. 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 facul- tative-aerobic bacteria. Effect of Motion, Sunlight, Heat, and Cold.— The majority of fungi grow best when at rest; agitation retards the growth of some and kills others. Sunlight antagonizes the growth of certain bacteria. Temperature influences bac- terial growth. Some organisms will only grow within narrow temperature-limits, while others can sustain sweeping altera- tions, but most grow best between the limits of from 86° to 104° F. Freezing renders bacteria motionless and incapa- ble of multiplication, but it does not kill them : they again become active when the temperature is raised. The absurd- ity of employing 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, cell-activities by such a temperature only being rendered dormant. High temperatures are fatal to bacteria ; moist heat is more destructive than dry heat, and adult cells are more easily killed than spores. A temperature less than 212° F. will kill many organisms, and boiling will kill every pathogenic organism that does not form spores. Some spores are not destroyed after prolonged boiling, and some will withstand a temperature of 120° C. As a practical 24 MODERN SURGERY. fact, however, boiling water kills in a few minutes all cocci, most bacilli, and all pathogenic spores ; though the spores of anthrax, tetanus, and malignant edema are harder to kill than are the spores of other bacteria. Chemical Germicides. — Many chemical agents will kill bacteria, the most certain of them all being corrosive subli- mate. Koch showed that corrosive sublimate is an efficient test-tube 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. Badly infected wounds are occasionally irrigated with solutions of a strength of i to 500. Contact with albumin precipitates from a solution of corrosive sublimate an insoluble albuminate of mercury. In surgical operations by the wet method the mer- cury may be combined with tartaric acid in the proportion of I to 5, which combination prevents the insoluble albumi- nate from being formed. But though corrosive sublimate under certain conditions is very powerful, it is not always absolutely reliable. Many spores are very resistant to its action. Even a i per cent, solution of bichlorid of mercury is not certainly destructive of the .spores of anthrax. Geppert tells us that anthrax-spores may be active after a 25-hour immersion in a i : 100 solution of sublimate (Schimmelbusch). In the presence of hydrogen sulphide corrosive sublimate is useless, inert and insoluble, sulphide of mercury being precipitated ; hence corrosive sub- Hmate is without value as a rectal antiseptic; in fact, Gerl- oczy has proved that a concentrated aqueous solution of sublimate will not disinfect an equal quantity of feces. Cor- rosive sublimate contained in dressings after a time undergoes decomposition and ceases to be a germicide. It is not ger- micidal in fatty tissues because it is unable to attack bacteria which are coated with oil. Corrosive sublimate is very irri- tating to the tissues and causes copious exudation. Hence, after tissues have been irrigated with this agent drainage must be employed. In some cases the irritated tissues lose to a great extent their power of resistance, and infection may be actually facilitated by irrigation with sublimate. In rare instances corrosive sublimate is absorbed and produces poi- soning. In spite of these shortcomings and drawbacks it is a valuable aid to the surgeon and must be frequently used, especially upon the skin of the patient and the hands of the operator and his assistants. It should be dissolved in dis- tilled water, because ordinary water causes a precipitate to form (common salt prevents the formation of this precipitate). BACTERIOLOGY. 2$ Because of the facts that corrosive subHmate is poisonous and very irritant and that serous membranes quickly absorb it, this agent should not be used upon serous membranes. It is very irritant to joints, and many surgeons will not in- troduce it into them. It should never be put within the dura, and should not be applied, in strong solution at least, to mucous membranes. It is better to make the solution when it is needed, so as to have it fresh, for in old solutions much of the soluble corrosive sublimate has been converted into insoluble calomel, and the fluid has ceased to be germi- cidal. In order to make up fresh solutions use tablets, each of which contains about y}4 grains of the drug — one of these tablets added to a pint of water makes a solution of a strength of i to lOOO. Tablets which also contain ammo- nium chlorid are more soluble than those which contain corrosive sublimate only. Hot solutions of the drug are more powerfully germicidal than cold solutions. As corro- sive sublimate is irritant, leads to profuse exudation, and may produce tissue-necrosis, it should never be introduced into an aseptic wound. Griffin, in Foster's Practical Therapeutics, sets forth the strengths of solutions applicable to different regions. For disinfection of the surgeon's hands and the patient's skin, I : lOOO; for irrigating trivial wounds, i : 2000 ; for irri- gating larger wounds and cavities, i : 5000 to i : 10,000; for irrigating vagina, i : 5000 to i : 10,000; for irrigating urethra, I : 20,000 to I : 40,000 ; for irrigating conjunctiva, i : 5000 ; for gargling, i : 5000 to i : 10,000. Instruments cannot be placed in corrosive sublimate with- out being dulled, stained, and corroded. Corrosive sublimate may be absorbed from a wound, a serous surface, or a mucous membrane, ptyalism and diar- rhea resulting. The absorption of bichlorid of mercury may be followed by cramp in the limbs and belly, feeble pulse, cold skin, extreme restlessness, and even death by collapse. At the first sign of trouble withdraw the drug and treat the ptyalism (p. 202). Carbolic acid is a valuable germicide in the strength of from I : 40 to i : 20. It is certainly fatal to pus-organisms, but weak solutions do not destroy spores. Unfortunately, this acid attacks the hands of the surgeon ; consequently in the United States it is chiefly employed as an antiseptic me- dium in which to place the sterilized operating-instruments, or as a germicide to prepare the skin of the patient before the operation is performed. 26 MODERN SURGERY. Carbolic acid is very irritant to tissues, and carbolized dressings may be responsible for sloughing of the wound. Because of its irritant properties wounds which have been irrigated with it should be well drained. Carbolic acid, like corrosive sublimate, is inert in fatty tissues. Carbolic acid is readily absorbed, and may thus produce toxic symptoms. Absorption is not uncommon when the weaker solutions are used,' but rarely occurs when a wound has been brushed over with pure acid, because the pure acid at once forms an extensive zone of coagulation, which acts as a barrier to ab- sorption. One of the early indications of the absorption of carbolic acid is the assumption by the urine of a smoky, greenish or blackish hue. Examination of such smoky urine shows a great diminution or entire absence of sulphates when the acidulated urine is heated with chlorid of barium. This diminution of precipitable sulphates is explained by the fact that these salts are combined with carbolic acid, forming sol- uble sulphocarbolates (Griffin). Such urine is apt to contain albumin. If during the use of carbolized dressing or the employment of carbolic solutions the urine becomes smoky, the use of the drug in any form must be at once discon- tinued, otherwise dangerous symptoms will soon appear. These symptoms are subnormal temperature, feeble pulse and respiration, muscular weakness, and vertigo. If death occurs, it is due, as a rule, to respiratory failure. The treat- ment of slow poisoning by carbolic acid consists in at once withdrawing the drug, giving stimulants and nourishing food, and administering sulphate of sodium several times a day and atropin in the morning and evening. Pure carbolic acid is a reliable disinfectant for certain con- ditions. It is used to destroy chancroids, to purify infected areas, to disinfect the medullary cavity in osteomyelitis, to stimulate granulation after the open operation for hydrocele, or to purify sloughing burns. The pure acid will not pro- duce constitutional symptoms, but it occasionally causes sloughing. Its application causes pain for a moment only, and then analgesia ensues. Even dilute solutions of carbolic acid greatly relieve pain when applied to raw surfaces. Carbolic acid is certainly fatal to but few bacteria and it fails to kill most spores. It acts more slowly and less cer- tainly than corrosive sublimate. It requires 24 hours for a 5 per cent, solution to kill anthrax-spores. Pus or blood (albuminous matter) greatly weakens the germicidal power of carbolic acid, and fatty tissue cannot be disinfected by it. It is not even the best of agents in which to place instru- BACTERIOLOGY. 2/ ments, as it dulls them. After operation upon the mouth it is used as a wash or gargle, i to 2 per cent, being a suitable strength. It is used sometimes to irrigate the bladder and often to cleanse sinuses, but is not employed in the perito- neal cavity or the brain. It is occasionally injected into tu- berculous joints. Kreolin, which is a preparation made from coal-tar, is a germicide without irritant or toxic effects. It is less power- ful than carbolic acid but acts similarly, and is used in emul- sion of a strength of from i to 5 per cent., and does not irri- tate the skin like carbolic acid. Peroxid 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 bacteria live, and starves the fungi. The pero.xide of hydrogen is not fatal to tetanus bacilli. Some surgeons use it to wash out appendicular ab- scesses. It must not be injected into an abscess unless a large opening exists, as otherwise the evolved gas may tear apart structures and dissect up the cellular tissue. In a deep abscess of the neck the author saw this agent almost produce suffocation, the gas passing under the mucous mem- brane and nearly blocking the air-passages. Iodoform is largely used ; it is not truly a germicide, as bacteria will grow upon it, but it hinders the development of bacteria and directly antagonizes the toxic products of germ-life. It can be rendered sterile by washing with a solution of corrosive sublimate. It is of the greatest value when applied to infected areas and tuberculous processes. Clinically, no real substitute for it has yet been found. It need not be applied to clean wounds, but the powder is very useful when dusted in infected wounds. It prevents wound-discharges from decomposing and greatly allays pain. Gauze impregnated with iodoform is used to drain abscesses, to drain the belly under certain circumstances, to pack aside the intestines and prevent their infection during some abdom- inal operations, and as packing to arrest intracranial hemor- rhage. Tuberculous joints and cold abscesses are injected with iodoform emulsion, which is made by adding the drug to glycerin or olive oil. The strength of the emulsion is 10 per cent. A solution in ether of a strength of 10 per cent, may be used to inject the cavity of a cold abscess. The drug must be used with some caution. Absorption from a wound sometimes happens, producing toxic symptoms. These symptoms are frequently misinterpreted, being usually 28 MODERN SURGERY. attributed to infection. The symptoms in some cases are acute and arise suddenly, and consist of a hallucinatory de- lirium, nausea, fever, watery eyes, contracted pupils, metallic taste in mouth, yellowness of the skin and eyes, an odor of iodoform upon the breadth, the presence of the drug in the urine, the outbreak of a skin eruption resembling measles, and excessive loss of flesh and strength. Patients with such acute symptoms usually pass into coma and die within a week. Such attacks are most apt to arise in those beyond middle life (see Gerster and Lilienthal, in Foster's Practical Therapeutics). In some chronic cases the first symptoms observed are moroseness, bewilderment, and irritability, fol- lowed by depression with unsystematized persecutory delu- sions, delirium, coma, and even death. In systemic poisoning by iodoform, stop the use of the drug and sustain the strength of the patient while nature is removing the poison. Iodoform sometimes produces great local irritation of the cu- taneous surface, shown by crops of vesicles filled with turbid yellow serum or even bloody serum. These vesicles rupture and expose a raw oozing surface, looking not unlike a burn. The use of the drug must be at once abandoned, for to con- tinue it will not only increase the dermatitis, but will produce constitutional symptoms. Wash the vesiculated area with ether to remove iodoform, open each vesicle and dress the part for several days with gauze wet with normal salt solu- tion. After acute inflammation ceases apply zinc ointment or cosmolin. Europhen is a powder containing iodin, and the iodin separates from it slowly when the powder is applied to wounds or ulcers. It does not produce toxic symptoms readily, if at all, and is a valuable substitute for iodoform. It is used especially in the treatment of ulcers and burns. Nosophen is a pale yellow powder containing 60 per cent. of iodin. Its bismuth salt is known as antinosin. Nosophen is not toxic, is free from odor, and is the best of the substi- tutes for iodoform. Acetanilid is frequently used as a substitute for iodoform. It is of value when applied to suppurating, ulcerating, or sloughing areas, but it does not benefit tubercular conditions. Sometimes absorption takes place to a sufficient extent to cause cyanosis. If cyanosis arises, stop the drug and order stimulants by the stomach. Silver is a valuable antiseptic. Halsted and Bolton have shown that metallic silver exerts an inhibitive action upon BACTERIOLOGY. 29 the growth of micro-organisms and does not irritate the tis- sues. Crede has demonstrated the same facts. These state- ments indicate one great reason why silver wire is so useful as a suture-material. Halsted is accustomed to place silver foil over wounds after the wounds have been sutured, and Crede employs as a dressing a fabric in which metallic silver is intimately incorporated. Crede considers that silver lactate (actol) is an admirable antiseptic. It does not form insoluble albuminates when in- troduced into the tissues and is not an irritant. Silver citrate (itrol) is said to be even a better preparation than silver lac- tate, and it is a useful dusting-powder. Formaldehyd or formic aldehyd has valuable antiseptic properties. Formalin is a 40 per cent, solution of the gas in water. Solutions of this strength are very irritant to the tissues, but 2 per cent, solutions can be used to disinfect wounds. The stronger solutions are valuable for asepticizing chancroids and other ulcers. The vapor of formalin is used to disinfect wounds, and Wood suggests its employment in septic peritonitis as a means of disinfection after the abdomen has been opened. A 2 per cent, solution disinfects instru- ments satisfactorily. Formalin-gelatin has recently been introduced by Schleich as an antiseptic powder. When applied to a clean wound it gives off formalin and keeps the wound aseptic. When it is applied to a sloughing surface it will not give off formalin unless it is mixed with pepsin and hydrochloric acid. The commercial preparation is known as glutol. Formalin-gela- tin is used to replace bone-defects. Nucleins, especially protonuclein, possess germicidal powers. Protonuclein is of value in treating areas of in- fection, particularly when sloughing exists. Among other antiseptics of more or less value we may mention trichlorid of iodin, iodol, chlorid of zinc, chlorid of iron, loretin, salol, oxycyanid of mercury, fluorid of so- dium, argonin, sugar, mustard, lannaiol, bichlorid of palla- dium (in very dilute solution), thymol, potash soap, iodin, salicylic acid, boric acid, camphor, eucalyptol, cinnamon, bromin, chlorin (as gas or as chlorin-water), cinnamic acid, permanganate of potassium or of calcium, chlorate of potas- sium, alcohol, and normal salt solution. The best germicide is heat, and the best form in which to apply heat is by means of boiling water (even better than steam). One can use boiling water upon instruments and dressings, but rarely upon a patient and never upon the sur- 30 MODERN SURGERY. geon. Jeannel, of Toulouse, uses boiling salt solution in abscess-cavities, and other surgeons employ steam or boiling water to disinfect the medullary canal in osteomyelitis. Nev- ertheless, boiling water is rarely applied to the patient, and in many cases a chemical germicide must be used. The surgeon should always scrub his hands in a germicidal solu- tion, and corrosive sublimate is one of the best we possess. 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 the depth of 3 feet ; and in air, except that of the desert, that over the open sea, and that of lofty mountains. Microbes may be useful. Some of them are scavengers, 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 are taken up from the air by vegetables, and the mineral matter is dissolved in rain-water and passes into the soil from which it came, to there again be food for plants, which plants will become food for animals. Other organisms purify rivers ; others cause bread to rise ; still others give rise to fermentation in liquors. Microbes may be harmful. They may poison rivers and soils ; they may be parasites on vegetable life ; they cause diseases of the growing vine, and also of wine ; they produce the mould on stale damp bread ; they occasionally form poisonous matter in sausages, in ice-cream, and in canned goods ; 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 man dies these organisms at once attack the tissues, and post-mortem putrefaction begins in the abdomen. Kocli'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 BACTERIOLOGY. 3 1 must again be found associated with the artificially produced morbid process. Disease - production. — Disease - producing organisms which enter the body are usually rapidly destroyed. They cannot dwell there 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 diseased part — a so-called point of least re- sistance (a loais iniiioris i-csistcntice) — which affords a nest for them to develop and to multiply, the cellular activities of the weakened part being unable to cope with the activi- ties of the germs. Even large numbers of pathogenic or- ganisms 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 suppuration took place. This experiment proves that an organism can reach a dam- aged area by means of the blood, and it enables us to under- stand how a knee-joint can suppurate when we merely break up adhesions, and how osteomyelitis can follow trauma when the skin is intact. A given number of organisms might pro- duce no effect on a healthy man, whereas the same number might produce disease in an individual who was weak or ill- nourished, suffering from depression or fear, or debilitated by the habitual use of alcohol. The personal increment plays a great part in disease-production. Some individuals seem to be immune to certain diseases ; others seem especially liable to develop certain diseases ; and these immunities and liabilities may be hereditary. Toxins. — The action of pathogenic bacteria upon the tis- sues 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, oxygen, albumins, carbo- hydrates, etc. — and bring about body-wasting and exhaustion from want of food. In the second place, bacteria produce a vast number of compounds, some harmless and others highly poisonous. The symptoms of a microbic disease are largely due to the absorption of poisonous materials from the area of infection. These poisons may be formed from the tissues by the action upon them of the bacteria (toxins and pep- tones) or may be liberated from the bodies of degenerating microbes (bacterial proteid). Bacteria contain and secrete ferments like pepsin or trypsin, and as albumoses are formed in the alimentary canal by the action of digestive ferments 32 MODERN SURGERY. upon proteids, sugars, and starches, so microbic albumoses are formed by the action of microbic ferments upon tissues. Just as the albumoses formed in digestion are poisonous when injected, so the albumoses of microbic action are poi- sonous when absorbed. The albumoses of microbic action are called " toxalbumins." These albumoses often operate as virulent poisons to the body-cells. A series of compounds formed by the microbic destruction of tissue is alkaloidal in nature. These poisonous alkaloids are readily diffusible and, many of them, very virulent. It is probable that every pathogenic organism has its own special toxin which produces its characteristic effects, although the effects are modified by the nature of the soil — that is to say, by the condition of the tissues. The absorption of tox- ins may be very rapid ; for instance, the toxins of cholera may kill a man before the bacillus has migrated from the intestine. Brieger uses the term toxin to designate all of the poisonous products of bacterial action. He divides toxins into alkaloidal or crystallizable and amorphous, the latter being called toxalbumins. Ptomains. — By many writers the term " ptomain " is used to designate these toxins, but in reality a ptomain is a form of toxin that is due to the action of saprophytic bac- teria. A ptomain is a putrefactive alkaloid, and a toxin is any poison of microbic origin. Among these poisonous al- kaloids may be mentioned tetanin, typhotoxin, sepsin, putres- cin, muscarin, and spasmotoxin. I/eucomains must not be confounded with the above- mentioned bodies. Leucomains are alkaloidal substances existing normally in the tissues, and arising from physio- logical fermentations or retrograde chemical changes. They are natural body-constituents, in contrast to toxins, which are morbid. Leucomams are found in expired air, saliva, urine, feces, tissues, and the venom of serpents. If not excreted, these bodies may induce illness, and when injected may act as poisons. Ordinary colds and some fevers result from leucomains ; they play a great part in uremia, and when excretion is deficient the retained leucomains make the sys- tem a hospitable host for pathogenic bacteria. Among leu- comains may be mentioned adenin, hypoxanthin, and xan- thin, allied to uric acid, and other substances allied to creatin and creatinin. Alexins and Antitoxins. — Another group of substances which may arise from microbic action are known as " anti- toxins." When a person suffers from a bacterial malady the BACTERIOLOGY. 33 toxins of the bacteria, by acting upon the body-cells, cause the body-cells to produce a product which may kill the bac- teria (alexin) or may simply antagonize the toxin (antitoxin) These materials may exist in blood-scrum as leucomains, or may be toxins or toxalbumins absorbed by the blood from an area of bacterial disease. It is a well-recognized fact in fer- mentation that after a time the process ceases, and the addi- tion of more ferment is void of result. The same is true of specific maladies ; thus, if a person 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 exhaus- tion 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 body-cells to destroy germs, and partly to the production of alexins or antitoxins, which, when they have developed in sufficient amount, destroy the bacteria or render bacterial products harmless. In other words, bacteria not only produce poisons, but also the antidotes for them. Many observers are endeavoring to find the antitoxin of each microbic disease for the purpose of applying it thera- peutically. Great claims are made as to the value of the antitoxins of diphtheria, tetanus, and suppurations. Roux maintains that an antitoxin is not derived from a toxin, but that a toxin stimulates the body-cells to secrete an antitoxin. He further shows that an antitoxin does not destroy a toxin, but acts upon the body-cells and renders them capable of withstanding the poison. Buchner believes that the reason the leukocytes help to ward off disease is not because they act as phagocytes to bacteria, but because they furnish defensive proteids (alexins or antitoxins). Vaughan and others have proved that blood-serum is germi- cidal ; that the germicidal agent is dissolved in the alkaline serum ; that this agent is a nuclein which is furnished by the white cells, and this nuclein may be extracted and used therapeutically. Phagocytes. — 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, the microbes fighting the body-cells with most active ferments ; the body-cells endeavoring to devour and destroy the bac- teria (Fig. lo). In some cases the bacteria win absolutely and the patient dies. In other cases they win for a time and 3 34 MODERN SURGERY. overwhelm the organism, but presently the body-cells, whose movements were inhibited by the poison, regain their ac- tivity and successfully recur to the attack. After the attack is over the body-cells have been educated to withstand this poison, and new cells in the future retain this capacity ; the weak cells were killed, the fittest survived, and the descend- ant cells of the survivors are born insusceptible. This in- susceptibility is called immunity, 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 origi- .«-*^ Fig. io. — Phagocytosis : A, successful ; B, unsuccessful (Senn). nated with Sternberg, but it is usually accredited to Metsch- nikoff. Lankester gave us the term " educated corpuscle." Protective and Preventive Inoculations. — Our knowledge of protective inoculations for contagious dis- eases dates from Jenner's discovery in 1796. Preventive inoculations with attenuated virus are due to the experi- ments of Pasteur. This observer discovered the cause of chicken-cholera, and 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 attenuated cultures, inoculated in fowls, caused a mild attack of the disease, which attack was protective, and rendered the fowl immune to the most virulent cul- tures. Cultures can be attenuated by keeping them for some time, by exposing them for a short period to a tem- perature 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 BACTERIOLOGY. 35 animal rendered immune by inoculation is capable of making a susceptible animal also immune. A most important fact is that animals may be rendered immune to certain diseases by inoculating them with filtered cultures of the microbes of the disease, the filtrate contain- ing microbic products, but not living microbes. By this method animals can be rendered immune to tetanus and diphtheria. Pasteur's protective inoculations against hydro- phobia owe their power to microbic products, and Koch's lymph contains them as its active ingredients. The chief feature in acquired immunity is the presence in the blood and tissues of elements which can neutralize the toxic products or which can kill bacteria. These elements are " antitox- ins " and " alexins." The present knowledge of them arose from the discovery of Nuttall and Buchner 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 said that in tetanus injections of the serum of an immune animal may cure the disease. The above facts are of immense im- portance, for on these lines may be solved the problems of the prevention and treatment of microbic maladies. Orrhotherapy or serum-therapy is an attempt to utilize therapeutically the germicidal properties of blood-serum. It is believed that when a man gets an infectious disease the toxins act upon the body-cells and cause the formation by these cells of defensive proteids, alexins, curative nucleins or antitoxins. These products enable the body-cells to with- stand further injury by the toxins, the disease comes to an end, the bacteria die, and the alkaline blood-serum is satu- rated with protective material. If the above facts are true, it is an easy deduction that blood-serum containing protective material should cure the disease if injected into a patient suf- fering from an attack. Instead of using the blood-serum itself, some observers have precipitated the curative nuclein from the serum and used the nuclein in solution in fixed amounts. Instead of using the serum of persons rendered immune by an attack of the disease, many physicians have employed the serum of animals rendered artificially immune by injections of attenuated cultures of the bacteria. Some experimenters have employed even the serum of animals nat- urally immune to the disease. That Pasteur has devised a method which will usually prevent hydrophobia is certain (p. 182), and that Murri, of Bologna, has cured a case of hydrophobia seems proved (p. 182). Hosts of observers 36 MODERN SURGERY. believe in the utility of tetanus antitoxin and diphtheria antitoxin. Inconclusive experiments have been made in the treat- ment of syphilis by the serum of dog's blood, or the blood- serum of men laboring under tertiary syphilis ; in the treat- ment of pneumonia with the blood-serum of persons conva- lescent from pneumonia; and in the treatment of sufferers from septic diseases with antistreptococcic serum — blood- serum of animals rendered immune to septic infections. Ma- lignant tumors (both sarcomata and carcinomata) have been treated with the blood-serum of dogs, which animals had been injected with fluid expressed from malignant growths (Richet and Hericourt). Many claims made for serum- therapy are exaggerated, sensational, and unscientific. That there is truth in the method seems highly probable, but how much of it is true is not yet definitely ascertained. It is our duty to study, experiment, and observe, and to reach a con- clusion only after honest, careful, and thorough investigation. A little skepticism is as yet a safe rule. Antagonistic Microbes. — Another observation of im- portance is that certain microbes are antagonistic to one another. The streptococcus of erysipelas attacks the or- ganism of anthrax, and is antagonistic to several infectious diseases (syphilis and tuberculosis), also to sarcoma. We should note also that the growth of some microbes affects culture-media favorably or otherwise for the growth of other organisms, and the same may be true in the tissues of the human body. Mixed Infection. — A fact of practical importance to the surgeon is that an area infected by one form of patho- genic organism may be invaded by another form. This is known as a mixed infection, and consists of a primary infec- tion with one variety of organism, and a secondary infection with another. Koch found both bacilli and micrococci in the same lesion of tubercle. A soil filled with pneumococci favors the growth of pus cocci and tubercle bacilli. Tuber- culous or syphilitic lesions may be attacked by erysipelas. Chancre and chancroid can exist together. A syphilitic ulcer is a good culture-soil for tubercle bacilli (Schnitzler). Sup- puration in lesions of tuberculosis is due to secondary infec- tion with pus organisms. Placental Transmission. — The direct transmission of bacteria from parent to fetus is a problem still in course of solution. Certain it is that some diseases (as syphilis) are due to the direct carrying of the microbes by sperm-cell to BACTERIOLOGY. 37 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 mi- crobe 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. — Suppuration is caused by microbes. Can it exist without them ? The answer is, no. Injection of a fluid containing dead organisms will form a limited amount of pus ; injection of irritants forms a thin fluid which may resemble pus, but which is not pus. In surgery pus is not met with without the micro-organisms, and the presence of pus proves the presence of micro-organisms. Pus microbes, or pyogenic microbes, possess the property of peptonizing albumin, and thus forming pus. The peptonizing action is brought about by bacterial proteids or ferments. The inflammation which surrounds an area of pyogenic in- fection is caused by the irritant products of bacterial action (toxalbumins, ammonia, etc.). In the presence of the pyo- genic peptones inflammatory exudate is unable to coagulate. The most usual causes of suppuration are the following micro-organisms : StapJiylococc7is pyogcjics auretis (Fig. 1 1), the golden-yellow coccus. This is the most usual cause of abscesses (circum- scribed suppurations); JJ per cent, of acute abscesses are due to staphylococci (W. Watson Cheyne). Staphylococci are Fig. II.— Staphylococcus pyogenes aureus in pus (X looo) (Frankel and Pfeiffer). Fig. 12. — Streptococcus pyogenes in pus (X lOoo) (Frankel and Pfeiffer). found also in osteomyelitis. The staphylococcus pyogenes aureus is a facultative anaerobic parasite which is widely dis- tributed in nature, and is found in the soil, the dust of air, water, the alimentary canal, under the nails, on and in the superficial layers of skin, especially in the axillae and peri- 38 MODERN SURGERY. neum. It forms the characteristic color only when it grows in air. It is killed in lO minutes by a moist temperature of 58° C, and is instantly killed by boiling water. Carbolic acid (i : 40) and corrosive sublimate (i : 2000) are quickly fatal to these cocci. Staphylococcus pyogenes albus, the white staphylococcus, acts like the aureus, but is more feeble in power. When this organism is found upon and in the skin it is called the staphylococcus epidermidis albus, an organism which Welch proved to be the usual cause of stitch-abscesses. Staphylococcus pyogenes citreus, the lemon-yellow coccus, is found occasionally in acute circumscribed suppurations, but far more rarely than the other two forms. Its pyogenic power is even weaker than that of the albus. Staphylococcus cereus albus, found occasionally in acute abscesses. Staphylococcus cereus flavus, found occasionally in acute abscesses. Staphylococcus flavescens, occasionally found in abscesses. Is intermediate between the aureus and albus (Senn). Micrococcus pyogenes tenuis rarely takes the form of a bunch of grapes. Is occasionally found in the pus of acute abscesses. Streptococcus pyogenes (Fig. 1 2), found in spreading suppu- rations. Woodhead tells us (Treves' System of Surgery) that six organisms, each of which bears a separate name, are dis- cussed under this designation. Three of these organisms he places in one group, two in another, and says the sixth may be a separate species. 1st Group. — Streptococcus pyogenes, found especially in spreading suppuration and in very acute abscesses. Cheyne says that 16 per cent, of acute abscesses contain streptococci. Is easily killed by boiUng, and can be destroyed by carbolic acid and corrosive sublimate. Exists normally in nasal pas- sages, vagina, saliva, and urethra. Streptococcus pyogenes malignus, an uncommon organism found in splenic abscess. Streptococcus septicus has a strong tendency to break up into diplococci. 2d Group. — Streptococcjis of erysipelas, found in capillary lymph-spaces in erysipelas. Many bacteriologists believe it to be identical with the streptococcus pyogenes. Streptococcus of septicemia and pyemia. Most observers maintain that it is identical with the streptococcus pyogenes and streptococcus of erysipelas. BACTERIOLOGY. 39 3d Group. — Streptococcus articulonon, found in false mem- brane of diphtheria (see the excellent article by Woodhead in the System of Surgery by Frederick Treves). Bacillus pyogenes foetidus, found especially in the pus of ischiorectal abscesses. Bacillus pyocyaneus, found by Ernst in blue pus. Other Surgical Microbes. — Streptococcus of erysipelas (Fehleisen's coccus), as stated before, is thought to be iden- tical with the streptococcus pyogenes. Their difference in action is believed by Sternberg to be due to difference in viru- lence induced by external con- ditions and by the state of the tissues of the host. The coc- cus of erysipelas is somewhat larger than the ordinary form of streptococcus pyogenes. In- fection takes place by a wound, often a very trivial wound, or by the mucous membrane. The organism multiplies in the small lymph-channels. This organ- ism will cause puerperal fever in a woman in childbed when it gains access to " an absorb- ing surface in the genital tract" (Senn). The streptococcus may cause suppuration in ery- sipelas, mixed infection not being necessary to cause pus to form. The gonococcus (Fig. 14, the bacillus of Neisser), the diplo- coccus which causes gonorrhea. Bumm proved that this coc- cus was certainly the cause of the disease, by reproducing the disease in a healthy female urethra by inoculation with the twentieth generation in descent from a pure culture. Diplo- cocci are found often in the secretions of apparently healthy mucous membranes, and simulate very closely gonococci. Gonococci cannot be cultivated upon ordinary media, but grow best upon human blood-serum. In gonorrhea the organism is found both inside and outside of pus-cells and mucus-cells. It is not certain that the gonococcus is pyo- genic, the pus in gonorrhea being possibly due to mixed infection. Gonococci stain easily and are readily decolorized by Gram's method. Streptococci are found in noma. No specific organism has Fig. 13. — Anthrax bacilli in blood (Vierordt). 40 MODERN SURGERY. been isolated for traumatic spreading gangrene or hospital gangrene, only pus cocci having been found. The bacillus tctani (Fig. 15, Nicolaier's bacillus), an an- aerobic organism, found especially in the soil of gardens, in * ♦ • • •!• Fig. 14. — Gonococci from gonorrheal pus. the dust of old buildings, in street dirt, and in the sweepings of stables. Spores develop at the ends of these bacilli. This organism is capable of producing toxins of deadly power. Its spores are hard to kill. The drug which is most cer- tainly fatal to tetanus bacilH is bromin. The bacillus iuberciilosis (Fig. 16, Koch's bacillus), the Fig. 15. — Bacillus of tetanus, with spores. cause of all tubercular processes, is met with especially in dusty air which contains the dried sputum of victims of phthisis. This infected air is the chief means of its trans- mission, though it may be conveyed by the milk of tubercu- BACTERIOLOGY. 4 1 lar COWS and the meat of tubercular animals. Wounds may open a gateway for infection. Bacillus anthracis (Fig. 13), the cause of malignant pus- tule, or splenic fever. Bacillus mallei, the cause of glanders. Bacillus of syphilis (Lustgarten's bacillus). That syphilis is due to a micro-organism is highly probable, but that we have found the causative organism in Lustgarten's bacillus is by no means sure. A fact which points strongly against it as the cause is that it is found rather in non-contagious ter- tiary lesions than in contagious secondary^ lesions. The bacillus coli communis, called also the bacterium coli commune or the bacillus of Escherich. Feces invariably ^^ t \ .\ t \ r ^, - V \ V Fig. 16. — Tubercle bacilli in sputum fZiegler). contain this organism. It is believed by many observers to be the cause of appendicitis, peritonitis, and abscesses about the intestine. In cases of appendicitis we can rarely get a pure culture of Escherich's bacillus, but usually find also streptococci, staphylococci, or pneumococci. The bacillus of malignaut edema (the vibrione septique of Pasteur), found especially in stagnant water and certain varieties of soiL The bacillus of typhoid fever (Eberth's bacillus) is respon- sible for some cases of gangrene, some of embolism, and not a few of bone and joint disease. We may mention, in conclusion, as of occasional surgical importance, the bacillus of influenza, bacillus of diphtheria, bacillus of leprosy, bacillus of rhinoscleroma, bacillus of fetid ozena, bacillus of hemorrhagic septicemia, bacillus lac- tis aerogenes (an occasional cause of peritonitis). Proteus vulgaris, or bacterium termo, induces putrefaction and is respon.sible for many septic intoxications. 42 MODERN SURGERY. II. ASEPSIS AND ANTISEPSIS. Surgical cleanliness may be obtained by either the aseptic or the antiseptic method. In the aseptic method heat, chemical germicides, or both are used to cleanse the instru- ments, the field of operation, and the hands of the surgeon and his assistants, the surface being freed from the chemical germicide by washing with boiled water or with sahne solu- tion. After the incision has been made no chemical germi- cide is used, the wound being simply sponged with gauze sterilized by heat ; if irrigation is necessary, boiled water or normal salt solution is used, and the wound is dressed with gauze which has been rendered sterile by heat. The effort of the surgeon is simply to prevent the entrance of micro- organisms into the tissues. Some micro-organisms must enter, but the number will be so small that healthy tis- sues will destroy them. The aseptic method should be used only in non-infected areas. If chemical germicides are not used, the amount of wound-fluid will be small and the surgeon can often dispense with drainage. If a wound is to be closed without drainage, every point of bleeding must be ligated. It is often advisable to sew up the wound with Halsted's subcuticular stitch (Fig. 17). If this stitch is em- FiG. 17. — Halsted's subcuticular suture. ployed, the skin staphylococcus does not obtain access ta stitch-holes and stitch-abscesses cannot arise. This suture may consist of catgut, silk, or, preferably, silver wire, this lat- ter agent being capable of certain sterilization by heat and exercising a powerful inhibitory action on micro-organisms. If a wound is closed without drainage, firm compression is applied over the wound to obliterate any cavity which may exist In some regions of the body wounds are sealed with collodion or iodoform-collodion. If irrigation is not prac- tised and the wound is dressed with dry gauze, the pro- cedure is said to be by the " dry " aseptic method. In the antiseptic method the same preparations are made for the operation as in the aseptic method, but during the operation sponges impregnated with a chemical germicide are used. ASEPSIS AND ANTISEPSIS. 43 and the wound is dressed with gauze containing corrosive sublimate or some other chemical germicide. If the wound is not flushed with a chemical germicide, and is dressed with dry gauze, the operation is said to be by the " dr>^ " antisep- tic method. The antiseptic method is preferred in infected areas. Dry dressings are usually preferable to moist dress- ings, because they are more absorbent and do not act as poultices, and dry dressings may be used even when the wound has been flushed. Year by year the aseptic method becomes more popular. Surgeons have learned that the most important factor in asepsis is mechanical cleansing by means of soap and water. The chemical germicide plays a secondary rather than a vital part. In many regions a strong chemical germicide must not be used (in the abdomen, in the brain, in joints, in the pleural sac, and in the bladder), and in other regions (mucous surfaces and fatty tissue) it is produc- tive of harm rather than good. Preparations for an Operation. — The surgeon and his assistants remove their coats, roll up their sleeves, and envelop their bodies in aseptic or antiseptic sheets to pro- tect the patient and themselves. The hands and forearms are scrubbed with soap and hot sterile water. There is nothing equal to the ethereal soap of Johnston, which is a solution of castile soap in ether. Green soap or castile soap can be used. The brush employed is kept constantly in a I : 1000 solution of corrosive sublimate. The nails are cut short, are cleansed with a knife, and the hands are again scrubbed. The hands are dipped in a hot solution of cor- rosive sublimate, and with the forearms are scrubbed for at least a minute, the nails receiving especial care ; they are then dipped for one minute into pure alcohol and are again bathed with the mercurial solution. Kelly disinfects the hands by washing them with soap and water, dipping them in a so- lution of permanganate of potassium (a saturated solution in distilled water), and decolorizing them in a saturated solution of oxalic acid and washing off the oxalic acid in sterile water. Weir has highly commended the following plan and Stim- son is also pleased with it. Scrub the hands with a brush and green soap and in running hot water. Clean under the nails with a piece of soft wood. Place about a tablespoonful of chlorinated lime in the palm of the hand, place upon the lime an equal amount of washing-soda, add a little water, and rub the creamy mixture over the arms and hands until the rough granules of sodium carbonate are no longer felt. Place the paste under and around the nails by means of a 44 MODERN SURGERY. bit of sterile orange wood. Wash off the arms and hands in hot sterile water.' Instruments are disinfected by boiling for fifteen minutes in a I per cent, solution of carbonate of sodium and then rinsing them in a 5 per cent, solution of carbolic acid. The carbonate of sodium prevents rusting. Boiling unfortunately destroys to some extent the keenness of the cutting instru- ments. They are kept in trays containing boiled water. In- struments can be disinfected satisfactorily by keeping them for fifteen minutes in a 5 per cent, solution of carboHc acid. Instruments with handles of wood must not be boiled. If such instruments are used, they can be disinfected by the use of carbolic acid, but they should not be used. After the completion of the operation the instruments should be scrubbed with soap and water, boiled, and dried. Marine sponges are rarely used, small pieces of sterilized or anti- septic gauze being preferred. In the abdomen Ashton's aseptic gauze pads are employed. These pads are about ten inches square, and are made of a number of folds of gauze stitched loosely at the edges. Whenever possible, give the patient some days' rest in bed before a severe operation, and place him on a diet nutri- tious but not bulky. The night before the operation give a saline cathartic, and the morning of the operation employ an enema. Emptying the bowels lessens the danger of sepsis after operation. It is desirable that the rectum be empty, because in shock the stomach cannot absorb, and we may wish to utilize the absorbing power of the rectum and give stimulants by enema. Whenever possible, give a gen- eral warm bath the day before. The evening before the operation scrub the entire field of operation, and well clear of it, with soap and water ; shave if necessary ; wash with ether ; scrub well with hot corrosive-sublimate solution (i : 1000); apply a layer of moist corrosive-sublimate gauze, and place over this dry antiseptic gauze, a rubber dam, and a bandage. On removing the dressings to perform the opera- tion cleanse the part again exactly as before. In emergency cases disinfection can only be practised just previous to the operation. Disinfection can be thoroughly effected by the use of chlorinated lime (Weir, Stimson). Surround the field of operation with dry sterile sheets. To clean the vagina or rectum, use a sponge soaked with creolin and Johnston's ethereal soap (i : 16), and subse- quently irrigate with hot saline fluid or boric acid solution. ' Medical Record, April 3, 1897. ASEPSIS AND ANTISEPSIS. 45 To clean the mouth scrub the teeth with a brush and castile soap twice a da}' and rinse out the mouth with peroxide of hydrogen, or a solution of boracic acid every three hours for several days. Irrig-ation is often practised in septic wounds, but is not required in aseptic wounds. Among irrigating fluids we may mention corrosive sublimate, carbolic acid, peroxid of hydro- gen, boric acid solution, and normal salt solution. Hot normal salt solution is the best agent with which to irrigate the peritoneal cavit}-, the pleural sac, the interior of joints, and the surface of the brain. This solution contains 0.7 per cent, of sodium chloride. Many surgeons employ Landerer's dry method in ope- rating aseptically. No fluid is applied to the wound. As the wound is enlarged gauze sponges are packed in to arrest hemorrhage. On the completion of the operation the sponges are removed, any bleeding points are ligated, and the wound is closed without drainage. The favorite ligature-material is catgut, which is well pre- pared by boiling in alcohol. Another method is to take raw catgut, keep it in ether for twenty-four hours, soak it for twenty- four hours in an alcoholic solution of corrosive sublimate (i : 500), wind it on sterilized glass rods, and place it for keep- ing in ether or in alcohol. Fowler's catgut is prepared by boiling in alcohol, and is carried in hermetically sealed glass tubes containing alcohol, each tube holding twelve ligatures. Johnston's quick method of preparing catgut is as follows : place it for twenty-four hours in ether ; at the end of this period place it in a solution containing 20 grains of corro- sive sublimate, 100 grains of tartaric acid, and 6 ounces of alcohol. The small gut is kept in this for ten or fifteen minutes, the larger gut from twenty to thirty minutes, but never longer. It is placed for keeping in a mixture contain- ing I drop of chlorid of palladium to 8 ounces of alcohol. This gut is strong and reliable. At the time of operation the gut is placed in a solution one-third of which is 5 per cent, carbolic-acid solution and two-thirds of which are alcohol. Chromicized gut will not be absorbed so readily as other gut. It is prepared by adding 200 parts by weight of cat- gut to 200 parts of carbolic acid, 2000 parts of water, and i part of chromic acid. After remaining in this solution twenty-four hours it is transferred for permanent keeping to ether or to alcohol. Kelly and Clark prepare catgut by boil- ing it in cumol. Senn uses gut prepared with formalin. The great advantage of formalin gut is that it can be boiled with- 46 MODERN SURGERY. out injury. Silk can be used for both ligatures and sutures ; many sizes should be kept on hand. Sutures of silk should be well boiled before using. A convenient method of prepa- ration is to wind the silk on a glass spool, place the spool in a large test-tube, close the mouth of the tube with jeweller's cotton, introduce the tube into a steam sterilizer, and keep it there for one hour. These tubes are carried in wooden boxes sealed with rubber corks. Silkworm gut contains fewer bac- teria than catgut and does not swell when introduced into a wound. It is a very valuable suture-material, but is not used for ligatures. Silkworm gut is prepared by placing it in ether for forty-eight hours and in a solution of corrosive sublimate (i : looo) for one hour. It is carried in a long tube filled with alcohol. A few minutes before using the gut is placed in carbolic acid and alcohol (one-third of a 5 per cent, solution of acid, two-thirds of alcohol). Silk and catgut should be tied by the reef-knot. Silkworm gut is tied by the surgeon's knot. The first double knot is double and tight, the second is single and is lightly tied. If the second knot is light, it will not cut (Greig Smith). Silver wire is prepared by boiling. Most wounds are closed by interrupted sutures of silk- worm gut, but silk, catgut, chromic catgut, or silver wire can be used. The old continuous suture (Glover's stitch) is rarely used. An admirable closure can be effected by Halsted's subcuticular stitch, and scarcely any scar results. Marcy's buried tendon sutures are very valuable, especially in hernia operations and in various operations upon the abdomen. Kangaroo tendon is the best material for buried sutures. This tendon is prepared by boiling it for one hour in alcohol and then treating it by the palladium process exactly as cat- gut is treated. Dressings are made of cheese-cloth. This material is boiled in a solution of carbonate of sodium, rinsed out, and dried ; it is then soaked for twenty-four hours in a solution containing i part of corrosive sublimate, 2 parts of table-salt, and 500 parts of water. It is placed in jars, and it may be kept moist or dry. Sterilized gauze is prepared by boiling the material in soda, rinsing, and either boiling it for fifteen minutes or placing it in the steam sterilizer for the same time. Iodoform gauze is useful for packing and for dressing foul wounds. It is prepared as follows : make an emulsion com- posed of equal quantities by weight of iodoform, glycerin, and alcohol, and add corrosive sublimate in the proportion ASEPSIS AND ANTISEPSIS. 47 of I part to the 1000 of the mixture. This mixture stands for three days. Take moist bichlorid gauze, .saturate it with the emulsion, let it drip for a time, and keep it in ster- ilized and covered glass jars (Johnston). Lister's cyanid gauze (double cyanid of zinc and mercury) is not certainly antiseptic, and must be dipped into a corrosive-sublimate so- lution (i : 2000) before using. All forms of gauze can be bought ready prepared from reliable firms. Some surgeons place silver foil upon a wound before applying the gauze (Halsted, p. 29). Small wounds in which drainage is not employed may often be dressed by laying a film of aseptic absorbent cotton over the wound and applying, by means of a clean camel's-hair brush, iodoform collodion (grs. xlviij to 3j). When a wound is dressed with gauze a rubber-dam is sometimes laid over the dressings, so as to diffuse the dis- charge and prevent it from coming rapidly to the surface. The use of the rubber-dam is not nearly so common as for- merly. In an aseptic wound dry dressing uncovered by rub- ber is the most useful. When a dressing is covered by an impermeable material it becomes wet, acts as a poultice, and the discharges on the dressing may undergo decomposition. Drainage is obtained when needed by rubber or glass tubes, by strands of horsehair, silkworm gut, or catgut, or by pieces of gauze. Gauze, catgut, etc., are known as capillary drains. When moist they drain serum excellently, but pus very badly, or not at all. Drainage-tubes or strands are brought out at a portion of the wound which will be dependent when the patient is recumbent. Drainage is used in all infected wounds, in most very large wounds, in wounds to which irri- tant antiseptics have been applied, and in cases in which large abnormal cavities exist. Dressings must be changed as soon as soaking is apparent, and the change must be effected with all of the aseptic care employed in the operation. Stitches may usually come out about the sixth day. In large wounds only a iQw of them are taken out at one time, the remainder being allowed to remain for a couple of days longer. When a stitch begins to cut it is doing no good, and it should be removed, no matter how short a time it has been in place. Preparation of Marine Sponges. — Beat out the dust ; place them for forty-eight hours in a solution of hydro- chloric acid (15 per cent.) ; wash them out with water ;' place them for one hour in a solution of permanganate of potas- sium (siij to 5 pints of water) ; soak for four hours in a solu- 48 MODERN SURGERY. tion containing lo ounces of hyposulphite of sodium, 5 ounces of hydrochloric acid, and 3 pints of water ; wash with running water for six hours. Keep the sponges in a jar containing corrosive-subHmate solution (i : 1000). After using, wash in hot water, soak for half an hour in a solution of sodium carbonate (i : 32), wash in hot water, and replace in corrosive sublimate. A marine sponge inevitably becomes foul in its interior, and should not be used. Senn's Decalcified Bone-chips. — Take the shaft of the tibia or femur of a recently killed ox, saw it into portions two inches in length, remove the marrow and periosteum, and place the fragments of bone in a 15 per cent, solution of hydrochloric acid. Change the solution every twenty- four hours. In from two to four weeks the bone will be decalcified. Wash in distilled water, place the pieces of de- calcified bone for a few minutes in a dilute solution of potash to neutrahze the acid, and then immerse for twenty-four hours in distilled water. The portions of bone are cut into strips in the direction of the long axis of the segments. Each strip is three-quarters of an inch wide and should be sliced into bits one millimeter thick. These chips are kept in an alcoholic solution of corrosive sublimate (i : 500). III. INFLAMMATION. Definition. — Inflammation is a nutritive disturbance aris- ing from tissue-damage, and is not an increase of nutrition. It is defined by 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 cir- culation ; (2) departure of fluids and solids from the vessels ; and (3) changes in the perivascular tissues. Vascular and circulatory changes are essential to in- flammation in both vascular and non-vascular tissues. In the former they occur in the inflamed tissues ; in the latter (cornea and cartilage) they are manifest in neighboring tis- sues from which the non-vascular area derives its nutritive material. Active Hyperemia. — When an irritant is applied to tissue 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,, INFLAMMA TION. 49 venules, and arterioles — appearing first and being most pro- nounced in the small arteries. As a result of the dilatation there are increased rapidity of circulation and increased deter- mination of blood to the part, and the area of hyperemia becomes warmer than is normal. This condition of in- creased circulatory activity is known as " active hyperemia " (Fig. 19). Active hyperemia is an increase in the amount of moving blood in a part. Passive hyperemia is an increase in the amount of blood in a part, but not of moving blood, as passive hyperemia or con- gestion is due to venous ob- struction, and the blood is stagnated. Plethora means an increase in the total amount of body blood. Diminution in the amount of blood in a part is ischemia. In active hyperemia more blood goes to the part and more blood passes through it, an increased amount of venous blood comes from the hyperemic area, the venous tension is increased, and the veins may even pul- sate. The capillaries, which under ordinary circum- stances contain but few blood-cells (Fig. 18), become filled with corpuscles, and even the smallest capillaries pulsate. The capillaries contain no muscle-fiber, and hence these tubes cannot actively contract, contraction or dilatation depending upon the amount of blood sent to or retained in them. In active hyperemia the in- creased amount of blood sent to the part causes capillary di- latation. Fluid elements rarely leave the blood-vessels dur- ing active hyperemia, but they occasionally do. The wheals of urticaria are thus formed (Warren). Active hyperemia is often the first stage of an inflammation, but it is not of neces- sity followed by other inflammatory changes, and it can be caused by nerve-section or nerve-stimulation. During active hyperemia 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 4 Fig. 18. — Normal vessels and blood-stream. so MODERN SURGERY. -centre of the current (in the axial stream); the white blood- cells float lazily along near the vessel-wall (Fig. 19). Retardation. — After active hyperemia has existed for a variable time the blood-current begins to lessen in velocity, until it becomes more tardy than in health. This is known as " retardation of the circulation." Retardation is first noted in the venules, next in the capillaries, and last in the arteri- oles ; but arterial pulsation continues. The white cells show a strong tendency to adhere to the vein-walls, and, as a re- sult, accumulate against the inside of, and stick to, these walls and to one another, until the veins are entirely lined with layers of leukocytes. In the capillaries some leu- kocytes gather, but not many. In the arteries they adhere during car- diac dilatation, but are swept away by the force of the heart's contraction. Retardation is believed to be chiefly due to paresis of the muscular walls of the arterioles. This causation seems probable when we recall Lord Lis- ter's experiments upon the pigment-cells of the frog's foot. Lister proved that inflammation paralyzes the pigment-cells, and concluded that dilatation at the focus of an inflammation is due to the paralyzing action of an irritant. Dilatation at a distance from the focus is a reflex phenomenon (W. Watson Cheyne). Oscillation and Stagnation. — By this accumulation of leukocytes the blood-stream is progressively narrowed and the axial current is impeded. The red blood-cells begin to stick to one another, forming aggregations like rouleaux of coin, which increase the difficulty the axial current has to contend with, until progressive movement ceases and the contents of the vessels sway to and fro with the heart-beat. This is the stage of oscillation. In a short time oscillation ceases and the vessels are filled with blood which does not move, and the vessel-walls become irregular in outline or Fig, 19. — Dilatation of the vessels in inflammation. IXFLAMMA T/OiV. 51 even pouched. This is known as " stasis " or " stagnation " (Fig. 20). If stasis persists, coagulation or thrombosis oc- curs, because the vessel-walls hav^e been so injured by the irritant as to be practically dead material, and they are no longer able to prevent clotting of their contents. -^^ Stasis is chiefly due to paralysis and damage of the vessel-walls. We can then sum up the vascular changes of inflammation by stating that they con- sist in a dilatation of the vessel-walls, in a primary acceleration, a secondary retardation, and a subse- quent stagnation of the blood-current with adhe- sion of leukocytes to the walls of veins and capil- laries, and the aggrega- tion into masses of the red blood-cells. If stasis persists, the vessel-walls become profoundly in- volved in the inflam- matoiy change, and they may rupture or be completely de- stroyed. Bxudation of Fluids. — It is to be remembered that in the process of nutrition serum and even white cells pass into the tissues through the walls of veins and capillaries. In in- flammation the same thing happens, but the exudation is vastly greater in amount and is different in composition. In a slight inflammation, and in the early stage of any inflam- mation, there is an increase in the fluid exudate, and we speak of the condition as " serous inflammation." This fluid is really not serum, but is liquor sanguinis. We find true serum in passive congestion, not in active inflammation. The fluid in a serous exudation contains very few white cells, and hence little or no fibrin can form in it, and coagu- lation does not take place ; and if the inflammation goes no further, it is absorbed by the lymphatics. A blister is an example of serous inflammation. If the inflammation con- tinues to intensify, the exudation is altered in character — it becomes thicker, turbid, and very coagulable. It contains Fig. 2o. — Stasis of blood and diapedesis of white corpuscles in inflammation. 5^ MODERN SURGERY. white cells and fibrin-elements, and coagulates in the tissues. This fluid is known as " lymph " or plastic exudation, and when it is present we speak of the condition as " plastic in- flammation." The lymphatics endeavor to absorb the fluid, but become occluded by coagulation, and the area they drain becomes swollen, hard, and " brawny." Lymph can be seen in the anterior chamber of the eye in cases of plastic iritis. The slighter the inflammation the less albuminous is the fluid — the higher the inflammation the more albuminous is the fluid. The focus of an inflammation feels brawny be- cause of coagulation of a highly albuminous exudate — the periphery of an inflammation is soft and edematous because of the presence there of thin and non-coagulable exudate. Diapedesis or Migration. — Even early in an inflamma- tion some few white corpuscles pass through the vessel-walls ; Fig. -Stages of the migration of a single white blood-corpuscle through the wall of a vein (Caton). but when the inflammation is well established large numbers, and when it is severe vast hordes, pass into the perivascular tissues. This process is known as " diapedesis " or " migra- tion." The leukocytes throw out protoplasmic arms, insert themselves between the cells of the walls of the vessel, and pull themselves through by their power of ameboid move- ment. They do not pass through existing open doors, but form openings which close after them. This is readily ac- complished, because the vessel-wall is itself damaged, weak- ened, and convoluted. The escape of leukocytes takes place chiefly from the venules, though some migrate through the capillaries and even the arterioles (Fig. 21). In very acute inflammation the vessel-walls are so dam- aged that red corpuscles also escape, making the tissue ap- INFLAMMATION. 53 pear as if infiltrated with blood. The white corpuscles often greatly increase in number in the blood of a person who has an acute inflammation (leukocytosis), and the blood-making organs, such as the spleen and lymphatic glands, are often enlarged. The blood-plaques or third corpuscles are found to be present in increased numbers. These blood-plaques are not seen in moving blood, but are found in blood-clot, their usual proportion to red cells being as i to 20, and they are especially numerous at the height of fever-processes and during convalescence from an extensive abscess. Changes in the Perivascular Tissues. — The exuded liquor sanguinis coagulates, and as a result of the exudation of elements of the blood the tissues are softened, separated, and overfed. The abundance of food causes tissue-cells to multiply, and this process is known as " cell-proliferation." To the proliferating cells of the perivascular tissues are added the migrated leukocytes, the individual tissue-elements are separated and their identity is destroyed, and a mass is formed consisting of small round or oval cells held together by ge- latinous intercellular material. The newly formed cellular mass is called " embryonic tissue," inflammatory new forma- tion, indifferent tissue, juvenile tissue, or plastic infiltration. The tissues have reverted to a condition identical with the tissues of the embryo, as the first step in repair. Embryonic tissue may be absorbed by the lymphatics. It may be con- verted into pus if infected with pyogenic bacteria. It may be vascularized by the extension into it of capillary loops de- rived from adjacent capillaries. When embryonic tissue is filled with blood-vessels, that is to say, when it is vascularized, it is called granulation-tissue. Granulation-tissue is finally converted into fibrous tissue. The above complicated pro- cesses, vascular and perivascular, are not accidents nor hap- hazard freaks, but are Nature's efforts to bring about a cure. The acceleration of the circulation is an attempt to wash away offending material ; when this fails ensuing congestion is relieved by exudation and migration, the blood becoming fibrinous and more corpuscular in order that foreign bodies may be encapsuled or extruded, so that damaged parts may be amply repaired and vital structures may be protected and shielded. The exudation of germicidal blood-serum may destroy bacteria in the perivascular tissues. Dilatation is due to the direct effect of the irritant upon the muscle or its nerve-elements. Retardation and stasis are due to paralysis of the vessel-wall, which paralysis causes re- sistance to the passage of the blood-stream and adhesion of 54 MODERN SURGERY. the corpuscles to the vessel, and which deprives the blood of a force which normally urges it onward, namely, contraction of the arterioles. Stasis can be increased by the pressure of an enormous exudate, producing tension. Tension may be so great as to produce gangrene. Inflammation in Non-vascular Tissue. — A type of non-vascular tissue is the cornea, and the cornea can inflame. When it inflames the episcleral vessels dilate and pour out exudate, and the fluid exudate and the leukocytes enter into the corneal lymph-spaces. The exudate coagulates and cell- multiplication ensues as in any other inflammation. If new formation takes place, a permanent opacity mars the cornea as a consequence. When cartilage inflames it becomes filled with leukocytes, which are obtained from the vessels of the synovial membrane or the bone, and changes ensue identical with those previously studied. Classification of Inflammations. — The various forms of inflammations are — (i) Simple or coimno?i, that which is due to any ordinary traumatic, chemical, or thermal cause, and not to bacteria, such as traumatic periostitis or sun der- matitis. It does not tend particularly to spread. As a rule, the cause of a simple inflammation is momentary in action ; (2) infective or specific, that which is due to micro-organisms, as the streptococcus of eiysipelas. An unsuccessful attempt has been made to charge all inflammations to bacteria. It is true that bacteria can generally be found in inflammatory areas, but that they are the only causes of inflammation is accepted by few. Infective inflammations tend to spread widely; (3) traumatic, which is due to a blow or an injury; (4) idiopathic, which is without an ascertainable cause. There is certainly a cause, even if it cannot be pointed out, and the term " idiopathic " means that we do not know the cause ; (5) acute, which is rapid in course and violent in action ; (6) chronic, which follows a prolonged course ; (7) subacute, which is intermediate in violence and duration be- tween acute and chronic ; (8) sthenic, characterized by high action. Occurs in strong young subjects ; (9) asthenic or adynamic, occurring in the old, the debilitated, and the broken-down. It is unable to reach a sufficient degree of intensity to limit itself; (10) parencliyinatous, affecting the "parenchyma," or active cells of an organ; (11) interstitial, affecting the connective-tissue stroma; (12) serous, charac- terized by profuse non-coagulating exudation, as in pleuritis, or by marked inflammatory edema ; ( 1 3) plastic, adhesive, ox fibrinous, characterized by an exudation which glues to- INFLAMMA TION. 5 5 gether adjacent surfaces, as in peritonitis; (14) piirulcnt, phlcguwnoiis, or suppurative, when the pus cocci are present and multiply ; (15) /umorrhagic, when the exudate contains many red blood-cells, as in strangulated hernia and in black small-pox; (16) croupous, when an inflammation produces upon the surface of a tissue a fibrinous exudate which can- not be organized (aplastic lymph), and which is due to the action of micro-organisms. It occurs most usually on mucous membrane; {ly) diphtheritic, \\\\\c\\ differs from croupous in the fact that the false membrane is in the tissue rather than upon it; {\^) gangrenoits, an inflammation resulting in death of the part, the gangrene being due to the tension of the exudate or the violence of the poison; (19) healthy, when the tendency is to repair; (20) unhealthy, when the ten- dency is to destruction; (21) latent, an inflammation which for some time does not announce itself by any obvious symptoms, as the inflammation of Peyer's patches in typhoid fever ; (22) contagious, when its own secretions can propa- gate it ; (23) diy, without exudation ; (24) hypostatic, arising in a region of passive congestion (as a bed-sore); (25) malig- nant, due to malignant growths ; (26) catarrhal, affecting mucous membranes ; (27) neuropathic, due to impairment of the trophic functions of the nervous system, as in perfo- rating ulcer ; and (28) sympathetic or reflex, due to disease or injury of a distant part, as when orchitis follows mumps. Extension of Inflammation. — Inflammation extends by continuity of structure, by contiguity of structure, by the blood, and by the lymphatics. Extension by continuity is seen in phlebitis. Extension by contiguity is seen when a cutaneous inflammation advances and attacks deeper struc- tures. Extension by the blood is seen in the formation of the small-pox exanthem. Extension by the lymphatics is witnessed in a bubo following chancroid. Terminations of Inflammation. — Inflammation may be followed by a return of the tissues to health, and this return may take place by delitescence, by resolution, or by new growth. By delitescence is meant abrupt termination at an early stage, as when a quinsy is aborted by the ad- ministration of quinin and morphin, and the production of a sweat ; resolution means the gradual disappearance of the symptoms when inflammation has passed through its regular stages ; and nezv grozvtJi means that an inflammation has lasted a considerable time, with ample blood-supply, and without suppuration has gone on to the formation of em- bryonic tissue, granulation-tissue, and fibrous tissue. Inflam- 56 MODERN SURGERY. mation may terminate in death of the inflamed part, or necro- sis. Death of the part may be due to suppuration, ulceration, or gangrene. The causes of inflatnination are — predisposing, or those residing in the tissues, and rendering them Hable to inflame ; and exciting, or those which directly awake the process into activity. The first constitute the inflammable material, the second the sparks of fire. Predisposing causes are those which impair the general vigor, injure the blood, weaken the tissues, or lower nutri- tive activities. Among these causes are shock, hemorrhage, nervous irritation, gout, rheumatism, diabetes, Bright's dis- ease, and syphilis. Plethora renders a person liable to sthenic inflammations (those characterized by high action). Tissue-debility renders one prone to adynamic or asthenic inflammations. Exciting Causes. — The exciting causes of inflammation are — traumatic, as blows and mechanical irritation ; chemical, as the stings of insects, ivy poison, etc. ; thermal, heat and cold ; and specific, the micro-organisms, causing, for instance, tuber- cular peritonitis or erysipelas. Symptoms. — Inflammation announces its presence by symptoms which are both local and constitutional. The local symptoms are heat, pain, discoloration, swelling, and dis- ordered function ; the chief constitutional symptom is fever. Local Symptoms of Inflammation. — The most promi- nent local symptoms were known centuries ago to the famous Roman Celsus, who stated them as " rubor, calor cum tumore et dolore " — redness and heat with swelling and pain. As set forth to-day, the local symptoms are — (i) heat; (2) pain; (3) discoloration; (4) swelling; and (5) disordered function. Heat is due to the passage of an increased quantity of blood through the damaged area and to the arrival at the surface of the body of warm blood from internal parts. Al- though an inflamed part may be, and usually is, warmer than the surrounding parts, its temperature is never greater than the temperature of the blood. This increase of heat is especially noticeable when we contrast the feeling of an arm affected with erysipelas with a sound arm ; the diseased arm feels much warmer, but still its temperature is not above the general body-temperature. The extremities in health, as is well known, show on the surface a temperature below that of the blood ; in an inflamed state their temperature may nearly equal that of the blood. Heat is always present in INFLAMMA TIOX. 5 J inflammation. The surgeon examines for heat by placing his hand upon the suspected area and then placing it upon a corresponding portion of the opposite side of the patient. If great accuracy is desired, a surface thermometer is used. Pain is a constant and a conspicuous symptom. It is due to stretching of or pressure upon nerves from exudate ; to irritation of nerves ; or to inflammation in the nerves them- selves, producing cellular changes. Pain is associated with tenderness (pain on pressure), it is aggravated by motion and by a dependent position of the part, and it varies in degree and in character. In serous membranes it is acute and lancinating, like dagger-thrusts ; in connective tissue it is acute and throbbing ; in large organs it is dull and heavy ; in the bone it is gnawing or boring ; in the skin and mucous membrane it is itching, burning, smarting, or stinging ; in the urethra it is scalding ; in the testicle it is sickening or nauseating ; in the teeth it is throbbing ; and in inflamma- tion under tense fascia it is pulsatile. Pain in inflammation after presenting itself in one form may change in character. If a pain becomes markedly throbbing, suppuration may be anticipated. Pain does not always occur at the seat of trouble, but may be felt at some distant point. This is known as a " sympathetic " pain, and means that a nervous communi- cation exists between the inflamed part and a distant area, a nerve-trunk referring pain to its peripheral distribution. Pain of hepatitis is often felt in the right shoulder. Pain at the point of the shoulder is felt also in gall-stones and in cancer of the liver. The pain arises in filaments of the pneumogastric from the hepatic plexus, which filaments reach the spinal accessor^', pain being expressed in the branches of the spinal accessor}^ which supply the trapezius and communicate with the third and fourth cervical nerves.^ Pai)i of coxalgia is often felt on the inside of the knee, because the obturator nerve, which sends a branch to the ligamentum teres, also sends a branch to the interior and to the inner side of the knee-joint. Inflammation of an eye with increased tension causes brow-ache. Inflammation of the neck of the bladder causes pain in the head of the penis. Inflammation of a testicle causes pain in the groin. Renal calculus and pyelitis cause pain in and retraction of the testicle, and pain in the thigh. If the covering of an organ is involved, pain becomes more violent ; for instance, a hepatitis becomes much more • Embleton's view in Hilton on Rest and Pain, a book every student should read. 58 MODERN SURGERY. painful when the perihepatic structures are attacked.- In- flammation without pain is known as " latent " (as the inflam- mation of Peyer's patches in typhoid). The sudden disap- pearance of inflammatory pain, when not due to opiates, suggests the possibility of gangrene, for analgesia exists in gangrene. The characteristics of inflammatory pain are that it cornes on gradually, has a fixed seat, is continuous, is attended by other inflammatory symptoms, and is increased by motion, by pressure, and by the hanging down of the part. If there be no tenderness in a part, the source of the pain is not local infl.ammation ; but tenderness may exist when there is no local inflammation, as in pain referred from a distant part. Pain of inflammation does not correspond to an exact nervous distribution. If pain corresponds ex- actly to an area of a nerve's distribution, the cause of it is acting on the nerve-trunk or on its roots. If the cutaneous surface is involved, the lightest touch causes pain. If touch- ing the skin produces no pain, but deep pressure does pro- duce it, the deeper structures are the source. Pain in mus- cle and ligament is developed by motion : in muscle, by contraction, but not by passive movements with the muscle relaxed ; in ligament pain is developed by active or passive movements which stretch the ligament. If, for example, a man with a stiff neck has pain on the right side of the back of his neck on voluntarily turning his face toward the left shoulder, but is without pain when his face is turned by the surgeon, who, conversely, induces pain by turning the patient's face far to the right, this condition indicates the trouble to be muscular. If, however, no pain arises on turning the face to the right, but it is manifest on turning the face actively or passively to the left, the pain is in those ligaments which stretch when the face is turned to the left (A. Pearce Gould). In inflammation of the synovial mem- brane gentle passive motion in any direction causes pain. The pain of colic differs from that of inflammation. It is sudden in onset, intermits, recurs in paroxysms, and is re- lieved by pressure. The pain of inflammation is gradual in onset, is continuous, and is made worse by pressure. The pain of neuralgia is often preceded by the onset of cutaneous anaesthesia of the skin of the part, is very paroxysmal, comes suddenly, darts through recognized nerve-areas, lasts some hours, and is apt to recur at a certain hour. It presents no general tenderness, as does inflammation, but w^e may find several points which are acutely sensitive to pressure (Val- leix's points dotdoiiraix). The tender spots of Valleix are INFLAMMATION. 59 met with in inveterate neuralgia, and occur at points where nerves " pass from a deeper to a more superficial level, and particularly where they emerge from bony canals or pierce fibrous fascia " (Anstie). Pain is often of great value by calling attention to parts diseased ; but it may be a great evil, racking the organism and even causing death. If pain continues long, it becomes in itself formidable : it prevents sleep, it destroys appetite, and it disorders the mind, and one of the surgeon's highest duties is to relieve it. The physiognomy or expression of physical pain presents the following characteristics : Heavy, fulness about the eyes, and dropping of the angles of the mouth, added to appearances due to anemia, widespread tremor, etc. The absence of the physiognomy of pain in a person who complains of great agony is a strong indication that the patient exaggerates the gravity of his sufferings or deliberately deceives. Discoloration arises from determination of blood to the part ; hence the more vascular the tissue the greater the discoloration. A non-vascular tissue presents no discolora- tion, though we find discoloration adjacent in the zone of blood-vessels which furnish the tissue with nutriment. Dis- coloration is most intense at the focus or centre of inflam- matory action. Discoloration varies in tint and in character according to the tissue implicated and the nature of the in- flammation. It may be circumscribed or diffuse. Arbores- cent redness means a distribution in dendritic lines. Linear discoloration signifies redness running in straight lines, as in phlebitis. Punctiform discoloration occurs in points, and is due to vascular rupture. Maculiform redness resembles an ecchymosis or blotch. Dusky discoloration points to sup- puration. Inflammation of the throat and skin produces scarlet dis- coloration ; inflammation of the sclerotic coat of the eye and of the fibrous coat of muscle produces lilac or bluish discol- oration ; inflammation of the iris produces brick-dust, gray- ish, or brown discoloration ; erysipelas causes a yellowish- red discoloration ; secondary syphilis causes a copper-hued discoloration ; and tonsillitis causes a livid discoloration. A scrofulous ulcer is of a purple color on the edge. Gangrene is shown by a black discoloration. A scorbutic ulcer is sur- rounded by an area of violet color. Redness as a sign of inflammation must be permanent and joined with other symptoms. Redness due to inflam- mation disappears on pressure, but returns as soon as the 60 MODERN SURGERY. pressure is removed. If redness is due to staining of the surface by dye, pigmentation, or extravasation of blood, press- ure will not blanch the spot. If on taking off pressure the redness of inflammation rapidly returns, the circulation is ac- tive ; if, on the contrary, it very slowly reappears, the circula- tion is very sluggish and gangrene is threatened. Subcuta- neous hemorrhage gives rise to a purple-red color which does not fade when subjected to pressure. Stains of the surface by dyes fail to disappear on pressure, are distributed over a considerable surface, show a hue which is uniform throughout, are obviously superficial, are not associated with other signs of inflammation, and can be washed away. A. Pearce Gould, in his excellent little work upon Sur- gical Diagnosis, tells us that the color of a hyperemic sur- face may furnish important information. Lividity may mean failure of the heart and lungs, or simply venous congestion in the part. In lividity from obstruction of the lungs or heart the color slowly returns after pressure has driven it out. In lividity due to local congestion the color quickly returns when pressure is released and the dilated veins are often distinctly visible. Szvelling or tumefaction arises in small part from vascular distention, but chiefly from effusion and cell-multiplication. The more loose cellular material a part contains, the more it swells ; hence the eyelids, scrotum, vulva, tonsils, glottis, and conjunctivae swell very largely when inflamed. A swelling is soft or edematous when due to uncoagulable effusion, and it is hard and elastic when produced by coagulated exudate or embryonic tissue. Swelling may do good by unloading the vessels and acting like a blister or local bleeding, or it may do great harm by pressing upon the vessels and cut- ting off the blood-supply. Swelling of the conjunctiva, or chemosis, may cause sloughing of the cornea, and swelling of the prepuce may cause gangrene. A swelling may do harm by obstruction of a natural passage, as in edema of the glottis, or by compression of a normal channel, as in the swelling of the perineum. A swollen area may be covered with blisters or blebs. This condition is noted particularly in burns. Disordered function is always present in inflammation. It may be manifested by increased tenderness or sensibility, a slight touch, it may be, producing torturing pain. Parts almost or entirely destitute of feeling when healthy (as ten- dons, ligaments, and bones) become highly sensitive when inflamed. It may be manifested by increased irritability. In INFLAMMATION. 6 1 dysentery the colon constantly contracts and expels its con- tents ; the stomach does likewise in gastritis ; and the blad- der acts similarly in cystitis. Spasmodic twitching of the eyelids occurs in conjunctivitis, and twitching of the muscles in fracture and after amputation. hnpainiiciit of Special Function. — In inflammation of the eye, when an attempt is made to look at objects, the lids close spasmodically, and even a little light causes great pain and lachrymation (photophobia). In inflammation of the ear noises cause great suffering, and even when in a quiet room the patient has subjective buzzing and roaring sounds in his ears (tinnitus aurium). In coryza the sense of smell, in glossitis the sense of taste, in dermatitis the sense of touch, and in laryngitis the voice may be lost. In inflammation of the brain the mind is affected ; in arthritis the joints can scarcely if at all be used ; and in myositis it is difficult and painful to employ the muscles. Derangement of Secretions. — In dermatitis the sweat is not thrown off; in hepatitis bile is not properly secreted; and in nephritis urea is not satisfactorily removed. The secretions may undergo important changes of composition. Pneu- monia causes rusty sputum, and dysentery' causes bloody mucus (Gross). Derangement of Absorbejits. — In the height of an inflam- mation the absorbents are blocked and clogged by coagu- lated fibrin, and they cannot perform their offices. Constitutional symptoms of acute inflammation may be absent, and often are in moderate or limited inflammations ; but in severe, extensive, or infective inflammations the symp- tom-group known ^js, fever is certain to exist. This is known as symptomatic, sympathetic, or inflammatory fever, and it arises in non-septic cases from the absorption of aseptic pyrog- enous exudate and in microbic inflammations from absorption of pyrogenous toxic products. In young and robust individ- uals an acute non-microbic inflammation causes a fever char- acterized by full, strong pulse, flushed face, coated tongue, dry skin, nausea, constipation, and possibly acute delirium (the sthenic type of the older authors). In broken-down and exhausted individuals an ordinar)^ inflammation, and in any individuals a bacterial inflammation may cause a fever with t\'phoid symptoms (the typhoid, asthenic, or adynamic type). In inflammatory conditions the leukocytes are markedly in- creased in number, the condition being spoken of as leuko- cytosis or transient leukocythemia. Blood plaques are also increased. The fibrin-ferment is obtained from the white cor- 62 MODERN SURGERY. puscles ; it is liberated as the corpuscles break up in the ex- udate, and acting on the liquor sanguinis forms fibrin. The absorption of fibrin-ferment many believe causes aseptic fever (page 88). Inflammatory blood contains an increased amount of albumin and salts. If a person with inflammatory fever is bled, the blood coagulates rapidly, the clot sinks, and there is found on the surface a cup-shaped coat, made up of liquor sanguinis and white cells, known as the " buffy coat," but this is not a sign of inflammation and occurs normally in the blood of the horse. The buffy coat forms when blood con- tains a great number of leukocytes, because these leukocytes sink more slowly than do the red corpuscles. Cupping oc- curs because the white corpuscles sink more slowly by the sides of the tube than far from the sides. Treatment of Inflammation. — The first rule in treat- ing an inflammation must be to remove the exciting cause. If this cause is a splinter in the part, take out the splinter ; if it is a foreign body in the eye, remove the foreign body ; if urine is extravasated, open and drain ; take off pressure from a corn ; pull out an ingrown nail, and remove irritants from an infected area by asepticizing. The rule, remove the cause, applies to a chronic as well as to an acute inflamma- tion. If the cause of an inflammation was momentary in action (as a blow), we cannot remove it, for it has already ceased to exist. After removing the cause, endeavor to bring about a cure by local and constitutional treatment. Local Treatment of Inflammation. — It must be remem- bered that the division of inflammation into stages is natural, and not artificial, and that a remedy which does good in one stage may do harm in another. Certain agents are suited to all stages of an inflammation, namely, rest and elevation. Rest is of infinite importance, and is always indicated in acute inflammation. Its principles were first thoroughly studied by Hilton.^ The means of securing rest differ with the structure or the part diseased. When rest is used, do not employ it too long. In cerebral concussion rest must be secured by quiet, by darkness, by the avoidance of stimu- lants and meat, by the application of ice to the head, and by the use of purgatives to prevent reflex disturbance and the circulation of poisons in the blood. In inflamed joints rest must be obtained by proper position, associated in many cases with the adjustment of splints or plaster, or the em- ployment of extension. In pleurisy partial rest can be secured by strapping the ^ Lectures upon Rest and Pain. IXFLAMMA TIOX. 63 affected side with adhesive plaster or by using a bandage or a binder to Hmit respiratory movements. \Vi fractures Nature procures rest by her spHnts — the callus — and the surgeon pro- cures rest by his splints — immovable dressings, or extension. In fractures of the ribs strap the chest on the injured side. In cancer of the rectum a colostomy secures rest for the damaged bowel. In enteritis opium gives rest to the bowel by stop- ping peristalsis. In cystitis rest is obtained by opium and belladonna, which paralyze the muscular fibres of the blad- der. The use of the catheter gives rest to the bladder by removing urine. A cystotomy allows complete rest by per- mitting the bladder to suspend its function as a reservoir of urine. In vesical calculus rest is obtained by cutting or crush- ing the stone. In inflamed mucous membranes rest is secured (from the contact of irritants) by touching them with silver nitrate, which forms a protective coat of coagulated albumin. Opening an abscess gives its walls rest from tension. In i>i- flammations of the eye light must be excluded to obtain com- plete rest, but tolerable satisfactory rest is given in some cases by the use of glasses of a peacock-blue tint. In aneurism the operation of ligation cuts off the blood-current and giv^es rest to the sac. In hernia the operation gives rest from pres- sure. Instances of the value of rest could indefinitely be multiplied. Elevation partly restores circulatory equilibrium. A felon is less painful when the hand is held up in a sling than when it is dependent. A congestive headache is worse during re- cumbency. A gouty inflammation in the great toe is more painful with the foot lowered than when it is raised. A tooth- ac/ie becomes worse on lying down. Relaxation is in reality a form of rest, and consists in placing the part in an easy position. In synovitis of the knee semiflexion of the knee-joint lessens the pain. In muscular inflammations relaxation relie\-es the pain. Certain agents are suited to the stage of vascular engorge- ment, increased arterial tension, and beginning effusion. These agents are — (i) local bleeding or depletion ; (2) cut- ting off the blood-supply ; and (3) cold. Local bleeding or depletion is the abstraction of blood from the inflamed area. This abstraction relieves circulator}' re- tardation and causes the blood to move rapidly onward ; the corpuscles clinging to the vessel-walls are washed away, the capillaries shrink to their natural size, and the exudate is absorbed. In other words, local blood-letting increases the rate of the circulation, though not its force. 64 MODERN SURGERY. The methods of bleeding locally are — («) puncture ; {B) scarification ; {c) leeching ; and. {d^ cupping. Puncture is recommended in inflammation, not only because it abstracts blood locally, but also because it gives an exit to effusion under fibrous membranes. It is very use- ful in relieving tension — for instance, in epididymitis. It is performed with a tenotome and with aseptic precautions. If numerous punctures are made, the procedure is termed " multiple puncture." This is very useful when applied to the inflamed area around a leg-ulcer. The late Prof Joseph Pancoast was very fond of employing multiple punctures, designating the operation " the antiphlogistic touch of the therapeutic knife." Scarification or Incision. — By means of scarification we bleed locally, evacuate exudates, and relieve tension. One cut or many cuts may be made, and these cuts may be deep or may not even go entirely through the skin, according to circumstances. Multiple incision is very useful appHed to inflamed ulcers, ulcers in danger of gangrene, and to almost any condition of great tension. Leeching. — Leeches must not be applied to a region plen- tifully endowed with loose cellular tissue, as great swelling and discoloration are sure to ensue. These regions are the prepuce, labia majora, scrotum, and eyelids. Leeches should never be applied to the face (because of the scar), near specific scars or inflammations, nor over a superficial artery, vein, or nerve. A leech is best applied at the periphery of an inflammation and between an inflammation and the heart. To leech at the inflammatory focus only aggravates the case. Before applying leeches, wash the part and shave it if hairy. If the leeches will not bite, smear the part with milk or with a little blood. In u.sing a leech, place it on the skin under a glass tube or an inverted wine-glass. Never pull off a leech : let it drop off; and if it refuses to do so, sprinkle it with salt. After removing a leech, employ warm fomentations if continued bleeding is desired. Sometimes the bleeding persists, but this may be arrested by styptic cotton and pressure. Leeching leaves permanent triangular scars. The Swedish leech, which is preferred to the Ameri- can, draws from four to six drachms. Leeching has both a constitutional and a local effect. It is at the present time used comparatively rarely, but it is employed by some sur- geons over the spermatic cord in epididymitis, on the temple in ocular inflammation, and over the right iliac region in mild cases of appendicitis. IXFLAMMA riON. 65 Cupping: Wet dtps. — In wet cupping apply a cup for a moment, remove it, incise or puncture the skin, and apply the cup again to draw the requisite amount of blood. Baron Heurteloup devised an instrument (Fig. 22) in which the incision is made by a scarifier. The blood is drawn by a pump, the tube being placed upon the cut area and the withdrawal of the piston creating a vacuum. This instru- ment is known as the " artificial leech." Wet cupping is of value in pleuritis, pericarditis, and nephritis. Cutting off' the Blood-supply. — Onderdonk, of New York, in 181 3 recommended ligation of the main artery of a limb for the cure of inflammation in important structures supplied by the vessel. The procedure was warmly advocated by Campbell, of Georgia, for the treatment of gunshot-wounds Fig. 22. — Heurteloup's artificial leech. of joints. This plan of treatment is now not to be considered for a moment ; antisepsis furnishes us with a safer and more certain plan. Vanzetti, of Padua, advocates digital pressure to cut off the blood-supply to an inflamed part. Cold is a very powerful and an extremely useful agent. It constringes the vessels, prevents migration of corpuscles, favors the absorption of exudate, retards cell-proliferation, and relieves pain, swelling, and tension. Cold must not be applied to the old or to the feeble, as it may induce gan- grene. It is harmful in advanced inflammations or severe congestions (as strangulated hernia). There are two forms of cold, the dry and the wet. Wet Cold. — To apply wet cold, the part is wrapped in wet linen or muslin and laid upon a rubber sheet folded like a trough and emptying into a bucket. A vessel filled with cold water is placed upon a higher level than the bed. A wet lamp-wick is now taken, one end is inserted into the water of the vessel, and the other end is laid upon the part. 66 MODERN SURGERY. Capillary action and gravity combine to keep the part moist. A rubber tube may be used instead of a wick. If a tube is employed,' tie it in a knot or clamp it so that the fluid is de- livered drop by drop (Fig. 23). Ordinary water or iced water can be used. If the water be too warm, it can be reduced to about 45° F. by adding i part of alcohol to every 4 parts of water. A mixture of 5 parts of nitrate of potas- sium, 5 parts of chlorid of ammonium, and 16 parts of water produces great cold. If wet cold is used upon an open Fig. 23. — Siphon (Esmarch). wound, the fluid should be antiseptic. Irrigation by cold fluid is rarely employed at the present day. In severe con- junctivitis wet cold is applied by means of cloths soaked in ice-water and frequently changed. Evaporating lotions owe a portion of their efficacy to the cold they induce. Diy cold is applied by means of a rubber bag or a blad- der filled with ground or finely cracked ice, several folds of flannel being first laid over the part. A part can be encircled with a rubber tube through which ice-water is made to flow INFI.AMMA TJON. 67 (Fig. 24). Leiter's tubes, which are made to fit various re- gions and which carry a stream of cold water, can also be used. An ice-bag, if applied at once, is the best treatment for a sprained joint. Ice-bags are very useful in acute mye- litis, meningitis, joint-inflammation, epididymitis, and other acute inflammations in the early stage. Certain agents are suited to the stage of fully developed inflammation, when we have a great deal of swelling due to effusion and cell-proliferation. The indication in this stage is to abate swelling by promoting absorption. This is accom- plished by (i) compression; (2) the local use of astringents Fig. 24. — The Esmarch cooling coil. and sorbefacients ; (3) the douche ; (4) massage ; and (5) in- termittent heat. Compression is the agent which is especially useful in fully developed or in chronic inflammation, but it will do good also in the first stage. Compression is of great usefulness : it supports the vessels and causes them to drink up effusion, and it strongly rouses the absorbents. This agent is valu- able in most external inflammations with much swelling. In erysipelas of an extremity the part should be elevated and the extremity bandaged from the periphery to the body. In ulcers, especially those with hard and blue edges, the use of Martin's elastic bandage or of straps of adhesive plaster gives decided relief In chronic inflammation of a joint elas- tic compression is of great value. In epididymitis, after the 68 MODERN SURGERY. acute stage, the testicle may be strapped with adhesive plas- ter. In lymphadenitis compression by a weight or by a bandage is vQxy generally employed. In fractures compres- sion not only antagonizes spasm, but often combats the swelling and pain of inflammation. Compression must be judicious : it must never be too forcible, and it must not be applied to a limb without including the extremity of it (never, for instance, strongly compress the elbow without including the hand, nor the palm without bandaging the fingers). Injudicious compression causes severe pain, and may produce gangrene. Astringents and Sorbcfacients : Solutions of Acetate of Lead. — Ammonium chlorid was formerly employed in the strength of oj to 2 quarts of water; but if long used, it produces pus- tules and thus causes irritation and pain. A solution of the acetate of lead is astringent and sorbefacient ; it promotes the contraction of distended vessels, accelerates the blood-cur- rent, and urges the absorbents to increased activity. This agent, in practice, is usually mixed with laudanum, as fol- lows : Tinctura opii, f.lj ; Hquor plumbi subacetatis, f 5j ; aqua, Oj. This solution, spoken of as lead-water and laud- anum, is extensively used and is very soothing. It can be employed cold, the evaporation which it undergoes cooling the part. It is best applied by soaking a double layer of flannel in the lead-water, laying it on the affected part, and by means of a sponge squeezing more of the lotion upon it from time to time. If it is desired to have it very cold, an ice-bag can be placed upon the soaked flannel. Lead-water and laudanum may be used warm, the flannel being covered with oiled silk or waxed paper or a piece of rubber. If it is desired hot (veritably a poultice), the lead-water is heated before the flannel is soaked in it. The soaked flannel is ap- plied to the part and covered with a rubber-dam, and a hot- water bag is placed upon the dressing. Lead-water is not used in treating open wounds. Tincture of iodin acts like lead acetate. It is astringent, sorbefacient, counterirritant, and antiseptic. It must not be used pure. For adults it should be diluted with an equal amount of alcohol, and for children with 3 parts of alcohol. In using iodin, paint it upon the part with a camel's-hair brush and fan it dry, applying one or more coats. The re- peated application of iodin to the skin is of great benefit in inflammation of the glands, muscles, tendons, joints, and peri- osteum. Iodin is apt, after a time, to vesicate, and must not be used in full strength, because it is irritant. It is of lA'FLAMMA TION. 69 especial value in chronic inflammation. In deep-seated in- flammation it acts as a counterirritant. Nitrate of silver is a non-irritating astringent of great value in inflammation of mucous membranes. It forms a protective coat of coagulated albumen, and is much used in treating the throat, mouth, and genital organs. lehtJiyol is a drug of decided efficacy in reducing inflam- matoiy swelling. It is usually employed in ointments, the strength being from 25 to 50 per cent. It is best exhibited with lanolin. When rubbed in over the glands, the joints, and in lymphatic enlargements it is of great value. In children a 25 per cent., and in adults a 50 per cent., ointment is well rubbed in twice a day. In inflammatory skin disease, syno- vitis, thecitis, frost-bite, bubo, chilblain, and in many other conditions, acute or chronic, the use of ichthyol is indicated. The odor of ichthyol is highly disagreeable, and when ordered for a refined person it had better be deodorized. For this purpose Hare uses oil of citronella, TTLxx to 5J of ointment. Mercurials. — Blue ointment, pure or diluted to various strengths, is valuable to a high degree. It is spread upon lint and kept applied over chronically inflamed joints, glands, tendons, etc. Blue ointment is strongly irritant, and will soon blister or excoriate a tender skin. It is ver>' beneficial in periostitis, and is employed largely in chronic inflammations. TJie douche consists of a stream of water falling upon a part from a height. The water may be poured from a receptacle . or may run through a tube, and may either be hot or cold. Alternating hot and cold streams are very popular in chronic inflammations of joints and tendons, and they con- stitute the " Scotch douche." In a sprain of the knee, for instance, where, after a time, thickening has occurred, pour upon the part daily, from a height, first a pitcherful of very hot water, then a pitcherful of very cold water ; then use friction with a hand greased with cosmoline. The douche acts by restoring vascular tone and by promoting the action of the absorbents. Hot vaginal douches are largely employed in pelvic inflammations. Interniittoit lieat is often \Q.xy useful. In a sprained and badly swollen ankle much relief can be obtained by plunging the foot in a bucket of hot water several times a day. The part is put into water as hot as can be tolerated. Every few moments some very hot water is added. This gradual ad- dition of vt.xy hot water permits the patient to stand a high degree of heat. Massage is a procedure not frequently enough employed. 70 MODERN SURGERY. It is powerful for good in chronic inflammations at the period when rest is abandoned. It acts by promoting the move- ments of tissue-fluids (blood, lymph, and areolar fluid), stimu- lating the absorbents, strengthening local nervous control, and thus improving nutrition. Passive motion in joints acts as massage. Certain agents are indicated when embryonic tissue exists in large amount or when suppuration exists or is threatened, these agents being the various forms of heat. Heat increases the mobility of the white corpuscles, increases their migra- tion, relieves stasis and thus diminishes tension, promotes tissue-change and cell-activity. Continuous heat may be used early in an inflammation, as in the first stage of a pneumonia; but it is so used only in a deep-seated trouble, and acts purely as a revulsive, dilating the superficial vessels and helping to empty the deeper ones. Heat is often used to relieve pain and without any other purpose. The /(?r;«j- of heat are — (i) fomentations; (2) poultices; (3) water-bath ; and (4) dry heat. Fomentations. — A fomentation is the application of a liquid to the surface of the body on sponges or other material. To apply a fomentation, wring out a piece of flannel in hot water, lay it upon the part, and cover it with oiled silk or with waxed paper, changing it as soon as it begins to cool. The flannel which is dipped into the hot liquid is known as a " stupe." The turpentine stupe is made by wringing out the flannel as above and then putting upon it from 10 to 20 drops of turpentine. Instead of fomenting the part, steam may be thrown upon it. Fomentations are used chiefly for their reflex influence over deep congestions or inflammations. The liquid of a fomentation may, if de- sired, contain corrosive subHmate, carbolic acid, or other agents. Fomentations are very useful in relieving pain in any stage of an inflammation and act also as counter-irri- tants. Poultice or Cataplasm. — A poultice is a soft mass applied to a part to bring heat and moisture to bear upon it. Poul- tices can be made of ground flaxseed, of slippery-elm bark, of arrowroot, starch, bread and milk, potatoes, turnips, etc. To make a flaxseed poultice, scald a spoon and a tin basin, put the flaxseed into the dry hot basin, and pour upon it boiling water in sufficient quantity to form a thick paste. The proper consistence is found when the mass would stick if it were thrown against a wall. It is now spread to the thickness of a quarter of an inch upon a piece of muslin, and INFLA MMA TION. 7 1 is covered with a bit of gauze to prevent adhesion to the skin. Flaxseed retains heat a long time, and a flaxseed poul- tice needs to be changed only every five or six hours. The poultice should be covered outside with oiled silk, a rubber- dam, or waxed paper. It can be kept very warm for a con- siderable period by placing upon it a bag filled with hot water. Spongiopilin, when moistened with hot water, is a good substitute poultice. Lint soaked with hot water and covered with some impermeable material does very well. The fermented poultice, which was once popular for gan- grenous ulcers, was made by sprinkling yeast upon an ordi- nary cataplasm. The charcoal poultice is made by stirring charcoal into the usual poultice-mass. A poultice containing opium is known as a " sedative " poultice. About gr. ij of opium to the ounce of poultice-mass relieves pain. An an- tiseptic poultice is made by partly wringing out gauze in a hot solution of corrosive sublimate (i : looo), covering it with oiled silk, and placing a hot-water bag upon it to main- tain the heat. The antiseptic poultice or fomentation is of great service in removing sloughs from foul wounds and ulcers. It is the only form of poultice which is admissible when the skin is broken. Poultices must not be kept on too long, as they will then vesicate, especially in adynamic con- ditions. If a poultice is found to be vesicating, stop using it or sprinkle it with powdered oxid of zinc. If suppuration exists or is seriously threatened, do not waste time by using poultices, but incise at once. If suppuration is simply threat- ened, incision can prevent it by relieving tension, affording drainage, and permitting of the local use of antiseptics. If pus exists, it cannot be evacuated too soon. To use poul- tices and delay incision is often productive of irreparable harm. After incision of a purulent focus it is often useful to apply an antiseptic poultice. Water-bath. — The continuous hot bath is now rarely em- ployed except in burns and cases of phagedena, when it often proves curative. In these cases an antiseptic agent may be dissolved in the water. Continuous immersion in a warm bath is used by some surgeons for the treatment of slough- ing wounds and large purulent areas. Dry heat is applied by a metallic object dipped in hot water and laid upon the part ; by Leiter's tubes, through which hot water flows ; or by the hot-water bag. Some surgeons use the hot-water bag in cases of mild appendicitis in order to favor the formation of adhesions. The hot-water bag is often soothing and beneficial when laid upon an in- 72 MODERN SURGERY. flamed joint, or on the perineum or the hypogastric region in cystitis. A bag of hot sand, a hot brick, or a bottle or can of hot water can be used instead of the bag. Irritants and Counteidrritants in Inflamtnation. — Irritants attract an increased supply of blood to the part whereon they are applied, and are used for their local effects. Co7interirritants are used to affect by reflex influence some distant part. In chronic inflammation irritants may do good by promoting the blood-supply, thus favoring the removal of exudates (liniments in rheumatism and synovitis, and nitrate of silver in ulcers). Counter-irritants are powerful pain-relievers when used over an inflamed structure ; they bring blood to the surface and cause anemia of internal parts, the site and area of anemia depending on the site, the area, and the duration of the surface-irritation. To strongly counterirritate too near an inflammation is harmful instead of beneficial. (Do not blister for pericarditis directly over the pericardium. — Brunton.) Counterirritants not only re- lieve pain and congestion in the earlier stages of inflamma- tion, but they also promote absorption of exudate in the later stages. This is seen in blistering old thickened ulcers, and in painting the chest with iodin to relieve pleuritic effu- sion. Frictions, besides their pressure-effects, act as counter- irritants. Frictions may relieve skin-pain, and are associated with the application of stimulating liniments in the treatment of stiff joints. There is no more efficient method of relieving pleural effusion than by the application of a succession of blisters. Blisters are also used in the treatment of inflamed joints, pericarditis, pneumonic consolidation of the lung, acute and chronic rheumatism, etc. ; and are applied back of the ears or at the nape of the neck in congestive coma or meningitis. A blister can be produced in a few minutes by soaking a bit of lint in chloroform, and, after applying it to the surface, covering it with oiled silk, and then with a watch-glass. Equal parts of lard and ammonia will blister in five minutes. It is easier to blister with cantharidal collodion or blistering- paper. Before applying a blister, shave the part if it be hairy ; then grease the plaster with olive oil and apply it. Blistering plaster is left in place six hours in the case of an adult, but only two hours in the case of an old person or a child ; the plaster is then removed, and if a blister has not formed, the part must be poulticed for a few hours. When a blister is obtained, open it with a clean needle. If it be desired to heal the blister, grease it with cosmolin or with J NFL A MM A 7 /ON. 7 3 zinc ointment. If it is to remain open, cut away the stratum corneum and dress with cosmolin, each ounce of which con- tains six drops of nitric acid. Pustulation can be effected with tartar-emetic ointment, with the hot iron, or with Vienna paste. Tartar-emetic oint- ment was formerl}' used on the scalp in meningitis. To pus- tulate with the hot iron, raise the iron to a white heat, lay it on the part, remove it quickly, apply iced-water cloths for an hour, or two, and then employ a poultice. The hot iron is the most powerful of counter-irritants, and is used for joint- inflammations, bone-diseases, and inflammations of the spinal cord. Vienna paste consists of 5 parts of caustic potash and 6 parts of lime made into a paste with alcohol. It is applied for five minutes, and is then washed off with vinegar. Constitutional Treatment of Inflammation. — Certain remedies are used in inflammation for their general or con- stitutional effects; these remedies are — (i) general bleeding; (2) arterial sedatives ; (3) cathartics ; (4) diaphoretics ; (5) di- uretics ; (6) anodynes ; (7) antipyretics ; (8) emetics ; (9) mer- cury and iodids ; (10) stimulants ; and (11) tonics. General bleeding, venesection, or pJilebotoniy, is suited to the early stages of an acute inflammation in a young and robust subject. The indication for its employment is increased arte- rial tension, as shown by a strong, full, rapid, and incompress- ible pulse in a vigorous young patient. General blood-let- ting diminishes blood-pressure and increases the speed of the blood-current, thus amending stasis, absorbing exudate, and washing adherent corpuscles from the vessel-wall ; further- more, it reduces the whole amount of body-blood, thus forcing a greater rapidity of circulation, decreases the amount of fibrin and albumin, lowers the temperature, arrests cell-proliferation, and stops effusion. This procedure was in former days so highly esteemed that it settled into a routine formula to be applied to every condition from yellow fever to dislocation. The terrible mortality of the cholera epidemics from 1830 to 1835 led practitioners to question the belief that bleeding was a general panacea, and from this doubt there w^as born in the next generation violent opposition to blood-letting in any disease. Like most reactions, opposition has gone too far, the pendulum of condemnation has swung be}-ond the line of truth and sense, and thus is univ^ersally neglected or broadly condemned a powerful and valuable resource. Many physicians of long experience have never seen a person bled; its performance is not demonstrated in most schools, 74 MODERN SURGERY. and but few patients and families will permit it to be done. But when properly used it is beneficial. It is only appli- cable, however, to the young, strong, and robust, and not to the old, weak, or feeble. It is used for violent acute in- flammations of important organs or tissues, and not for low inflammations or for slight affections of unimportant parts. It is used in the early, but not in the late, stages of an inflammation. It is used when the pulse is frequent, full, hard, and incompressible, but not when it is slow, small, soft, compressible, and irregular. It is used when the face is flushed, but not when it is pallid. It is not used in fat persons, drunkards, very nervous people, or the sufferers from adynamic, septic, or epidemic diseases. It is of value in some few cases of congestion of the lungs, pneumonitis, pleuritis, meningitis, prostatitis, cystitis, and other acute in- flammatory conditions. (See Phlebotomy, p. y^}^ After bleeding, the patient should be put upon arterial sedatives, diuretics, diaphoretics, anodynes, and, if necessary, purgatives. A favorite mixture of Prof. S. D. Gross was the antimonial and saline, consisting of gr. xl of Epsom salt, gr. Y^^ of tartar emetic, 3 drops of tincture of aconite, and 3j of sweet spirits of niter, in enough ginger syrup and water to make Iss ; given every four hours. Arterial sedatives are of great use before stasis is pro- nounced ; but if used after stasis is established, they will increase it. If stasis exists, relieve it by bleeding before using the sedatives. Either local bleeding or venesection abolishes stasis and lowers tension, and arterial sedatives maintain the effect and hold the ground which is gained. The arterial sedatives employed are aconite, veratrum viride, gelsemium, and tartar emetic. These sedatives lessen the force and the frequency of the heart-beats, and thus slow and soften the pulse, and are suited to a robust person with, an acute inflammation, but are not suited to a weak man in an adynamic state. Aconite is given in small doses, never in large amounts. One drop of the tincture in a little water is given every half hour until its effect is manifest on the pulse, when it may be given every two or three hours. Large doses of aconite produce pronounced depression, and are dangerous. Aco- nite lowers the temperature, slows the pulse, and produces diaphoresis. Veratrum viride is a powerful agent to slow the pulse and to lower blood-pressure ; it produces moisture of the skin, and often nausea. It is given in i-drop doses of the tine- IXFLAMMA TION. J 5 ture every half hour until its physiological effects are mani- fested, when the period between doses is extended to two or three hours. Ten drops of laudanum given a quarter of an hour before each dose of veratrum viride will prevent nausea. Giiscmuim is an arterial sedative highly approved by Bartholow. It is given in doses of 5 to 10 drops of the tincture every three or four hours. Tartar emetic lowers arterial tension and lessens the pulse- rate. This drug is not largely employed ; if it is used with the greatest care, it is no better than some other agents, and if it is not so used it will cause dangerous depression. The dose is from gr. 4q to gr. -^-^ in water every three hours until the physiological effects are manifest. Cathartics. — The tongue affords the chief indication for the use of cathartics. Treatment in an inflammation can be inaugurated, if constipation exists, by giving a cathartic. Castor oil can be given in capsules, or the juice of half a lemon is squeezed into a tumbler, i ounce of oil poured in, and the rest of the lemon is squeezed on top, thus making a not unpalatable mixture. Aloin, podophyllum, the salines, and calomel in 5- or lo-grain doses, followed by a saline, have their advocates. In peritonitis the salines are of unquestionable value, a teaspoonful of Epsom salt and a teaspoonful of Rochelle salt being given hourly until a move- ment occurs. In the course of inflammation, from time to time, if there be constipation, coated tongue, and foul breath, there should be ordered gr. j of calomel with gr. xxiv of bicarbonate of sodium, made into twelve powders, one being given every hour ; if the bowels are not moved by the time the powders are all taken, a saline should be given. If a violent purgative effect is desired, as in meningitis, croton oil or elaterium may be ordered. If constipation is persistent, give fluid extract of cascara sagrada daily (20 to 40 drops), or a pill at night containing gr. \ of extract of belladonna, gr. \ of extract of nux vomica, gr. -^-^ of aloin, gr. \ of extract of physostigma, and gr. ss of oil of cajuput. Enemas or clysters may be used in some cases. A very useful enema is composed of fsj of oil of turpentine, fsiss of olive oil, f^ss of mucilage of acacia, in f5x of water. Soap-suds and vinegar in equal parts make a serviceable clyster. A combination of oil of turpentine, castor oil, the yolk of an &^%, and water can be used. Asafetida, gr. xxx to the yolk of one Q%%, makes a good enema to amend flatulence. Diaphoretics are very useful. A good sweat in the start 76 MODERN SURGERY. of an acute inflammation, such as tonsillitis, may abort the disease. Dover's powder is commonly used, but pilocarpin is preferred by some. Camphor in doses of from 5 to 10 grains is diaphoretic, and so are antimony and ipecac. Ace- tate and citrate of ammonium, opium, alcohol, hot drinks, heat to the surface (baths, hot bricks, hot-water bags), ser- pentaria, and guaiac are diaphoretic agents. Diuretics are useful in fevers when the urine is scanty and high-colored, and are valuable aids in removing serous effu- sions and other exudates. Among the diuretics may be men- tioned calomel in repeated large doses, cocain, caffein, al- cohol, digitalis, the nitrites, squill, turpentine, copaiba, and cantharides. The liquor potassae and the acetate of potas- sium are the best agents to increase the solids in the urine. The liquor potassii citratis in doses of fgij to fgiv is efficient. Large draughts of water wash out the kidneys. If the heart is weak, citrate of caffein is a good stimulant diuretic. Anodynes and hypnotics may be required. Dover's powder, besides being diaphoretic, is anodyne. Opium acts well after bleeding or purgation. If it causes nausea, it should be pre- ceded one hour by gr. xxx of bromid of potassium. Opium is used by the mouth, by the rectum, or hypodermatically. It is used when there is pain, but its use is not to be long per- sisted in if it can be avoided. It is given in doses measured purely by the necessities of the case. If opium disagrees, try the combination of morphin with atropin. After an ope- ration antipyrin or phenacetin will often quiet pain and secure sleep. When a person feels " so tired he can't sleep," alco- hol in the form of whiskey or brandy must be given. Sleep- lessness not due to pain is met by chloral, trional, the bro- mids, or sulphonal. Chloral is dangerous in conditions of weak heart or exhaustion. Bromids must be given in large doses to be efficient. Sulphonal must be given about four or five hours before sleep is expected, in doses of from gr. X to gr. XX in hot milk or hot mint-water. Trional is safe and very satisfactory. It is given in doses of gr. xv to gr. XXV in hot water. Antipyretics. — Diaphoretics, purgatives, and arterial seda- tives lower temperature, and have previously been alluded to (p. 74). There are two great classes of febrifuges — those which lessen heat-production and those which increase heat- elimination. In the first group we find quinin, salicylic acid and the salicylates, kairin, alcohol, antimony, aconite, digitalis, cupping, and bleeding. In the second group we find alcohol, nitrous ether, antipyrin, acetanilid, phenacetin, opium, ipecac. INFLAMMA T/OX. "JJ cold to the surface, and cold drinks. In surgical inflammations it is rarely necessary to employ heroic means to lower temper- ature. The use of such an agent as antipyrin is contraindi- cated in the weak and adynamic, and it is never to be thought of as a means of lowering temperature unless the latter goes above 103°. Quinin, in doses of gr. xx to gr. xxx given at 4 p. M., may prevent an evening rise ; salol or salicin can be given during the day. Inunctions of 30 minims of guaiacol lower the temperature in tubercular conditions and in septic fevers. These inunctions are made upon the abdomen, and often produce surprising results. Dujardin-Beaumetz main- tained that fever is a condition in which the organism is en- deavoring to oxidize and render inert certain poisonous ma- terial, and that antipyretic drugs lessen oxidation and actually make the patient worse. This view is in accordance with the experience of a number of surgeons. The mere discomfort of fever may be much mitigated by antipyretic drugs, but the fever-process is not benefited by them. Euictics. — Emetics may do good when the patient suffers from a parched, coated tongue, a dry and hot skin, nausea, and gastric oppression, but it is very rarely in these days that we employ them. There can be used .^j of alum in molasses, gr. XX of sulphate of zinc, or a tablespoonful of mustard and a teaspoonful of salt given in warm water and followed by large draughts of warm water. Ipecac in a dose of gr. xx can be employed. The emetic dose of tartar emetic is gr. ij, but it is too depressant a drug to trifle with. The sulphuret of antimon\' in doses of from i to 5 grains is safe. Apomor- phin hypodermatically, in a dose of from gr. -^-^ to gr. -|, will act in five minutes. Emetics are valuable in inflammatory conditions of the air-passages, but their use is contraindicated in diseases of the heart, brain, and bowels, in hernia, in dis- locations, in fractures, and in aneurysms. Mercury and the lodids. — Mercury is an alterative — that is, an agent which favorably affects body-nutrition without causing any recognizable change in the fluids or the solids of the body. Mercury lessens blood-plasticity, hinders the exudation of liquor sanguinis — thus furnishing less food to the cells in the perivascular tissues — and retards the forma- tion of embryonic tissue. Further, by a stimulant action on the absorbents it promotes the breaking up of an existing inflammatory exudate, and hence limits damage from excess of embryonic tissue. The time at which mercury is best given is when violent symptoms have abated, the guide being reduced temperature and moist skin. It is often given in con- 78 MODERN SURGERY. junction with the local use of sorbefacients (the acetate of lead), and is, when possible, associated with compression. It is sometimes given until the gums are slightly touched, but is not given to the point of salivation. When the breath becomes offensive and the gums tender on snapping the teeth, or when griping and diarrhea begin, the dose should be re- duced. In iritis mercury is used to get rid of the plastic ef- fusion which is causing pupillary fixation and opacity. In keratitis the gums should be touched ligJitly. In orchitis, after the subsidence of the acute symptoms, mercury should be employed. In pericarditis, meningitis, peritonitis, and in many chronic and lingering, and in all syphilitic, inflamma- tions this drug can be used. Some persons will be salivated with very minute doses of mercury, either because of idiosyncrasy or previous satura- tion. Others can take enormous doses without any appre- ciable constitutional effect. The action of mercurials can be favored by a combination with ipecac or with tartar emetic. (For salivation see p. 202). In giving mercury, if a prompt effect is desired, give gr. iij of calomel every three hours until a metallic taste is noted in the mouth. If the case is not so urgent, gray powder is a good combination. Children are given calomel and sugar or mercury and chalk. If it is desired to give the drug for some time, corrosive sublimate is a suitable form, and small doses will actually increase the number of red blood-cor- puscles. Corrosive sublimate is to be given alone or com- bined only with iodid of potassium. The green iodid of mercury is a drug suitable for prolonged administration. In the prolonged use of mercury it will often be necessary to give at the same time a little opium to prevent diarrhea and griping. A rapid effect can be obtained by rubbing with a gloved hand .5j of the oleate of mercury or 3ss of the ointment into the groins, the axillai, or the inside of the thighs. Suppositories of mercurial ointment induce rapid ptyalism. Hypodermatic injections of corrosive sublimate or gray oil can be used, and must be thrown deeply into the muscles of the buttock. Old people, those who are exhausted, anemic, and broken down, and the scrofulous, bear mercury badly. If it be given to them at all, it must only be in small amounts and for a brief time. Alkaline iodids are useful in removing the products of inflammation ; they can be given for a long time, and admir- ably supplement mercurials. Iodid of potassium can be pre- scribed in combination with corrosive sublimate as follows : IX FLA MM A TION. 79 R. Ilydrarg. chlor. corros., gr. ij ; Potass, iodidi, _^v et ^j j Syr. sarsaparill^ comp., q. s. ad f5viij. — M. Sig. f^ij, in water, after meals. lodid of potassium, well diluted, is given on a full stom- ach ; it is never given concentrated nor before meals. A convenient mode of administration is to procure a concen- trated solution of the iodid of potassium, remembering that every drop equals gr. i of the drug, and giving as many- drops as may be desired in half a glass of water after meals. If the medicine disagrees, add to each dose, after it is put in water, 5j of the aromatic spirits of ammonia. Extract of lic- orice is a good vehicle for iodid. If the mixture in water disagrees, the drug should be given in milk. Capsules are satisfactory^ but a drink ©f water should be taken just before and again just after taking a capsule, to protect the stomach from the concentrated drug. Iodid of sodium may agree when iodid of potassium does not. When the iodids dis- agree they produce iodism. The first indications of iodism are a bad taste in the mouth, running of the eyes and nose, and sneezing, followed by a feeling of exhaustion, absolute loss of appetite, nausea, tremor, and skin-eruptions (acne, hemorrhages, blebs, hydroa, etc.). If iodism occurs, stop the drug and give the patient Fowler's solution in increas- ing doses, laxatives, diuretic waters, and also good food and stimulants if depression is great. Sometimes belladonna does good in obstinate cutaneous disorders induced by the iodids. Remedies Directed Against Special Morbid States. — If in- flammation is associated with rheumatism, gout, scurvy, syphilis, tuberculosis, or any other constitutional disease or predisposition, appropriate treatment should be instituted to control the disease or combat the predisposition, and at the same time the area of inflammation must be locally treated. Syphilis is treated by the internal use of mercury and the iodids ; scur\'y, by vegetable juices and potash salts ; rheu- matism, by the alkalies or salicylates ; gout, by colchicum or piperazin ; tuberculosis, by the fats, tonics, and an open-air life. The use of alcoholic stimulants is called for by conditions rather than by diseases, being indicated by the state of the patient rather than by the name of the malady. For a brief acute inflammation in a robust young person alcohol is not needed ; but all who are weak or exhausted, be they young or old, all who are aged, those who are accustomed to alcoholic beverages, those who have high temperatures or failure of circulation, and those who labor under septic in- 8o MODERN SURGERY. flammations or adynamic processes — require alcohol to be given with a free hand. In an acute malady a feeble, com- pressible, rapid, or irregular pulse, and great weakness of the first sound of the heart, are indications that alcohol is required. Low, muttering delirium is a strong indication. There is no dose of alcohol for these states : it is given for its effect. Two ounces may be needed in a day, or perhaps twenty ounces. If the breath of the patient smells strongly of the alcohol, he is cretting- too much. If delirium increases after each dose, alcohol is doing harm. Alcohol is contraindicated in acute meningitis. In acute illness use whiskey, brandy, champagne, or alcohol and water. During convalescence there may be used a little spirit, port, claret, or sherry wine, or malt liquor. These agents will promote appetite, diges- tion, and sleep. Tonics are indicated during convalescence from acute and throughout the course of chronic inflammations. There may be used iron, quinin, and strychnin in the form of elixir ; iron alone, as in the tincture of the chlorid ; quinin in tonic doses (gr. vj to gr. viij daily) ; or Fowler's solution of arsenic. An excellent pill consists of — R. Acid, arsenos. gr. j ; Strychnin!, gr. ss ; Quinini, gr. xlviij ; P'erri redact., gr. vj. Ft. in pil. No. xxiv. Sig. One after each meal. Bitter tonics before meals improve the appetite. One of the best of tonics is tincture of nux vomica in gradually increas- ing doses. Antiphlogistic regimen is a term comprising the necessary directions relating to diet, ventilation, cleanliness, etc. Diet. — When, in the early stages of an acute inflammation, the patient cannot eat, there must be administered a cathartic before food is given. Nausea is combated with calomel and soda, drop-doses of a 6 per cent, solution of cocain, iced champagne, iced brandy, chloroform-water, hot water, cracked ice, or the application of counterirritation to the epigastric region. When the process is depressive from the start, and in any case after the earliest stage, feeding is of vital mo- ment. The great tissue-waste calls for large quantities of nutritive material, but the impaired digestion demands that the food shall be easily assimilable; hence it is taken in liquid form, small quantities being frequently given. Milk contains all the elements required by the body, and is the food of foods. I NFL A MMA TION. 8 I If it disagrees, it should be boiled and mixed with lime-water, or to each dose an equal amount of Vichy or soda-water may- be added. Peptonized milk is a valuable agent. One part of milk, 2 parts of cream, and 2 parts of lime-water make a nutritious and digestible mixture. Milk punch is largely used. Whey may be used when plain milk cannot be taken. Eggs are highly nutritious, but are apt to disturb the stom- ach ; they may be given as egg-nog, or simply soft-boiled, or the yolk can be beaten up in a cup of tea. When con- siderable nausea exists the yolk of an q^^ may be added to 5J of lemon-juice and sij of sugar, the glass being filled with carbonated water. Beef tea is certainly a stimulant, but its food-powers are questionable. It is prepared by cut- ting up one pound of lean beef, adding to it a quart of water, and then simmering, but not boiling, down to a pint, finally filtering and skimming the liquid. The dose is a wineglass- ful seasoned to taste. Meat-juice, obtained by squeezing partly cooked meat with a lemon-squeezer, is also highly nutritious. Liquid-beef peptonoids are both agreeable and nutritious; they are given in doses of Sss to sj. Clam-juice is palatable and digestible. When nothing else will stay on the stomach koumiss will often be retained. This fermented milk is nutritious, stimulant, and very useful. Coffee is a valuable stimulant in febrile conditions. If the stomach re- tains no food, the patient must be fed entirely by the rectum. If the stomach rejects most of the food swallowed, mouth- feeding must be supplemented by nutritive rectal enemata. When the sufferer feels able to eat a little, any good soup, strained and skimmed, should be ordered. As the patient gets better he may be fed on sweetbreads, chops, etc., until he gradually reaches ordinary diet. Ventilation and Cleanliness. — The ventilation of the apart- ment is of the greatest importance. Every day the windows should be opened widely for a time, the patient of course being protected. When the windows are open the air of a room can be quickly changed by swinging the door to and fro. A constant access of fresh air must be secured, and the temperature kept at about 68°. The sick man must be cleaned and be sponged off with alcohol and water every day if high fever exists. It is important that the bed-cloth- ing be clean and that the sheet be unwrinkled, as otherwise bed-sores may form. Chronic Inflammation. — This condition progresses slowly and does not produce symptoms of severity either in the part or the body at large. 6 82 MODERN SURGERY. Causes. — Blood diseases, as rheumatism and gout; infec- tive diseases, as tuberculosis and syphilis ; retained pus in an ill-drained abscess ; blockage of the duct of a gland ; foreign body in part ; flow of an irritant secretion (as saliva from a fistula) ; repeated identical traumatisms of an occupation, etc. W. Watson Cheyne tells us it is not due to the ordinary pyogenic organisms (see Cheyne's article in Treves' System of Siirgery). Tissiie-clianges. — Practically the same as in acute inflam- mation, but take place far less rapidly. It is maintained by Cheyne and others that typical granulation-tissue does not form, the tissues of the part being replaced by fibrous tissue. The amount of fibrous tissue produced is relatively very great. This tissue may cause permanent thickening, or may contract, and thus diminish the size of a part. Contraction is very considerable in cirrhosis of the liver and in inter- stitial nephritis. Symptoms. — Pain varying in intensity and character ; ten- derness ; great swelling, which in some cases is followed. by shrinking, and is usually indurated or brawny ; sometimes heat, rarely discoloration unless the skin is itself inflamed. There are no constitutional symptoms attributable purely to the in- flammation. If there are such symptoms, they are due to the disease which induced the inflammation or to interference with the function of an organ because of the fibrous mass. (For treatment of chronic inflammation see articles upon special regions and particular structures.) IV. REPAIR. Repair is an active process by which destroyed tissues are replaced, and it is due to increased nutritive activity, rather than to inflammation. Inflammation may occur, or we may be obliged to induce it when the blood-supply is scanty or the exudation deficient ; but certain it is that an aseptic wound heals without many of the evidences of inflammation. Healing by First Intention. — A wound may heal by " first intention." This mode of healing, which is known as " primary union," occurs without suppuration, and is observed in the healing of an aseptic wound. If pus forms, primary union will not take place. If an incised wound is asepticized, the hemorrhage arrested, and the edges brought into nice apposition, slight swelling arises, but no discoloration appears. Lymph and leukocytes are exuded from the vessels, fibrin forms in this lymph, and the edges e REPAIR. 83 of the wound are stuck together by a natural cement. In extensive wounds the exudation is in excess, and much of it must be drained away, for its retention will cause ten- sion and inflammation, and the exudate furnishes a favor- able soil for the growth of pus organisms. The exudation is converted into embryonic tissue by multiplication of its own cells and multiplication of tissue-cells. Embryonic tissue consists of small round or oval cells held together by a jelly-like intercellular substance. In a few days some spindle-shaped cells can be found, and also large cells with one or more nuclei (epithelioid cells). Prolongations of embryonic tissue are raised up by capillary loops, which prolongations fuse with one another end to end, or fuse with other capillary loops, are hollowed out and become endothelial tubes or capillaries. By vascularization embry- onic tissue becomes granulation-tissue. Granulation-tissue becomes fibrous tissue, and the new fibrous tissue contracts to a great degree (Figs. 25, 26). The final step in healing is 'y ^^tx . — Nuclei developing into fibers (Bennett;. Fig. 26. — Cells developing into fibers (Bennett). contraction of the fibrous tissue and the covering of the sur- face with epithelium, which springs from the epithelial cells upon the edges. This final process is called " cicatrization," and consists in contraction of the wound and skimming over with epithelium. The " immediate union " of some writers never occurs. This term means the union of microscopical parts to their counterparts without any effort at repair. A first union is effected always by fibrin, and next by embryonic tissue. A wound healing by first intention exhibits no evi- dence of inflammation. There is some slight tenderness, but no actual pain. A certain amount of swelling arises because of exudation of fluid from the blood, and the coagulation of this fluid makes the wound-edges hard. Venous obstruc- tion leads in some cases to a considerable fluid swelling. 84 MODERN SURGER Y. During the first twenty-four hours after a wound begins to heal by first intention the discharge is most plentiful, but after this period it becomes very scanty and soon ceases entirely, and can be much diminished in quantity in the first day by the application of pressure. In a large wound we notice a profuse flow of bloody serum. Warren says that after a hip-joint amputation over a pint flows out during the first twenty-four hours. In a large wound special methods to secure drainage are required. In a small wound drainage is obtained between the stitches. The use of irritant germicides in a wound greatly increases the amount of discharge and ren- ders drainage necessary in even a small wound for the first twenty-four hours. In an aseptic wound, as a rule, one-half of the stitches are removed on the fifth or sixth day and the remainder on the eighth day, but for two weeks more the wound should be rested and supported, as the new tissue is not very resistant to infection. Aseptic fever always arises when much exudation is given out, and is due to the ab- sorption of aseptic pyrogenous material (p. 87). Healing by Second Intention. — In a wound whose edges cannot be approximated a great gap has to be filled, and this is accomplished by granulation. This process is known as " healing by granulation " or " second intention." In an hour or so after the infliction of such a wound (it may be in less time) the raw surface is covered with a thin glazed layer of coagulated blood and exudate. This glaze is fibrin, which soon becomes filled with leukocytes ; underneath this fibrin-coat cell-proliferation is proceeding and embryonic tis- sue is forming. The wound-discharge is at first thin and red, but in a few days becomes purulent and so profuse as to wash away the discolored fibrin-coat. Granulations are now disclosed, the embryonic tissue being lifted up in countless points by capillary loops. When these loops approach the surface contraction begins in the fibrous tissue in the depth of the damaged area, which contraction brings the edges of the wound nearer together and gradually cuts off by press- ure the excessive blood-supply which is no longer needed. When the granulations reach the surface, epithelium in a thin bluish film grows from the epithelial cells at the edge and covers the ulcer. Cicatrization is contraction plus skin- ning over with epithelium. Epithelium can only spring from the wound-edges, unless there be some epitheHal structural remains in the wound, such as an undestroyed papilla, a sweat-duct, or a hair-follicle. If the granulations rise above the surface, constituting exuberant granulations REPAIR. 85 or proud flesh, they must be cut off or burned away before epitheUum will grow over the wound. Pale edematous gran- ulations are usual in tuberculous processes, and if they form pressure must be applied. The contraction of cicatrization results from the conversion of granulation-tissue into fibrous tissue (Figs. 25, 26). Contraction is so great after some wounds as to cause terrible deformities. This is notably the case after burns, whose scars or cicatrices contain much elastic tissue. Coagulation-necrosis of a superficial layer of granulation-tissue produces a diphtheritic membrane or aplas- tic lymph. This coagulation-necrosis depends on capillary closure or lack of capillary development, the embryonic tis- sue dying for want of nutriment. Ulcers heal by second intention. Healing' by Third Intention. — This consists in the union of two granulating surfaces, and is seen in the union of col- lapsed abscess-walls. The surgeon occasionally seeks to ob- tain union by third intention by approximating two granulat- ing surfaces. In subcutaneous wounds, if aseptic, healing oc- curs without suppuration. First a blood-clot fills the wound, exudation occurs, and embryonic tissue forms in the walls of the cavity, embryonic tissue is converted into granulation- tissue, the new granulation-tissue grows into the clot, which is broken up and absorbed, and fibrous organization and con- traction of the new tissue take place. If suppuration occurs, an abscess forms. Healing under an aseptic blood-clot is healing " by first intention." The fibrous tissue of a scar arises from granulation-tissue, which itself arose from embr>'- onic tissue. The multiplication of connective-tissue cells may be by direct, but it is usually by indirect, division. Cell-division. — Direct cell-divisio?i consists in division of the nucleus followed by division of the entire cell. Indirect cell-division, or karyokinesis, shows remarkable changes in the neucleus. The membrane of the nucleus disappears ; the nuclear network becomes first close and then more open, and the cells become round, if not so be- fore. The network of the nucleus, now consisting of one long fiber, takes the shape of a rosette ; next it takes a star- form — the aster stage ; two sets of V's next form — the equa- torial stage ; an equatorial line appears and widens, and each set of V's retreats toward a pole. Thus two new nuclei are formed, each polar V passing in inverse order through the previous changes of shape, and the protoplasm of the orig- inal cell collecting about each nucleus (Fig. 27). In non-vascular tissues, such as cornea or cartilage, the '86 MODERN SURGERY. wound is glued together by fibrin, the exudate having come along the lymph-spaces from adjacent vascular areas. Organ- ization occurs by multiplication of fixed tissue-cells and leu- kocytes. Divided muscle, if the ends are widely separated, unites by fibrous tissue. The ends of a divided muscle, if closely approximated, unite by fibrous tissue, which becomes filled with muscle-fibres. It is not yet definitely known whether these fibres arise by growth from the muscle-cells of the ends of the muscle, or by metamorphosis of the new connective tissue. Divided nerve, when approximated, can regenerate. The ends are first united by new connective tissue ; this new tissue is a bridge for nerve-cells, and is finally converted into nerve by the growth of cells from both the Fig. 27. — Forms assumed by a nucleus dividing (Green, from Flemming). central and distal ends, the cells finally meeting. If the ends are not approximated, they join by fibrous tissue, the distal end atrophies, and the proximal end becomes bulbous. The above view is entertained by Mayer and Eichhorst. Waller holds that repair is effected by the central end alone. When a tendon is divided the ends retract, and the sheath, as a rule, becomes filled with blood-clot. The blood-clot is rapidly removed, embryonic tissue replacing it. This new tissue arises from the sheath, and the cut ends do not partici- pate in the process. Granulation-tissue is formed; this is con- verted into fibrous tissue, and after a time the fibrous tissue becomes true tendon. If no blood-clot forms in the sheath, the walls of this structure collapse and adhere, and the sep- arated tendon-ends are held together by a flat fibrous band formed from the collapsed sheath (Warren's Surgical Pa- thology). When a bone is broken a large blood-clot forms in the medullary canal, between the broken ends, below and outside of the periosteum. Granulation-tissue replaces the SURGICAL FEVERS. 87 blood-clot, granulation-tissue becomes fibrous tissue, and the fibrous tissue in many places becomes cartilaginous. In the second week lime-salts begin to deposit and bone forms (p. 333). Cartilage can heal as cartilage, but usually unites by fibrous tissue. When an artery is ligated, embryonic tissue forms in and around it, the walls soften and are converted into the same tissue, vascularization occurs, fibrous tissue forms and contracts, and the artery is converted into a fibrous cord. An ulcer heals in the same manner as does a wound with loss of substance — by second intention. An abscess heals by collapse of its sides and their adhesion (by third intention). The sides are embryonic tissue, which is formed into granulations, these granulations unite, and organization into fibrous tissue takes place. V. SURGICAL FEVERS. The surgeon encounters fever as a result of an inflamma- tion or an aseptic wound, in consequence of infection, and in certain maladies of the nervous system. It is important to remember that, while elevated temperature is generally taken as a gauge of the intensity of fever, it is not a certain index. There may be fever with subnormal temperature (as in the collapse of typhoid or pneumonia), and there may be elevated temperature without true fever (as in certain diseases of the nervous system). It is true, however, that elevation of tem- perature is almost always noted. The essential phenomena of fever, according to Maclagan, are — (i) wasting of nitrogenous tissue; (2) increased con- sumption of water; (3) increased elimination of urea; (4) increased rapidity of circulation ; and (5) preternatural heat. Traumatic fevers follow a traumatism and attend the healing or infection of a wound. The forms are — (i) benign traumatic fever ; (2) malignant traumatic fever. Benign traumatic fever is divided into two classes — the aseptic and the septic. There is but one form of aseptic fever, the post-operation rise. The septic benign fevers are surgical fever and suppurative fever. The malignant trau- matic fevers are sapremia, septic infection, and pyemia. In this section we discuss only the benign fevers. Aseptic fever appears after a thoroughly aseptic operation and after a simple fracture or a contusion. It may appear during the evening of the day of operation or not until the next day, and reaches its highest point by the evening of the second day (100° to 102°). This elevation is spoken of as the 88 MODERN SURGERY. " post-operation rise." Besides the fever there are no obvious symptoms ; the patient feels first-rate, sleeps well, and often wants to sit up ; there are no rigors and there is no delirium. The wound is free from pain and appears entirely normal. Blood examination shows leukocytosis. This fever is due to absorption of pyrogenous material from the wound-area, the material being obtained from clot or inflammatory exudate, or from both. Many observers believe that the pyrogenous element is fibrin-ferment, which is absorbed from disintegrat- ing blood-clot and coagulating exudate. Warren thinks the fever due to fibrin-ferment, and " also to other substances sHghtly altered from their original composition during life." Some have asserted that the fever is due to nervous shock. Schnitzler and Ewald have recently studied aseptic fever.^ These observers maintain that aseptic fever can exist when no fibrin-ferment is free in the blood, that fibrin-ferment can be free in the blood when there is no fever, and in conse- quence that fibrin-ferment is not the cause of the elevation of temperature. They rule out of consideration nervous shock as a cause, and assert that a combination of several factors is responsible, nucleins and albumoses which are set free by traumatism being looked upon as the most active causative agents. The presence of nuclein in the blood in aseptic fever is indicated by leukocytosis and by the increase of the alloxur bodies (including uric acid) in the urine. The capacity of nucleins and albumoses to cause fever is greater in the tubercular than in the non-tubercular. The diagnosis of aseptic traumatic fever is only made after a careful exam- ination has assured the surgeon there is no obscure or hid- den area of infection. In some cases an aseptic fever may appear after an opera- tion, and later be replaced by a septic fever. If the tempera- ture remains high after a few days, or if other symptoms appear, the wound should be examined at once, as trouble certainly exists. Traumatic or surgical fever is seen as a result of infected wounds where there is inflammation, but no pus. This fever is due to the presence of fermentative bacteria in the wound and the absorption of their toxic products. The most active and commonly present organisms are those of putrefaction. Fever ceases as soon as free discharge occurs, and its appear- ance is an indication for instant drainage. The temperature rises pretty sharply in a day or so after the operation, ascends ^ See Archiv filr klinische Medicin, Bd. liii., H. 3, 1896; also statement of their views in Medical Record, Dec. 19, 1896. SURGICAL FEVERS. 89 with evening exacerbations and morning remissions, and reaches its height about the third or fourth day, when sup- puration sets in ; the temperature begins to drop when pus forms, if the pus has free exit, and reaches normal at the end of a week (see Suppurative Fever). Stitch-abscesses are often found in surgical fever. If a post-operation rise continues for an unnaturally long time, or if after it has passed away a secondary rise is noted, suspect infection and examine the wound. The wound is painful, tender, swollen, discolored, and often foul. The stitches must be cut, and the area asepticized, and packed with iodoform-gauze or drained by a tube. The fact that this fever is apt to cease when suppura- tion begins led the older surgeons to hope for pus and to endeavor to cause it to form. Suppurative Fever. — This fever, which is due to the ab- sorption of the toxins of pyogenic organisms, occurs after suppuration, has begun, and is found when the pus has not free exit. It can follow or be associated with surgical fever, or may arise in cases in which surgical fever has not existed. Suppuration in a wound is indicated by a rapid rise of tem- perature — possibly by a chill. The skin becomes swollen, dusky in color, and edematous, pain becomes pulsatile, and much tenderness develops. The wound must at once be drained and asepticized. In a chronic suppuration, such as occurs in the mixed infection of a tubercular area, there exists a fever with marked morning remissions and vesperal exacerbations, attended with night-sweats, emaciation, diar- rhea, and exhaustion. This is known as " hectic fever ;" it is really a chronic suppurative fever. The treatment of hec- tic fever consists in the drainage and disinfection if possible, the excision of the infected area, the employment of a nutri- tious diet, stimulants, tonics, remedies for the exhausting sweats, and free access of fresh air. Other Forms of Fever. — Fever of Tension. — When there is great tension upon the stitches the spots where the stitches perforate ulcerate and some fever arises. To re- heve the fever of tension cut one or several stitches. This fever is in some cases surgical, and in some suppurative, ac- cording as to whether the infective organisms cause fermen- tation or suppuration. Fever of Iodoform Absorption (p. 27). Malaria. — It is wise to examine the blood in supposed sep- tic fevers, for only by this means can malaria be excluded. It is more common to mistake sepsis for malaria than mala- ria for sepsis. 90 MODERN SURGERY. Surgical Scarlet Fever. — It is maintained by some writers (notably Victor Horsley and Sir James Paget) that a child is rendered especially susceptible to scarlet fever by the shock of a surgical operation. Scarlet fever which develops after an operation is spoken of as surgical scarlet fever. Warren quotes Thomas Smith as having had ten cases of scarlet fever in forty-three operations for lithotomy in children. The puerperal state is supposed also to predispose to scarlet fever. Some writers hold that an attack of scarlet fever after an operation is a coincidence. Others maintain, and with great show of reason, that a red scarlatiniform eruption ap- pearing after an operation rarely indicates genuine scarlet fever, but usually points to infection, as such eruptions are known occasionally to arise in septicemia. Hoffa has discussed this subject elaborately. He con- cludes that four types of eruption can follow operation: (i) a vaso-motor disturbance due to irritation of sensory nerves, and manifested by a transient urticaria or erythema ; (2) a toxic erythema due to absorption of aseptic pyrogenous ma- terial from the injured area — the absorption of carboHc acid, iodoform, or corrosive sublimate, or the effect of ether; (3) an infectious rash which is sometimes found in septicemia or pyemia, and due to minute emboli composed of bacteria, which emboli lodge in the capillaries ; (4) true scarlet fever, with the usual symptoms and complications, the organisms having entered by way of the wound, and the eruption often beginning at the wound-edges (quoted in Warren's Surgical Pathology). VI. TERMINATIONS OF INFLAMMATION. Inflammation may terminate in a return of the part to health or in its death. Recovery is said to be by delitescence when the inflammation is arrested at an early stage, and by resolution when the inflammation passes on regularly to the formation of embryonic tissue and this tissue is absorbed. New formation is the termination of inflammation when there has been loss of substance or when the embryonic tissue is not absorbed. Death of a part is by suppuration (molecular death) or gangrene (molar death). Inflammation may terminate in — (i) efllision of liquor san- guinis ; (2) formation of embryonic tissue ; (3) formation of pus ; (4) ulceration ; and (5) mortification. Diffusion of I/iquor Sanguinis. — The so-called " se- rum " of inflammation is not serum at all, but is Hquor san- TERMINATIONS OF INFLAMMATION. 9 1 guinis, which contains few cells and in consequence does not tend to coagulate. We meet with true serum in passive con- gestions, but not in active inflammation. Effusion of " se- rum " into connective tissue constitutes edema; and into a sac, like the peritoneum, dropsy ; dropsy being designated by the prefix hydro-, as hydrothorax. Abdominal dropsy is ascites. Anasarca is general effusion of serum resulting from altered blood-pressure. Edema is made manifest by the signs of inflammation, the swelling being soft, smooth, and inelastic, and the parts pitting on pressure. Effusion of blood liquor can be beneficial, unloading the vessels and hence relieving pain, tension, and hyperemia. P^ffusion of blood liquor can be harmful. In connective tissue fluid in great quantity can cut off the circulation of certain areas, thus causing necrosis. Effusion into a cavity causes press- ure on its contained parts ; for instance, in a hydrothorax the lung is compressed. Treatment. — Edema can be relieved by multiple punctures ; but if it threatens necrosis, free incisions must be made. If the dropsy be considerable, the fluid must be let out by tap- ping, aspiration, or incision. Tapping must be done as asep- tically as cutting. In aspirating use full aseptic care. When it is wished to drain the abdomen, the latter should be opened with a knife, because an intestine might happen to be glued to the abdominal wall, and when not detected by previous percussion, a trocar or a needle could easily perforate. In a moderate edema use locally compression, and tincture of iodin diluted with an equal bulk of alcohol. In persistent edema employ frictions with a stimulating liniment. Inter- nally, salines and diuretics are indicated. The compound jalap powder is well suited to dropsies. Mercurials can be used, and in severe cases also elaterium. Formation of Bmbryonic Tissue. — The term " lymph " is a synonym for fibrinous exudate, coagulable lymph, plastic infiltrate, indifferent tissue, or embryonic tissue. Granulation- tissue is vascularized lymph, and when it forms inflammation has passed into new formation. It is customary to speak of new formation as a termination of inflammation, but, as a matter of fact, inflammation has ceased when it begins. New formation is discussed in the section upon Repair. In in- flammation effusion of liquor sanguinis and migration of white corpuscles take place, fibrin forms in the exudate and the liquor sanguinis coagulates. This is followed by pro- liferation of the corpuscles and of the fixed connective-tissue cells (Fig. 28). Effused liquor sanguinis, which contains 92 MODERN SURGERY. many corpuscles and which coagulates, is met with in se- vere inflammation. Lymph may be absorbed or it may be organized into tissue. If it becomes organized, capillaries form in it by the extension from the surrounding tissue of capillary loops, which raise up the lymph and form granula- tions. A granulation may be defined as a small mass of lymph containing vessels (Fig. 29). If lymph is absorbed, it is taken up by the lymphatics. Lymph is divided into two forms — plastic or foruiative lymph, that which can be converted into tissue, hence that which can bring about repair ; aplastic or croupous lymph, that which develops no fibres and cannot be converted into tissue, and which in consequence cannot bring about repair. Effusion of lymph may be beneficial. It repairs all injuries ; it surrounds and encapsules foreign bodies ; it circumscribes Pig. 28. — Recent lymph, forming false membrane (Gross). Fig. 29. — Blood-vessels in granulation (Gross) abscesses ; and it often prevents pus from evacuating into a cavity, gluing together structures to make a channel and leading the pus to the surface. It may be injurious. It forms adhesions of the brain, pleura, peritoneum, pericardium, and joints ; it produces opacity in the cornea and adhesions of the iris ; it constitutes the false membrane of the larynx or trachea ; and it causes stricture of the urethra and thicken- ing of organs. Treatment. — Locally, employ compression, tincture of iodin, lead-water and laudanum, alternating hot and cold douches, friction, and massage ; also ichthyol and lanolin. Internally, use mercurials and iodid of potassium or tartar emetic. S. W. Gross recommended the following mixture for inflammatory thickening : R. Potassii iodidi, gr. x; Hydrargyri chloiidi corrosivi, gr. j^g ; Antimonii et potassii tartratis, gr. J^. — M. Sig. Three times a day, in half a glass of water, after meals. TERMINATIONS OF INFLAMMATION. 93 Suppuration is a process in which tissues and inflamma- tory exudates are Hquefied by the action of pyogenic organ- isms, and it is a common termination of infective inflamma- tion. Localized suppurations are due to staphylococci ; spreading suppurations, to streptococci. Pyogenic bacteria liquefy exudate by peptonizing it. The pyogenic organisms are very irritant, and when deposited cause inflammation ; in- flammation leads to exudation, but the exudate cannot coag- ulate because it is peptonized by the ferment of the micro- organisms. If an area of embryonic tissue is invaded by the p)'ogenic micro-organisms, it is promptly peptonized. Pep- tonized exudate or embryonic tissue is called pus. In in- flammations induced by staphylococci granulation-tissue, as a rule, forms at the periphery of the inflammation, the micro- cocci are imprisoned, and the process is circumscribed. In inflammations induced by streptococci granulation-tissue rarely forms in time to imprison the micro-organisms, and the suppuration spreads widely. Suppuration can be induced by the injection of pyogenic bacteria, by their entry through a wound, and by rubbing them upon the skin. In some rare instances, especially when the diet has been putrid, they may enter through the blood and lodge at a point of least resist- ance. The entry of pyogenic bacteria does not necessarily cause suppuration, as the healthy human body can destroy a considerable number, even if given in one " dose ;" but a large number in a healthy, or even a small number in an un- healthy, organism almost certainly does. The pus of all acute abscesses contains bacteria of suppuration, but the pus of tubercular abscesses does not, unless there be a mixed in- fection ; in other words, pure tubercular pus is not pus at all. Can suppuration be induced without micro-organisms ? It is true that the injection of irritants can cause the formation of a thin fluid which contains no organisms, but is this non- bacterial pus really pus ? The same sort of fluid is formed by injecting cultures of pus cocci which have been rendered sterile by heat, the organisms being killed, a ferment con- tained in the bacterial cells being the active agent. Spu- rious or " aseptic " pus does not concern us, as it is never found practically. Impaired health or an area of lowered vitality predisposes to suppuration. The lymphatic glands, medulla of bones, serous membranes, and connective tissue are especially prone to suppurate. When a medullary canal suppurates after a chill to the surface or after a blow that does not cause a wound, we know that the organisms must have arrived by means of the blood. 94 MODERN SURGERY. Pus may form in twenty-four hours after an inflammation begins, or it may not form for days. The older surgeons claimed that pus could do good by protecting granulations and separating disorganized tissue. It is now held that it is absolutely harmful by melting down sound tissue and poi- soning the entire organism. Modern surgery has to a great degree abolished pus. If pus stands for a time, it separates into two portions — (i) a watery portion, the liquor puris or pus-serum, contain- ing peptone, fat, microbic products, osmazone, and salts, and not tending to coagulate ; (2) a solid portion, or sediment of micro-organisms of suppuration, pus-corpuscles (Fig. 30), and Fig. 30.— Fragmentation of nucleus in leukocytes undergoing transformation into pus- corpuscles (Senn). broken-down tissue. The pus-corpuscles are either white blood-cells or altered connective-tissue cells. Some of them are dead, some have ameboid movements, some are fatty, others are granular and contain more than one nucleus, and all are degenerating. A pus-cell is waste-matter, and it can- not aid in repair. Forms of Pus. — Laudable or healthy pus, a name long in vogue, is a contradiction, no pus being healthy. In former days free suppuration after an operation was regarded as a favorable indication, and when it occurred the surgeon con- gratulated himself that surgical fever was at an end. At the TERMINATIONS OF INFLAMMATION. 95 present day suppuration after an operation is an evidence of previous infection, of lack of care, or of infection by the blood. The so-called laudable pus is seen coming from a healing ulcer, and is a yellowish-white or a greenish fluid of the consistence of cream, opaque, with a very slight odor if it is not putrid, and having a specific gravity of about 1.030. Malignant, zuatoy, or ichorous pus is a thin, watery, putrid fluid. It is pus filled with the organisms of putrefaction. Sanious pus is a form of ichorous pus containing blood coloring-matter or blood. It is thin, of a reddish color, and very acrid, corroding the parts that it comes in contact with. It is found notably in caries and carcinoma. Concrete or fibrinous pus, which contains flakes of fibrin or coagulated fibro-purulent masses, is met with in serous cavities (joints, pleura, etc.). These masses are found in infective endocarditis (Bowditch). Blue pns. — The color of blue pus is due to the bacillus pyocyaneus. Orange pus is due to the action of sarcina aurantiaca, and appears in violent inflammations. Serons pus is a thin serous fluid containing a few flakes. So-called scrofulous or curdy pus is not pus at all, unless the tubercular area has undergone pyogenic infection. So-called gummy pus arises from the breaking down of a gumma which has outgrown its own blood-supply. It is not pus. Muco-pus is found in purulent catarrh — that is, in suppura- tive inflammation of an epithelial structure. It contains pus- elements and epithelial cells. Caseous pus comes from the fatty degeneration of pus- corpuscles or inflammatory exudations. This mass may calcify. It occurs especially in tubercular processes. Contagious pus is that which contains and conveys the elements of some specific contagion, such as small-pox or a chancroid. Suppuration is announced by the intensification of all local inflammatory signs. The heat becomes more marked, the discoloration dusky, the swelling augments, the pain be- comes throbbing or pulsatile, and the sense of tension is greatly increased. The skin at the focus of the inflammation after a time becomes adherent to the parts beneath, and fluc- tuation soon appears. This adhesion of the skin is a prepa- ration for a natural opening, and is what is known as " point- ing." An important sign of pus beneath is edema of the skin. This is sometimes noticeable in empyema or pyotho- 96 MODERN SURGERY. . rax and in appendicitis. The above symptoms can be rein- forced and their significance proved by the introduction of an aseptic tubular exploring-needle and the discovery of pus. Irregular chills, high fever, and drenching sweats are very significant of suppuration in an important structure or of a large area. Diffused Cellulitis or Phleg-monous Suppuration ; Puru- lent Infiltration. — This process may involve a small area or an entire limb, and is due to infection by the streptococcus pyogenes or streptococcus of erysipelas. It is announced in severe cases by enormous swelling, the development of areas which feel boggy, a dusky-red discoloration, and great burn- ing pain. Gangrene of superficial areas is not unusual. The discharges of the wound, if a wound exists, are apt to dry up, and the wound becomes foul, dry, and brown. The adjacent lymphatic glands are much enlarged. The patient has chills, sweats, and high oscillating temperature, due to suppurative fever, sapremia, or even septic infection or pyemia. Diffuse suppuration tends to arise in infected com- pound fractures, in extravasation of urine, and after the infliction of a wound upon a person broken down in health. It is not unusual after scarlet fever, and is typical of phleg- monous erysipelas. The pus is sanious and offensive. This diffused suppuration may widely separate muscles, and even lay bare the bones. It is a very grave condition, and may cause death by exhaustion, septic intoxication, septic infec- tion, pyemia, or hemorrhage from a large vessel which has been corroded. CelluHtis of a mild degree may surround an infected wound or a stitch-abscess. Its spread is mani- fested by red lines of lymphangitis running up to the adja- cent lymphatic glands. Light cases may not suppurate, the lymphatics carrying off the poison. Any case of cellulitis is, however, a menace, and any severe case is highly dangerous (see Erysipelas). Acute Abscesses. — An abscess is a circumscribed cavity of new formation containing pus. We emphasize the fact that it is a circumscribed cavity — circumscribed by a mass of embryonic tissue. A purulent infiltration is not circum- scribed, hence it does not constitute an abscess. An essen- tial part of the definition is the assertion that the pus is in a cavity of new formation, in an abnormal cavity ; hence pus in a natural cavity (pleural, pericardial, synovial, or perito- neal) constitutes a purulent effusion, and not an abscess unless it is encysted in these localities by walls formed of inflammatory tissue. TEHMIXATIOXS OF INFLAMMATION. 97 An acute abscess is due to the deposition and multiplica- tion of pyogenic bacteria in the tissues or in inflammatory exudates. These bacteria attack exudates or tissues, form irritants which intensify the inflammation, and by exerting a peptonizing action on intercellular substance and fibrin of the exudate liquefy tissue and the products of inflammation, and form pus. As a rule, within twenty-four hours after lodgement of the bacteria the exudation increases in amount, the migrated leukocytes gather in enormous numbers, the fibers of tissue swell up, and the connective-tissue spaces distend with cells and fluid. The connective-tissue cells, acted on by pus cocci, multiply by kar>'okinesis, develop many nuclei, lose their stellate projections, degenerate, and constitute one form of pus-corpuscle, leukocytes forming Fig. 31. — Infiltration of connective tissue of cutis (X 500), with beginning suppuration in the center (Senn;. the other. All the small vessels are choked with leukocytes, this blocking serving to cut off nourishment and tending to produce anemic necrosis. Liquefaction occurs at many foci of the inflammation, drops of pus being formed, the amount of each being progressively added to and many foci coales- cing (Fig. 31). The pus-cavity is circumscribed, not by a secreting pyogenic membrane, but b\' embryonic tissue whose cells and intercellular material have not as yet broken down, and this area of embryonic tissue is circum- scribed by a zone of inflammation. As an abscess increases in size the embr\'onic tissue from within outward liquefies into pus, and the zone of inflammation beyond continually 7 9^8 MODERN SURGERY. enlarges and forms more lymph. After a time the inflam- mation reaches the surface, the embryonic tissue glues the superficial to the deeper parts, liquefaction of this lymph occurs, a small elevation due to fluid pressure appears (point- ing), and this elevation thins and breaks from tension and liquefaction (spontaneous evacuation). When an abscess forms in an internal organ or in some structure which is not loose like connective tissue — for instance, in a lymphatic gland — a mass of pyogenic bacteria, floating in the blood or lymph, lodges, and these bacteria by means of irritant products cause coagulation-necrosis of the adjacent tissue and inflam- matory exudation around it. The area of coagulation-necrosis becomes filled with white blood-cells, and the dry necrosed part is liquefied by the cocci. Suppuration in dense struc- tures causes considerable masses of tissue to die and to be cast off", and these masses float in the pus. Death of a mass with dissolution of its elements is necrosis or inflammatory gangrene. An abscess heals by the collapse of its walls and the formation of an abundance of granulation-tissue ; in many cases the granulations of one wall join those of the other side, the entire mass of granulations being converted into fibrous tissue, and this tissue contracting (healing by third intention). If the walls do not collapse, the abscess heals by second intention. Forms of Abscesses. — The following are the various forms of abscesses : acute or phlegmonous, which follows an , acute inflammation ; strumous, cold, lymphatic, tubercular, or \ chronic abscess is due to tubercle, and does not contain true pus without there is secondary infection. It presents no signs of inflammation. A lymphatic abscess may form in a week or two, and hence is not necessarily chronic, which term may also be used to mean a persistent non-tubercular abscess ; caseous or cheesy abscess, a cavity containing thick cheesy masses, is due to the fatty degeneration of exudate, and most commonly results from the caseation of a tubercu- lar focus ; circumscribed abscess is one limited by embryonic tissue ; diffused abscess is an unlimited collection of pus, in reality not an abscess, but either a purulent effusion or a purulent infiltration; congestive, gravitative, wamiering, or hypostatic abscess is a collection of pus or tubercular mat- ter which travels from its formation-point and appears at some distant spot (as a psoas abscess) ; critical or consecutive abscess is one which arises during an acute disease ; diathetic abscess is due to a diathesis ; embolic abscess is due to an in- fected embolus ; tympanitic or emphysematous abscess is one TERMINATIONS OF INFLAMMATION. ■ 99 which contains the gases of putrefaction ; encysted abscess, in which pus is circumscribed in a serous cavity ; fecal or ste?'- coraceous abscess is one containing feces in consequence of a communication with the bowel ; follicular abscess is one aris- ing in a follicle ; lieniatic abscess is that which arises around blood-clot, as a suppurating hematoma ; marginal abscess, which appears upon the margin of the anus ; pyemic or metastatic abscess is the embolic abscess of pyemia ; 7/iilk abscess is an abscess of the breast in a nursing woman ; ossifluent abscess, arising from diseased bone ; psoas or tuber- cular abscess, arising from vertebral caries, following the psoas muscle and usually pointing in the groin ; sympathetic abscess, arising some distance from the excitinsr cause, such as a suppurating bubo from chancroid, is not in reality sym- pathetic, because infective material has been carried from the primary focus ; thecal abscess is suppuration in a tendon- sheath ; tropical abscess is an abscess of the liver, so named because it occurs chiefly in tropical countries. It usually follows dysentery ; urinary abscess, caused by extravasated urine ; verminous abscess, one which contains intestinal worms and communicates with the bowel ; syphilitic abscess, which occurs in the bones during tertiary syphilis ; Brodics abscess is a chronic abscess of a bone, most common in the head of the tibia ; superficial abscess, which occurs above the deep fascia ; deep abscess, occurring below the deep fascia ; and residual or Pagefs abscess, a recurrence of suppuration, it may be after years, about the residue of a former abscess. Symptoms of Acute Abscess. — In an acute abscess, as before stated, a part becomes inflamed and embryonic tissue forms ; this is liquefied (as above noted) and pus is produced. If the abscess is in the brain, in the tonsil, or in the neigh- borhood of the rectum, the odor of the pus is apt to be offensive. An acute abscess can occur in a person of any constitution. Local Symptoms. — Locally there is intensification of in- flammatory signs ; swelling enormously increases, the dis- coloration becomes dusky, the pain becomes throbbing and the sense of tension increases, the cutaneous surface is seen to be polished and edematous, and after a time pointing is observed and fluctuation can be detected. Constitutional Symptoms. — In cases of small collections of pus in unimportant structures there may be no obvious con- stitutional disturbance. If the abscess contains much pus or affects an important part, generally disturbances appear, from slight rigors or moderate fever to chills, high temperature, lOO MODERN SURGERY. and drenching sweats. The constitutional condition typical of an abscess is due to the absorption of retained toxins, and is known as " suppurative fever." When suppuration is long continued there exists a fever which is markedly periodic : the temperature rises in the evening, attaining its highest point usually between 4 and 8 p. m., and then sinks to normal or nearly normal in the early morning (from 4 to 8 A. M.). When the temperature begins to fall profuse per- spiration takes place. This fever is known as " hectic." The symptoms of an abscess are somewhat modified by location, and it is wise to discuss acute abscesses in different situations. Acute Abscesses in Various Regions. — Abscess of the brain in about 50 per cent, of cases results from suppurative disease of the middle-ear. In abscess of a silent region of the brain symptoms may long be entirely absent. The usual symptoms are headache, vomiting, delirium, drowsiness, optic neuritis, and often a subnormal temperature. Local- izing symptoms may be present. In but few cases are there fever and sweats (p. 561). In extradural abscess there is fever. Appendicinal or appendicular abscess results from inflam- mation, usually with perforation of the vermiform appendix, plastic peritonitis circumscribing the pus. If the pus is not limited by adhesion, the peritoneum is attacked by diffuse septic peritonitis (p. 655). The signs of appendicular abscess are pain, tenderness, muscular rigidity, often swelling, dul- ness on percussion, and sometimes fluctuation and skin- edema in the right iliac fossa, fever, vomiting, sometimes constipation, and sometimes diarrhea. Abscess of the liver may not be announced by symptoms until rupture. It may follow dysentery, may be a result of the lodgement of infected clots from the hemorrhoidal veins, or may follow upon the pylephlebitis of appendicitis. We usually find fever of an intermittent type, profuse sweats, pain in the back, the shoulder, or the right hypochondriac region, enlargement of the area of liver-dulness, also hepatic tenderness, and finally constitutional symptoms of the exist- ence of pus. Sometimes there are fluctuation and skin- edema over the liver, and the general cutaneous surface may be a little jaundiced. The symptoms vary as the pus invades adjacent organs (p. 660). Snbphrenic abscess is apt to begin beneath the diaphragm, though in some few instances the pus forms above this mus- cle, and subsequently gains access to the region beneath. This TERMINATIONS OF INFLAMMATION. 10 1 abscess may contain not only pus, but gas, and also in some cases fluids from the stomach or intestine. It may arise after perforation of the bowel or stomach, or it may result from Pott's disease, perinephric abscess, traumatism, abscess of the liver, kidney, spleen, or pancreas, empyema or pneumonia (Greig Smith). The signs are pain, fever, sweats, dyspnea, cough, and the physical signs of gas in the cavity of the abscess. Abscess of the hing gives the physical signs of a cavity ; the expectoration is offensive and contains fragments of lung- tissue. Pyemic abscesses may exist and yet escape dis- covery. Abscess of the niediasti)iuin causes throbbing retrosternal pain, chills, fever, sweats, and often dyspnea. A tumor may appear which pulsates and fluctuates, but the pulsation is not expansile. Perinephric abscess usually causes tenderness and pain in the lumbar region or about the hip-joint, which pain runs down the thigh and is accompanied by retraction of the tes- ticle. Induration, fluctuation, or edema of the skin may ap- pear. The constitutional symptoms of suppuration usually exist. Abscess of the aiitniin of HigJivwre causes pain, edema- tous swelling, and crepitation on pressure. Pus escapes from the nostrils, and a rhinoscopic examination can find the fluid passing into the nares. The antrum on the side of the ab- scess cannot be transilluminated by an electric light in the mouth (Garel's sign). Abscess of the larynx induces violent cough, pain, interfer- ence with the voice, swallowing, and breathing, and can be seen with a laryngoscope. Prostatic abscess is manifested by chills, fever, and sweats, developing during an attack of acute prostatitis. Abscess of the breast can arise from absorption of pyogenic bacteria from a fissure or abrasion of the nipple. Some sur- geons maintain that the bacteria enter along the milk-ducts, while others assert that they gain entry by the lymphatics. It is most common in nursing women. Its symptoms are pulsatile pain, dusky discoloration, skin-edema, fluctuation, and usually constitutional disorder. Suppurative thecitis or felon is a form of diffuse suppura- tion (p. 5 I 2). Palmar abscess is a purulent effusion (p. 512). Furuncle and carbuncle are discussed upon pages 739 and 740. 102 MODERN SURGERY. Empyema is a purulent effusion (p. 605) into the pleural sac. It is technically an abscess if it becomes encapsuled. Diag-nosis. — The diagnosis of an abscess rests upon — (i) its history; (2) fluctuation ; (3) pointing ; (4) surface-edema ; and (5) the use of the tubular exploring-needle. A suspected abscess in a dangerous or important part under no circumstance should be opened by a bistoury with- out knowing that the diagnosis is certainly correct. This knowledge is obtained in some cases by inserting a small aspirating-needle and observing the nature of the fluid which exudes. An abscess which moves with the pulse because it rests upon an artery may be confounded with an aneurysm. The pulse-movements of an abscess are in one direction only ; the abscess is lifted with each pulse-beat, but does not en- large, and if a finger is laid upon either side of it the fingers will be lifted, but not separated. The pulse-movements of an aneurysm are in all directions ; they are pulsatile, the tu- mor grows larger, and the fingers will not only be lifted, but will also be separated. The tubular exploring-needle can be used in doubtful cases ; if aseptic, it will do no harm even to an aneurysm. Many able surgeons object to the employ- ment of a grooved exploring-needle, on the ground that when plunged into infected areas and withdrawn the track of the penetration becomes infected by the fluid which es- capes. A rapidly growing, small-cell sarcoma feels not unlike an abscess ; but the exploring-needle discovers blood, and not pus. A cystic tumor is separated from an abscess by the absence of inflammation, or, if it inflames, by the nature of the contained fluid.^ Ordinary caution will prevent us from confounding an abscess with strangulated hernia. A tubercular abscess is separated from an acute abscess by the absence of inflammatory signs in the former. Prognosis. — The prognosis varies according to the num- ber of abscesses, their location and size, and the strength of the patient. Treatment. — In the treatment of an abscess there is one absolute rule which knows no exception, namely, that when- ever and wherever pus is found the abscess should be evac- uated at once, and, after evacuating it, thorough drainage provided for. It should be opened early, if possible even before pointing or fluctuation, to prevent tissue-destruction, subfascial burrowing, and general contamination. Drainage is continued until the discharge becomes scanty, thin, and seropurulent. Abscess of the liver requires that an incision be made TERMINATIONS OF INFLAMMATION. . I03 along the edge of the ribs down to the liver, which organ is then stitched to the edges of the wound. In a day or two after the first operation the two layers of peritoneum are firmly adherent and the abscess can be opened without danger of the passage of pus into the peritoneal cavity. The abscess is opened and washed out, and a tube inserted. Surgeons occasionally try to locate the pus by the use of an aspirator before doing the cutting operation (p. 660). Abscess of the liver is occasionally reached by resecting a rib, open- ing the pleural sac, and incising the diaphragm (transthoracic hepatotomy). Abscess of the mediastinum, like all other abscesses, requires incision and drainage. This is most eas- ily effected by trephining the sternum. In abscess of the lung an incision is made and the pleura is exposed. The incision is usually through an intercostal space ; but if the spaces are narrow, it will be necessary to resect a rib. If the two layers of pleura are found adherent, the operation is proceeded with. If they are not adherent, they are stitched together with a cat- gut suture, and the surgeon waits 48 hours before continuing. The operation is completed by locating the pus by means of an aspirator, evacuating it by the cautery at a dull red heat, and inserting a drainage-tube into the abscess-cavity (p. 607). In abscess of the antrum bore a gimlet-hole through the superior maxillaiy bone above the canine tooth, or perforate the bone by means of a trocar. Irrigate daily with boiled water or normal salt solution. Keep the open- ing from contracting by inserting a small tent of iodoform gauze. In persistent cases it may be necessary to draw a tooth, break through the socket into the antrum, and in- sert a silver or hard-rubber tube. In very persistent cases osteoplastic resection of a portion of the upper jaw will be demanded. In appendicular abscess incise, support abscess- walls with gauze, in many cases do not remove the appendix, and insert a drainage-tube and strands of gauze (p. 653). In abscess of the breast make an incision radiating from the nipple, or, what is better, incise under the breast by means of a cut at the inferior thoracic mammary junction, and enter the abscess from beneath. In abscess of the brain the skull should be trephined, the membranes incised, and the abscess sought for, opened, and drained (p. 562). In an ordi- nary superficial abscess, after cleansing the parts, make the skin tense, incise with a sharp-pointed curved bistoury, and let the pus run out itself, pressure being, as a rule, unde- sirable. If tissue-shreds block up the opening, they must be picked out with forceps. If the atmospheric pressure I04 MODERN SURGERY. will not cause the pus to flow out, make light pressure with warm, moist, aseptic sponges. After the pus has come away wash the cavity with peroxid of hydrogen and then with corrosive solution (i : looo), and pack with iodoform gauze for two or three days, when the discharge becomes serous. Pursue rigid antisepsis in dealing with pus. It is true we already have infection, but infection can take place with or- ganisms of putrefaction, causing pus to become putrid, or with other bacteria. In a deep abscess, or an abscess situated near important vessels, do not boldly plunge in a knife. Hilton says to " plunge in a knife is not courageous, as it is without danger to the surgeon, but may be fatal to the patient." Remember also that a large amount of pus displaces normal anatomical relations. Hilton's method of opening a deep abscess (as in the axilla or neck) is to cut to the deep fascia, nick the fascia with a knife, and then push into the abscess a grooved director until pus shows in the groove ; along the groove push a pair of dressing-forceps, shut ; after they reach the depths upon them and withdraw, and so dilate the opening ; then insert a tube and irrigate. In an abscess in the posterior part of the orbit, after incising transversely a portion of the upper lid, the abscess should be reached by this method. Always endeavor to open an abscess at its most dependent part, re- membering that the situation of this part may depend upon whether the patient is erect or recumbent. If we do not make the opening at the lowest point, all the pus will not run out and the walls will not completely collapse. A deep abscess must be drained thoroughly until the discharge be- comes seropurulent. When the tube is removed it is wise to insert a tent of iodoform gauze just through the outlet of the abscess. This tent prevents the skin from closing over the channel. It is reinserted every day until it becomes clear that there is no longer danger of fluid becoming blocked and retained. When an abscess contains diverticula or pouches, they should be slit up or a counter-opening ought to be made. A counter-opening is made by entering the dressing-forceps at our first incision, pushing them through the abscess to the point where we wish to make our counter-opening, opening the blades, and cutting between them from without inward. The blades are then closed and projected through the incision ; they are opened to dilate the new door, and closed again upon a drainage-tube which is pulled through from opening to opening as the instrument is withdrawn. When pus burrows, insert a grooved director TERMIXATIONS OF INFLAMMATION. I05 in each channel and sht the sinus with a knife. An abscess may make an opening through dense fascia, the opening being small like the neck of an hour-glass (shirt-stud ab- scess). Always examine to see if such a condition exists, and if it is found, incise the fascia. Rest is of the first importance in the healing of an abscess, and we try to obtain it by bandages, splints, and pressure, which will immobilize adjacent muscles and approximate the abscess-walls. If an abscess is slow to heal, use as a daily injection peroxid of hydrogen followed by i : 1000 corrosive sublimate, or 3 drops of nitric acid to .^j of water, or 3 grains of zinc sulphate to 5j of water, or a 5 per cent, solution of carbolic acid, or a 2 per cent, aqueous solution of pyoktanin, or 20 drops of tincture of iodin to 7,] of water or a solution of bichlorid of palladium. Peroxid of hydrogen is a dangerous agent to inject into the cavity of a deep abscess of the neck, as the liberated gas may not escape from the opening, but may pass widely into the tissues and cause great distention. The author saw a child who narrowly escaped death after such an injection. In this patient the gas passed beneath the pharyngeal mucous membrane and the swelling almost occluded the air-passages. The constitutional treat- ment of an abscess depends upon its severity and upon the importance of the structures involved. In a bad case the patient should be put to bed, opiates given with a free hand, the bowels kept active by calomel and salines, skin-activity maintained, nutritious food insisted on, and stimulants liber- ally employed. Purulent Effusions. — See Suppurative Thecitis, Palmar Ab- scess, Suppurative Synovitis, Purulent Peritonitis, Empyema, etc. Tubercular abscess, called also chronic, cold, scrofu- lous, and lymphatic, is an area of disease produced by the action of the bacilli of tubercle and circumscribed by a dis- tinct membrane. Ashhurst says that the term " chronic " is a bad one. " It refers etymologically only to time. A phlegmonous abscess, if deeply seated, may be of slower development than a chronic or cold abscess which is super- ficial." A tubercular abscess is most common in the lym- phatic glands, bones, joints, and subcutaneous connective tissues, and is rare after the twentieth year. It may contain quarts of curdy pus. The bacilli of tubercle cause inflam- mation, and granulation-tissue is formed, which in the centre undergoes coagulation-necrosis and caseation, and at the pe- riphery is converted into fibrous tissue. The irritation of I06 MODERN SURGERY. toxins produces the exudation, and anemia due to the mass outgrowing its own blood-supply is the cause of the case- ation. First, there forms from granulation-tissue a cheesy- matter, which is liquefied into scrofulous, curdy, or tubercular fluid. This really is not pus, as the tubercle bacillus is not pyogenic ; if true pus forms, it is because of a secondary infection with pus cocci — an accident, and not a part of the natural process of formation of a cold abscess. A cold abscess may be absorbed, or may become encapsuled by densely fibrous organization of its limiting-wall into a thick pyogenic membrane. The fibrous wall of a tubercular ab- scess is lined by a thin, yellowish membrane, which is stud- ded with miliary tubercles (Volkmann's membrane). Tuber- cular matter rarely invades a muscle, whereas syphilis often attacks muscle (Warren). Symptoms. — The term cold abscess is employed for a tubercular abscess because it presents no inflammatory signs. There is no local heat ; no discoloration unless pointing occurs ; the parts look paler than natural ; pain is absent in the abscess, though it may exist at the point of origin of the fluid ; the tubercular material often wanders from its point of origin under the influence of gravity ; fluctuation is pres- ent unless thick walls mask it. Constitutional symptoms are trivial or absent unless secondary infection occurs. The swelling may suddenly appear in some spot — the groin, for instance. When it appears suddenly it has travelled from a distant and older area of disease. The abscess may last for years without producing pain or annoyance. The tubular exploring-needle will settle the diagnosis. The constitution is invariably below normal because of the tubercular infec- tion, and the temperature is a little above normal. A cold abscess which is infected with pus organisms exhibits great inflammation, and septic fever rapidly develops. In tuber- cular disease of the vertebrae the fluid may find its way to the lumbar region, to the iliac region, or to the immediate neighborhood of Poupart's ligament, above or below it. Tubercular Abscesses in Various Regions. — Tu- bercular abscess of the head of a bone (Brodie's abscess) arises in the cancellous structure of a long bone, most often in the head of the tibia. Pain is continued but not usually very severe, is of a boring character, and is worse when the patient is in bed. Attacks of synovitis arise from time to time in the adjacent joint. There is no such thing as an acute ab- scess of bone. A pyogenic inflammation of such severity that it would cause an acute abscess in soft parts, in bone TERMINATIONS OF INFLAMMATION. 107 causes acute necrosis. The organism obtains access to the bone by means of the blood, and finds in the bone a point of least resistance. Retropharyngeal or postpharyngeal abscess is usually due to caries of the cervical vertebrae, but can arise in the connective tissue of the parts or as a tubercular adenitis. An abrasion of the mucous membrane may admit the bacilli to the tissue or the glands. A swelling projects from the posterior pharyngeal wall, and there is great interference with respiration and deglutition. Caseous matter from caries of the cervical vertebrae may reach the posterior mediastinum by following the esophagus, or it may appear in front of or behind the sternomastoid muscle (Edmund Owen). Dorsal Abscess. — The tubercular matter in dorsal ab- scess arises from dorsal caries, flows into the posterior medi- astinum, and reaches the surface by passing between the transverse processes. The tubercular matter from dorsal caries may run forward between the intercostal muscles or between these muscles and the pleura, pointing in an inter- costal space at the side of the sternum or by the rectus muscle. It may open into the gullet, windpipe, bronchus, pleural sac, or pericardium. It may descend to the dia- phragm and travel under the inner arcuate ligament to form a psoas abscess, or under the outer arcuate ligament to form a lumbar abscess. A psoas abscess points external to the femoral vessels, a characteristic which distinguishes it at once from a femoral hernia. Iliac abscess arises from lumbar caries, the swelling lying in the iliac fossa and pointing above Poupart's ligament. Psoas abscess is usually due to lumbar caries, the fluid pointing in Scarpa's triangle external to the femoral vessels. A psoas or iliac abscess, by following the lumbosacral cord and great sciatic nerve, forms a gluteal abscess. These abscesses may open into the bowel, bladder, ureter, or peri- toneal cavity. Lumbar Abscess. — In a lumbar abscess the fluid produced by dorsal caries descends beneath the outer arcuate liga- ment, or the fluid from lumbar caries which collected ante- rior to or in the quadratus lumborum muscle passes between the last rib and iliac crest in the triangle of Petit, the small space bounded by the crest of the ilium, the posterior edge of the external oblique muscle, and the anterior edge of the latissimus dorsi muscles.^ ^ For a lucid description of these abscesses see Owen's Manual of Anatomy, from which much of the above is condensed. I08 MODERN SURGERY. Chronic abscess of the breast is a caseated area of tu- berculosis of the breast. A lump is detected which slowly enlarges and finally ruptures, sinuses being formed. The axillary glands are apt to be implicated. The patient be- longs to a tubercular stock, as a rule gives a history of previous tubercular troubles of various sorts, and has usually borne children. Chronic abscess of the breast causes little or no pain. Treatment. — If a small cold abscess exists in a superficial structure, open it with aseptic care, rub its walls with bits of gauze to remove tubercular masses, irrigate with i : looo mercurial solution, pack with iodoform-gauze, and dress anti- septically. When the discharge becomes thin and scanty the packing can be dispensed with. If it be slow in healing, inject or swab out with a stimulating fluid as in acute abscess, or inject with iodoform emulsion. Chronic Abscess of Bone. — Make an incision to bare the bone. Open the abscess with the trephine, the gouge, or the chisel ; curet with a sharp spoon and gouge ; cut away the edges of the bone with rongeur forceps ; irrigate the cav- ity with hot corrosive sublimate solution (i : lOOo), and swab it out with gauze wet with pure carbolic acid ; pack with iodoform gauze and apply dry antiseptic dressings. It is better not to employ an Esmarch apparatus. Bleeding will not be severe, and when no apparatus is used we can be sure that all the diseased bone has been removed, because sound bone bleeds and dead bone does not. Cold Abscess of Lymphatic Glands. — In non-exposed portions of the body the capsule should be incised and dis- sected or scraped away, and the cavity swabbed out with pure carbolic acid and packed with iodoform gauze. If the abscess is allowed to burst, it will make an ugly scar ; there- fore in exposed portions of the body an effort should be made to prevent a scar. When only a little caseated matter exists and the skin is not discolored, prepare the parts anti- septically and carry a silk thread by means of a needle through the skin, through the gland, and out at its lowest point. Dress with gauze. In three days the thread can be taken out and a firm compress applied. When the gland is almost entirely broken down and the skin above it is purple and thin, insert a hypodermatic needle through sound skin into the abscess, draw off the pus, and inject iodoform emul- sion (lo per cent, of iodoform, 90 per cent, of glycerin or olive oil). This procedure is to be repeated when pus again accumulates. By this means we can often effect a cure in TERMINATIONS OF INFLAMMATION. IO9 a week or so. When an abscess breaks or is at the point of breaking cut away all purple skin, curet the abscess- walls (the abscess having become a scrofulous ulcer), remove the remains of gland and capsule, swab the cavity with pure carbolic acid, and dress with iodoform and corro- sive gauze. Tubercular glands ought to be extirpated before they caseate and form abscess. Cold Abscess of Mammary Gland. — Many operators simply incise, curette, pack with iodoform gauze, and dress antiseptically. It is wiser to remove the entire gland and clean out the axilla, in order to prevent both recurrence and dissemination. Large Cold Abscesses (Psoas Abscess). — In view of the facts that these abscesses may cause no trouble for years and that an operation may be fatal, some eminent surgeons are opposed to an operation unless the abscess is moving toward inevitable rupture or is disturbing the functions of organs by pressure. Most practitioners believe, however, that this mass of tuberculous matter is a source of danger through being a depot of infective organisms which may overwhelm the system, and that death will rarely occur in the hands of the operator who employs with intelligence strict antisepsis. In no other cases is attention to every detail more important, as a mixed infection can easily take place, and will probably mean death. In many cases aspiration can be employed to empty the cavity, injecting either a 10 per cent, iodoform emulsion to the amount of siij, or 5iij of a 5 per cent, ethereal solu- tion of iodoform after the fluid is sucked out. After inject- ing the emulsion squeeze and manipulate the fluid into every nook and cranny. The American Text-book of Surgery advises the injection of from i to 3 ounces of the following preparation: iodoform, 10 parts; glycerin, 20; mucil. gum Arab., 5 ; carbolic acid, i ; water, lOO. Whatever fluid is chosen, the operation must be repeated three or four times at intervals of four weeks. It is danger- ous to inject large amounts of iodoform, as poisoning may be produced (p. 27). Some surgeons incise such an abscess, inject iodoform emulsion, and sew up without drainage. Such a procedure often fails and is sometimes followed by iodoform-poisoning. If aspiration and injection fail, open, under rigid antisepsis, the most dependent portion of the abscess, scrape its wall with bits of gauze, and over-distend with a I : 1000 solution of warm corrosive sublimate. Let no MODERN SURGERY. the mercurial solution run out and then irrigate the cavity with hot normal salt solution, which will remove the re- mains of the corrosive fluid. With a long probe find the highest point of the cavity, and make a counter-opening; scrape well, search for and remove carious bone, flush out the whole area with corrosive sublimate, wash out the mei- curial solution with hot normal salt solution, inject emul- sion of iodoform, and either make tube-drainage from open- ing to counter-opening and from bone to counter-opening, or pack the entire cavity with iodoform gauze. If hemor- rhage is severe, after injecting with hot salt solution the cav- ity must be packed. When a large abscess breaks of itself, it should at once be drained and asepticized as above. In the treatment of a cold abscess give nutritious food, cod-liver oil, quinin, iron, and the mineral acids. Removal to the sea- .side is often indicated, and mechanical appliances may be needed for diseases of the bones and joints. If secondary infection does occur, the patient develops hectic fever {cj. v)). Dorsal abscess and lumbar abscess are treated after the same plan as psoas abscess, although one incision only is usually necessary unless the fluid has travelled to a distant point. A postpharyngeal abscess must not be opened through the mouth. To open it in this manner puts the patient in danger of suffocation by fluid running into the larynx during or after the operation. Further mixed infection of the abscess-area will be certain to ensue. Septic pneumonia will be apt to arise from inhaled infected particles, and pro- found gastro-intestinal disturbance will be liable to develop because of the inevitable swallowing of purulent, putrid, and tubercular masses. Incise the neck and open by Hilton's method, going through the sternocleidomastoid muscle or behind it. Rub the wall with bits of gauze, remove any loose bone, irrigate with hot normal salt solution, inject iodoform emulsion, insert a tube or pack with iodoform gauze. VII. ULCERATION AND FISTULA. An ulcer is a loss of substance due to necrosis of a superficial structure. The action of the pus organisms is the same as in an abscess. A broken abscess becomes an ulcer, and an ulcer is a half-section of an abscess. The floor of an ulcer consists of granulation-tissue and corre- sponds with the abscess-wall. An abscess arises from molecular death within the tissues ; an ulcer, from molec- ULCERATION AND FISl^ULA. Ill ular death of a free surface. An ulcer must not be con- founded with an excoriation. In an ulcer the corium is always, and the subcutaneous tissue is generally, destroyed, and a scar is left after healing. In an excoriation the mucous layer of epithelium is exposed, or this is destroyed and the corium exposed. In an excoriation the corium is never destroyed, and no scar remains after healing. An ulcer heals by granulation (p. 84). Embryonic tissue by vascu- larization becomes granulation-tissue, granulation-tissue is converted into fibrous tissue, the fibrous tissue contracts, and by pulling the edges of the ulcer toward each other lessens the size of the cavity. When the granulations reach the level of the skin the epithelium at the edges of the ulcer proliferates and the sore is soon covered over with new epithelium. Necrosis may arise from — (i) Inflammation. The press- ure of the exudate can cut off the circulation, or bacteria may directly destroy tissue. Suppuration occurs. (2) The action of pus bacteria, causing primary cell-necrosis. (3) Bacteria of putrefaction and organisms of suppuration acting upon a wound. (4) Traumatism or irritants, producing at once stasis, which is added to by secondary inflammation, the exudate undergoing purulent liquefaction. (5) Pro- longed pressure. (6) Deficient blood-supply. (7) Faulty venous return. (8) Degeneration of a neoplastic infiltration (gummatous, malignant, or tubercular). (9) Trophic dis- turbance. (10) Nutritional disturbances (as scurvy). Most ulcers are due to pus organisms, and even those that arise from something else (as gummatous degeneration) are apt to suppurate. Classification. — Ulcers are classified into groups ac- cording to the condition of the ulcer and the associated constitutional state. In the first group we find the varicose, hemorrhagic, acute, chronic, irritable, neuralgic, etc. In the second group are placed the tubercular, syphilitic, senile, scorbutic, etc. All ulcers, whatever their origin, are either aaitc or cJiroiiic, and such conditions as great pain, hemor- rhage, edema, exuberant granulations, phagedena, slough- ing, eczema, gout, syphilis, scurvy, etc., are to be looked upon as complications. The leg is so common a site of ulcers as to warrant a special description of ulcers of this part. In describing an ulcer state the patient's previous history ; the supposed cause ; the situation ; the outline ; the duration ; and the mode of onset of the ulcer. State if the ulcer is single or if multiple sores exist, and if there is or is not pain. 112 MODERN SURGERY. Whether or not any healing has ever occurred, and the pa- tient's constitutional condition. Set forth the complications ; the state of anatomically related glands ; the condition of the edge, the floor, and the parts about the ulcer, and the nature and quantity of the discharge. Acute ulcer of the leg may follow an acute inflamma- tion and may be acute from the start, or may be first chronic and then become acute. It is characterized by rapid progress and intense inflammation. There is rarely more than one ulcer. In outline these ulcers are usually oval, but may be irregular. The floor of an acute ulcer is covered with a mass of gray aplastic lymph, or it may have upon it large greenish sloughs. The edges are thin and undermined. The discharge is very profuse and ichorous, excoriating the surrounding parts. The adjacent surface is inflamed and edematous. There is much burning pain. In some cases the glands in the groin enlarge. When the ulcer spreads with great rapidity and becomes deeper as well as larger in surface-area, it is called " phagedenic." If sloughs form, this indicates that tissue-death is going on so rapidly that the dead portions have not time to break down and be cast off Limited stasis produces molecular death ; more exten- sive stasis, a slough. Constitutionally, there is gastro-intes- tinal derangement, but rarely fever. Treatment. — In treating an acute ulcer of the leg, give a dose of blue mass or calomel, followed in eight or ten hours by a saline (.^ij each of Rochelle and Epsom salt). Order light diet. Deny stimulants except in diphtheritic ulcer. Administer opium if pain is severe. Insist upon rest in the recumbent position with the leg elevated. Use a spray of hydrogen peroxid and the scissors and forceps to get rid of sloughs, and after sloughs are removed wash the ulcer with corrosive sublimate solution (i : looo). If the sloughs can- not be removed completely, use an antiseptic poultice. After asepticizing local bleeding is of great value. Tie a fillet below the knee, make multiple punctures in the parts about the ulcer, and let the patient sit with his leg in tepid water until six or eight ounces of blood have been lost ; then untie the fillet and dress with antiseptic poultices, keep- ing the leg elevated. In two days paint around the ulcer with equal parts of tincture of iodin and alcohol, and repeat this treatment every day, dusting the ulcer with iodoform, covering it with gauze, and producing pressure by means of a roller. Many cases do very well after local bleeding and antisep- ULCERATION AND FISTULA. II3 tization by the local use of lead-water and laudanum upon the inflamed parts around the ulcer, a roller bandage being applied to make compression. The lead-water and laud- anum should not be applied to the ulcer, but around about it. The ulcer is dressed with an antiseptic poultice. If the discharge is offensive, dress antiseptically, apply acetanilid, aristol, or iodoform, or use gr. iij of chloral to every 5j of water. A 25 per cent, ointment of ichthyol is very useful applied around the ulcer. If sloughs continue to form, touch with a I : 8 solution of acid nitrate of mercury or with a solution of pure carbolic acid, and reapply antiseptic poul- tices. If an ulcer continues to spread, clean it up with per- oxid of hydrogen, dry with absorbent cotton, touch with nitrate-of-mercury solution (i : 8), and apply an antiseptic poultice. Repeat the application of nitrate of mercury every day until the ulcer ceases to extend and granulations begin to form. In an ulcer covered with a great mass of aplastic lymph touch daily with solution of silver nitrate (gr. xl to §j) or with acid nitrate of mercury (1:15), and dress with iodo- form and antiseptic fomentations. Give internally tonics, stimulants, and good food. In any case, when granulations form we should dress antiseptically with dry dressings, or we can employ a non-irritant ointment, such as cosmolin. If granulation is slow, touch every day with a solution of silver nitrate (gr. x to §j) and dress antiseptically, or with a stimulating ointment (resin cerate or 3j of ung. hydrarg. nitratis to 3vij of ung. petrolii), or with an ointment of copper sulphate, gr. iij to |j, or with 3 drops of nitric acid to 5j of gum Arabic. Chronic ulcer of the leg is characterized by low action and slow progress. It may be chronic from the start, or it may result from acute ulcer. More usually it is found as a solitary ulcer two inches above the internal malleolus. Syph- ilitic ulcers often occur in a group, are usually crescentic, and are frequent upon the front of the knee. A tubercular ulcer may have no granulations, but is usually covered with pale edematous granulations, which signify the existence of a tendency to venous stasis. The edges of the tubercular ulcer are undermined and irregular, the parts about it are livid and tender, and the discharge is thin and scanty (p. 152). An ordinary chronic ulcer is circular or oval, and is sur- rounded by congested, discolored, and indurated skin, this induration being due to fibrous tissue, and there is often ec- zema or a brown pigmentation of the neighboring skin. The 114 MODERN SURGERY. floor of the ulcer is uneven, and usually is covered with granulations, each of which is red and the size of a pin-point, but which may be exuberant or edematous. If granula- tions are absent, the ulcer has the appearance of a piece of liver, or is smooth and glazed. The edges are thick, turned out, and not sensitive to the touch. Occasionally, but rarely, they are thin and undermined. Some ulcers are indurated and adherent ; this adhesion to the deeper struc- tures prevents healing by antagonizing contraction. An ulcer may fail to heal because of severe infection ; because of want of rest; because of absence of granulations, the result of deficient blood-supply ; because of edematous granulations ; because of exuberant granulations ; because of adhesion to deep structures, and because of some con- stitutional disease. Treatment. — In treating a chronic ulcer, give a saline every day or so. Treat any existing diathesis. Insist on rest and, if possible, elevation. Asepticize the ulcer. Draw blood by shallow scarifications of the bottom of the ulcer and the skin. If the ulcer is adher- ent, make incisions like either of those shown in Fig. 32, each cut going through the deep fascia. These incisions, besides permitting contrac- tion, allow granulations to Fig. 32.-Incisions for adherent ulcer. SprOUt in them, which CaUSC the absorption of the exudate. After incision keep the part elevated and dressed antiseptic- ally for two days. In two days after scarification or incision scrape the ulcer with a curet until sound tissue is reached. Use antiseptic poultices for two days more, then paint around the ulcer with tincture of iodin and alcohol (1:3), dress the parts about the ulcer with hot lead-water and laudanum, and dress the ulcer antiseptically or with sterile gauze. In a day or so the lead-water can be discontinued and the ulcer can be dressed antiseptically with sterile gauze, nor- mal salt solution, boric acid, bichlorid of palladium, chlorin- water, solution of permanganate of potassium, sulphur, glutol, protonuclein, or bovinin. Glutol (formalin-gela- tin) is very useful in some cases and so is protonuclein. When healing begins, treat as outlined for healing acute ulcer (p. 1 13). Complications. — Remove by scissors and forceps any useless tissue. Take out dead bone ; slit sinuses ; trim over- ULCERATION AND FISTULA. II5 hanging edges. Treat eczema by attention to the bowels and stomach, and locally by washing with ethereal soap and by the use of powdered oxid of zinc or borated talcum, the leg being wrapped in cotton. Avoid ordinary soap, grease, and ointment. Varicose veins demand either ligation at several points, excision, incision by Schede's method (p. 274), or the continued use of a flannel roller or a Martin rubber-bandage. Never operate on varicose veins if any phlebitis exists. In- flammation is met by rest, elevation, painting the neighbor- ing parts with dilute iodin, and applying about the ulcer a hot solution of lead-water and laudanum. For calloused edges, blister, employ radiating incisions, or cut the edges away. Ordinary thick edges can be strapped. In strapping use adhesive plaster and do not completely encircle the limb. For edematous granulations apply pressure by a flannel bandage, a rubber bandage, or adhesive plaster strapping. When the parts are adherent the ulcer is immovable, being firmly anchored to structures beneath it. In such a condi- tion completely or partly surround the sore with a cut through "the deep fascia (Fig. 32). This cut sets the ulcer free from its anchorage and permits it to contract. If the bottom of the ulcer is foul, dry it and touch with a solution of acid nitrate of mercury (i : 8) or with crystals of pure carbolic acid. Re- peat this every third day and dress with an antiseptic poultice until granulations appear. Superfluous granulations (proud flesh) should be cut away or mowed down with silver nitrate. Absence of granulations or scantiness of granulations means deficiency of blood-supply. The surgeon endeavors to bring more blood to the part, and to do this induces inflammation. The usual method of procedure is to apply daily to the sore a solution of nitrate of silver (10 to 15 grains to the ounce). In obstinate cases blister the ulcer or scrape it, or paint it with tincture of iodin, or apply pure carbolic acid, or touch with the actual cautery. Irritable ulcer is due to exposure of a nerve and destruc- tion of its sheath. Find with a probe the painful granulation and divide it with a tenotome, or curet the ulcer or burn it with solid stick of silver nitrate. If healing entirely fails, skin-graft. Among the methods of skin-grafting are — (i) Reverdin's, (2) Thiersch's, and (3) Krause's. (See Plastic Surgery}^ When a man having an ulcer must go out, use a firmly applied roller, or, better still, a Martin bandage. This band- age, which is made of red rubber, limits the amount of arte- rial blood going to the ulcer and favors venous flow from the Il6 MODERN SURGERY. sore and its neighborhood. The bandage should be used as follows : before getting out of bed spray the sore with hydro- gen peroxid by means of an atomizer, dry off the froth with cotton, wash the leg with soap and water, dry it, and put on the bandage — all of which should be done before putting a foot to the floor. At night, after getting in bed, take off the bandage, wash it with soap and water, hang it over a chair to dry, and again cleanse the leg and ulcer. If these rules are not strictly observed, the Martin bandage will produce pain, suppuration, and eczema of the leg. Tubercular Ulcers (p. 1 5 2). Syphilitic Ulcers (p. 197). A healthy ulcer is covered with small, bright-red granu- lations which bleed on touching, are painless, and grow rap- idly. The edges are soft and show the opalescent blue Hne of proliferating epithelium. The sore is movable, the dis- charge is purulent and yellow, and the parts about are not inflamed. Various Ulcers. — The fangous or exuberant ulcer is especially common in burns and other injuries when cicatri- cial contraction causes venous obstruction. The granulations form rapidly and mount above the level of the skin. These granulations bleed when touched. Burn them off with solid stick of silver nitrate, or cut them off with a sharp knife ; stop hemorrhage if there be any, and strap or use the rubber bandage. A varicose ulcer is usually single, is oval, round, or ir- regular in outHne, and is most often seen above the inner malleolus. Its edges are thick, everted, and swollen. This swelling is largely due to edema, and is found to pit on pressure. The edges are not undermined, but slope gently to the floor of the ulcer. The floor is usually covered with rather large granulations which bleed freely on touching. In a varicose ulcer the destruction of tissue often begins at the margin of a congested area and advances toward the centre. Such an ulcer is usually surrounded by eczema. Erethistic, irritable, or painful ulcers, which are very sensitive, are due to the exposure of nerve-filaments and destruction of their sheaths. They are especially found near the ankle, over the tibia, in the anus (fissure), or in the matrix of the nail (ingrowing nail). Curet an erethistic ulcer, and touch with pure carbolic acid or with the solid stick of silver nitrate. Chloral, gr. xx to the ounce, allays the pain ; so do cocain and eucain for a time. The indolent ulcer has no granulations and shows no ULCERATION AND FISTULA. WJ tendency to heal. It requires stimulating applications to in- crease the blood-supply. The hemorrhag-ic ulcer bleeds easily and profusely. Press- ure must be applied, and it is sometimes necessary to cut away or burn away the granulations. Phagedenic Ulcer. — The phagedenic ulcer, which means the profound microbic infection of tissues debilitated by local or constitutional disease, is commonly venereal. This ulcer has no granulations and is covered with sloughs ; its edges are thin and undermined, and it spreads rapidly in all directions. It requires the use of strong caustics or Paque- lin's cautery followed by iodoform dressing and antiseptic poultices. Internally, use tonics and stimulants. The callous ulcer is sunken deeply below the level of the skin. Its border is hard and knobby. Its floor shows no granulations, and is either smooth and glistening or foul and liver-colored. The discharge is thin and scanty, and the ulcer varies little in appearance from week to week or even from month to month. The treatment is scraping and cauteriza- tion of the ulcer ; cutting through the edges by radiating in- cisions ; application of antiseptic dressings, and a firm band- age. In some cases strap the ulcer. In severe cases cut the ulcer out and skin-graft. A rodent or Jacob's ulcer is a superficial epithelioma developing from sebaceous glands, sweat-glands, or hair- follicles. It requires scraping and cauterization, or, what is better, excision. Decubital ulcer, or bed-sore, is due to pressure upon an area of feeble circulation (p. 130). Neuroparalytic or trophic ulcer is due to impairment of the trophic centres in the cord. The perforating ulcer, a name given by Vesigne, com- monly affects the metatarsophalangeal joint or the pulp of the great toe about a corn. The parts about the corn in- flame, and pus forms and reaches into the bone. A sinus evacuates the pus by the side of the corn. As this ulcer may be present in anesthetic leprosy, paralyzed limbs, and tabes dorsalis, and as the part on which it occurs is apt to be sweaty, cold, and more or less anesthetic, and as the sore may be hereditary, it is usually set down as trophic in origin. Treatment of a perforating ulcer consists, according to Treves, in going to bed and poulticing. Every time a poultice is re- moved the raised epithelium around the ulcer is cut away and then the poultice is reapplied. In about two weeks an ulcer remains surrounded by healthy tissue. Treves treats this Il8 MODERN SURGERY. sore with glycerin made to a creamy consistency with sali- cylic acid, to each ounce of which TTLx of carbolic acid have been added. He directs the patient to wear during the rest of his life some form of bunion-plaster to keep off pressure. If in a perforating ulcer the bone is diseased, it must be re- moved. This ulcer tends to recur in the same spot or in adjacent parts, and it may be necessary to amputate the toe or the foot. The scorbutic ulcer is covered with a dark-brown crust, beneath which are pale and bleeding granulations. The parts adjacent are of a violet color. Epitheliomatous, sarcomatous, tubercular, and syphilitic ulcers are considered under these respective diseases. Fistula. — A fistula is an abnormal communication be- tween the surface and an internal part of the body, or between two natural cavities or canals. The first form is seen in a rectal fistula, a urethral fistula, or a biliary fistula, and the second form is seen in a vesicovaginal fistula. Fis- tulae may result from congenital defect, as when there is fail- ure in the closure of the branchial clefts, and can arise from sloughing, traumatism, and suppuration. Fistulae are named from their situation and communications. A sinus is a tortuous track opening usually upon a free surface and leading down into the cavity of an imperfectly- healed abscess. A sinus may be an unhealed portion of a wound. Many sinuses may be due to pus burrowing subcu- taneously. A sinus fails to heal because of the presence of some irritant fluid (as saliva, urine, or bile) ; because of the existence of a foreign body, as dead bone, a bit of wood, a bullet, a septic ligature, etc. ; or because of rigidity of the sinus-walls, which rigidity will not permit collapse. The walls of a tubercular sinus are lined with a material identical with the pyogenic membrane of a cold abscess. Sinuses may be maintained by want of rest (muscular movements) and general ill-health. Treatment. — In treating a fistula, remove any foreign body, lay the channel open, curet, swab with pure car- bolic acid, and pack with iodoform gauze. In obstinate cases entirely extirpate the fibrous walls, sew the deeper parts of the wound with buried catgut sutures and approxi- mate the skin-surfaces with interrupted sutures of silkworm gut. Fresh air is a necessity, and nutritious food and tonics must be ordered. MORTIFICATION, GANGRENE, OR SPHACELUS. II9 VIII. MORTIFICATION, GANGRENE, OR SPHACELUS. Mortification or gangrene is death in mass of a portion of the surface of the living body — the dead portions being visible — in contrast to ulceration or molecular death, in which the dead particles are too small to be seen and are cast away. Gangrene is in reality a form of necrosis. But clinically the term necrosis is restricted to molar death of bone or to death of parts below the surface. In gangrene the dead portions may either desiccate or putrefy. Gan- grene may be due to tissue-injury, either chemical or me- chanical, to heat or cold, to failure of the general health, to circulatory obstruction, to nerve-disorder, the nerves in- volved being the vasomotor or possibly the trophic, or to microbic infection. A microbic poison can directly destroy tissues. It can indirectly destroy them by causing such inflammation that the products obstruct the circulation. When the mortified portion is entirely dead the process is spoken of as " sphacelus." Classification. — Gangrene is divided into the following three great groups : (i) Dry gangrene, which is due to circulatory interference, the arterial supply being decreased or cut off. As venous return is still active, all fluid is taken up from the tissues, which shrivel and mummify. (2) Moist gangrene, which is due to interference not only with arterial ingress, but also with venous return or capillary circulation, the dead parts remaining moist. (3) Septic gangrene, arising from virulent septic matter coming from outside. In this form the septic process causes the gangrene, and is not merely associated with it. There are many gangrenous processes which belong under one or other of the above heads, namely : co7igenital gan- grene, a rare form existing at birth ; constitutional gangrene, arising from a constitutional cause, as diabetes ; ciitajieoiis gangrene, which is limited to skin and subcutaneous tissue, as in phlegmonous erysipelas ; gaseous or cuiphyseviatous gangrene, in which the subcutaneous tissues are filled with putrefactive gases and crackle on pressure ; diabetic or gly- cemic, due to diabetes ; hospital gangrene, which is defined by Foster as specific serpiginous necrosis, the tissues being pulpefied : some consider it a traumatic diphtheria ; cold gangrene, a form in which the parts are entirely dead (sphacelus) ; hot gangrene, which presents some inflamma- tion, as shown by heat ; dermatitis gaugrcenosa infantum, or I20 MODERN SURGERY. the multiple cachectic gangrene of Simon ; idiopathic gan- grene, which has no ascertainable cause ; mixed, which is partly dry and partly moist ; primary, in which the death of the part is direct, as from a burn ; secondary, which follows an acute inflammation ; multiple, as gangrenous herpes zoster ; diabetic gangrene, which arises during the existence of dia- betes ; gangrenous ecthyma, a gangrenous condition of ec- thyma ulcers ; pressure, which is due to long compression ; purpuric or scorbutic, which is due to scurvy ; Raynaud's or idiopathic symmetrical, which is due to vascular spasm from nerve-disorder; senile, the dry gangrene of the aged; venous or static, which is due to obstruction of circulation, as in a strangulated hernia ; trophic, which is due to nutritive failure by reason of disorder of the trophic nerves or centers ; thrombotic, which is due to thrombus ; embolic, which is due to embolus ; and decubital gangrene, or bed-sores due to pressure. Dry or chronic gangrene, Pott's gangrene (Fig. 33), arises Fig. 33. — Chronic gangrene of the feet (Gross). from deficiency of arterial blood. Even in a person with healthy arteries dry gangrene may result from injury of the main trunk of an artery (lodging of an embolus, ligation, or laceration). Gangrene only follows injury when the anas- tomotic circulation fails to sustain the part. Obstruction due to thrombus is not unusual in the diseased arteries of the aged. When an embolus lodges in an artery and causes gangrene, the case runs the following course: sudden severe pain at the seat of impaction, and also tenderness ; pulsation above, but not below, this point ; the limb below the obstruc- tion is blanched, cold, and anesthetic ; within forty-eight hours, as a rule, the area of gangrene is widespread and clearly evident; the limb becomes reddish, greenish, blue. MORTIFICATION, GANGRENE, OR SPHACELUS. 121 and then black ; the skin itself becomes shrivelled and its outer layer stony or like horn because of evaporation. The entire part may become as dry as a mummy, but usually there are spots where some fluid remains, and these spots are soft and moist, and the dead tissue where it joins the living is sure to be moist. The moist areas become foul and putrid, but the dry spots do not. At the point of con- tact of the dead and living tissue inflammation arises in the latter structure, a bright-red line forms, and exudation and ulceration take place. This line of ulceration in the sound tissues is called the " line of demarcation." It is Nature's effort at amputation, and in time may get rid of a large por- tion of a limb, and then heal as any other ulcer. In dry gan- grene from arterial obstruction there are gastro-intestinal de- rangement and some fever. The gangrene does not extend up to the point of obstruction, but only to a region in which the anastomotic circulation is sufficiently active to permit of the formation of a line of demarcation. Below this point in- flammatory stasis arises, but before this can go on to ulcera- tion the parts die. In cases where the arterial obstruction is sudden and complete the limb may swell considerably. This is due to the sudden loss of vis a tcrgo in the arterial system, venous reflux occurring and fluids transuding. In such a case, though the tissues contain some fluid and putrefy, the process is pathologically dry gangrene. Dry gangrene at- tacks the leg more often than the arm. Thrombus in an artery rarely causes gangrene except in the aged, as the circulation has time to adjust itself; but gangrene may fol- low thrombus, and when it does it comes on more slowly than does gangrene from embolus. Senile gangrene is a form of dry gangrene due to feeble action of the heart plus obliterating endarteritis or atheroma of peripheral vessels. The vessels do not properly carry blood, and may at any time be occluded by thrombosis. In a drunkard, or in a victim of syphilis or tubercle, the changes supposed to characterize old age may appear while a man is young in years. It was long ago said, with truth, " a man is as old as his arteries." Senile gangrene most often occurs in the toe or the foot. Symptoms. — A man whose vessels are in the state above indicated is generally in feeble health and has a fatty heart and an arcus senilis (a red or white line of fatty degeneration around the cornea). His feet feel cold and numb, and they " go to sleep " very easily. He is dyspeptic and short of breath, and his urine is frequently albuminous. The arte- 122 MODERN SURGERY. ries are felt as rigid tubes, like pipe-stems. He is in much danger of edema of the lungs and of dry gangrene. A very- slight injury of a toe will produce extensive inflammatory stasis, which completely cuts off the blood-supply and causes gangrene of the part. Gangrene is usually an- nounced by a blue spot, followed by a vesicle which lets out bloody serum and has a dry floor. The tissues adja- cent to the dead toe become victims to stasis and gangrene, and the process ascends until it reaches tissue whose circu- lation is sufficiently good to permit of ulceration instead of gangrene, when a line of demarcation forms. The dry parts do not putrefy. They are anesthetic, hard, leathery, and wrinkled, and resemble a varnished anatomical specimen or the extremity of a mummy (hence the term mummification). Before the line of demarcation forms there is some burning pain ; after it forms pain is rarely present. If embolism or thrombus in a diseased vessel caused the gangrene, the pain is severe. In senile gangrene the periphery is always dry, the part nearer the body being generally somewhat moist. A line of demarcation may start, but prove abortive, the tis- sue mortifying above it. This proves that tissue near the line is in a state of low vitality. An entire leg may become gan- grenous. When a limited area is gangrenous constitutional symptoms are trivial or are absent, but when a large area is. involved we find the fever of septic absorption. Death may ensue from exhaustion caused by sleeplessness and pain, from septic absorption, or from embolism of internal organs. In many cases of senile gangrene thrombosis arises in the super- ficial femoral artery or its branches (Heidenhain), an observa- tion it is important to bear in mind when amputating. Treatment of Dry Gangrene. — When injury of a healthy artery causes us to fear dry gangrene the patient should be placed in bed and the part elevated a little, kept wrapped up in cotton-wool and warmed with hot bottles or water-bags. The dying part is dressed antiseptically, and the surgeon sees to it that the patient gets plenty of sleep and nourishment. It is advisable to give tonics and stimulants. Wait for a line of demarcation and amputate well above it. When on am- putating no arterial blood flows, perform catheterism of the artery with a filiform bougie or a fine rubber catheter. In- sert the instrument into the artery, and work it up and down to break up the clot. Bleeding will occur; wash out the clot and then tie the vessel.^ If a person is of the type in which there is danger of senile gangrene, he should 1 See Mancozet's report before second Pan-American Med. Congress. MORTIFICATION, GANGRENE, OR SPHACELUS. 1 23 be cautioned against injuring his feet, especially cutting his corns carelessly, which is highly dangerous ; any wound, however slight, requires rest and antiseptic dressing. He must wear woollen stockings, put a hot-water bag to his feet on cold nights, and attend to his general health. A little whiskey after each meal is indicated, and occasional courses of nitroglycerin are desirable. When gangrene occurs, if it is limited to one toe or a por- tion of several toes, if it is a first attack, if there is no fever or exhausting diarrhea, if there is no tendency to pulmonary congestion, if appetite is fair and sleep refreshing, we can await the formation of a line of demarcation. While awaiting the line of demarcation dress the part antiseptically and raise it about two inches from the bed, apply warmth, give the patient nourishing diet, stimulants, and tonics ; see to it that he sleeps, and watch for fever, diarrhea, pulmonary congestion, and kidney-failure. When a line forms, dress with antiseptic fo- mentations and iodoform, and every day pick away dead bits with the scissors and forceps. In many cases healing will occur ; but even when the parts heal the patient will always be in deadly peril of another attack. If the gangrene shows a tendency to spread, if it involves more than a portion of several toes, if it is not a first attack, if there is sleeplessness, fever, exhausting diarrhea, absent appetite, or a strong ten- dency to pulmonary congestion, do not delay, but at once am- putate high up. If the gangrene shows no tendency to limit itself, or if the patient develops sepsis or exhaustion, at once amputate high up. The best point at which to amputate is above the knee, so that the deep femoral artery, which rarely becomes atheromatous, will nourish the flap. Never amputate below the tubercle of the tibia. Some operators disarticulate at the knee-joint. Heidenhain affirms that so long as the gangrene is limited to one or two toes we should merely treat it antiseptically, elevate the limb, and wait for the dead part to be cast off spontaneously ; if, however, it extends to the dorsum or sole of the foot, amputate at once above the knee. He further states that gangrene of the flaps almost always occurs in amputation below the knee, and high am- putation is indicated in advancing gangrene with or without fever.^ When amputation has been performed and no arte- rial bleeding occurs, clots exist in the femoral artery. If such a condition exist, insert into the artery a fine rubber sound and break up the clot. When blood runs the clot is washed out (Severeanu). ' Deutsche medicinische Wochenschrift, 1891, p. 1087. 124 MODERN SURGERY. In moist or acute gangrene (Fig. 34) the dead part re- mains moist and putrefies. It results from interference with venous return or capillary flow, as well as from arterial in- gress. It may arise in a limb after ligation or destruction of its main artery and vein, after long constriction, after crushes and lacerated wounds, and after thrombosis of the vein. Moist gangrene may follow acute inflammation, or may be Fig. 34. — Acute mortification (Gross). due to local constriction (strangulated hernia), crushing, chemical irritants, heat, and cold. Moist gangrene of a limb is seen typically when both vein and artery are damaged or destroyed. The leg swells and is pulseless below the obstruction ; the skin becomes cold, livid, and anesthetic, and is raised up into blebs which contain serosanguineous fluid. The extremity swells enormously, there is pain at the seat of obstruction, and sapremic symp- toms quickly develop. The bullae break and disclose the deeper structures, which are swollen and edematous. The fetor is horrible. Portions of the extremity become em- physematous and crepitate on pressure. A line of demarca- tion soon forms. Moist gangrene from inflammation is due to pressure of the exudate cutting off the blood-supply, or to loss of blood- circulation because of microbic involvement of vessels and clotting of blood. It occurs in phlegmonous erysipelas. When an inflammation is about to terminate in gangrene all the signs of inflammation, local and constitutional, increase ; when gangrene occurs they cease, bullae and emphysema are noted, with great swelling and all the other symptoms of molar death. The sudden cessation of pain is very suggestive of gangrene. The constitutional symptoms are those of sup- purative fever and sapremia, or possibly of septic infection. Treatment of Moist Gangrene. — In extensive moist gan- grene of a limb wait for a line of demarcation, and amputate clear of and above it. While waiting for the line to form dress the dead parts antiseptically, wrap in cotton, apply heat, and slightly elevate the limb. Give opium, tonics, nour- MORTIFICATION, GANGRENE, OR SPHACELUS. 1 25 ishing food, and stimulants. In inflammatory gangrene re- lieve tension by incisions and then cut away the dead parts, brush the raw surface with pure carbolic acid, dust with iodoform, and dress with hot antiseptic fomentations. Stim- ulate freely and feed well. Gangrene due to infective organisms comprises — (i) traumatic spreading gangrene ; (2) hospital gangrene ; (3) phagedena; (4) noma vulvae; and (5) cancrum oris. Fulminating- gangrene, gangrenous emphysema, gan- grene foudroyante, or traumatic spreading gangrene, re- sults from a virulent infection of a severe wound by strepto- cocci and organisms of putrefaction. The injury damages the main vessels of the limb, the pulse below the injury is imperceptible, and the surgeon is often at this time uncertain whether to amputate at once or wait. This form of gangrene is commonest after compound fractures, and begins within forty-eight hours after the accident. It does not begin at the periphery, as does ordinary moist gangrene, but at the wound-edges, which turn red, green, and finally black ; the extremity soon undergoes a like change and becomes morti- fied. The entire limb swells because of edema, the skin peels off, emphysema sets in, and the extremity becomes anesthetic and pulpy. The gangrene spreads up and down from the wound, and red lines run from above the wound. These are due to lymphangitis, the adjacent lymph-glands swell, and in thirty-six hours the gangrene may involve an entire limb. No line of demarcation forms. The system is soon overwhelmed with ptomains, and the patient has septic in- toxication, or he passes into profound collapse with subnor- mal temperature. Traumatic spreading gangrene must not be confused with erysipelas. In erysipelas the color is red, pressure instantly drives it out, and on the release of pressure it at once returns. In early gangrene the color is purple, pressure fails to drive it out at all or only does so very slowly, and if the surface is blanched by pressure, on the release of pressure the color crawls slowly back. Treatment. — In treating traumatic spreading gangrene a line of demarcation need not be waited for, as none can form. Amputation should at once be performed high up, the flaps are brushed with pure carbolic acid, and stimulants must be given in large amount. Hospital gangrene or sloughing phagedena is a disease that has practically disappeared from civilized communities. It formerly occurred in crowded, ill-ventilated hospitals. Some consider it traumatic diphtheria. Koch thinks it is due to 126 MODERN SURGERY. streptococci. Jonathan Hutchinson says, " hospital gangrene is set up by admitting to the wards a case of syphilitic phage- dena." It may show itself as a diphtheritic condition of a wound, as a process in which sloughs Hke masses of tow form, or as a phagedenic ulceration. The surrounding parts are inflamed and painful, and buboes form in adjacent lymphatic glands. The system passes into a low septic state. Treatment. — In treating hospital gangrene ether should be given, the large sloughs removed with scissors and forceps, the part dried with cotton and cauterized with bromin. Take a tumblerful of water and into it pour the bromin : this falls to the bottom ; draw it up with a syringe and inject it into the depths of the wound. The wound is plentifully sprinkled with iodoform and is dressed with antiseptic poultices until the sloughs separate, when the sore is treated as an ordinary ulcer. Constitutional treatment is that of sepsis. If a limb is hopelessly damaged by this form of gangrene, we must wait for a line of demarcation and amputate. Special Forms of Gangrene. — Symmetrical or Ray- naud's gangrene arises in severe cases of Raynaud's disease. It is a dry gangrene. Raynaud's disease, a vasomotor neu- rosis seen in children and young adults, is characterized by attacks of cold, dead bloodlessness in the fingers or toes as a result of exposure to cold or of emotional excitement (local syncope). In the more severe cases we may have capillary congestion and livid swelling (local asphyxia). Chilblains belong to this group. The patient complains of pain, ting- ling, and stiffness. It is after local asphyxia that the gan- grene may appear. This gangrene is usually seen upon the ends of the fingers or the toes, but it may attack the lobes of the ears, the tip of the nose, or the skin of the arms or the legs. When gan- grene is about to occur the local asphyxia at that point deepens, anesthesia is complete, and the part blackens and becomes cold. The epidermis is now raised up into blebs, which rupture and expose dry surfaces. A line of demarca- tions forms, and the necrosed area is removed as a slough. Widespread gangrene from Raynaud's disease is rare ; there is not often a large area involved — rather a small superficial portion. Sometimes the disease is seen upon the trunk. These attacks recur again and again, are often accompanied by hemoglobinuria (Osier), and are sometimes excited by cold or by mental disturbance. The pathology is uncertain. Local syncope is thought to be due to vascular spasm, and MORTIFICATION, GANGRENE, OR SPHACELUS. 12/ local asphyxia to some contraction of the arterioles with dilatation of the capillaries and venules. TrcatDioit of Raynaud's Disease. — When attacks of Ray- naud's disease arc so severe as to threaten gangrene, the patient should be put to bed ; if the feet are affected, elevate the legs, wrap the extremity in cotton-wool, and apply heat. If the hands are affected, they should be elevated, wrapped up, and the arms and hands warmed. Massage is useful. When gangrene occurs, dress the part antiseptically until a line of demarcation forms, and then remove the dead parts by scissors, forceps, and antiseptic poultices. If amputation becomes necessary, which will rarely be the case, wait for a line of demarcation. Diabetic gangrene resembles in many points senile gan- grene, but the dead portions remain somewhat moist and putrefy. Some attribute it directly to sugar in the blood. Some think the tissues are simply less resistant to infection. Many hold that it is of neurotic origin. Heidenhain be- lieves that it is due to arterial sclerosis. Diabetic gangrene is most usually met with upon the feet and legs of elderly people, but it may arise at any age and may attack the gen- ital organs, thigh, lung, buttock, eye, back, finger, or neck (Hunt). It may show a single area, may show several areas, or may be symmetrical. It may arise in any stage of dia- betes from the earliest to the latest. It may begin as a per- forating ulcer, and, as in senile gangrene, a trivial injury is apt to be the exciting cause. It may arise without any ante- cedent injury. When the gangrene follows a traumatism there are no prodromic symptoms. When it arises spontaneously in the skin it is often preceded by pain of a neuralgic nature and attacks of " livid or violaceous discoloration of the skin, with lowered surface-temperature and sometimes loss of sen- sation " (Elliot). This gangrene is often superficial, but may become deep if it follows an injury or ulcer. The gan- grenous area is somewhat moist as a rule, but may be dry. The parts about are livid and may be covered with vesicles. It spreads slowly, but more rapidly than senile gangrene. There is little tendency to the formation of any line of de- marcation, although occasionally spontaneous healing occurs. Surgeons have become shy of amputating in such cases, but the experience of Kuster, of Berlin, proves conclusively that an amputation should be performed at once in diabetic gan- grene, and should be done above the knee. If we operate below the knee, the flaps will become gangrenous. It has been noted that sugar will sometimes disappear from the 128 MODERN SURGERY. urine after an amputation. Of 1 1 amputations by Kuster, 6 recovered and 5 died; and of these 5, 3 had albumin in the urine as well as sugar.^ Heidenhain warmly advocates early high amputation, with the making of short flaps. When the patient dies after ope- ration he usually does so in coma. In any case after opera- tion, or in any case not operated upon, treat the diabetes by means of drugs and diet. Never fail to examine the urine in every case of gangrene, for diabetes might be present when it had not been suspected. Surgical operations upon diabetes are, of course, very dangerous, and are only advised in emergencies, because the wound is apt to slough and coma may arise. Gangrene from erg-otism is a peripheral dry gangrene arising from tonic vascular contraction produced by the ergot in bread made from diseased rye. The gangrene is preceded by anesthesia, muscular cramp, tingUng pains, itching, and " gradual blood-stasis in certain vascular areas " (Osier). This form of gangrene occurs in epidemics where rye-bread is largely used, but is very rare in the United States. It usually affects the fingers or toes, but may involve an entire limb, and can be symmetrical. In acute cases death occurs in from seven to ten days.^ In severe chronic cases await a line of demarcation and then amputate. In superficial cases dress with hot antiseptic fomentations and elevate the part, and every day take scissors and forceps and remove the loose crusts. Gangrene from Frost-bite. — When parts have been badly frozen the peripheral portions dry up. The parts are deprived of all blood because of contraction of the vessels and because plasma coagulates at a few degrees above freezing. Cold disorganizes the blood, breaking up white corpuscles with the liberation of fibrin-ferment and the subsequent coagula- tion of plasma, and destroying red corpuscles with the libe- ration of hemoglobin. When a patient so afflicted is brought into a warm atmosphere, blood cannot run into the dead part, and the living tissues in contact with it inflame, form- ing a line of demarcation. Hence we note that severe frost- bite causes dry gangrene. If a part which is not so badly frozen is brought suddenly into a warm atmosphere, inflam- mation takes place when the blood runs into the frosted tissues, and moist gangrene results. A frost-bite in which the skin is livid and not as yet gangrenous should be treated 1 See the convincing article of Chas. A. Powers in Amer. Journal of Med. Sciences, Nov. ii, 1892. '^ Pick, in Heath's Surgical Dictionary. iVORTIFICATION, GANGRENE, OR SPHACELUS. 1 29 by frictions with snow or towels soaked in iced water. As the skin becomes warmer and congestion disappears the part should be wrapped in cotton-wool. A sufferer from frost-bite should not suddenly be brought into a warm room. When gangrene follows, if only small areas be involved, al- low the dead part to come away spontaneously, applying in the meanwhile hot antiseptic fomentations. If separation be delayed by cartilage, ligament, or bone, cut through the re- taining structure. If amputation becomes necessary, await a line of demarcation, as we are not sure how high tissue- damage extends, and to amputate through devitalized parts would mean renewed gangrene. Noma, or cancrum oris, is a gangrene beginning as a sloughing ulcer on the gums or cheeks, and affecting young children who live amid filth and squalor or who are conva- lescing from acute fevers. This disease may destroy large portions of the cheeks and jaws. The constitutional symp- toms are diarrhea, fever, and great exhaustion. Death is the usual result, due frequently to septic bronchopneumonia (Bowlby). Lingard has found a bacillus which he believes is causative of noma, but most observers consider pus organ- isms as causative. The treaUncnt of noma consists in destruction of the dis- eased tissue by nitric acid or the actual cautery, the use, lo- cally and often, of peroxid of hydrogen and antiseptic washes, and, internally, the employment of nutritious food, stimulants, and tonics. After arrest of the gangrene a plastic operation may be required. Sloughing is a process of ulceration by which visible portions of dead tissue are separated. These visible portions are called " sloughs ;" if they were large, they would be called " gangrenous masses." A large slough is a gangre- nous mass ; a small gangrenous mass is a slough ; there is no difference in the process, which corresponds to the forma- tion of a line of demarcation. Sloughing requires thorough cleansing, removal of the sloughs, and antiseptic treatment. Antiseptic fomentations are applied until granulation is well advanced. Phagedena is a process (most common in a venereal sore) in which the surrounding tissues are rapidly eaten up, the sore becoming jagged and irregular, with a sloughy base and thin edges ; the discharge becoming thin and reddish, and the encircling tissues becoming deeply congested. This ulcer has no tendency to heal. It is due to a specific poison which has not yet been isolated. Nojua viilvcs is a form of 9 130 MODERN SURGERY. phagedena which attacks the genitals of Httle girls who are unhealthy, dirty, or convalescent from a specific fever. The treatment of phagedena consists in repeated touch- ing with tincture of chlorid of iron and the local use of iodoform, the employment of continued irrigation, or the application of the cautery, chemical or actual. The parts are dressed with hot antiseptic fomentation. Whatever else is done, tonics, stimulants, and nutritious diet must be given. Decubital Gangrene, or Bed-sore.— A bed-sore is the result of local failure of nutrition in a person whose tissues are in a state of low vitality from disease or from injury. Such sores are due to pressure, aided it may be by the pres- ence of urine, of feces, and of sweat, by wrinkHng of the sheets, or the dropping of foreign bodies (such as crumbs) in the bed. These ordinary pressure-sores arise like splint- sores due to the pressure of a splint upon the tissues over a bony prominence. They occur over the heels, elbows, scapulae, trochanters, sacrum, and nucha. The pressure in- terferes with the blood-supply, the weakened tissues inflame, vesication occurs, sloughs form, and an ugly ulcer is ex- posed. The acute bed-sore of Charcot is seen during certain dis- eases and after some injuries of the nervous system. These sores are usual over the sacrum in acute myelitis, and may appear in four or five days after the beginning of a disease or the infliction of an injury. The surgeon sees acute bed- sores upon the buttock of the paralyzed side after brain- injuries, and over the sacrum in spinal injuries. Some believe these sores are due to vasomotor disorder, but others, notably Charcot, attribute them to disturbance of the trophic nerves or centres. Treatment of Bed-sores. — The " ounce of prevention " is here invaluable. From time to time, if possible, alter the position of the patient, keep him clean, maintain the blood- distribution of the skin by frequent rubbing with alcohol and a towel, and keep the sheet clean and smooth. When congestion appears (paratrimma, or beginning sore), at once use an air-cushion or a water-bed and redouble the care to frequently change the position of the patient. Not only protect, but also harden, the skin. Wash the part twice daily and apply spirits of camphor or glycerole of tannin ; or rub with salt and whiskey (3ij to Oj) ; or apply a mixture of 5ss of powdered alum, fgij of tincture of camphor, and the whites of four eggs ; or paint with corrosive sublimate and alcohol (gr. ij to 3j) ; or apply tannate of lead or equal MORTIFICATION, GANGRENE, OR SPHACELUS. I3I parts of oil of copaiba and castor oil ; or paint on a protective coat of flexible collodion. When the skin seems on the verge of breaking, paint it with a solution of nitrate of silver (gr. xx to 5j). When the skin breaks, a good plan of treatment is to touch once a day with silver solution (gr. x to 5J) and cover with zinc- ichthyol gelatin. We can wash the sores daily with i : 2000 corrosive-sublimate solution, dust with iodoform, and cover with soap plaster, with lint spread with zinc ointment, or with dry aseptic gauze. When sloughs form, cut most of them off with scissors after cleaning the parts, slit up sinuses, and use antiseptic poultices. In sloughing Dupuytren employed pieces of lint wet with lime-juice and dusted the sore with cinchona and charcoal. In obstinate cases use the contin- uous hot bath or the intermittent ice poultice. When the sloughs separate, dress antiseptically or with equal parts of resin cerate and balsam of Peru. If healing is slow, touch occasionally with silver solution (gr. x to 5j). Bed-sores, being expressive of lowered vitality, demand that the pa- tient shall be stimulated, shall be well nourished, and shall sleep soundly. Postfebrile Gangrene. — Dry or moist gangrene may follow any fever, but is most frequent after typhoid (may follow influenza, measles, scarlet fever, etc.). Keen, in the Toner lecture for 1876, collected 113 cases of postfebrile gangrene, and 43 of these were due to typhoid. It is most usual in the lower extremities, but may appear in the upper extremities, cheeks, ears, nose, genitals, lungs, etc. Some writers have assigned as the cause weakness of cardiac action, but most observ^ers believe an obstructing clot is the usual cause. This clot is secondary to endarteritis due to toxins of the typhoid bacillus.'^ It most often appears in the third week, but may arise far into convalescence. Treatment presents nothing exceptional. If an extremity is extensively involved, await a line of demarcation before amputating. Rules when to Amputate for Gangrene. — In dry gangrene, due to obstruction of a non-diseased artery, wait for a line of demarcation. In senile gangrene, if it affect only one or two toes, let the dead parts be cast off sponta- neously. If a greater area is involved or the process spreads, amputate above the knee without waiting for the line. In ordhiary moist gangrene wait for a line of demar- cation. In traumatic spreading gangrene amputate at once. In hospital gangrene and in Raynaitd's gangrene wait for a ^ Mettler, in iVe-w York Med. Joiir., March 9, 1895. 132 MODERN SURGERY. line of demarcation. In diabetic gangrene amputate at once, high up. In ergot gangrene, in postfebrile gangrene, and in frost gangrene wait for a line of demarcation. IX. THROMBOSIS AND EMBOLISM. Thrombosis is the antemortem coagulation of blood in the heart or in a vessel, the coagulum remaining at its point of origin and plugging up the vessel partially or completely. This process is an essential part in the arrest of hemor- rhage ; it occurs in phlebitis and arte- ritis, and affords a frequent basis for embolism. Thrombi may form in the veins, in the arteries, and in the heart. Clotting is due to destruction of white blood-cells, fibrin-ferment being set free, causing the union of calcium and fibrin- ogen and thus forming fibrin. Throm- bosis is more common in the veins than in the arteries, the slow blood-current and the existence of valves favoring the deposit, though not causing it. Fig. 35 shows thrombosis. Causes of Thrombus. — The essential cause of all intravascular thrombi is damage to the endothelial coat, though many other conditions favor their formation. Among these favoring conditions are retarded circulation in tuberculosis, influenza, and fevers, the blood clotting behind the vein- valves after the endothelium has been damaged by toxins ; or the pressure of a bandage or of a splint ; varicose veins ; ligation of a vessel ; injuries of a vessel ; foreign bodies in a vessel ; atheroma in arteries ; sutures in a vessel ; certain dis- eases, such as gout, typhoid fever, pregnancy, and septic processes ; phlebitis or arteritis arising in the vessel or from extension of surrounding inflammation ; and entrance of spe- cific organisms. It has been asserted that so long as the endothelium of a vessel is uninjured a clot does not form. Slowing of the blood-current in aseptic conditions, it is now taught, will not cause thrombosis. One of the functions of the endo- thelial coat is to keep the blood fluid by preventing corpus- cular disintegration. A thrombus can form only v/hen fibrin- ferment is set free, and fibrin-ferment can be set free only when white corpuscles disintegrate. When moving blood Fig. 35. — Thrombus in the saphenous vein (Green). THROMBOSIS AND EMBOLISM. I 33 coagulates, the third corpuscles first settle out, and then the leukocytes. This is known as the white or " antemortem " thrombus — the clot of moving blood. Thrombi from mov- ing blood are rarely pure white : they contain some red cor- puscles, forming mixed thrombi. The red thrombus plugs vessels which are cut across or ligated ; it also occurs in sep- tic processes, and is formed after death. A thrombus may be absorbed, first embryonic tissue and then fibrous tissue re- placing it (organization). A thrombus may degenerate and break down (fatty degeneration), giving rise to emboli. A thrombus may calcify or may undergo purulent liquefaction, infective emboli being set free. A thrombus in an artery is apt to extend to the first collateral branch, but does not pass higher. The blood-current into the branch prevents further extension. Remember this fact when an artery is cut near a large branch. If we simply tie the artery, such a short clot will be formed that the vessel will not be oblit- erated. Tie not only the artery, but also the branch. A clot in a vein may extend a long distance. The author has seen in a postmortem examination a venous thrombus reach- ing from the ankle to the vena cava. Symptoms. — The symptoms are dependent on the seat of the obstruction. An organ or a part of an organ may exhibit functional aberration. The local signs in a vessel accessible to touch or sight are the presence of a clot ; if it be an artery, anemia and the absence of pulse below the clot ; if it be a vein, swelling and edema below it. There is usually pain at the seat of trouble, and anesthesia below it. Moist gangrene may follow venous thrombosis, and dry gan- grene arterial thrombosis. Thrombophlebitis is inflammation of a vein in which a septic thrombus forms. We see this condition sometimes in the lateral sinus of the brain as a result of suppuration in the middle ear; in any of the cere- bral sinuses after compound fracture of the skull ; and in the uterine veins in puerperal sepsis. It is the first step in pye- mia. Thrombo-arteritis is inflammation of an artery in which a septic thrombus forms or in which a septic embolus lodges. It occasionally attacks an aneurysmal sac. Treatment. — If in a limb, raise the limb a few inches from the bed, keep it perfectly quiet to avoid detachment of frag- ments (emboli), paint with iodin or rub with ichthyol, apply a bandage from the toes up, and place hot bottles around the extremity. The great danger is the formation of emboli, so avoid movements and rough handling. In thrombophle- bitis, if the vessel is accessible, tie it above and below the 134 MODERN SURGERY. clot, open the vessel, remove the clot, irrigate, and pack with iodoform gauze. Internally the treatment is stimulant and supporting. Massage is unsafe. In thrombo-arteritis treat as in thrombophlebitis. ^^mbolism signifies vascular plugging by a foreign body (usually a blood-clot) which has been brought from a dis- tance. Emboli may arise either in the venous or in the arterial' system, but lodge only in an artery or in the veins of the liver. The initial thrombus may form upon diseased heart-valves or in a vein. It may be composed of fat, mi- cro-organisms, air, or a portion of a tumor. An embolus is arrested when it reaches a vessel whose diameter is less than its own. It is usually caught just above a bifurcation. When an embolus lodges, it at once partially or entirely obstructs the circulation, and increases in size by throm- bosis. A non-septic embolus usually organizes. A soft embolus may disintegrate and permit of re-establishment of the circulation. An embolus may cause an aneurysm. A septic embolus breaks down, forms a metastatic abscess, and sends other emboli onward. Fig. 36 shows an impacted embolus. An embolus is more serious than a thrombus : it causes sudden plugging which makes dangerous anemia inevit- able, and it may produce gangrene if the collateral circulation fails. In organs with terminal arteries (spleen, kidney, brain, and lung) there is no collateral circulation and embolism causes infarction. The embolus produces an area of anemia ; the removal of all propulsion upon the venous blood causes it to flow back and stagnate, and vascular elements exude, forming a wedge- shaped area of red tissue, the embolus being the apex of the wedge. This is known as the " red infarction," and is often seen in the lung. The white infarction seen in the brain and kidney is not due to retrogression of venous blood, but is due to anemia and resulting coagulation-necrosis. A septic embolus causes septic arteritis and a septic infarction, and a septic infarction suppurates and forms a pyemic abscess. Symptoms. — The symptoms depend upon the organ in- volved. They are sudden in onset, and consist of loss of function which may be permanent or which may be followed Fig. 36. — Embolus impacted at bifurcation of a branchi of the pulmonary artery (Green). THROMBOSIS AND EMBOLISM. I 35 by inflammation or softening. Embolism of the cerebral arteries may cause aphasia, paralysis, or coma. Embolism of the pulmonary artery may cause almost instant death. Embolism of the central artery of the retina causes blindness. Embolism of a large artery of a limb produces symptoms identical with thrombus, except more sudden and decided. Treatment. — The treatment of aseptic embolism depends upon the part involved. In a limb, keep the part warm in order to stimulate the collateral circulation, elevate several inches from the bed, and insist on perfect quiet. Massage is unsafe. If gangrene ensues, await a line of demarcation and amputate. In septic arteritis in an accessible region it would be good surgery to act as in thrombo-arteritis from thrombosis. Unfortunately, such a condition is not often in an accessible region. After an operation upon veins (as the operation for varicocele or for hemorrhoids), after a cutting operation, and after fracture, avoid as much as possible move- ments or handling, as fragments of thrombus may be de- tached. Operations upon the rectum may be followed by hepatic embolism and abscess of the liver. Fat-embolism is an accumulation in the capillaries of liquid fat after injuries of adipose tissue, high tension forcing the fat into the open mouths of veins. Some little fat may get into the blood by means of the lymphatics. Fat-em- bolism occasionally arises in osteomyelitis, after extensive bruises, crushes, or lacerations, and after amputations, frac- tures, resections, or rupture of the liver.' This fluid fat ac- cumulates especially in the capillaries of the lung and brain. Symptoms. — The symptoms are those of edema of the lungs and exhaustion, often with coma or delirium. There are restlessness, dyspnea, rapid pulse and respiration, and low temperature. If life is prolonged a day or two, oil is found in the urine. Small amounts of oil may be found in the urine after serious injuries or operations when no symptoms of embolism exist. Nevertheless, the presence of the oil is always an ominous sign, and is often a w^arning. These symptoms never occur until at least twenty-four hours after the accident, and rarely before the third day. The symptoms occur at a later period than those of shock, and at an earlier period than those of ordinary embolism of the lung. Severe cases are commonly fatal ; milder cases are often recovered from. Treatment. — The treatment consists of the ordinary meth- ods used in shock — stimulants, heat, etc., with dry cupping 1 G. H. Makins, in Heath's Dictionary. 136 MODERN SURGERY. of the chest, the use of diuretics, strychnin, digitalis, and, it may be, artificial respiration. See that drainage of the wound is free, if an external wound exists, and thoroughly immobil- ize the damaged part. In order to prevent fat-embolism after a severe injury insist on rest. Massage used early after some injuries is dangerous, as it may force fluid-fat into the vessels. When a severe contusion gives rise to a large cavity filled with blood Groube advises incision, to lessen the danger of fat-embolism.' X. SEPTICEMIA AND PYEMIA. Septicemia, or sepsis, is a febrile malady due to the in- troduction into the blood of septic organisms or their prod- ucts. There is no one special causative organism, and any microbe which produces inflammatory and febrile products may cause it. Either streptococci or staphylococci may be present. Septicemia arises by absorption of septic matter by the lymphatics. CHnically we make two forms of septicemia : (i) sapremia, septic or putrid intoxication ; and (2) septic in- fection, true or progressive septicemia. In these conditions the area of infection is usually discovered by the surgeon, but when it is not located the case is called by the Germans cryptogenetic septicemia. Sapremia, or septic intoxication, is due to the absorp- tion of poisonous ptoma'ins from a putrefying area. The bac- teria rarely enter the blood, but their toxins do, and, as these toxins are active poisons, the condition is comparable to poisoning by successive alkaloidal injections, the symptoms and prognosis depending upon the dose. Even if some of the organisms enter the blood, they do not multiply in this fluid. Slight symptoms and recovery follow a small dose ; grave symptoms and death follow a large one. The poison does not multiply in the blood, and a drop of the blood of a person laboring under putrid intoxication will not produce the disease when introduced into the blood of a well person ; in other words, the disease is not infective. Sapremia results from the absorption of putrid matter from considerable areas which are under high pressure. It may follow labor where putrid fluid is retained in the womb, or follow amputation where decomposing blood-clot or wound-fluid is pent up within the flaps. In this condition there always exist a con- siderable absorbing surface and a large amount of dead mat- ter which has become putrid. Roswell Park points out^ that 1 Rev. de Chir., July, 1895. ^ Treatise on Surgery by Avierican Authors. SEPTICEMIA AND PYEMIA. I 37 saprcmia arises from putrefaction of a blood-clot or from wound-fluids which are retained like foreign bodies in the tissues, and does not arise from putrefaction of the tissues themselves. He speaks of the condition as due to the ab- sorption of poison from a " putrid suppository." We use the term putrefaction because this is the usual change, but any fermentative organism may cause the disorder. Sapre- mia is a malignant form of surgical fever, and its existence means an ill-drained wound, and a fermenting and probably putrid collection of blood-clot or wound-fluid. Symptovis. — In twenty-four hours or more after labor, after an injury, or after an operation, there is a chill followed by high temperature, gastric disturbance, dry tongue, weak, rapid pulse, great prostration, muscular twitching, restless- ness, headache, often delirium, diarrhea, foulness of wound, often drying up of wound-discharge, diminution or suppres- sion of urine, and a strong tendency to congestion of various organs. Blood-examination shows leukocytosis. Great ele- vation of temperature precedes death. Trcat7nent. — The treatment is to at once drain and asep- ticize the putrid area and give enormous doses of alcohol. Strychnin and digitalis are useful. Purge the patient, and favor diaphoresis, using in some cases the hot bath. Estab- lish the action of the kidneys ; allay vomiting by champagne, cracked ice, calomel, cocain, or carbolic acid with bismuth. Give food every three hours. Feed on milk, milk and lime- water, liquid beef-peptonoids, and other concentrated foods. Use quinin in stimulant doses. Antipyretics are useless. Watch for any visceral congestion, and treat it at once. The use of saline fluid by hypodermoclysis or venous transfusion dilutes the poison and stimulates the heart, skin, and kidneys to activity. Septic infection, or true septicemia, is a true infective process. In sapremia the blood contains toxins of fermenta- tive organisms, but not the organisms themselves. In septic infection the blood contains both pyogenic toxins and multi- plying pyogenic organisms. In sapremia the causative con- dition is putrid material lodged like a foreign body in the tissues. In septic infection the tissues themselves are suppu- rating, and both bacteria and toxins are being absorbed by the lymphatics. Of course, septic infection may be associated with septic intoxication or may follow it. In suppurative fever the tissues suppurate, but only the pyogenic toxins are ab- sorbed, and not the pyogenic organisms. In septic infection both the pyogenic bacteria and toxins enter the blood, and 138 MODERN SURGERY. the bacteria multiply in the blood and produce continually- increasing amounts of poison. The symptoms of sapremia depend on the dose. In septic infection only a small number of organisms may get into the blood, but they multiply enor- mously. The pus microbes cause true septicemia, and reach the blood chiefly through the lymphatics, but to some degree by penetrating the walls of vessels. A drop of blood from a man with septic infection will reproduce the disease when in- jected into the blood of an animal; hence it is a true infective disease. The wound in such cases is often small, and is commonly punctured or lacerated. Symptoms. — The type of this condition is met with in puerperal septicemia or in an infected wound. It begins, in from four to seven days after labor or an injury, with a chill, which is followed by fever, at first moderate, but soon be- coming high. The fever presents morning remissions and evening exacerbations, and may occasionally show an inter- mission. When the remission begins there is a copious sweat. The pulse is small, weak, very frequent, and com- pressible. The tongue is dry and brown with a red tip. The vomiting is frequent, and diarrhea is the rule. Delirium alternates with stupor, and coma is usual before death. Prostration is very great. Toward the end the face often becomes Hippocratic. Visceral congestions occur. The spleen is enlarged, ecchymoses and petechiae are noted, secretions dry up, urinary secretion is scanty or is sup- pressed, and the wound becomes dry and brown. Blood- examination detects disintegration of red globules, and marked leukocytosis. When a wound inaugurates septi- cemia, red lines of lymphangitis are seen about it and there is enlargement of related lymphatic glands. No thrombi or emboli exist in septicemia. The prognosis is bad, and in some malignant cases death occurs within twenty-four hours. The treatment is the same as for septic intoxication. An- tistreptococcic serum is employed by some surgeons, but the value of this method is as yet doubtful. Pyemia. — Pyemia is a condition in which metastatic ab- scesses arise as a result of the existence of septic thrombo- phlebitis, the disease being characterized by fever of an in- termittent type and by recurring chills. It is not actually due to free pus in the blood, but to the passage into the blood of clots infected by streptococci and staphylococci. If an area of infection leads to thrombophlebitis, lymphatic absorption of toxins or organisms is apt to be occurring at SEPTICEMIA AND PYEMIA. 1 39 the same time. Hence in many cases septicemia exists with pyemia. In an area of suppuration there are coagulation-necrosis, thrombosis, and septic inflammation of the adjacent vessels, and the thrombi are infected. A vessel-thrombus runs up in the lumen of a vein, and the apex of the purulent clot softens, a portion of it is broken off by the blood-stream and carried as an embolus into the circulation. Many of these poisonous emboli enter into the blood and lodge in some vessels which are too small to transmit them, and at their points of lodgement form embolic, secondary, or metastatic abscesses. Wounds of the superficial parts and bones pro- duce pyemic infarctions and metastatic abscesses of the lungs. When these infarctions break into fragments particles may return to the heart and lodge, or may be sent out through the arterial system to form other foci in distant organs. In- fected areas connected with the portal circulation (intestinal injuries or suppurating piles) produce abscess of the liv^er. Malignant endocarditis is called " arterial pyemia," and is due to endocardial embolic infection. In this disorder in- fected emboli lodge in the kidneys, the spleen, the alimen- tar}' tract, the brain, or the skin (Osier). Idiopathic pyemia is a misnomer. Some primar}- focus of infection must exist (often in the middle ear). Symptoms. — The wound becomes dr>', brown, and offen- sive. A severe and prolonged chill or a succession of chills ushers in the disease ; high fev^er follows, and drenching sweats occur. The chills recur every other day, every day, or oftener. After the sweat the temperature falls and may become nearly normal. The temperature often oscillates violently. The general symptoms of vomiting, wasting, etc., resemble those of septicemia. In some cases the mind remains clear, in many the delirium is purely nocturnal. The skin becomes jaundiced, and a profound adynamic state is rapidly established. The blood shows disintegra- tion of red corpuscles and leukocytosis. The spleen is enlarged. The lodgement of emboli produces symptoms whose nature depends upon the organ involved. Lodge- ment in the lungs causes shortness of breath and cough, with slight physical signs. Lodgement in the pleura or peri- cardium gives pronounced physical evidence. Lodgement in the spleen produces severe pain and great enlargement. The parotid gland not unusually suppurates (as in the case of President Garfield). In a suspected case of pyemia always look for a wound, 140 MODERN SURGERY. and if this does not exist, remember that the infection may arise from gonorrhea, osteomyehtis, suppuration in the middle ear, or abscess of the prostate. Chronic pyemia may last for months ; acute pyemia may prove fatal in three days. The complications are joint-suppuration, broncho- pneumonia, pleuritis, endocarditis, pericarditis, peritonitis, pyelitis, venous thrombosis, and abscesses. Treatment is the same as for septicemia. Open, drain, and asepticize any wound and any accessible secondary abscess. XI. ERYSIPELAS (ST. ANTHONY'S FIRE). il^rysipelas is an acute, contagious, spreading capillary lymphangitis due to the streptococcus of erysipelas, which grows and multiplies in the smaller lymph-channels of the skin and its subcutaneous cellular layers and of serous and mucous membranes. The disease is characterized by a rap- idly spreading dermatitis, by a remittent fever due to ab- sorption of toxins, and by a tendency to recur. It is al- ways due to a wound. Idiopathic erysipelas is due to a small wound which escapes notice. The involved area may or may not suppurate. Suppuration, some say, does not require a mixed infection, as the streptococcus is identical with the streptococcus pyogenes (Osier, Koch) ; others think suppuration does require mixed infection, as they believe the streptococcus is not pyogenic. Erysipelas is most common in the spring and fall, and is most usually met with among those who are crowded into dark, dirty, and ill-ventilated quarters ; it attacks by preference the debilitated and broken-down (as alcoholics and sufferers from Bright's disease). The disease may become endemic in special places or localities. The poison of erysipelas will produce puer- peral fever in a lying-in woman. The streptococcus was first obtained in pure cultures by Fehleisen (Tillmann's Principles of Surgery). This organism is widely diffused. The question of identity with the streptococcus pyogenes is discussed on p. 38. Forms of Erysipelas. — Ambulant, erratic, migratory, or wandering erysipelas is a form which tends to spread wide- ly over the body, leaving one part and going to another. Bidlous erysipelas is attended by the formation of bullae. In diffused erysipelas the borders of the inflammation grad- ually merge into healthy skin. Erythematous erysipelas involves the skin superficially. Metastatic erysipelas appears in various parts of the body. Puerperal erysipelas begins ERYSIPELAS. I4I in the genitals of lying-in women, producing puerperal fever. Eiysipclas simplex is the ordinary cutaneous form. Erysipelas ncotiatoruvi begins in the unhealed navel of a newborn child and spreads from this point. Typhoid er\'- sipelas occurs with profound adynamia. Universal er>'sip- elas involves the entire body. Cellulitis is erysipelas of the subcutaneous layers. PJilegmonoiis erysipelas involves the skin and subcutaneous tissues, and causes suppuration, and often gangrene. Edematous erysipelas is a variety of phleg- monous erysipelas with enormous subcutaneous edema. LympJiatic erysipelas is characterized by rose-red lines of lymphangitis. Venous erysipelas is marked by the dark color of venous congestion. Mucous erysipelas involves a mucous membrane. Erysipelas may attack the fauces, pro- ducing a very grave condition. Clinical Forms. — The clinical forms are cutaneous er\'sip- elas, cellulocutaneous or phlegmonous, cellulitis, and mucous erysipelas. Cutaneous erysipelas most frequently attacks the face. A fever suddenly appears, rises rapidly, reaches a consider- able height, and at the time of febrile onset spots of redness appear on the skin. These spots run together, and a large extent of surface is found to be red and a little elevated. Any wound, ulcer, or abrasion which exists becomes dry and unhealthy, and its edges redden and swell. This com- bination of redness and swelling extends, and its area is sharply defined from the healthy skin. The color fades at once on pressure and returns at once when pressure is removed. In the hyperemic area vesicles or bullae form, containing first serum and later it may be sero-pus. Edema affects the subcutaneous tissues, producing great swelling in regions where they are lax (as in the eyelids). The anatom- ically related lymphatic glands become large and tender, and between them and a wound are often seen the red lines of inflamed lymphatic vessels. In an ordinarily strong person the color is bright red or more rarely dark red. A dusky color precedes suppuration. A blue color precedes gan- grene or indicates profound cardiac and pulmonar}' involve- ment. There is slight burning pain in er)'sipelas which is increased by pressure. Erysipelas spreads at its periphery and fades at its point of origin. It spreads now in one direc- tion, now in another, influenced, according to Pfleger, by the furrows of the skin. When spreading stops the swelling and redness gradually abate, and after they disappear des- quamation takes place, and the blebs become dry and 142 MODERN SURGERY. crusted. Cutaneous erysipelas rarely suppurates, but may do so. The fever is remittent, and usually terminates in four or five days by crisis. In strong subjects the symptoms are usually slight. In the old or debilitated the symptoms are typhoid, dehrium comes on, and death is usual. Possible complications are meningitis, pneumonia, septicemia, pleuritis, pyemia, endo- carditis, and albuminuria. Erysipelas neonatorum is gen- erally fatal. In some instances an attack of erysipelas will cure an old skin eruption, a new growth, an ulcer, or an area of lupus. This is the erysipele salutaire of our French confreres (p. 230). Treatment. — Isolate the patient, asepticize any wound, and give a purge. Cases of cutaneous erysipelas tend to get well without treatment. If a person is debilitated, stimu- late freely. Tincture of chlorid of iron and quinin are usually administered. Nutritious food is important. For sleeplessness or delirium use chloral or the bromids ; for high temperature, cold sponging and antipyretics. To pre- vent spreading some have advised injection of the healthy skin near the blush with a 2 per cent, carbolic solution or with gr. ^ of corrosive sublimate. Locally, paint the in- flamed area with equal parts of iodin and alcohol and apply lead-water and laudanum. If an extremity be involved, bandage it. Another good apphcation is a 50 per cent, ich- thyol ointment with lanolin. A very useful method is Von Nussbaum's. The author applies it somewhat modified, as follows : wash with ethereal soap, irrigate with a solution of corrosive sublimate (i : looo), dry with a sterile towel, apply an ointment of ichthyol and lanolin (50 per cent.), and dress with antiseptic gauze. Some use iced-water cloths and some prefer hot fomentations. Others apply borated talc or sali- cylated starch. Ringer advised painting every three hours with a mixture composed of gr. xxx of tannic acid, gr. xxx of camphor, and .^iv of ether. J. M. Da Costa recommends pilocarpin internally in the beginning of a case. Antistrepto- coccic serum has been used in erysipelas, and great results have been claimed for it. Roger and Charrin's serum may be used. The dose is 30 c.cm. It is asserted that under its influence the temperature soon becomes normal. We have had no personal experience with the serum treatment. Cellulocutaneous or phlegmonous erysipelas is charac- terized by high temperature (i04°-io6°), the rapid onset of grave prostration, irregular chills, sweats, and a strong ten- dency to delirium. The parts are not so red as in the pre- ERYSIPELAS. 1 43 ceding form, but the tumefaction is vastly greater ; it is brawny, comes on early and with exceeding rapidity, induc- ing a high degree of tension and frequently producing slough- ing or even cutaneous gangrene. The lymphatic glands are swollen, but the inflamed lymphatic vessels are hidden by the tumefaction. In most cases suppuration occurs, and when this happens the parts become boggy. When the disease abates sloughs form, which leave ulcers upon being thrown off In bad cases muscles, vessels, tendons, and fascia may slough away. The commonest complications are suppression of urine, bronchopneumonia, congestion and edema of the lungs, meningitis, congestion of the kidneys, and acute pleurisy. We see this form of erysipelas some- times after extravasation of urine. It is not a pure strepto- coccus infection. There is a mixed infection with other pyo- genic cocci, and often with organisms of putrefaction. Treatment. — At once asepticize and drain any existing wound ; apply iodin to the inflamed area and cover it with lint wet with lead-water and laudanum, and if a limb is in- volved use a roller-bandage and a sling. Instead of iodin and lead water, ichthyol may be applied. Open the bowels with calomel and salines ; order quinin, iron, stimulants, and nourishing diet. If suppuration occurs, make many incisions near together, each cut being 2 or 3 inches long. Spray out by means of hydrogen peroxid in an atomizer, and then wash with corrosive-sublimate solution (i : looo). Drain by means of iodoform gauze in strips. Excise spots of gan- grene. Dress with many layers of gauze wet with a hot solution of corrosive sublimate and covered with a rubber- dam ; a hot-water bag being laid upon the dressing. If sloughs form, cut them partly away and employ antiseptic poultices. Change dressings often. Antistreptococcic serum is employed by some. In severe cases employ hypodermo- clysis or saline transfusion. When granulations begin to form, treat as a healing wound. Cellulitis. — In cellulitis redness of the skin is not very pronounced and is late in appearing, following swelling, and not preceding it. It is essentially the same condition as phlegmonous erysipelas, but is often mild in degree. Its spread is heralded by red lines of lymphangitis ascending from an infected wound, swelling of glands, and fever. In slight cases the lymphatics may dispose of the poison and suppuration fail to occur. In severe cases septicemia arises. Cellulitis is usually a result of infection not only with strep- tococci, but also with other pyogenic cocci. 144 MODERN SURGERY. Treatment. — Incise and curet the wound and sear it with pure carbolic acid. Treatment is the same as for the phleg- monous form. XII. TETANUS, OR LOCKJAW. Tetanus is an infectious spasmodic disease invariably pre- ceded by some injury. The wound may have been severe, it may have been so slight as to have attracted no attention, or it may have been inflicted upon the alimentary canal by a fish-bone or other foreign body, or may have been situated in the nose, urethra, vagina, or ear. Idiopathic tetanus is either not tetanus at all, or is a term expressive of the fact that we have not found an injury which did exist. This dis- ease is commonest after punctured or lacerated' wounds of the hands or feet, and before it appears a wound is apt to suppurate or slough ; but in some instances the wound is found soundly healed. Tetanus may appear twenty-four hours after an accident, but it may not arise until several weeks have elapsed. It prevails more in certain localities than in others. Colored people are very susceptible, and it may exist epidemically. Tetanus is due to infection by a bacillus (first described by Nicolaier and first cultivated by Kitasato), the toxic products of which, absorbed from the in- fected area, poison the nervous system precisely as would dosing with strychnin. This bacillus is found particularly in garden-soil, in the dust of walls, walks, and cellars, in street-dirt, and in the refuse of stables. Symptoms. — Acute tetanus begins within nine days of an accident. The usual period of incubation is from three to five days. First, the neck feels stiff, and there is difficulty in deglutition, the patient thinking he has taken cold, and next the jaws also become stiff. The neck becomes like an iron bar, and the jaws as rigid as steel. The muscles of deglutition become rigid on attempts at swallowing. The muscles of the back, legs, and abdomen are thrown into tonic spasm, but the arms rarely suffer. If the infected in- jury is on the hand or foot, that extremity usually is found to be rigid. Spasm of the face-muscles causes the risus sar- doniens, or sardonic smile (contraction particularly of the imiscidus sardoiiicus of Santorini). The contraction of the muscles of the back is often so powerful as to bend the pa- tient back like a bow and allow him to rest only on his occi- put and heels. This condition is known as " opisthotonos." If he is bent forward, so that the face is drawn to the legs, it TETANUS, OR LOCKJAW. 1 45 is called " emprosthotonos." If his body is curved sideways, it is designated " pleurosthotonos." An upright position is " orthotonos." The spasm may be so violent as to cause muscular rupture. The state is one of widely diffused tonic spasm, aggravated frequently by clonic spasms arising from peripheral irrita- tions. These irritations may be draughts, sounds, lights, shaking of the bed, attempts at swallowing, contact of the bed-clothing, the presence of urine in the bladder or of feces in the rectum, or various visceral actions. The agonizing " girdle-pain " so often met with is from spasm of the dia- phragm. Each clonic spasm causes a hideous scream by the constriction of the chest forcing air through a contracted glottis. Constipation is persistent ; retention of urine is the rule (because of sphincter spasm). The mind is entirely clear until near the end — one of the worst elements of the disease. Swallowing in many cases is impossible. Talking is very difficult and it is impossible to project the tongue. The muscles throughout the body feel very sore. The tem- perature may be normal, but it is usually a little elevated, and always rises just before death. Hyperpyrexia some- times occurs (io8°-iio°), and the temperature may even ascend for a time after death. Insomnia is obstinate. Death almost invariably occurs in acute tetanus in two or three days. It may be due to exhaustion or to carbonic-acid narcosis from spasm of the glottis or fixation of the respiratory muscles. Chronic tetanus comes on late after a wound (from ten days to several weeks). The symptoms are not so severe ; the muscular spasm is widespread, but it may not be per- sistent, intervals of relaxation permitting sleep and the taking of food. It may last some weeks, and not infrequently the disease can be cured. Trismus is a mild form of tetanus, the contractions being limited to the face and jaw. Trismus neonatorum or trismus nasccntium, which is lockjaw in the newborn, is due to infection of the stump of the umbilical cord, and is invariably fatal. Hydrophobic tetanus, head tetanus, or cephalic tetanus, is a condition in which the spasms are confined chiefly to the face, pharynx, and neck, although the abdominal muscles are usually also rigid. It follows head-injuries, and gives a better prognosis than does general tetanus. Diagnosis. — Tetanus may be confounded with strj'chnin- poisoning or with hysteria. Wood's table makes the diag- nosis clear : ^ ^ A^en'oiis Diseases, by Prof. H. C. Wood. 10 146 MODERN SURGERY. Tetanus. Hysterical Tetanus. Strychnin-poisoning. Muscular symptoms usually commence with pain and stiffness in the back of the neck, sometimes with slight muscular twitch- ing ; come on gradu- ally. Jaw one of the earliest parts affected ; rigidly and persistent- ly set. Persistent muscular rigidity very generally, with a greater or less degree of permanent opisthotonos, empros- thotonos, pleurosthot- onos, or orthotonos. Consciousness pre- served until near death, as in strychnin- poisoning. Draughts, loud noises, etc., produce convulsions, as in strychnin - poisoning ; may complain bitterly of pain. Eyes open and rig- idly fixed during the convulsion. Commences with blindness and weakness. Muscular symptoms commence with rigidity of the neck, which creeps over the body, affecting the extremities last. Jaws rigidly set before a con- vulsion, and remain so between the paroxysms. Persistent opisthoto- nos and intense rigidity between the convulsions and after the convulsions have ceased, the opis- thotonos and intense rig- idity lasting for hours. Consciousness lost as the second convulsion comes on, and lost with every other convulsion, the disturbunce of con- sciousness and motility being simultaneous. Crying-spells alterna- ting with convulsions. Eyes closed. Begins with exhilaration and restlessness, the special senses being usually much sharpened. Dimness of vision may in some cases be manifested later, after the development of other symp- toms, but even then it is rare. Muscular symptoms develop very rapidly, commencing in the extremities, or the convulsion when the dose is large seizes the whole body simultaneously. Jaw the last part of the body to be affected ; its muscles re- lax first, and even when, during a severe convulsion, it is set, it drops as soon as the latter ceases. Muscular relaxation (rarely a slight rigidity) between the con- vulsions, the patient being ex- hausted and sweating. If re- covery occurs, the convulsions gradually cease, leaving merely muscular soreness, and some- times stiffness like that felt after violent exercise. Consciousness always pre- served during convulsions, ex- cept when the latter become so intense that death is imminent from suffocation, in which case sometimes the patient becomes insensible from asphyxia, which comes on during the latter part of a convulsion and is almost a certain precursor of death. The " slightest breath of air" produces convulsion. Patient may scream with pain or may express great apprehension, but "crying-spells" would appear to be impossible. Eyes stretched wide open. Partial spasm in the Legs stiffly extended with leg,producing in Wood's ^ feet everted, as the spasms affect cases crossing of the feet and inversion of the toes. If all the muscles were involved, eversion would occur, as the muscles of eversion are the stronger. all the muscles of the leg. TETANUS, OR LOCKJAW. \\'J Treatment. — Far better than even to treat tetanus well is to prevent it. Careful antisepsis will banish it as thoroughly as it has banished septicemia. Every wound must be dis- infected with the most scrupulous care. Every punctured wound is to be incised to its depth and thoroughly cleaned and drained. Puerperal tetanus is prevented by antiseptic midwifery, and tetanus neonatorum is obviated by the anti- septic treatment of the stump of the cord. When tetanus exists, always look for a wound, and if one is found, open it, cut away sloughs, wash with peroxid of hydrogen and cor- rosive sublimate, swab it out with bromin, and secure drain- age by packing it with iodoform gauze. Isolate the patient, as the disease is infective ; keep him in a darkened, well-ventilated, and quiet apartment, so as to exclude as far as possible peripheral irritation. Watch for retention of urine, and use the catheter if it occurs. Secure movements of the bowels by salines, castor oil, croton oil, or enemas. Give plenty of concentrated liquid food, and stimulate freely with alcohol. If swallowing causes convul- sions, give an inhalation of nitrite of amyl before an attempt is made to swallow. If this treatment fails, partially anes- thetize the patient and feed him by means of a pharyngeal tube passed through the nose. Large doses of the bromid of potassium, or of this drug with chloral, give the best re- sults. If bromid is used, give about 3j every four to six hours. Other drugs that have been used with some success are gelsemium, morphin, curare, injections and fomentations of tobacco, physostigmin, anesthetics, cocain, and cannabis indica. An ice-bag to the spine somewhat relieves the girdle-pain. Hot baths have been advdsed. Yandell says, in summing up Cowling's report on tetanus •} " Recoveries from traumatic tetanus have been usually in cases in which the disease occurs subsequent to nine days after the injury. When the symptoms last fourteen days, recovery is the rule, apparently independent of treatment. The true test of a remedy is its influence on the history of the disease. Does it cure cases in which the disease has set in previous to the ninth day ? Does it fail in cases whose duration exceeds fourteen days ? No agent tried by these tests has yet established its claims as a true remedy for tetanus." ^ It is now claimed by some observers that we have a rem- edy which fulfils the requirements of Yandell in the tetanus 1 American Practitioner, Sept., 1870. ^ Quoted by Hammond, in his Diseases of the Nervous System. 148 MODERN SURGERY. antitoxin of Tizzoni and Cattani. To prepare this antitoxin a horse is rendered immune to tetanus by inoculations with mitigated cultivations of the microbe ; stronger and stronger cultures are given ; the blood is drawn, and the serum is separated and treated with alcohol and dried in a vacuum. The antitoxin is dissolved in glycerin, and is used hypo- dermatically in doses of from 15 to 25 centigrammes. Some physicians have injected the serum itself Cures seem to have followed its use, and if it can be obtained it is our duty to try it in acute tetanus. Kitasato has shown that injec- tions of iodoform render animals immune, and Sonnani has maintained that this drug in a wound prevents the disease. If antitoxin is not obtainable, give hypodermatic injections of iodoform 3 to 5 grs. /. /. d. XIII. TUBERCULOSIS. Tuberculosis is an infective disease due to the deposition and multiplication of the bacilli of tubercle in the tissues of the body. It is characterized either by the formation of tubercles or by a widespread infiltration, both of these con- ditions tending to caseation, sclerosis, or ulceration. A tubercular lesion may undergo calcification. A tubercle is an infective granuloma, appearing to the unaided vision as a semitransparent gray mass the size of a mustard-seed. The microscope shows that a gray tubercle consists of a number of cell-clusters, each cluster constitut- ing a primitive tubercle. A typi- cal primitive tubercle shows a cen- ter consisting of one or of several polynucleated giant-cells surround- ed by a zone of epithelioid cells which are surrounded by an area of leukocytes. When the bacillus obtains a lodgement the fixed con- nective-tissue cells multiply by kary- okinesis, forming a mass of nucle- ated polygonal or round cells, called " epithelioid " from their resemblance to epithelial cells, and at the same time the blood-supply of the growth is limited by occlusion of surround- ing vessels through multiplication of their endothelial coats. Some of these epithehoid cells • r^:i^»» Fig. 37. — Synovial membrane, showirtg giant-cells (Bowlby). TUBE R CUL OSIS. 1 49 proliferate, and others attempt to, but fail for want of blood- supply. Those that fail succeed only in dividing their nuclei and enormously increasing their bulk (giant-cells). Giant-cells, which also form by a coalescence of epithelioid cells, are not always present. The presence of irritant bac- terial products induces surrounding inflammation and exuda- tion of white blood-cells (Fig. 37). The bacillus, when found, exists in the epithelioid cells, and sometimes in the giant-cells ; it may not be found, having once existed, but having been subsequently destroyed. It is often overlooked. In an active tubercular lesion, even if the bacil- lus be not found, injection of the matter into a guinea-pig will produce lesions in which it can be demonstrated. A tubercle may caseate — a process that is destructive and dan- gerous to the organism. Caseation is due to a coagulation- necrosis arising from direct microbic action upon a cellular area w^hich contains no blood-vessels, the nutrition of the area being cut off by obliteration of surrounding vessels. This process starts at the center, and the entire tubercle becomes converted into a soft yellowish-gray mass. Case- ation forms cheesy masses, which may soften into tubercu- lar pus, may calcify, and may become encapsuled by fibroid tissue. A tubercle may undergo sclerosis, which is an attempt on the part of Nature to heal and repair. Coagulation-necrosis occurs in the centre of the tubercle ; " hyaline transformation proceeds, together with a great increase in the fibroid ele- ments, so that the tubercle is converted into a firm, hard structure " (Osier). Infiltrated tubercle is due to the running together of many minute infective foci, or to widespread in- filtration without any formation of foci. Infiltrated tubercle tends strongly to caseate. The bacillus of tubercle, discovered by Koch, is a little rod with a length equal to about half the diameter of a red blood-corpuscle. It can be stained with anilin, and this stain is not removable by acids (it being the only bacillus except leprosy which acts in this way). In its growth the tubercle bacillus causes the formation of toxins, and the absorption of toxins induces constitutional symptoms. These bacilli exist in all active lesions : the more active the process the greater is their number. They may be widely distributed, and are occasionally though rarely identified in the blood. They exist in enormous numbers in phthisical sputum, but are not found in the breath of consumptives. Their great medium of distribution is dried sputum mixed with dust. 150 MODERN SURGERY. They are found in the milk of tubercular cows, and some- times in the meat of diseased animals. Infection may be due to hereditary transmission. Con- genital tuberculosis is occasionally, though rarely, seen. Tuberculosis is apt to appear in young children. Some think this is due to infection from without upon tissues whose resistance is lowered by hereditary predisposition ; others think it is due to a tardy development of the germs transmitted by heredity. That the disease may be present in a latent form is shown by the experiment in which the viscera of the fetus of a consumptive mother showed no tubercles, but produced the disease in guinea-pigs when inoculated.^ Tuberculosis may arise by inoculation, inocu- lation-tuberculosis being seen in leather- workers and in those who dissect tubercular bodies (butchers and doctors are liable to anatomical tubercle). Osier mentions as other causes of inoculation the bite of a tubercular patient, the washing of infected garments, and circumcision in which suction is employed by an individual with phthisis. Granulation-tissue, chronic abscess, and areas of dermatitis may be infected from without (G. R. Fowler). Infection through the air is very common. The bacteria of the dried sputum adhere to par- ticles of dust and are carried into the lungs. Infection by meat, milk, and other foods may arise by this dust settHng upon them in quantity. Commonly, however, it is due to disease of the animals. Milk is a common vehicle of con- tagion, and it can be infected even when an ulcerated udder does not exist. Infection is favored by hereditary predisposition — that is to say, by hereditary tissue-weakness, which, by maintaining a lowered momentum of nutritive processes, lessens the nor- mal resistance to infection. Hutley studied 432 cases of tuberculosis. In 23.8 per cent, one or both parents had the disease (the father alone in 11.5 per cent, the mother alone in 9.9. per cent, and both in 2.4 per cent). Two types of these predisposed persons are mentioned : (i) the sanguine - type, or those with oval faces, clear skin, large blue eyes, long lashes, a nervous manner, precocious minds, but little fat, and with long, slender bones, these children being often graceful and beautiful ; and (2) those with stolid counte- nances, thick lips and noses, thick, muddy skin, dark, coarse hair, swollen necks, heavy bones, clumsy gait, and ungainly figure. The latter type is the phlegmatic form — the classical scrofula. ^ Quoted by Osier from Birch-Hirschfeld. TUBERCUL OSIS. 1 5 1 There is no doubt that an inflammatory area in a person ma\' become infected when a sound area would escape, the process of phagocytosis being in this spot Hmited in activity, and the germicidal power of the body-fluids being at a low ebb. The organisms, which are destroyed by healthy cell- activities, are victorious when those activities are diminished. Catarrhal inflammations of the air-passages favor phthisis, and traumatism is not unusually followed by a development of tubercle. Lowered health, impure air, and improper or insufficient food all favor the development of tubercle. Any tubercular process tends to spread locally and to produce inflammation. A tubercular area is always a danger to the system ; from this as a focus dissemination may occur, tuber- cular lesions appearing in a distant part or general tubercu- losis setting in. Scrofula is not a disease. It is a condition of tissues in which low resisting power makes them hospitable hosts to in- vading bacilli of tubercle. Some observers teach that scrofula is tuberculosis of bones, glands, and joints ; others teach that it is latent tuberculosis until some cause lights it into activity; while still others say that it is a tendency rather than a dis- ease. It is certain that some lesions of scrofula are not tu- bercular (eczema capitis, facial eczema, corneal ulcers, gran- ular lids, and chronic catarrhal inflammations), and that they result from ill-health, poor nutrition, bad air, and improper diet. A person who is recognized as of a scrofulous type may nev^er develop tubercular lesions. It is unquestionable, however, that strumous subjects are peculiarly apt to develop true tubercular lesions. These lesions often appear after a tissue or an organ has become the seat of a primary non-tu- bercular inflammation ; the bacilli, which could not live in the non-inflamed tissue, thriv-e in the inflamed tissue. Scrofula is generally of congenital origin, one or both parents being tu- bercular, scrofulous, or in ill-health ; it may, however, be acquired as a result of poor food, bad air, crowding, and gen- eral lack of sanitation. The scrofulous are very prone to develop tubercular lesions of bones, joints, and lymphatic glands. When tubercular processes arise the urine is some- times found to contain indican. Tubercular Abscess. — For description of tubercular abscess, see p. 105. Tuberculosis of the Skin. — Lupus begins before the age of twenty-five, most usually upon the face, especially the nose. Three forms are recognized: {i) lupus vulgaris y in which pink nodules appear that after a time ulcerate and I 5 2 MODERN SURGE R V. then cicatrize. These nodules resemble jelly in appearance; (2) liipiis exedciis, in which ulceration is very great ; and (3) liLpiis hypei'tropJiiciis, in which a very great amount of em- bryonic tissue is produced (large nodules or tubercles). Lupus may appear as a pimple, as a group of pimples, Or as nodules of a larger size. The ulcer arises from desquamation, and is surrounded by inflammatory products which, by progres- sively' breaking down, add to its size. The ulcer is usually superficial, is irregular in outline, the edges are soft and neither sharp nor undermined, the sore gives origin to a small amount of thin discharge, the parts about are of a yellow-red color, and there is no pain, the edges are solid and puckered and scar-like. The ulcer is often crusted over, the crusts being thin and of a brown or black color ; it may be pro- gressing at one point and healing at another ; and it is slow in advancing, but often proves hideously destructive. The scars left by its healing are firm and corrugated, but are apt to break down. Clinically it is separated from a rodent ulcer by several points. The rodent ulcer is deep, its edges are everted, and the parts about filled with visible vessels. It is not crusted, has not a puckered edge, does not spontane- ously heal at any point, and its edges and base are hard. Anatomical tubercle, the verruca necrogenka of Wilks, is due to local inoculation with tubercular matter. It is seen in surgeons, the makers of post-mortems, leather-workers, and butchers, usually upon the backs of the hands and fin- gers. It consists of a red mass of granulation-tissue having the appearance of a group of inflamed warts. Pustules often form. Scrofulodermata or tubercular gummata are chronic skin-inflammations, the granulation-tissue product of which breaks down to form small abscesses, sinuses, or ulcers. A tubercular ulcer has a floor of a pale color, and has no gran- ulations at all, or is covered with edematous granulations. The discharge is thin and scanty. It is surrounded by a con- siderable zone of purple, tender, and undermined skin, which is apt to slough. When heaHng occurs the skin puckers and inverts. Tuberculosis of Subcutaneous Connective Tissue. — In this form of tuberculosis nodules of granulation-tissue form and break down (tubercular abscesses). In the deeper tissues these abscesses are usually associated with bone-, joint-, or lymphatic-gland disease. A large abscess is called " cold " (see Cold Abscess, p. 105). Tuberculosis of the mammary gland is rare, but occasionally occurs (p. 108). TUBERCUL OSIS. I 5 3 Pulmonary Tuberculosis. — In adults the lungs are more commonly affected than any other structure. The lung affection may be primary or may be secondary to some distant process of tubercular disease. Pulmonary tubercu- losis belongs to the physician and requires no description here. Tuberculosis of the Alimentary Canal. — A tuber- cular ulcer of the lip occasionally occurs, and is usually mis- taken for a cancer or a chancre. A tubercular ulcer of the tongue is commonly associated with other foci of disease. Such ulcers are separated from cancer by their soft bases and edges and by the absence of glandular enlargements, and from syphilitic processes by the therapeutic test. Con- firmation of the diagnosis is obtained by cultiv^ations and in- oculations. Tubercle may affect the pharynx, palate, tonsils, and very rarely the stomach. Intestinal tuberculosis may follow pulmonary tubercle, but it may arise primarily in the mucous membrane of the bowel or result from tubercular peritonitis. Intestinal tu- berculosis causes diarrhea and fever, may resemble appendi- citis, and may cause abscess and perforation. Fistula in ano is very often tubercular, and when it is the lungs are very often involved, the pulmonary lesion being primary. Tuberculosis of the liver causes cold abscess and cirrhosis. Tubercle may affect the kidneys, bladder, ureters. Fallopian tubes, prostate, urethra, seminal vesicles, ovaries, and uterus. Tubercular testicle is not rare. It is rarely primary, being, as a rule, preceded by tuberculosis of the kidney, bladder, or prostate. Tubercular orchitis affects one testicle at first, but the other usually becomes involved. It starts in the epidid- ymis as a painless nodule. As the vaginal tunic and testicle become involved a hydrocele forms. The tubercular mass softens, becomes adherent to the scrotum, and bursts. The cord is always more or less involved. Peritoneal tuberculosis may be primary, infection hav- ing been by way of the blood, may be part of a diffused process, or may follow intestinal tubercle, the serous and muscular coats of the bowel having been at some point in contact or a follicular ulcer having perforated (Abbe). The germ may have entered by the Fallopian tube. It may be due to ovarian or Fallopian tuberculosis, or to ulceration of a tubercular appendix. It causes usually ascites, tym- pany, and tumor-like formations composed of adherent bunches of bowel or omentum or distended mesenteric glands (p. 657). 154 MODERN SURGERY. The pericardium may be attacked with tuberculosis pri- marily or secondarily to pleural tuberculosis. The pleura is not uncommonly attacked. Tubercular pleurisy may be acute or chronic. In some instances mixed infection takes place and suppuration occurs. The tuberculosis may be primary, but is usually secondary to pulmonary tuberculosis, and may be due to direct extension or to the rupture of an area of pulmonary softening. Tuberculosis of the brain induces meningitis and hydrocephalus (p. 559). Tubercular disease of bone is very common in youth ; is usually preceded by a sprain or a contusion, slight or se- vere. The injury establishes a point of least resistance, and in the damaged area the bacilli are deposited and multiply. The organisms may be deposited directly from the blood, or may come in an embolism from a distant tubercular focus (lung or lymph-gland), which embolus is caught in a termi- nal artery in the end of a long bone and causes a wedge- shaped infarction (Warren). Tubercular osteitis, as a rule, begins just beneath the articular cartilage or in the epiphysis (Warren). The prod- ucts of the tubercular inflammation may be absorbed, may be encapsuled by fibrous tissue, or may caseate. Tubercular disease of the joints is called "white swelling " and pulpy degeneration of the synovial mem- brane. Joints are especially liable to tuberculosis in youth, although the wrist and shoulder not infrequently suffer in adult life. Joint-tuberculosis is often preceded by an injury. The tubercular process may begin in the synovial membrane, especially in the knee, but it usually starts in the head of a bone, dry caries resulting, necrosis ensuing, or an abscess forming which breaks into the joint (p. 408). Tuberculosis of lymphatic glands is known as " tu- bercular adenitis." It is the most typical lesion of scrofula. The common antecedent of a tubercular adenitis of the neck is slight glandular enlargement as a result of catarrhal inflam- mation of the mucous membrane of the mouth. It is most fre- quent between the third and fifteenth years. A person not of the tubercular type may acquire tuberculosis of the glands, but adenitis is unquestionably of much greater frequency in the tubercular. Tubercular glands may get well, may even calcify, but usually caseate if left alone. After healing they may break down and soften (residual abscess). They very frequently suppurate because of mixed infection. Though at first a local disease, inflamed glands may prove to be foci TUBERCUL OS IS. 1 5 5 of infection, infecting distant organs or the entire system. Glandular enlargement is in rare instances widely diffused, but it is far more commonly localized. Enlargement of the cervical glands is most common. Enlargement of the mesen- teric glands causes tabes mesenterica. Cervical lymphadenitis may be confused with lymphade- noma. The former, as a rule, first appears in the submaxil- lary triangle, the latter in the occipital or inferior carotid tri- angles. Tubercular glands weld together, they are apt to remain localized, and they tend to soften. They may be ac- companied by other tubercular manifestations. Lymphade- noma from the start affects many glands in several regions, shows no tendency to suppurate, and is accompanied by great debility and anemia. Malignant gland-tumors infiltrate adja- cent glands and other structures, binding skin, muscles, and glands into one hard firm mass. Diagnosis. — The diagnosis may be determined by purely clinical facts. It may require the use of the microscope, cultivation-experiments, or inoculations. In a suspected tubercular lesion remove a portion of the tissue if it be accessible (by Mixter's cannula) and make sections, stains, and cultivations. If no bacilli are found, inoculate a guinea- pig with the suspected material. If it be tubercular, the pig will develop miliary tuberculosis in a few weeks. Prognosis. — The prognosis varies with age, sex, duration, extent, and situation of the lesion. Prognosis is best in chil- dren, and is better in males than in females. Tuberculosis of the skin gives a fair prognosis. Tubercular adenitis is often cured. Any tubercular lesion is, however, a menace to the organism, and tends strongly to recurrence. Treatment. — Destroy the bacilli present and radically re- move infected areas which are accessible. Never remove only part of a focus. Incomplete operations are apt to be fol- lowed by diffuse tuberculosis. Among the many drugs which have been recommended for local use we mention the following : iodin, carbolic acid, guaiacol, arsenous acid, corrosive sublimate, chlorid of zinc (Lannelongue), phosphate of iron, balsam of Peru (Landerer), camphorated naphtol, oil of cinnamon, cinnamic acid (Landerer), and iodoform.^ Iodoform used locally upon or in tubercular areas is of great value, and there is no drug which takes its place. Lupus may be treated by the application of blue oint- ment ; by curetting, cauterizing with carbolic acid, and ^ See article upon "Tuberculosis" by George Ryerson Fowler, Brooklyn Med. Jour., Nos. 8 and 9, 1894. 156 MODERN SURGERY. dressing with iodoform ; by excision, followed in some instances by sliding in of a flap of sound tissue or im- mediate skin-grafting. If we are treating a nodular and non-ulcerated area, wash it with a 2 per cent, solution of cor- rosive sublimate and inject several nodules with camphorated naphtol, one drop for each nodule. In seven or eight days inject other nodules, and so on. Koch's lymph has cured some cases of lupus. Tubercular glands before breaking down should be rubbed with ichthyol, and if this fails to cure they should be removed. When they break down they should be removed or opened, curetted, and packed. The rule must be to completely dissect out enlarged lymphatic glands which fail to quickly respond to treatment, removing capsules and glands. Climate is of very great importance. Osier sums up climatic necessities as " pure atmosphere, equable temperature, and maximum amount of sunshine." Open-air life is imperative. The patient must have a well- ventilated sleeping-room, and his house should be free from dampness. Nourishing diet is essential. To gain in weight is a constant aim. Give meat, milk, cream, butter, and cod- liver oil, which may be administered in capsules. The oil is poorly borne in hot weather, during which it should be dis- continued. Advancing doses of creasote, arsenic, quinin, and stimulants have their uses. (For treatment of tuberculosis of bones, joints, peritoneum, pleura, etc., look under special re- gional headings.) Bier's Method. — A few years ago Bier set forth a new plan for treating tubercular lesions. It consists in causing venous obstruction and passive congestion. In the area of passive congestion the tissue-cells form antitoxins which kill the bacteria or attenuate their virulence. The treatment is founded upon the principle announced by Laennec, that " cyanosis is antagonistic to tubercle." The plan is applied particularly in joint-tuberculosis. An elastic band three inches broad is placed around the limb, above the seat of disease, and it is applied sufficiently tightly to cause conges- tion. Several pieces of lint ought to be interposed between the skin and the band. By applying a flannel bandage from the periphery to the lower border of the disease the congestion is limited to the area of trouble. The patient should wear the band continually and move about with it on. Some people wear it without any inconvenience, but others complain greatly after wearing it but a short time. Bier and others have reported cures. We have seen great mitigation of pain and temporary arrest in the advance of TUBEK CUL OSIS. 1 5 7 the malady, but have never seen a cure brought about by the method. Koch's T2ibcrc2(li)t. — The specific treatment by Koch's tu- bercuHn or paratoloid has excited widespread interest. It has not fulfilled the expectations which many entertained, but does benefit some cases, notably lupus. A serious draw- back to the value of Koch's tuberculin is that it often causes fever and inflammation to a dangerous degree. In some cases, as Virchow showed, it produces acute miliary tubercu- losis. Koch's lymph is a glycerin-extract of a culture of tubercle bacilli, and the usual dose is i milligram, given hy- podermatically into the back by Koch's pistonless syringe. After it has been used for a time the dose may be increased to 10 milligrams, or even much more. Bergmann gave i gram. Koch's lymph causes inflammation and necrosis of tubercular tissue by the action of certain antitoxins. Many cases it improves. Some cases it apparently cures, but the disease is apt to return. In pulmonary tubercle it must not be given if there be much fever or extensive consolidation. Chiene used tuberculin largely in joint-cases by giving two or three doses a day and increasing the dose. It is best to associate other treatment with the lymph. Tuberculin may be used for diagnostic purposes in animals. If tuberculosis exists, an injection of tuberculin produces a marked reaction. Czerny has shown that in renal tuberculosis in a human being bacilli are often absent from urine, but an injection of tuberculin will cause bacilli to appear plentifully. Koch has recently modified his tuberculin. He makes it as follows : dried cultures of bacilli are mixed with distilled water, and the mixture is agitated in a centrifuge. Two layers separate. The upper layer is the old tuberculin. The lower layer is the new tuberculin. The new tuberculin is given hypoderm- atically, at first in very small doses, but finally in doses as large as 20 milligrams. It is not to be given to far advanced cases or cases with much fever. Hunter, of London, declares that Koch's lymph contains one principle which causes fever, another which causes in- flammation, and a third which produces atrophy of tuber- cular foci without either fever or inflammation. This third desirable element he believes he has isolated in what is called a " derivative of tuberculin," a modified lymph. Some remarkable results have followed the use of this material ; its administration seems entirely safe, and it should thor- oughly and carefully be tried to ascertain its true rank as a remedy. The injection of serum obtained from animals re- 158 MODERN SURGERY. fractory to tubercle has been employed, but Richet and Hericourt have seen no benefit from the plan. Maragliano, of Genoa, uses a serum which he believes can cure tubercu- losis. He immunizes animals not by injection of living cul- tures, but by employing the toxic principles extracted from them. Progressive vaccinations immunize a dog. The serum of the animal is injected for the cure of tuberculosis in man or other animals. If injected with tuberculin, it neutralizes the general and local reaction of the latter agent. The serum has apparently benefited many cases, but is useless against mixed infections.^ XIV. RICKETS. Rickets is a constitutional disease arising during the early years of life (the first two or three) as a result of insufficient or of improper diet and bad hygienic surround- ings. A deficiency of fat and phosphate in the food or the use of a diet which, by inducing gastro-intestinal catarrh, prevents assimilation, causes rickets. The disease is never congenital, the so-called " congenital rickets " being sporadic cretinism (Bowlby). Evidences of Rickets. — The condition is one of gen- eral ill-health ; the child is ill-nourished, pallid, flabby ; it has attacks of diarrhea and a tumid belly; it is disinclined for exertion and has a capricious appetite ; it is liable to night-sweats and night-terrors ; enlarged glands are often noted, the teeth appear behind time, and the fontanels close late. The long bones become much curved, the upper part of the chest sinks in, curvature of the spine appears, the head is large and the forehead bulges, and the pelvis is distorted. Swelling appears in the articular heads of long bones, by the side of the epiphyseal cartilages, and in the sternal end of the ribs, forming in the latter case rhachitic beads. The lesions of rickets are due to imperfect ossi- fication of the animal matter which is prepared for bone- formation, and consequently to softening of the bones, which causes them to bend. The swellings at the articular heads are due to pressure forcing out the soft bone into rings. Rhachitic children rarely grow to full size, and the disease is responsible for many dwarfs. Most cases recover without deformity, but the time lost during the period when active development should have gone on cannot be made up, and some slight deficiency is sure to remain. Bowlegs, knock- ' Brit. Med. Jour., 1895, ii., 444. RICKETS. 159 knees, and spinal curvature are usually rachitic in origin. The disease may be associated with scurvy, inherited syph- ilis, or tuberculosis. Treatment. — The treatment consists in open air, sunshine, salt-water baths, sea-air, fresh food (milk, cream, and meat- juice), cod-liver oil, syrup of the iodid of iron, arsenic, and some form of phosphorus. It is absolutely necessary to improve the primary assimilation. Scurvy. — This disease is rare to-day in adults, but was at one time very common among those who took long voyages, or who engaged in campaigns, or were the victims of sieges. Of recent years it is very uncommon, and has occurred chiefly among voyagers in the Arctic regions. It is a constitutional malady due to the consumption of improper diet, and especially to the employment of a diet characterized by the absence of vegetables. The use of salt meat as a staple article seems to favor the production of the disease. Garrod considered absence of potassium salts to be the real cause. Absence of variety in diet, bad water, poorly ventilated quarters, and insufficient exercise favor the development of the disease. The disease begins by weakness, drowsiness, muscular pains, and great susceptibility to cold. The skin is pallid or dirty white, and is occasionally mottled and often peels off. The pulse is excessively weak and slow. There is no fever. After two or three weeks the gums become tender, painful, and swollen, and bleed at frequent interv^als ; the breath becomes offensive, the teeth loosen and even drop out ; subcutaneous hemorrhages take place, giving rise to petechise or extensive extravasations ; the vision becomes dim, the urine becomes scanty and of low specific gravity ; vesicles form, rupture, and give rise to bleeding ulcers, and ulcers likewise arise from breaking down of blood extravasa- tions {American Text-Book of Surgery') ; hemorrhages take place into and between the muscles, and in severe cases be- neath the periosteum and into joints, and blood may come from the nose, lungs, kidneys, stomach, and intestines. Deep hemorrhages are felt as hard lumps. Bleeding at an epiph- yseal line may separate the epiphysis from the shaft. If an inflammation or ulceration arises at any point, fever is observed. It was observed in the expedition in search of Sir John Franklin that scurvy causes old and soundly healed wounds to ulcerate. Most cases get well under treatment, but complete recovery is not attained for a long time. It is important to remember that though scurvy is rare in l6o MODERN SURGERY. adults, it is by no means uncommon in ill-nourished infants. The author has seen two cases in one of which a large sub- periosteal hemorrhage was mistaken for sarcoma of the femur. It may exist with rickets. Treatment. — Vinegar, lemon juice, onions, cider, nitrate of potassium, antiseptic mouth washes, strychnin, plenty of nourishing food, and whiskey or brandy. Secure sleep ; treat ulcers by antiseptic dressings and compression. Scurvy can be prevented entirely by securing a proper diet, and maintaining cleanliness and hygienic conditions {American Text-Book of Surgery). The following agents are believed to be especially useful as preventives : fresh meat, lemon juice, cider, vinegar, milk, eggs, onions, cranberries, cabbages, pickles, potatoes, and lime juice. Infantile scurvy may exist alone or with rickets. It oc- curs most often in the children of the rich, those who have been brought up on artificial foods. It occurs between the eighth and eighteenth month. The child is anemic, has gas- tro-intestinal disorder, spongy gums, weakness of the legs, general muscular tenderness, night-sweats, and often febrile attacks (Rotch). May have bleeding beneath skin (blue spots), bloody urine and stools, bleeding into joints, viscera, or mus- cles. A subperiosteal hemorrhage is very dense, is tender, is fusiform in outline, and does not fluctuate. The limb at- tacked is flexed, and the child will not move it. It is some- times mistaken for sarcoma. Separation of epiphysis may result from hemorrhage between it and the bone. Treatment. — Oranges, grapes, meat-juice, potatoes, nour- ishing food, tonics, and antiseptic mouth-washes, XV. CONTUSIONS AND WOUNDS. Contusions. — A contusion or bruise is a subcutaneous laceration, the skin above it being uninjured (as in the abdo- men), or being damaged without a surface-breach (as in a part overlying bone), and blood being effused. If a large vessel is damaged, hemorrhage is extensive. An ecchymosis is diffuse hemorrhage over a large area ; a hematoma is a blood-tumor or a circumscribed hemorrhage. • In a diffuse hemorrhage the coagulation of fibrin induces induration ; the serum and leukocytes are absorbed ; the red blood-cells disintegrate, and the coloring-matter is widely diffused by the tissue-fluids (suggillation) ; and hemoglobin is changed into hematoidin, which crystallizes. In union with these CONTi'SIOiVS AND WOUNDS. l6l chemical changes, color-changes ensue, the part being at first red and then becoming purple, black, green, lemon, and citron. The stain following a contusion is most marked in the most dependent area. A hematoma acts as an irritant, inflammation ensues around it, and it is encapsuled by em- bryonic tissue, which, by organizing into fibrous tissue, forms a blood-cyst and gradually absorbs the fluid blood, the cyst- contents becoming thicker and thicker. A fibrous scar may remain. A blood-clot with very much indurated surround- ing tissue, giving a hard edge, is noticed after bruises of the periosteum. If serum is not absorbed, hematoidin forms and the fluid becomes clear. A hematoma may suppurate, an abscess forming ; but this rarely happens, except in drunkards, although it occasionally occurs in persons who do not use alcohol. Symptoms. — The symptoms are tenderness, swelling and numbness, followed by considerable pain. The pain rarely persists beyond the first twenty-four hours. Discolora- tion appears quickly in superficial contusions, but only after days in deep ones ; shock and loss of function are present after severe contusions. The swelling is first due to blood, and is soon added to by inflammatory exudation. Treatment. — In a severe injury bring about reaction from the shock. Local treatment consists of rest, elevation, and compression to arrest bleeding, antagonize inflammation, and control swelling. Cold is useful early in most cases, but it is not suited to severe contusions or to contusions in the debili- tated or aged, as in such cases it may cause gangrene. Lead- water and laudanum and iodin may be used. In very severe contusions employ heat and stimulation. When inflamma- tion is subsiding after a contusion, massage and inunctions of ichthyol should be employed. Massage and passive mo- tion are imperatively needed after contusion of a joint. A contusion should never be incised unless hemorrhage con- tinues, infection takes place, or a lump remains for some weeks. For persistent bleeding freely lay open the contused area, turn out clots, ligate vessels, insert drainage strand or tube, and close the wound. If gangrene is feared, apply heat to the part and use iodin locally, and if a slough forms, em- ploy antiseptic fomentations. Constitutional treatment for contusion is the same as that for inflammation. Wounds. — A wound is a breach of surface-continuity effected by a sudden mechanical force. Wounds are divided into open and subcutaneous, septic and aseptic, contused,, incised, lacerated, punctured, gunshot, and poisoned. 11 1 62 MODERN SURGERY. The local phenomena of wounds are pain, hemor- rhage, loss of function, and gaping or retraction of edges. Pain is due to the injury of nerves, and it varies according to the situation and the nature of the injury. It is influ- enced by temperament, excitement, and preoccupation. It may not be felt at all at the time of the injury. At first it is usually acute, becoming later dull and aching. In an asep- tic wound the pain is slight, but in an infected wound it is severe. The nature and amount of hemorrhage vary with the state of the system, the vascularity of the part, and the variety of injury. Loss of function depends on the situation and extent of the injury. Gaping or Retraction of Edges. — Due to tissue-elasticity. The constitutional condition after a severe injury is a state known as sJiock, which is a sudden depression of the vital powers arising from an injury or a profound emotion acting on the nerve-centers and inducing vasomotor paresis, the blood accumulating in the abdominal vessels and the amount of circulating blood being much diminished. The term collapse is used by some to designate a severe condi- tion of shock, and is employed by others as a name for a condition of shock produced by mental disturbance rather than by physical injury. Shock may be slight and transient, it may be severe and prolonged, and it may even produce almost instant death. It is more severe in women than in men, in the nervous and sanguine than in the lymphatic, in those weakened by suffering than in those who are strangers to illness. Injury of the abdomen produces great shock, and so does damage to the viscera, the urethra, and the testicles. •Cerebral concussion is a form of shock plus other conditions. Sudden and profuse hemorrhage causes shock ; so, often, does anesthetization. Symptoms. — The symptoms of ordinary shock (torpid or apathetic shock) are a subnormal temperature ; irregular, weak, rapid, and compressible pulse ; cold, pallid, clammy, or profusely perspiring skin ; shallow and irregular respira- tion ; and a tendency to urinary suppression. Consciousness is usually maintained, but there is an absence of mental orig- inating power, the injured person answering when spoken to, but volunteering no statements and lying with partly closed lids and expressionless countenance in any position in which he may be placed. The pupils are dilated and react but slowly to hght. Pain is slightly or not at all appreci- CONTUS/OiVS AND WOUNDS. 1 63 ated. Vomiting may, as in concussion, presage reaction. Gastric regurgitation after a considerable duration of shock is not unusual, and is a bad omen. Shock is not rarely fol- lowed by suppression of urine. If delirium arises, the con- dition is very grave (delirious shock). Travers called shock with delirium erethistic shock. It is seen typically after poi- soning from a serpent-bite. As a matter of fact, such a state is not genuine shock, but is either a traumatic or a toxic delir- ium. Many years ago Travers described a secondary or de- layed form of shock, which comes on several hours after an injury or violent emotional disturbance. This form of shock is seen not unusually in those injured in a railroad accident. It may be a sign of hemorrhage, and is sometimes met with after the administration of ether or chloroform. Diagnosis. — Concealed hemorrhage is difficult to separate from shock. It produces impairment of vision (retinal ane- mia), irregular tossing, frequent yawning, great thirst, nausea, and sometimes convulsions. In shock the hemoglobin is unaltered ; in hemorrhage it is enormously reduced (Hare and Martin). In hemorrhage recurrent attacks of syncope are met with. In pure shock such attacks do not occur. In concealed hemorrhage the abdomen may exhibit physical signs of a rapidly increasing collection of fluid. Shock and hemorrhage are often associated. The essential character- istic of shock is sudden onset, which separates it distinctly from exhaustion. It arises at a much earlier period after an injury than does fat-embolism. Treatment. — In treating ordinary apathetic shock raise the feet and lower the head, unless this position causes cyanosis. At least place the head flat and the body recumbent. Apply hot bottles and hot blankets, and give hypodermatic injections of ether, brandy, strychnin, digitalis, or atropin, or inhala- tions of amyl nitrite. Strychnin can be used in large doses ; gr. ^ can be given every 10 or 15 minutes until 3 doses are taken. If the skin is very moist, atropin is indicated, alone or combined with strychnin. A turpentine enema is useful. Hot coffee or other hot fluids should be given by the mouth and rectum, and mustard should be placed over the heart, spine, and shins. The use of hot and stimulating rectal ene- mata is very important. The rectum may absorb when the stomach refuses to do so. Enemata of hot normal salt solu- tion are very beneficial (enteroclysis). The tube is carried into the sigmoid flexure and the injection is introduced so as to distend the colon. In severe cases bandage the extrem- ities in order to send blood to the brain and correct the 164 MODERN SURGERY. ischemia of the vital centers. For this purpose ordinary muslin bandages may be used, or gauze bandages, or the bandage of Esmarch (autotransfusion). Abdominal massage helps drive out the imprisoned blood, and after massage sets free the abdominal blood apply a compress and binder. Hy- podermoclysis is of great value. Insert an aspirator-tube into the cellular tissue of the buttock, loin, or scapular re- gion, cleansing the part first. The tube is attached to a fountain-syringe, which is filled with normal salt solution, and is hung at a height of two or three feet above the bed. In an hour's time a pint or more of fluid will enter the tis- sue and be absorbed. In very dangerous cases transfuse salt solution into a vein (p. 277) and make artificial respira- tion, and stimulate the diaphragm with a galvanic current. If shock comes on during operation, the proceedings must be hurried or even stopped, and proper treatment must be instituted at once. The anesthetizer should give very little ether when shock becomes at all evident. Should we operate during shock ? We should only do so when death without instant operation is inevitable. We must operate, if it is necessary to do so, to arrest hemorrhage, to relieve strangulated hernia, intestinal obstruction, obstruction of the air-passages, compound fractures of the skull, extravasated urine or intraperitoneal extravasations from ruptured viscera. If hemorrhage can be temporarily controlled by pressure or a clamp so much the better, and the permanent arrest can be effected after the reaction from shock. It is not wise, in the author's opinion, ever to amputate during shock. A tourni- quet or Esmarch bandage should be applied, and attempts be made to bring about reaction, and when reaction is ob- tained the amputation should be performed. It is only just to say that some eminent surgeons oppose this rule. Ros- well Park says that " shock is often alleviated by the prompt removal of mutilated limbs which, when still adherent to the trunk, seem to perpetuate the condition." The same teacher believes in operating at once upon severe compound frac- tures.^ After shock has passed away give diuretics to pre- vent suppression of urine. Delayed shock is treated in the same manner as apathetic shock if hemorrhage can be ex- cluded. If hemorrhage is the cause, the bleeding must be stopped. If delirious shock is due to sepsis, the treatment is the treatment of sepsis. If it is a nervous delirium, give mor- phin and other sedatives. Fat-embolism. — (Seep. 135.) ^ Park's Surge;y by American Authors. CONTUSIONS AND WOUNDS. 1 65 Fever. — (See Fevers, p. 87.) Treatment of Wounds. — The rules for treating wounds are — (i) arrest hemorrhage; (2) bring about reaction; (3) remove foreign bodies ; (4) asepticize ; (5) drain, coaptate the edges, and dress ; and (6) secure rest to the part and combat inflammation. Constitutionally, allay pain, secure sleep, keep up the nutrition, and treat inflammatory conditions. Arrest of HcJiwrrhagc. — To arrest hemorrhage the bleed- ing point must be controlled by digital pressure until ready to be grasped with forceps ; it is then caught up and tied with catgut or aseptic silk. Slight hemorrhage stops spon- taneously on exposure to air, and moderate hemorrhage ceases after the vessels are clamped for a time; an injured vessel of some size must be ligated, even if it has ceased to bleed. Capillary oozing is checked by hot-water compresses. If a large artery is divided in a limb, apply a tourniquet before ligating (see Wounds of Vessels). Bringing about of Reaction. — (See Shock.) Removal of Foreign Bodies. — Remove all foreign bodies visible to the eye (splinters, bits of glass, portions of cloth- ing, gun-wadding, grains of dirt, etc.) with forceps and a stream of corrosive-sublimate solution. In a lacerated or contused wound portions of tissue injured beyond repair should be regarded as foreign bodies and be removed with scissors. Cleaning the Wonnd. — To clean the wound scrub the area around it with ethereal soap and then with corrosive-sub- limate solution (i : 1000). If the surface is hairy, it must be shaved before the scrubbing. An accidental wound is in- fected, and must be well washed out with an antiseptic solu- tion. A clean wound made by the surgeon need not be irrigated; in fact, irrigation with an antiseptic fluid leads to necrosis of tissues, causes a profuse flow of serum, and ne- cessitates drainage. If clots have gathered in a wound they must be removed, as their presence will prevent accurate co- aptation of the edges. In an infected wound they are washed out with a stream of corrosive-sublimate solution. In a clean wound they are washed out with hot salt solution. If dirt is ground into a wound, as is often seen in crushes, pour sweet oil into the w^ound, rub it into the tissues, and scrub the wound with ethereal soap. The oil entangles the dirt, and the soap and water remove both oil and dirt. After the rough cleans- ing irrigate with corrosive-sublimate solution. In some cases, especially in bone-injuries, it is necessary to scrape the wound with a curet. If a fissure of the skull is infected. 1 66 MODERN SURGERY. enlarge the fissure with a chisel in order to clean it. In a bad infection one of the most valuable agents for local use is pure carbolic acid. In wounds which cannot be approxi- mated it is often wise to employ grafting after the method of Thiersch. In very small wounds which cannot be ap- proximated, dust with glutol and dress with dry sterile or aseptic gauze ; and if sloughs form, apply antiseptic poultices until granulation begins. A granulating wound is dressed as a healing ulcer. Drainage, Closure, and Dressing. — Superficial wounds re- quire no special drain, as some wound-fluid will find exit between the stitches and the rest will be absorbed. A large or deep wound requires free drainage for at least twenty-four hours by means of a tube, strands of horse-hair, silk, or catgut, or bits of iodoform gauze. An infected wound must invariably be drained. Good drainage largely compensates for imperfect antisepsis. If capillary drains be employed, apply a moist dressing. Divided nerves and tendons must be sutured. Close the edges with silk sutures or silkworm- gut if the wound is deep and tension is inevitable. Catgut is used for superficial wounds and for those where tension is slight. The interrupted suture is, as a rule, the best. If the wound is infected, dress with antiseptic gauze ; or with either aseptic or antiseptic gauze if it is not infected. The custom once was to cover the gauze with a rubber-dam to diffuse the fluids, but we now prefer to omit the rubber-dam and use plentiful dressings. A dry dressing absorbs wound- fluids quickly and is less Hkely to become infected. Change the dressings in twenty-four hours, or sooner if they become soaked with discharge. After this, in an aseptic wound, the dressing need not be changed for days. If pus forms, open the wound at once. Many surgeons sprinkle wounds before approximation and wound-surfaces after approximation with a drying-powder. These powders are of great use in infected wounds, but are not necessary in clean wounds. Among the substances employed are salicylic acid, boracic acid, calomel, acetanilid, aristol, iodoform, subiodid of bismuth, and glutol. A sloughing wound is dressed with antiseptic poultices after being opened and dusted with protonuclein, acetanilid, glutol, or iodoform. Rest. — Severe wounds require the confinement of the pa- tient to bed. Bandages, splints, etc., are used to secure rest. The methods of combating inflammation have previously been set forth. Constitutional Treatment. — Bring about reaction from de- CONTUSIONS AND WOUNDS. 167 pression, but prevent undue reaction. Feed the patient well, stimulate him if necessary, and attend to the bowels and bladder. Watch the temperature as the danger-signal, se- cure sleep, and allay pain. Look out for complications, namely, inflammation, suppuration, gangrene, tetanus, and erysipelas. Incised Wounds. — An incised wound is a clean cut in- flicted by an edged instrument. Only a thin film of tissue is so devitalized that it must die. These wounds have a splendid chance of union by first intention. A sword-cut is an incised wound. Sytnptoms. — The symptoms of incised wounds are sharp pain for a time, followed by smarting, profuse bleeding, and decided retraction of the edges. Treatment. — The treatment of incised wounds is according to general rules. Do not use styptics, as they cause a large, soft clot to form, produce irritation, and favor infection. Lacerated and Contused Wounds, — A lacerated wound is a tearing apart of the tissues ; a contused wound is a crush- ing and pulpefying of tissues. These two forms may be combined. They are irregular, contain masses of partially detached tissue and blood-clots, and their edges are cold and discolored. Such wounds tend to necrosis. Symptoms. — The symptoms are excessive shock, slight hemorrhage, and only a moderately dull pain. Reactionary and secondary hemorrhages are common. Infection is liable to occur, and more or less sloughing is bound to ensue. Treatment. — Any damaged vessel, whether it bleeds or not, is to be tied, the devitalized tissues are cut away, and foreign bodies are removed. Asepticize with great care and secure thorough drainage, making if necessary counter-open- ings. In dressing, put iodoform in the wound and close the wound only partially. Watch for bleeding during reaction. When sloughing begins use antiseptic fomentations. A brush-burn, which is a contused-lacerated wound due to fric- tion, requires the use of an antiseptic poultice until the slough is cast ofl". In badly lacerated wounds and crushes it is often necessary to amputate. Punctured wounds are wounds made by pointed instru- ments. A punctured wound is usually deep, it closes partly after withdrawal of the instrument, blood-clot and wound- fluids cannot get exit, and infection is almost certain if the instrument carried microbes. The danger is not only of in- fection by pus organisms, but by tetanus bacteria. Large- sized foreign bodies may be driven in or a portion of the in- 1 68 MODERN SURGERY. strument may break off. Arrow-wounds are punctured and incised. Bayonet-wounds are punctured, and so are sticks from a sword. Symptoms. — In punctured wounds the pain is rarely severe, and hemorrhage is slight unless a large vessel be wounded. Infection is apt to ensue. Varicose aneurysm may be caused if both a vein and an artery have been punctured. Treatment. — In treating punctured wounds incise to the depth of the puncture, stop the hemorrhage, asepticize with pure carbolic acid in many cases, and drain. An arrow should never be pulled out, but should be pushed through or cut down upon by enlarging the wound. Gunshot-wounds. — Gunshot -wounds are contused or contused-lacerated wounds inflicted by materials projected by explosives. A bit of rock or a crowbar hurled by dynamite inflicts a gunshot-wound, as does a shell-fragment, a pistol- ball, a small birdshot, a rifle-bullet, a flying cap, a piece of wadding, grains of powder, a buckshot, a fragment of wood broken off by a shell concussion, grapeshot and canister, or a cannon-ball. Injuries by shell-fragments, portions of a bursted boiler, pieces of masonry or wood, are either lacer- ated or punctured wounds, and need no special consideration here. In this article we treat of injuries caused by bullets and shot. At the present day the old round ball is very rarely used, the conical projectile having taken its place. For the fire- arms of civilians, as a rule, the bullets are made of lead, hardened and shaped by compression, or hardened by an admixture with tin. The conical shape of the pistol-ball, the great velocity with which it is propelled and with which it rotates, and its hardness, make it unlikely that at near range the bullet will only contuse and not enter the skin. It will almost always enter ; it will occasionally lodge and often perforate ; it is rarely deflected, and is not nearly so much flattened by impact as the softer round ball. A pistol-ball or a spent rifle-ball, however, may fail to enter the tissues, grazing the surface and inflicting a brush-burn, or simply contusing the part. A bullet may enter the tissues, a cavity, or an organ, and lodge there, causing a penetrating wound. It may enter and emerge, causing a perforating wound. The bullet may not enter alone, but may carry with it bits of clothing or other foreign bodies. This com- plication is much more rare in injury by the conical bullet. The military surgeon deals with wounds inflicted by small, densely hard, conical projectiles, which are impelled at a CONTUSIONS AND WOUNDS. 1 69 great velocity, and are carried to long distances. The old Springfield rifle, of a caliber of 0.45 inch, projected a bullet with a velocity of thirteen hundred feet in a second. The Mannlicher rifle, of a caliber of 0.25 to 0.32 inch, sends a bullet with a velocity of over two thousand feet a second. This bullet revolves with great velocity upon its own axis (two thousand times the first second) and is effective at several miles. The bullet of the modern rifle is conical, has a leaden core, and is hardened by being covered with a mantle or jacket of copper, steel, nickel, or of alloys of copper and nickel, or of copper, nickel, and zinc. The older projectile was apt to lodge ; was often deflected in the tissues ; was flattened out on meeting with resistant structures, such as bone or cartilage, and after flattening be- came larger and tore and lacerated the soft parts and com- minuted the bone. The new projectile is apt to perforate, is rareh' deflected, and is so hard that its shape is generally but little altered on meeting with resistant structures, and hence it was thought that the new bullet would prove more humane than the old projectile, and inflict wounds which would be more easily treated than of old, because the bullets would not lodge and because extensive damage would not be in- flicted. This view has proved fallacious. It is true that in many instances a modern bullet will make a clear track without laceration or comminution ; but in other instances it pulpefies structure for a considerable distance around the track of the ball by what is known as the explosive effect. This term does not mean that the bullet has exploded, but that its sudden impact against and rapid rotation in the tissues have by waves of force caused extensive and dis- tant damage, and often horrible and irreparable injury. Ex- plosive effects are seen most often at close range, when the velocity of the ball and the frequency of its rotation are most marked. A pistol-ball has no explosive action at all, and the old-time bullet possessed it only at ver)' close range. The modern projectile always produces explosive effects up to five hundred yards. Up to thirteen hundred yards it pro- duces them upon the skull and brain. At this distance a single small projectile may entirely destroy the cranium and brain (see Demosthen's studies of the action of the Mann- licher rifle). Explosive effects are noted at long distances upon the liver, spleen, kidney, and lungs, and upon hollow viscera containing fluid. Cancellous bone struck by the old-style bullet was much lyO MODERN SURGERY. comminuted at any range ; struck with the new bullet at a range of from three hundred and fifty to fifteen hundred yards, perforation occurs rather than comminution. At a distance of less than three hundred and fifty yards the new ball has an explosive effect and causes great damage. Hard bone is extensively damaged at even long range by the hard projectile. This projectile theoretically does not flatten, but practically in many instances it does flatten a little, and in others its coat is torn off when it strikes hard bone at a dis- tance of less than eighteen hundred yards. The old-style bul- let rarely caused much primary hemorrhage, as the vessels as well as the nerves and tendons were usually pushed aside rather than cut. Hence secondary hemorrhage was com- mon because of contusion of the vessel-walls. The modern bullet cuts rather than pushes aside the vessels. Hence pri- mary hemorrhage is usual, and may often prove fatal. The modern bullet rarely lodges at any range, and is rarely de- flected. Skin is usually split by it. Fascia and muscle are usually much damaged, but in a transverse wound of muscle the fibers may be separated rather than destroyed (Conner). In the warfare of the future numbers of the wounded will be fortunate in not harboring a ball and in escaping manipu- lations to extract it. Great numbers of people will be killed outright and great numbers will receive terrible injuries, from which recovery, if it takes place at all, will be attained after much time and agony. The effects of the modern bullet have been determined by careful study and experiment ; by a study of the wounds in the Chitral Expedition and of wounds inflicted by accident or with homicidal or suicidal intent ; by experiments : firing through boxes filled with wet sand ; firing into thick oak ; firing at cadavers at fixed distances with reduced charges (La Garde). Nancrede cau- tions us to remember that experiments upon the cadaver, employing reduced charges and standing at fixed distances, are uncertain in their provings. " The difference between the velocity of rotation and angle of incidence with reduced charges at fixed distances and service-charges at actual dis- tances are marked. The tension of living muscles and fasciae, as compared with dead tissues, and the physical change of the semiliquid fat of adipose tissue and medulla to a more solid condition by the loss of animal heat, influence the results.^" ^ Nancrede upon " Gunshot Wounds," in Park's Surgery by American Authors. For information upon wounds by the modern firearm, see report of Surgeon- General of the United States Army, 1893. Demosthen's study of the wounds inflicted by the Mannlicher rifle. Prof. Conner, in Dennis' Syste?ti of Surgery. CONTUSIONS AND WOUNDS. I/I In injuries from the old-style bullet the wound of entrance was often smaller than the ball (skin stretched at the moment of impact and contracted after perforation) ; it was depressed, and the edges were contused and inverted, and if the weapon were fired within ten feet usually were blackened from pow- der and contained powder-grains. If the wound was much larger than the bullet, it meant that some foreign body had been carried in. In injuries from the modern bullet the skin may be split or may be perforated, the wound is usually as large as the ball, and foreign bodies are not carried by the ball into the tissue. In wounds from the old-style bullet the wound of exit was everted, " triangular, linear, or stellate," and much larger than the wound of entrance ; in wounds from the modern bullet, if the wound of exit is not in the region of explosive action, it may be a little larger or a little smaller than the bullet, but is not noticeably larger than the wound of entrance. If within the area of explosive action, the wound of exit is much larger than the wound of entrance, and is irregular and everted. Wounds by Cannon-balls. — A cannon-ball weighing five or six pounds may be imbedded in tissues. A ball or shell-fragments may tear off a limb or lacerate it exten- sively. In some cases of injury by spent balls the bone is destroyed and the muscles disorganized while the skin is intact. Wounds by Small Shot. — Single shot may bruise the surface or may enter the tissues. When many shot enter together they strike as a solid body. Single shot are usually deflected from vessels and nerves, and rarely lodge in bone, but rather flatten on its surface. A load of shot entering together produces extensive laceration and inflicts damage which is often irreparable. Symptoms of a Gunshot--w"ound. — Hemorrhage is often considerable, but ceases spontaneously unless a large vessel has been divided. If hemorrhage is profuse, the con- stitutional symptoms of hemorrhage exist. These symp- toms are of great importance in abdominal wounds (p. 628). A pistol-ball rarely causes severe primary hemorrhage, because it rarely penetrates a large artery. It is apt to push aside a vessel, and secondary hemorrhage is not un- usual. Even if a large vessel is wounded and a succession of violent hemorrhages occur, a man may live for several days. Secondary hemorrhage may follow a gunshot-wound because of contusion of vessels or of infection. 1/2 MODERN SURGERY. Pain is often not noticed at first, especially if the injured individual were greatly preoccupied or excited. There may be a feeling of numbness, but there is usually a dull or stinging pain. If a large nerve is injured, there may be vio- lent pain. Even trivial gunshot-wounds frequently produce profound shock, and yet it may happen that even severe wounds may be accompanied by but slight shock. In most gunshot-wounds of the brain, abdomen, and spinal cord the shock is very great. General Considerations as to Treatment. — The dangers are shock, hemorrhage, and infection. Bullets are aseptic when they enter a part, and if infection is not inserted in the track of the ball the wound will in most instances heal kindly. " The fate of a wounded man is in the hands of the surgeon who first attends him " (Nussbaum). The danger of a wound depends upon the size and velocity of the bullet, the part struck, " and the degree of asepsis ob- served during the first examination and dressing" (Nan- crede). The rules of treatment are : bring about reaction, arrest hemorrhage, preserve asepsis, and, in some cases, re- move the ball. Always notice if a wound of exit exists. It is a good plan, when endeavoring to determine the extent of injury, to put the parts in the position they were in when the injury was inflicted. We should try to ascertain the size and nature of the weapon, and the range at which it was fired. Examine the clothing to see if any fragments are missing and could have been carried in. Such fragments render sepsis almost inevitable. The surgeon must not feel it his duty to probe in all cases. In many cases it is better not to probe at all. Explore for the ball when sure that it has carried in with it foreign bodies ; when its presence at the point of lodgement interferes with repair ; when it is in or near a vital region (as the brain) ; and when it is neces- sary to know the position of the bullet in order to determine the question of amputation or resection. If the wound is large enough, the finger is the best probe. Fluhrer's aluminum probe is a valuable instrument. It is employed especially in brain-wounds, and is allowed to sink into the track of the ball by the influence of gravity after the part has been placed in a proper position. If a lead bullet is imbedded, it is possible to distinguish the hard projectile from a bone by inserting the stem of a clay pipe, a bit of pine wood, or Nelaton's porcelain-headed probe. On any one of these appliances lead will make a black mark. No such test can be applied to a modern bullet, for this has COXTi'SWiVS AND WOUNDS. 1 73 a hard metal jacket, and will not make a black mark on a white substance. The induction-balance of Graham Bell has been employed to determine the situation of a bullet. The bullet may be located by Girdners telephonic probe. In order to construct this instrument, take a telephone receiver, fasten one of the wires to a metal plate and the other one to a metallic probe. Moisten a portion of the patient's body and place the metal plate in contact with it. The surgeon places the receiver to his ear and inserts the probe into the w^ound. If the probe strikes metal, a click is heard with distinctness. A bullet may be located by LilicntJiaV s probe. This appa- ratus consists of a mouth-piece, two insulated copper wires, and a probe. The mouth-piece is composed of two plates, one of copper and one of zinc, which are applied to the sides of the tongue. An insulated wire runs from each plate and into the metal probe. The tip of the probe is composed of two or four pieces of metal, is separated from the shank by a washer of rubber, and is attached to the wires. The operator closes the teeth upon the mouth- piece and inserts the probe into the wound. If the probe touches the bullet, a distinct and continuous metallic taste is appreciable. The best means of discovering a bullet is to use the fluoro- scope or take a skiagraph. In order to locate it accurately view it through a series of squares, insert guide-pins, or employ Sweet's apparatus (p. 875). Bullets are readily seen in the superficial soft parts, but are also recognizable in deeper structures (bone, abdomen, lung, brain, etc.). Though Nelaton's probe will not show the difference be- tween ball and bone, it is a valuable instrument to follow the track of a wound. The porcelain head ought to be larger than it is usually made — in fact, it should be nearly the size of the bullet (Senn). In passing a probe use no more force than in passing a catheter (Senn). In extracting the ball use very strong forceps. The old American bullet-forceps is useless for the extraction of the hard-jacketed ball, as the points of the in- strument will not penetrate and the instrument will not hold. If hemorrhage is severe in a gunshot-wound, enlarge the wound, find the bleeding vessel, and tie it. Before handling a gunshot-wound asepticize the parts about it. Irrigate with hot sterile salt solution, and drain with a tube or a bit of iodoform gauze and dress antiseptically. Primaiy union rarely takes place because of the necrosis of damaged tissue 1/4 MODERN SURGERY. in the track of the ball, but in some cases it can be obtained. Healing begins in the depths of the wound and extends toward the wound of entrance, or, if there be also a wound of exit, toward both. Radical operations may be demanded : laparotomy (p. 666), trephining (p. 571), rib-resection (p. 610), joint-resection, and amputation. Amputation is sometimes demanded because of great injury to the soft parts (as by a shell-fragment), the splinter- ing of a bone, injury of a joint, damage to the chief vessels or nerves, or the destruction of a considerable part of a limb. Perform a primary amputation if possible, and make the flaps through tissue that will not slough. In civil prac- tice, with careful antisepsis, more questionable tissue can be admitted into a flap than in military practice, where trans- portation will become necessary and antisepsis may be im- perfect or wanting. In warfare at the present day an attempt is made to limit the death-rate from gunshot-wounds by protecting them from infection at an early period after the accident. Es- march offered a suggestion, which has been adopted in the German army and other armies. Every soldier carries a package which contains antiseptic dressings, and at the first opportunity after the infliction of a wound, if possible on the field, these dressings are applied by the soldier or by a com- rade (for even the privates are instructed in the application), or by an ambulance man. If not applied on the field, they are applied at the first dressing-station by a surgeon or a hos- pital steward. Senn considers Esmarch's package too cum- brous.^ He suggests a package containing half an ounce of compressed salicylated cotton. In the center of this cotton is an antiseptic powder (2 gm. of boric acid and \ gm. of salicylic acid). The cotton is wrapped in a triangular gauze bandage. A safety-pin is placed in the bandage and the en- tire bundle is wrapped in gutta-percha tissue. Senn says the triangular bandage is sufficient to hold on a dressing, and it can be assisted by utilizing the gunstrap, safety-belt, or articles of clothing.^ (For gunshot-wounds of special structures, see Bones, Joints, etc.) Poisoned wounds are those in which a poison is intro- duced. This poison may be microbic and capable of self- multiplication, or it may be chemical, and hence incapable of multiplication. There are three classes of poisons:^ (i) "^ Jour. Ajn. Med. Assoc, July 13, 1895. ^ Senn, m Jour. Am. Med. Assoc., July 13, 1895. ' American Text-Book of Surgery. CONIX'SIONS AND WOUNDS. 1 75 mixed infection, as septic wounds, dissection-wounds, and malignant edema ; (2) chemical poison, such as snake-bites and insect-stings ; and (3) infection by such diseases as rabies, glanders, etc. Septic wounds are those which putrefy, suppurate, or slough. Open septic wounds freely for drainage, curet, or cut away hopelessly damaged tissue, wash with peroxid of hydrogen and then with corrosive sublimate, dust with iodo- form or glutol, and either use, a drainage-tube or pack with iodoform gauze. The antiseptic poultice is an excellent dressing. If lymphangitis arises, paint over the inflamed vessels and glands with iodin and cover with lead-water and laudanum, and give internally quinin and iron. Watch the temperature for evidences of general infection or intox- ication. Stimulate and secure good nourishment, rest, and sleep. Dissection-wounds are simple examples of infected wounds, and they present nothing peculiar except virulence. They affect butchers, cooks, surgeons who cut themselves in operating on an infected area, those who make postmor- tems, and those who dissect. A dissection-wound inflicted while working on a body injected with chlorid of zinc pos- sesses but few elements of danger unless the health of the student is much broken down. Postmortems are peculiarly dangerous when the subject has died of some septic process. When a wound is inflicted while dissecting, wash it under a strong stream of water, squeeze, and suck it to make the blood run, lay it open if it be a puncture, swab it out with pure carbolic acid, and dress it with iodoform and gauze. If infection shows itself, it must be treated as any other infected wound. Malignant edema or gangrenous emphysema arises most commonly after a puncture. It is due to a specific bacillus which produces great edema, and to secondary infec- tion with putrefactive organisms. Symptoms. — The symptoms are edema, the fluid being distinctly bloody, followed by rapidly diffusing gangrene which is surrounded by a zone of edematous tissue that crepitates under pressure because it contains gases of putre- faction. The zone of edema is covered with blebs which contain thin, putrid, reddish matter. The constitutional con- dition is one of septicemia. Death occurs, as a rule, in a few days. Treatment. — To treat malignant edema, if it affect a limb, amputate at once, high up. If it affect some other part, 176 MODERN SURGERY. excise, use the actual cautery, and dress antiseptically. Stimulate very freely. Stings and Bites of Insects and Reptiles : Stings of Bees and Wasps. — A bee's sting consists of two long lances within a sheath with which a poison-bag is connected. The wound is made first by the sheath, the poison then passes in, and the two lances, moving up and down, deepen the cut. The barbs on the lances make it difficult to rapidly withdraw the sting, which may be broken off and remain in the flesh. Besides bees, hornets, yellow-jackets, and other wasps produce painful stings. These stings rarely produce any trouble except pain and swelling. In some rare cases a bee-sting is fatal ; persons have been stung to death by a great number of these insects. Symptoms. — If general symptoms ensue, they appear rapidly and consist of great prostration, vomiting, purging, and delirium or unconsciousness. These symptoms may disappear in a short time, or they may end in death from heart-failure. Stings of the mouth may cause edema of the glottis. Treatment. — To treat a bee-sting, extract the sting if it be broken off, and apply locally ichthyol, a solution of wash- ing-soda, tincture of arnica, iodin, or lead-water and lauda- num. If constitutional symptoms appear, stimulate. Other Insect-bites and Stings. — The mandibles of a spider are terminated by a movable hook which has an opening for the emission of poison. The bite of large spiders is productive of inflammation, swelHng, weakness, and even death. The bite of the poisonous spider of New Zealand produces a large white swelling and great prostra- tion ; death may ensue, or the victim may remain in a de- pressed, enfeebled state for weeks or even for months. The tarantula is a much-dreaded spider. A scorpion has in its tail a sting, and a scorpion's sting produces great prostration, delirium, vomiting, diaphoresis, vertigo, headache, local swell- ing, and burning pain, followed often by suppuration, or even by gangrene and fever. Centipedes must be of large size to be formidable to man, and the symptoms arising from their stings are usually only local. Treatment. — Tie a fillet above the bitten point ; make a crucial incision, favor bleeding, and swab out the wound with pure carbolic acid or some caustic or antiseptic (if in the wilds, burn with fire or gunpowder) ; dress antiseptically if possible, and stimulate as constitutional symptoms appear. Slowly loosen the ligature after symptoms disappear. Chlo- CONTUSIONS AND WOUNDS. 1/7 roform stupes and ipecac poultices are recommended, also puncture with a needle and rubbing in a mixture of 3 parts of chloral and i part of camphor (Bauerjie). Snake-bites. — The poisonous snakes of America com- prise the copperheads, water-moccasins, rattlesnakes, and vipers. There is also a poisonous lizard. The symptoms of snake-bite are similar whether it is the bite of an Indian cobra or of an American rattler, and they depend upon the dose of poison introduced. Poison injected into a vein may prove almost instantly fatal. The poison is not ab- sorbed by the sound mucous membranes. It is discharged through the hollow fangs of the reptile by contractions of the muscles of the poison-bag. In most varieties of snakes the teeth lie along the back of the mouth and are only erected when the reptile strikes. The poison contains pro- teid constituents, globulins, and peptones (Mitchell and Reichert), and probably toxic animal alkaloids (Brieger). S. Weir Mitchell has shown that rattlesnake venom exerts a paralyzing action upon the walls of the smaller blood- vessels, converts the blood into a noncoagulable fluid, causes the white blood-cells and the fluid elements of blood to ex- travasate into the tissues, and disintegrates the red corpuscles. Symptoms. — The symptoms are — pain, soon becoming intense ; mottled swelling of the bitten part, which swelling may be enormous, and which is due to edema and extrava- sation of blood, and assumes a purpuric discoloration. There may be complete consciousness, or there may be lethargy, stupor, or coma. Some cases present spasms. The general symptoms are those of profound shock, which may present delirium (delirious shock). Death may arise from paralysis of the heart or paralysis of respiration, and may occur in about five hours, but as a rule it is postponed for a number of hours. If death is deferred many hours, profound sepsis comes upon the scene, with glandular en- largement, suppuration, and sometimes gangrene. Treatment. — Cases of snake-bite must, as a rule, be treated without proper appliances. The elder Gross was accus- tomed to relate in his lectures how he hacd seen an army officer blow off his finger with a pistol the moment it was struck, and thus escape poisoning. In general, the rules are to twist several fillets at different levels above the bite, to excise the bitten area, to suck or cup it if possible, and to cauterize it by a pure acid or by heat. An expedient among hunters is to cauterize by pouring gunpowder on the excised area and applying a spark, or by laying a hot ember 12 178 MODERN SURGERY. on the wound. When a hot iron is available, use it. The .fillets are not to be removed suddenly, and they had best be kept on for some time. Remove the highest constricting band first ; if no symptoms come on after a time, remove the next, and so on ; if symptoms appear, reapply the fillet. The constitutional treatment is expressed in one word : stimulate. Our only hope is in large doses of alcohol, and, if they can be obtained, ammonia, ether, strychnin, or digi- talis hypodermatically administered. Large doses of strych- nin hypodermatically are used by many surgeons in India. Morphin may be given for pain. There is no specific for snake-poison. Hypodermatic injections in the area adjacent to the bite of a i per cent, solution of the permanganate of potassium are commended by some. The local use of chlorid of lime has recently been recommended. Halford of Australia praises the intravenous injection of ammonia (loTTL of strong ammonia in 2oTrL of water). If a man is bitten by a large and deadly snake, the surgeon, if one is at hand, should at once amputate well above the bite.^ Attempts are being made to obtain a curative serum. Animals can be ren- dered immune by giving them at first small doses of the poison and gradually increasing the amount administered. It is asserted that the serum of immune animals will cure a person bitten by a venomous snake. Cures have been re- ported after the use of Calmette's antivenene serum. The dose is 20 c.c. hypodermatically, repeated if necessary in three or four hours. Alexander^ treated a case successfully by making an incision into the bitten area, pouring into the wound rattlesnake bile, and giving carbonate of ammonium internally. The poisonous lizard (Gila monster) can kill small animals, but it is not believed that its bite would prove fatal to man. Anthrax (malignant pustule, charbon, wool-sorters' dis- ease, Milzbrand, or splenic fever) is a term used by some as synonymous with ordinary carbuncle, but it is not here so employed. Anthrax, as met with in man, is a disease con- tracted in some manner from an animal with splenic fever. It may be contracted by working around diseased animals, by handling or tanning their hides, by sorting their hair or wool ; it may be conveyed by eating infected meat or by drinking infected milk. Flies may carry the poison. Inhala- tion of poisoned dust may infect the lungs. Catgut ligatures may be contaminated and carry the poison. Many attempts, 1 Charters James Symonds, in Heath'' s Dictionary of Practical Surgery. '^ Medical Record, Sept. 5, 1896. CONTUSIONS AND WOUNDS. 1 79 not altogether satisfactory, have been made to render ani- mals immune (Pasteur, Wooldridge, Hankin). Certain or- ganisms are antagonistic to anthrax (the streptococcus of erysipelas, the pneumococcus, the micrococcus prodigiosus, and the bacillus pyocyaneus). Forms of Anthrax. — There are two forms of the disease — external and internal. Internal anthrax may be intestinal from eating diseased meat or pulmonary from inhalation of poisoned dust. External anthrax may be anthrax carbuncle or anthrax edema. The external form appears in from three to six days after inoculation, and presents a papule with a red base ; the papule becomes a vesicle which contains bloody serum ; the vesicle bursts and dries, the base of it swells and enlarges, other vesicles appear in circles around it, and there is developed an " anthrax carbuncle," which shows a black or purple elevation with a central depression surrounded by one or more rings of vesicles. Pain is trivial. Lymphatic enlargements occur. Within forty-eight hours after the pus- tule begins organisms appear in the blood. In loose con- nective tissue the lesion may be anthrax edema, a spreading livid edema followed by blebs and even by gangrene. The constitutional symptoms may rapidly follow the local lesion, but may be deferred for a week or more. The patient feels depressed, has obscure aches and pains, and is feverish, but usually keeps about for a short period. After a time he is apt to develop rigors, high irregular fever, sweats, acute fugi- tive pains, diarrhea, delirium, typhoid exhaustion, dyspnea, cough, and cyanosis. The local carbuncle of anthrax is dis- tinguished from ordinary carbuncle by the central depres- sion, the adherent eschar, the absence of tenderness, and the absence of suppuration of the first, as contrasted with the elevated centre, the multiple foci of suppuration and slough- ing, and the acute pain of the second. Anthrax edema dif- fers from cellulitis in the absence of all tendency to form pus, and from malignant edema by the greater tendency of the latter to result in gangrene. If anthrax has a visible lesion and the constitutional symptoms are slight or absent, the chance of cure is good. Treatment. — If a person is wounded by an object sus- pected of carrjang the infection, cauterize the wound with the hot iron. A sufferer from anthrax must be isolated in a well-ventilated room. All dressings are to be burnt, all discharges asepticized, and after the removal of the patient the bed-clothes are burnt and the room disinfected. A malignant pustule should be entirely excised, and the wound l8o MODERN SURGERY. mopped out with pure carbolic acid or burnt with the hot iron, and afterward dressed with wet bichlorid-of-mercury gauze which is covered with an ice-bag. Excision should be practised even when glands are enlarged, but it will prove ineffectual if organisms are present in the blood. When excision cannot be performed make crucial incisions through the lesion, mop out with pure carbolic acid, and inject around and in the pustule carbolic acid (i : lo) every six hours until the disease abates or toxic symptoms appear. The adher- ent eschar is subsequently removed by antiseptic poultices. Davaine advised the following plan : Inject the pustule and the tissues about it at many points every eight or ten hours with I part of tincture of iodin diluted with 2 parts of water or with a lo per cent, solution of carbolic acid, or with a -^-^ per cent, solution of corrosive sublimate. Dress with wet antiseptic gauze and apply an ice-bag. Inflamed lymphatic vessels and glands should be painted with iodin and smeared with ichthyol. Constitutional treatment is sustaining and stimulating. Maffucci gives carbolic acid internally, and also uses it externally. Davies-Colley uses ipecac locally and gives large doses by the mouth. Pulmonary anthrax and intestinal anthrax are always fatal. The treatment is symptomatic. Hydrophobia, Rabies, or I^yssa. — Hydrophobia is a spasmodic and paralytic disease due to infection through a wound with the virus from a rabid animal. The animal may be a dog, a cat, a wolf, a fox, or a horse. Roux esti- mates that about 14 per cent, of the people bitten by mad animals develop the disease. If the bite is on an exposed part, it is far more apt to cause rabies than if the teeth pass through clothing. Hydrophobia is almost invariably fatal. The saliva is the usual vehicle of contagion, but other fluids and tissues contain the virus, especially the brain and cord. Symptoms. — The period of incubation of hydrophobia is from a few weeks to two years. The initial symptoms are mental depression, anxiety, headache, malaise, and often pain or even congestion in the cicatrix, which symptoms are quickly followed by a general hyperesthesia, pharyngeal spasms, dyspnea from laryngeal spasms, and constant attempts to expectorate thick mucus which forms because of congestion of the air-passages. Attempts at swallowing, as well as lights and noises, tend to bring on spasms, hence the fear of liquids (there is spasm from attempts at swallowing or from thinking of the act). The entire body may be thrown into clonic spasms, but there is no tonic spasm. The mind is usually clear, CONTUSIONS AND WOUNDS. l8l although during the periods of excitement there may be maniacal furor with hallucinations which pass away in the stage of relaxation. The temperature is moderately elevated (iOi° to 103° or higher). This spasmodic stage lasts from one to three days, and the patient may die during this period from exhaustion or from asphyxia. If he lives through this period, the convulsions gradually cease, the power of swal- lowing returns, and the patient succumbs to exhaustion in less than twenty-four hours, or he develops ascending paral- ysis which soon causes cardiac and respiratory failure. In hydrophobia death is practically inevitable. Almost all cases in which it is alleged that recovery ensued were not true hydrophobia, but hysteria. Wood says that in hysteria, especially among boys, " beast-mimicry " is common, the suf- ferer snarling like a dog, and in the form known as "spurious hydrophobia," in which there may or may not be convulsion, there are a dread of water, emotional excitement, snarling, and attempts to bite the bystanders (in genuine hydrophobia no attempts are made to bite, and sounds are uttered like those made by a dog). Lyssa is separated from lockjaw by the spasms of the larynx and the absence of tonic spasms in the former, as contrasted with the spasms of muscles of mastication and the tonic spasms with clonic exacerbations of lockjaw. Treatment. — When a person is bitten by a supposed rabid animal, apply constriction above the wound if possible, excise, and burn with the hot iron. Send the patient to a Pasteur institute at once, that he may be given preventive inocula- tions of an emulsion made from the dried spinal cords of hydrophobic rabbits (attenuated virus). Pasteur discovered the following remarkable facts : If the virus of a rabid dog (street rabies) be placed beneath the dura of another dog, it always causes hydrophobia in from sixteen to twenty days, and invariably causes death. If the virus is passed through a series of rabbits it gets stronger (laboratory virus), and if in- serted beneath the dura of a dog, it causes the disease in from five to six days, and kills in four or five days. The virus can be attenuated by passing through a series of monkeys or by keeping. To get attenuated preparations in a convenient form he made emulsions from the cords of rabbits dead two or three weeks. The emulsion obtained from the rabbit longest dead is the weakest. He injected a dog with emul- sions of progressively increasing strength and made it im- mune to hydrophobia. These emulsions cause the body-cells to develop antitoxins, which are already in the body when 1 82 MODERN SURGERY. the street rabies virus begins to develop. The report of the Parisian Pasteur Institute shows that since its foundation there has been a mortahty of 0.5 per cent. The lowest estimated number of those attacked by hydrophobia before this method was used was 5 per cent, of those bitten, and all attacked died ; hence, the Pasteur treatment shows one-twenty-fifth of the mortality which attends other preventive methods. The value of this plan seems definitely established. Murri, of Bologna, cured a case of hydrophobia by injecting emul- sions of cords of rabbits dead six, five, four, and three days respectively. This remedy should be tried. In the paroxysm the treatment in the past was palliative. If we try only pal- liative methods, keep the patient in a dark, quiet room, re- lieve thirst by enemata, saturate with morphin, in the parox- ysms anesthetize, empty the bowels by enemata, and attend to the bladder. Glanders, Farcy, or i^quinia. — Glanders is an infec- tious eruptive fever occurring in horses and communicable to man. If the nodules occur in a horse's nares, we call the disease " glanders ;" if beneath his skin, it is termed " farcy." This disease is due to the bacillus of Loffler, and is communi- cated to man through an abraded surface or a mucous mem- brane (Osier). The characteristic lesions are infective granu- lomata, which in the nose form ulcers and under the skin develop abscesses. Acute and Chronic Glanders. — In acute glanders there is septic inflammation at the point of inoculation ; nodules form in the nose, and ulcerate ; there is profuse nasal discharge ; the glands of the neck enlarge ; there are fever and an erup- tion like small-pox on the face and about the joints (Osier) and severe muscular pain. Acute glanders is always fatal. Chronic glanders lasts for months, is rarely diagnosticated, being mistaken for catarrh, and is often recovered from. Diagnosis is made by injecting a guinea-pig .with the nasal mucus. Acute and Chronic Farcy. — Acute farcy appears from a skin-inoculation ; it begins as an intense inflammation, from which run out inflamed lymphatics that present nodules or " farcy-buds." Abscesses form. There are joint-pain and the constitutional symptoms of sepsis, but no involvement of the nares. Chronic farcy may last for months. In it nodules occur upon the extremities, which nodules break down into abscesses and eventuate in ulcers resembling those of tuberculosis. Treatment. — In treating this disease the point of infection CONTUSIOiVS AND IVOUNDS. 1 83 is at once to be incised and cauterized, dusted with iodoform, and dressed antiseptically. Enlarged glands and swollen lymphatics are to be painted with iodin and smeared with ichthyol. Bandages are applied to edematous extremities. Ulcers are curetted, touched with pure carbolic acid, dusted with iodoform, and dressed antiseptically. The nose is sprayed at frequent intervals with peroxid of hydrogen, and is fre- quently syringed with sulphurous acid. The mouth is rinsed repeatedly with solutions of chlorate of potassium. Open the abscesses, swab out with pure carbolic acid, and dress antiseptically. Give stimulants and nourishing diet. Morphin will be necessary for the muscular pain, restlessness, and in- somnia. Digitalis is given to stimulate the circulation and kidney secretion. Sulphur iodid, arsenite of strychnin, and bichlorate of potassium have been used. Diseased horses ought at once to be killed and their stalls tcwn out and puri- fied. A man with chronic glanders should be removed to the seaside. The nasal passages should be kept clean ; ulcers must be cauterized and dressed with iodoform gauze. Nutritious foods, tonics, and stimulants are necessary. Actinomycosis is an infectious disorder characterized by chronic inflammation, and is due to the presence in the tis- sues of the actinoniyccs or ray-fungus. This disease occurs in cattle (lumpy jaw) and in pigs, and can be transmitted to man, usually by the food. At the point of inoculation (which is generally about the mouth) arises an infective granuloma, around which inflammation of connective tissue occurs, sup- puration eventually taking place. Inoculation in the mouth is by way of an abrasion of mucous membrane or through a carious tooth. Chewing straw which contains the fungi is the most common method of infection. The ray-fungi may pass into the lungs, causing pulmonary actinomycosis ; into the intestines, causing intestinal actinomycosis ; into the skin, the bones, the subcutaneous tissues, the heart, the brain, the liver, etc. Actinomycosis until very recently was looked upon as sarcoma. Cutaneous actinomycosis may be secondary to a visceral area of disease, may be a purely local condition, or may be associated with some adjacent area of bone-infection. The gummatous form of the disease resembles a gummatous syphilitic area, and in it many small purulent pockets open by fistulae (Monestie). In the anthracoid there are no distinct purulent collections, but many fistulae discharge pus at various points (Monestie). An area of cutaneous anthrax is characterized by the ex- 184 MODERN SURGERY. istence of violet, blue, gray, or black maculae, varying in size from that of a pin's head to that of a bean, the center of each macule being white and containing a minute quantity of pus (Derville). The pus of actinomycosis contains many sulphur-yellow bodies, visible to the naked eye and composed of fungi. These bodies feel gritty when rubbed between the fingers because of the presence of lime salts. In actinomycosis of bone the bone enlarges and becomes painful, the parts adjacent are infiltrated and soften, pus forms and reaches the surface through fistulae, and the skin is often involved secondarily. In actinomycosis the adjacent lymphatic glands are not involved. The diagnosis must be made from syphilis, sar- coma, and tuberculosis. The microscopic examination of the pus makes the diagnosis. Treatment. — Free excision if possible ; otherwise incision, cauterizing with pure carbolic acid, and packing with iodo- form gauze. Give internally large doses of iodid of potas- sium. This drug alone has cured many cases. Wounds of Mucous Membranes. — If the surgeon intends to inflict a wound upon a mucous surface, he should see to it that the patient's general condition is good. Thorough asepsis is impossible, and a good result depends largely upon the vital resistance of the tissues. Before operating many sur- geons irrigate the part frequently with boric acid, a proceed- ing of questionable value. When ready to sew up, be sure that all irritant fluids are removed from the wound (saliva in the mouth, etc.). Cleanse the wound with hot normal salt solution. The stitches must include submucous tissue as well as the mucous membrane, and consist of silver wire, silk, or silkworm gut. After sewing up, wash often with salt so- lution, and follow it by insufflation of iodoform. In accidental wounds irrigate with salt solution, dust with iodoform, and close as directed above. Corrosive sublimate is so irritant that it does only harm when appHed to a mu- cous membrane. XVI. SYPHILIS. Definition. — Syphilis is a chronic infectious, and some- times hereditary, constitutional disease. Its first lesion is an infecting area or chancre, which is followed by lymphatic en- largements, eruptions upon the skin and mucous membranes, affections of the appendages of the skin (hair and nails). SYPHILIS. 185 " chronic inflammation and infiltration of the cellulo-vascu- lar tissue, bones, and periosteum " (White), and, later, often by gummata. This disease is probably due to a microbe, but Lustgarten's bacillus has not been proved to be the one. One fact against its being the cause is its presence in the non-contagious late gummata. White quotes Fenger in his assumption that syphilitic fever is due to absorption of toxins ; that the eruptions of skin and mucous membranes in the secondary stage arise from local deposit and multipli- cation of the virus ; that many secondary symptoms result from nutritive derangement caused by tissue-products passing into the circulation ; that the virus exists in the body after the cessation of secondary symptoms ; and that it may die out or may awaken into activity, producing " reminders." During the primary and secondary stages fresh poison can- not infect, and this is true for a time after the disappearance of secondary symptoms. Immunity in the primary stage is due to products absorbed from the infected area. Colles's immunity is that acquired by mothers who have borne syph- ilitic children, but who themselves show no sign of the dis- ease. Profeta's immunity is the immunity against infection possessed by many healthy children born of syphilitic par- ents. Tertiary syphilitic lesions are not due to the poison of syphilis, but to tissue-products from the action of that poison, or to nutritive failure as a consequence of the disease. Tertiary syphilis is not transmissible, but it secures immunity. Transmission of Syphilis. — This disease can be trans- mitted — (i) by contact with the tissue-elements or virus — acquired syphilis ; and (2) by hereditary transmission — hered- itary syphilis. The poison cannot enter through an intact epidermis or epithelial layer, and abrasion or solution of con- tinuity is requisite for infection. Syphilis is usually, but not always, a venereal disease. It may be caught by infection of the genitals during coition, by infection of the tongue or lips in kissing, by smoking poisoned pipes, by drinking out of infected vessels, or by beastly practices. The initial lesion of syphilis may be found on the finger, penis, eyelid, lip, tongue, cheek, palate, anus, nipple, etc. A person may be a host for syphilis, carry it, give it to another, and yet escape it himself (a surgeon may carry it under his nails, and a woman may have it lodged in her vagina). Syphilis can be transmitted by vaccination with human lymph which contains the pus of a syphilitic eruption or the blood of a syphilitic person. Vaccine lymph, even after passage through a per- son with pox, will not convey syphilis if it is free from blood 1 86 MODERN SURGERY. and the pus of specific lesions ; it is not the lymph that poisons, but some other substance which the lymph may carry. Syphilitic Stages. — Syphilis was divided by Ricord into three stages : (i) the primary stage — chancre and indo- lent bubo ; (2) the secondary stage — disease of the upper layer of the skin and mucous membranes ; and (3) the tertiary stage — affections of connective tissues, bones, fibrous and serous membranes, and parenchymatous organs. This division, which is useful clinically, is still largely employed, but it is not so sharp and distinct as was believed by Ricord ; it is only artificial. For instance, ozena may develop during a secondary eruption, and bone disease may appear early in the case. Syphilitic Periods. — White divides the pox into the following periods: (i) period oi primary incubation — the time between exposure and the appearance of the chancre : from ten to ninety days, the average being three weeks ; (2) period of primary symptoms — chancre and bubo of adjacent lymph-glands ; (3) period of secondary incubation — the time between the appearance of the chancre and the advent of secondary symptoms : about six weeks as a rule ; (4) period of secondary symptoms — lasting from one to three years ; (5) intermediate period — there may be no symptoms or there may be light symptoms which are less symmetrical and more gen- eral than those of the secondary period : it lasts from two to four years, and ends in recovery or tertiary syphilis ; and (6) period of tertiary symptoms — indefinite in duration. The fifth and sixth periods may never occur, the disease being cured. Primary Syphilis. — The primary stage comprises the chancre or infecting sore and bubo. A chancre or initial lesion is an infective granuloma resulting from the poison of syphilis. A chancre may be derived from the discharges of another chancre, from the secretion of mucous patches and moist papules, from syphilitic blood, or from the pus or secretion of any secondary lesion. Tertiary lesions cannot cause chancre. It appears at the point of inoculation, and is the first lesion of the disease. During the three weeks or more requisite to develop a chancre the poison is con- tinuously entering the system, and when the chancre devel- ops the system already contains a large amount of poison. A chancre is not a local lesion from which syphilis springs, but is a local manifestation of an existing constitutional dis- ease, hence excision is entirely useless. If we take the dis- SYPHILIS. 187 charge of a chancre and insert it at some indifferent point into the person from whom we took it, a new chancre will not be formed, because he already has syphilis. Auto- inoculation of the discharge of an irritated chancre can cause a non-indtiratcd sore. If we insert the poison into another person, a chancre is formed. Hence we say that primary syphilis is not auto-inoculable, but is hetero-inoculable. A soft sore can be produced in lower animals by inoculation, but a hard sore cannot. Some observers, notably Kaposi, of Vienna, advocate the unity theory. This theory main- tains that both hard and soft sores are due to the same virus, the infective power of the soft chancre simply being less than that of the hard, the possibility of constitutional infection depending, not upon differences in the poison, but rather upon differences in the soil and in the local processes. The unicists advocate excision of chancres, soft or hard, to prevent, if possible, constitutional involvement. Most syph- ilographers believe in the duality theory, which we have previously set forth. This theory took origin from the clas- sical investigations of Bassereau and RoUet. The duality theory maintains that the soft sore is caused by a different poison than originates the hard sore, and that a true soft sore never infects the system.^ Initial I^esions. — An initial lesion, hard chancre, or infecting sore never appears until at least ten days after exposure ; it may not appear for many weeks, but it usually arises in about twenty-five days. There are three chief forms of initial lesion : (i) a purple patch exposed by peeling epidermis, without induration and ulceration — a rare form ; (2) an indurated area under the epidermis, without ulceration — a very common form ; and (3) a round, indurated, carti- laginous area with an elevated edge, which ulcerates, expos- ing a velvety surface looking like raw ham ; it bleeds easily, it rarely suppurates, it does not spread, and the discharge is thin and watery. This is the " Hunterian chancre," which is rarer than the second variety, but commoner than the first, and which ulcerates because of dirt, caustic applications, or friction. A chancre is rarely multiple, but if it is so, all the sores appear together as a result of the primary inoculation : they do not follow one another because of auto-infection. A hard sore does not suppurate unless irritated by caustics, friction, or dirt, or unless there be mixed infection with ^ For a full discussion of these points see the writings of Fournier, Alfred Cooper, and \'on Zeissl, and especially the great work of Taylor. 1 88 MODERN SURGERY. chancroid ; its nature is not to suppurate. The hardness may affect only the base and margins of an ulcer or it may affect considerable areas, but it has well-defined margins and feels hke cartilage encapsuled, so that it can be picked up in the fingers. This hardness or sclerosis is due to gradual inflammatory exudation into " the tissues at the base of the ulcer and to growth of the nodule " (Von Zeissl). It feels distinct from the surrounding tissues, like a foreign body lying in the part. A chancre untreated may last many months. The induration usually disappears soon after the appearance of secondary symptoms. A copper-colored spot remains, and does not disappear until the disease is cured. An induration may again appear before the outburst of some distant lesion. Mixed Infection of Chancre and Chancroid. — Von Zeissl says : " If syphilitic contagion is mixed with pus, a chancre begins as a circumscribed area of hyperemia and swelling, which undergoes ulceration, and does not develop hardness for a period of from ten days to several weeks, and may develop a nodule after the first ulcer has entirely healed." We see this condition when mixed infection occurs, the chancroid poison being quick, and the syphilitic poison being slow, to act. If chancroid poison is deposited some time after the syphilitic poison has been absorbed, the indu- ration may appear in a few days after the chancroid begins. A soft chancre may appear upon an existing syphilitic nodule and may eat out the induration. Diag-nosis of Chancre. — We must separate a chancre from a chancroid and from ulcerated herpes. A chancroid appears in from two to five days after contagion (always less than ten days) ; it may be multiple from the start, but, even if beginning as one sore, other sores appear by auto-inocu- lation ; it begins as a pustule, which bursts and exposes an ulcer ; this ulcer is circular, has thin, sharp-cut, or undermined edges, a sloughy, non-granulating base, and a thin, purulent, offensive discharge which is both auto- and hetero-inocu- lable. These soft sores have no true sclerotic area, do not bleed, produce no constitutional symptoms, and are apt to be followed by acute inflammatory buboes which tend to suppurate. A chancroid causes pain, and the original ulcer enlarges greatly. A chancre appears in about twenty-five days after inoculation (never before ten days) ; it is generally single, but if multiple sores exist, they all appear together, for their discharge is not auto-inoculable ; if the sore is not irritated, an auto-inoculation of the products of an irritated SYPHILIS. 189 chancre can at most produce only a soft purulent ulcer. It begins as an excoriation or as a nodule ; if an ulcer forms, its base is covered with granulations and it is red and smooth ; its discharge is thin and scanty and not offensive ; its edges are thick and sloping ; it is surrounded by an area of induration, and bleeds when touched ; it is followed by secondary s}-mptoms, and there appear about the same time with it indolent multiple enlargements of the adjacent glands, which rarely suppurate. A chancre causes little pain, and after it has existed for a few days rarely shows any tendency to spread. Herpetic ulceration has no period of incubation ; it may follow fever, but usually arises from friction or the irritation of dirt or acrid discharges. It appears as a group of vesi- cles, all of which may dr}' up, or some may dry up and others ulcerate, or they may run together and ulcerate. The edges of a herpetic ulcer are in " segments of small circles " (White) ; the ulcer is superficial, has but little discharge, and does not have much tendency to spread ; it has no indura- tion ; it is painful ; it has no bubo unless suppuration is extensive, and there is no constitutional involvement. A urethral chancre appears after the usual period of incubation ; it is situated near the meatus, one lip of which is usually indurated ; the discharge is slight, often bloody, and never purulent ; indurated multiple buboes arise ; the sore can be seen, and constitutional symptoms follow (White). A chan- cre may be mistaken for cancer of the tongue. "A chancre of this region is brownish-red, a cancer being bright red. A chancre is soft in the center ; .a cancer presents uniformity of induration. A chancre has a thin, purulent discharge, free from blood ; a cancer has a non-purulent, bloody dis- charge. A chancre is followed by indolent lymphatic en- largements under the jaw ; a cancer is followed by painful enlargements." A cancer is slower in evolution, is not fol- lowed by constitutional symptoms, and the lymphatic en- largements are much later in appearing than in chancre. A chancre can be attacked by phagedena, a very destructive form of ulceration which was at one time common, but at the present day is rare. The ulceration often spreads on all sides and also deeply into the tissues. In some cases it spreads in only one direction (serpiginous ulceration), in some cases sloughing occurs. Phagedena occurs only in the debilitated (anemic, drunkards, strumous subjects, suf- ferers from diabetes, Bright's disease, etc. ; sali\'ation can cause it). The phagedenic ulcer is irregular, with congested and edematous edges, and a foul, sloughy floor. 190 MODERN SURGERY. Syphilitic Bubo. — In syphilitic bubo anatomically related lymphatic glands enlarge about the same time as induration of the initial lesion begins. In the very beginning these glands may be a little painful, but they soon cease to be so. These enlargements are called " indolent buboes ;" they may be as small as peas or as large as walnuts, are freely movable, and very rarely suppurate. The lesion of these glands is hyperplasia of all the gland-elements and of their capsules, due to absorption of the virus. If a man is strumous, the bubo is apt to become enormous, lobulated, and persistent. If the chancre appears on the penis, the superficial inguinal and femoral glands enlarge, usually on the same side of the body as the sore; if the sore is on the frenum, both groins are involved. If a chancre appears on the lip or tongue, the bubo is beneath the jaw. These buboes may remain for many months ; they do not suppurate unless the sore suppurates or unless the patient is of the tuberculous type ; and they finally disappear by absorption or fatty degeneration. About six weeks after buboes have formed in the glands related to the lesion, all the lymphatics of the body enlarge. General lymphatic involvement arises about the same time as the secondary eruption. The enlargement of the post-cervical and epitrochlear glands is diagnostically important. These glandular enlargements persist until after the eruptions have disappeared. The bubo of syphilis is always present, while the bubo exists in only one-third of the chancroid cases. The bubo of syphilis is multiple, consisting of a chain of movable glands (the glandulae Pleiades of Ricord) ; the bubo of chancroid is one inflamed and immovable mass. The bubo of syphilis is indurated, painless, small, and slow in growth ; the bubo of chancroid shows inflammatory hardness, is painful, large, and rapid in growth ; the first rarely suppurates, the second often does. The skin over a syphilitic bubo is normal ; that over a chancroidal bubo is red and adherent. A syphilitic bubo is not cured by local treatment, but is cured by the internal use of mercuiy and is followed by secondar}^ symptoms. A chancroidal bubo requires local treatment, is not cured by mercury, and is not followed by secondaries. Herpes, balan- itis, and gonorrhea rarely cause bubo, but when they do the bubo in each case is similar to that caused by chancroid. A positive diagnosis of syphilis can be made when an indurated sore is followed by multiple indolent buboes in the groin and by enlargement of distant glands. General Syphilis. — As the general lymphatic enlarge- SYPHILIS. 191 ment becomes manifest there is apt to appear a group of symptoms known as " syphilitic fever." The patient usually thinks he has a bad cold and is feverish and restless ; he complains of sleeplessness and anorexia ; his face is pale ; he has intermitting rheumatoid pains in the joints and muscles, especially of the shoulders, arms, chest, and back, which pains change their location constantly and prevent sleep ; night- sweats occur, and the pulse is quite frequent. This fever usually reaches its height in forty-eight hours, and falls as the eruption develops. Syphilitic fever does not always arise. It may reappear during the progress of the disease. Secondary Syphilis. — The phenomena of secondary syphilis arise from poisoned blood. Fenger states that the poison is present in the blood during outbreaks, but not dur- ing the quiescent periods between outbreaks. Secondary syphilis is characterized by plastic inflammation, by the for- mation of fibrous tissue, and by thickening of tissue. Super- ficial ulcerations may occur. Structural overgrowths appear (warts). Syphilitic Skin Diseases. — Syphilodcrmata{?,y^^\vL\\^^e^), due to circumscribed inflammation, may be dry or purulent. There is no one eruption characteristic of syphilis. This dis- ease may counterfeit any skin disease, but it is an imitation which is not perfect and is never a counterpart. Syphilitic eruptions are often circumscribed ; they terminate suddenly at their edges, and do not gradually shade into the sound skin. In color they are apt to be brownish-red, like tarnished copper; especially is this the case in late syphilides. Hutch- inson cautions us to remember that an ordinary non-specific eruption may be copper-colored, especially in people with dark complexion and when it occurs on the legs. Eruptions are apt to leave a brownish stain. Early syphilitic eruptions are symmetrical. Syphilitic eruptions have an affection for particular regions, such as the forehead, the abdomen and chest, the neck and scalp, about the lips and the alae of the nose, the navel, anus, groins, between the toes, and upon the palms and soles. Early secondary eruptions rarely appear on the face or hands. Specific eruptions are polymorphous, various forms of eruption being often present at the same time, so that roseola is seen here, papules there, etc. These syphilides do not cause as much itching as do non-spe- cific eruptions, except when they occur about the anus or between the toes. They tend to an arrangement in curved lines. Forms of Eruption. — The chief forms of eruption are 192 MODERN SURGERY. (i) erythema, (2) papular syphilides, (3) pustular syphilides, and (4) tubercular syphilides. Besides these eruptions pig- mentation may occur (pigmentary syphilide), and blood may extravasate (purpuric syphilide). Prince A. Morrow does not believe in erecting the vesicu- lar syphilide into a special group. He tells us that vesicles sometimes form on erythemato-papular lesions, but their presence is an accident and not a regular phenomenon. So, too, the bullous syphihde is a rare accident in a case, and even when it occurs soon becomes pustular. The pem- phigoid syphilide is found almost exclusively in hereditary disease.^ I. Erythema {inaculce, roseola, or spots) presents round, circumscribed, red, hyperemic spots, about one-eighth of an inch in diameter, whose color does not entirely disappear on pressure in an old eruption but does in a recent one. In the papular form of erythema the spots are a little elevated. It is rare upon the face and dorsum of the hands and feet. It attacks especially the chest and belly, but appears often on the forehead, the bend of the elbow, and the inner portion of the thigh, the neck, and the flexor surface of the forearms and arms. Usually erythema follows syphilitic fever, about six weeks after the chancre appears, and the number and dis- tinctness of these spots are in proportion to the violence of the fever. Absent or slight fever means few and transient spots. In rare cases the disease is very transitory, lasting but a few hours, but it usually lasts for several weeks if un- treated. It may pass away or may be converted into a papu- lar eruption. Mercury will cause it to disappear in a couple of weeks. In examining for this form of eruption in a doubt- ful case, let cold air blow upon the chest and belly (Hearn) ; this blanches the sound skin and makes clear any discolora- tion. No desquamation attends this eruption. A brownish stain remains for a variable time after the eruption fades. Erythema means, as a rule, a mild and curable attack. Mac- ulae may be combined with the next form, constituting a maculo-papular eruption. The maculo-papular syphilides are evolved from the macu- lar syphilides. They are slightly elevated, are situated upon a hyperemic base, and the summit of some of them may un- dergo slight desquamation. A roseolar area may show one or several of these macular papules. They are apt to arrange themselves in segments of a circle, and are symmetrically distributed. This eruption usually appears early, but may 1 Morrow's System of Geniio-urinary Diseases, Syphilology, and Dermatology. SYPHILIS. 193 appear late. It may fade and reappear several times in the same patient. The eruption lasts a few weeks. 2. Papular syphilides, which are papules or elevations cov^- ered with dry skin, may or may not have a crust. They usu- ally appear from the third to the sixth month of the disease. They may be preceded by fever, and often reappear again and again. They are at first red, but become brownish. They are firm in feel and vary in size from the head of a pin to a five- cent piece or larger. They may be present as miliar}' papules, lenticular papules, papules which scale off (papulo-squamous eruption), and moist papules. Papules on fading leave cop- pery looking stains. Papules upon the palms and soles constitute the so-called " palmar and plantar psoriasis," which appears from three months to one year after the appearance of the chancre. These papules just below the line of the hair on the forehead constitute the coi'oiia venerea. This eruption affects especially the forehead, the neck, the abdomen, and the extremities. The papular or squamous syphilide of the palms and soles begins as a red spot which becomes elevated and brownish ; the epidermis thickens and is cast off, and there then remains a central red spot surrounded by under- mined skin. If papules are in regions where they are kept moist (as about the anus), they become covered with a sod- den gray film which comes off and leaves the papule without epidermis. These sodden papules are called " flat condylo- mata," moist or humid papules or plates. Papules which are at first small may become large. The small or miliary papules constitute syphilitic lichen. The lenticular papules are most common, and strongly tend to scale off. The papular syph- ilide gives a worse prognosis than roseola. 3. Pustular syphilides arise from papules. We have acne when the apex of a papule softens, impetigo when the whole papule suppurates, and ecthyma or rnpia when the corium is also deeply involved. Vesicles occasionally precede pustules. The pustular eruption appears some months after infection (later than the papular). The pustular eruption gives a very bad prognosis. Rupia is formed by a pustule rupturing or a papule ulcerating, the secretion drying and forming a conical crust which continually increases in height and diameter, while the ulceration extends at the edges. When the crust is pulled off there is seen a foul ulcer with congested, jagged, and undermined edges. Rupia may be secondary or tertiary, and it invariably leaves scars. It appears only after at least- six months have passed since the chancre began. Secondary rupia is symmetrical. Tertiary rupia is asymmetrical. 13 194 MODERN SURGERY. 4. Tubercular syphilides are greatly enlarged papules intermediate between ordinary papules and gummata. Diagnosis between Secondary and Tertiary Syphilides. — A secondary eruption is distinguished from a tertiary eruption by the following : the first tends to disappear, the second tends to persist and to spread ; the first is general and sym- metrical, the second is local and asymmetrical ; the first does not spread at its edge, the second tends to spread at its edge, and this tendency, which is designated " serpiginous," produces an ulcer shaped hke a horse-shoe (Jonathan Hutch- inson). Secondary lesions appear within certain limits of time, develop regularly and are dispersed by mercurial treat- ment. Tertiary lesions appear at no fixed time, develop irregularly, and are not cleared up by mercury. Aflfections of the Mucous Membranes. — The chief lesions in syphilitic affections of the mucous membranes are mucous patches, warts, and condylomata. The first phe- nomena of secondary syphilis are, as a rule, symmetrical ulcers of the tonsils, painless and superficial (Hutchinson). The borders of the ulcers are gray, and the areas are reni- form in shape. They rarely last long. Catarrhal inflamma- tions often occur. Eruptions appear on the mucous mem- branes or upon the skin. Mucous patches are papules de- prived of epithelium ; they are gray in color, are moist, and give off an offensive and virulent discharge. They usually appear as areas of congestion, swelling, and abrasion of the epidermis upon the lips, palate, gums, tongue, cheeks, vagina, labia, vulva, scrotum, anus, and under the prepuce. A moist papule of the skin is really a mucous patch. These patches, which are always circular or oval, are among the most con- stant lesions of 'the secondary stage, appearing from time to time during many months. If a patch has the papillae de- stroyed, it is called a " bald patch." If the papules present hypertrophied papillae fused together, there appear enlarge- ments with flat tops, termed " condylomata ;" if the papillae of the papule hypertrophy and do not fuse, the growths are called " warts." Mucous lesions of the mouth are commonest in smokers and in those with bad or neglected teeth. Hutchin- son says that persistence in smoking during .syphilis may cause leukomata, or persistent white patches. The vagina and lips of the vulva are often covered with mucous patches. The uterus may contain mucous lesions which poison the uterine discharge. The larynx may suffer from inflammation, erup- tions, and ulceration (hence the hoarse voice which is so usual). The nasal mucous membrane may also suffer. The SYPHILIS. 195 rectal mucous membrane may be attacked with patches, and so may the glans penis and inner surface of the prepuce. Early in the secondary stage in some cases there is a slight mucopurulent urethral discharge. Examination with an en- doscope shows redness of the mucous membrane of the anterior urethra. The discharge is contagious. The con- dition may be followed by constriction of the urethral cali- ber. Mucous patches may form in the urethra and ulcera- tions can take place. Aflfections of the Hair. — In syphilitic affections the hair is shed to a great extent. This loss may be widespread (beard, moustache, head, eyebrows, pubic hair, etc.) or it may be limited. Complete baldness sometimes ensues, but this is rarely permanent. The hairs are first noticed to come out on the comb ; on pulling them they are found loose in their sheaths — so loose that Ricord has said " a man would drown if a rescuer could pull only upon the hair of the head." This falling out of the hair, which is known as " alopecia," begins soon after the fev^er or about the time of the eruption, but it may be postponed. The skin of a syphilitic bald spot is never smooth, but is scaly. The hair may thin generally, baldness may appear in twisting lines, or it may be complete only in limited areas. Alopecia results from shrinking of the hair-pulp, death of the hair, and casting off of the sheath. Aflfections of the Nails. — Paronychia is inflammation and ulceration of the skin in contact with a nail and extend- ing to the matrix. The nail is cast off partially or entirely. Onychia is inflammation of the matrix and is manifested by white spots, brittleness or extended opacity, twisting, and breaking off of the nail. The parts around are not affected. The damaged nail drops off and another diseased nail appears. Affections of the Kar. — Temporary impairment of hearing in one or both ears is not uncommon in syphilitic affections of the ear. Rarely, permanent symmetrical deaf- ness is produced. Meniere's disease is sometimes caused by syphilis. Aflfections of the Bones and Joints. — In syphilis there may be slight and temporary periostitis. Pain and tenderness arise in various bones, the pain being worse at night (osteocopic pains). The bones usually involved are the tibiae, clavicles, and skull. Pain like that of rheumatism affects the joints. Local periostitis may form a soft node which by ossification becomes a hard node. Symmetrical synovitis has been noted. 196 MODERN SURGERY. Affections of the Bye. — Iritis is the commonest trouble of the eyes. It appears from three to six months after the chancre, and begins in one eye, the other eye soon becoming affected. The symptoms are a pink zone in the sclerotic, ciliary congestion, muddy iris, irregularity of the pupil accent- uated by atropin, the existence of pain and photophobia, and sometimes hazy or even blocked pupil. Rheumatic iritis causes much pain and photophobia, syphilitic iritis compara- tively little ; there is less swelling in the first than in the sec- ond ; the former tends to recur, the latter does not. Iritis is usually recovered from, good vision being retained. Diffuse retinitis and disseminated choroiditis never occur until a number of months have passed since the infection. The symptoms are failure of sight, muscae volitantes, and very little photophobia. Diagnosis of retinitis and choroiditis is by the ophthalmoscope. Affections of the Testes. — Syphilitic Sarcocele. — The testes enlarge from plastic inflammation. Both glands usually suffer, but not always. Fluid distends the tunica vaginalis. The epididymis escapes. The testicle is not the seat of pain, is troublesome because of its weight, and has very little of the proper sensation on squeezing. The plas- tic exudate is generally largely absorbed, but it may organ- ize into fibrous tissue, the organ passing into atrophic cirrhosis. Intermediate Period. — Secondary lesions cease to appear in from eighteen months to three years. In the intermediate period no symptoms may appear, but the dis- ease is still for some time latent and is not cured. Symp- toms may appear from time to time. These symptoms, which are called " reminders," are not so severe as tertiary symptoms ; reminders are apt to be symmetrical, and they do not closely resemble secondary lesions. Among the re- minders we may tiame palmar psoriasis and sarcocele. Sar- cocele in this stage is bilateral and rarely painful. Bilateral indolent epididymitis occasionally occurs. Sores on the tongue, a papular skin-eruption, and choroiditis may arise. Gummata occur in this stage, but they are apt to be sym- metrical and non-persistent. Arteritis occurs, beginning in the intima or adventitia, and causing, it may be, aneurysm, embolism, or thrombosis. Obliterative endarteritis may cause gangrene. This vascular condition is frequent in the brain ; thrombosis may occur, in which case a paralysis comes on gradually, preceded by numbness, although sud- den paralysis may occur. These paralyses may be limited^ SYPHILIS. 197 extensive, transitory, or permanent. The nervous system often suffers in this stage (anesthetic areas and retinitis). The viscera are often congested and infiltrated (tonsils, liver, spleen, kidneys, and lungs). Tertiary Syphilis. — This stage is not often reached, the disease being cured before it has been attained. It is re- garded by many as not so much a stage of syphilis as a condition of impaired nutrition which results from the dis- ease. This view finds confirmation in the fact that tertiary lesions do not furnish the contagion. The primary stage disappears without treatment, the secondary stage tends ultimately to spontaneous disappearance, but tertiary lesions tend to persist and to recur. Tertiary lesions may be single or may be widely scattered ; when multiple they are not symmetrical except by accident. These lesions may attack any tissue, even after many years of apparent cure ; they all tend to spread locally, they all leave permanent atrophy or thickening, they all tend to relapse, and a local influence is often an exciting cause. Tertiary skin-eruptions are liable to ulcerate. Various eruptions may occur : papular syphilides, pustular syph- ilides, gummatous syphilides, serpiginous syphilides, and pigmentary syphilides. The characteristic syphilide is riipia, which is formed by a pustule rupturing or a papule ulcer- ating. A crust forms because of the drying of the discharge, ulceration continues under the crust, new crusts form, and, as the ulcer is constantly increasing peripherally, the new crusts are larger in diameter than the old ones, and the mass assumes the form of a cone. An ulcer is exposed by tearing off the crust, which ulcer has destroyed the deeper layers of the skin, and on healing always leaves a permanent scar. Serpiginous ulcers are common in tertiary syphilis, and are especially common about the knees, nostrils, forehead, and lips. Serpiginous ulceration is spoken of as syphilitic lupus. It is preceded by a widespread, brown-colored nod- ular cutaneous infiltration. The nodules suppurate, run together, crust, and produce an ulcer which spreads rapidly and is the shape of a horseshoe. Gumma. — The gumma is the typical tertiary lesion. A gumma arises from an inflammation the products of which cannot organize for want of sufficient blood-supply, and which consequently undergo fatty degeneration. A gumma presents a center of gummy degeneration, a surrounding area of immature fibrous tissue, and an outer zone of em- 198 MODERN SURGERY. bryonic tissue and leukocytes. A gumma, when it is spon- taneously evacuated, exhibits a small opening or many open- ings with very thin red and undermined edges ; the ulcer is slow to heal, and forms a thin scar, white in the center, but pigmented at the margins and usually depressed (Jonathan Hutchinson, Jr.). These ulcers when once healed rarely recur. Such ulcers are apt to be seen upon the legs. The gummatous ulcer is deep, circular in outline, with under- mined edges and an uneven floor covered with a thick white adherent slough. Sometimes there is no slough, but an extensive area is infiltrated. A gummatous ulcer may coa- lesce with one or more adjacent ulcers. The discharge is scanty and tenacious. A gumma in the internal organs may become a fibrous mass. These gummata form in the skin, subcutaneous tissues, muscles, tongue, joints, bursas, testes, spinal cord, brain, and internal organs. In tertiary syphilis an inflammation may not form a circumscribed gumma, but, instead, may produce a diffuse degenerating mass. This type of inflammation, which is seen in bones, is called " gum- matous." A healing gumma in a mucous canal such as the rectum or larynx causes thickening and stricture. Tertiary syphilis is a most common cause of amyloid degeneration and arterial and nervous sclerosis. Various Lesions.— Hutchinson enumerates the lesions of tertiary syphilis as follows : Periostitis, forming nodes or causing sclerotic hypertrophy or suppuration or necrosis ; gummata in various parts ; disease of the skin of the type of rupia or lupus ; gumma or inflammation of tongue, causing sclerosis ; structural changes in the nervous system, causing ataxia, ophthalmoplegia externa and interna, general paresis, optic atrophy, and paralyses of cerebral nerves ; amyloid degenerations ; and chronic inflammation of certain mucous membranes (of the mouth, pharynx, vagina, rectum, etc.), with thickening and ulceration. Unilateral enlargement of the epididymis is sometimes noted, the mass feeling heavy, aching a little, but not being very tender. Unilateral sarco- cele may be met with. Visceral Syphilis. — In visceral syphilis the lungs may undergo fibroid induration (syphilitic phthisis). Syphilitic phthisis is a nonfebrile malady. Gummata may form in the heart, liver, spleen, or kidneys. The capsule and fibrous septa of the liver may thicken, the organ being puckered from con- traction. Amyloid changes may appear in any of the vis- cera. Albuminuria may occur in tertiary syphilis. It may be caused by fibroid changes in the kidneys, by the formation SYPHILIS. 199 of gummata, or by amyloid degeneration. Its occurrence should be watched for. Mercury and iodid of potassium have been suspected as causative of albuminuria. Nervous syphilis may be manifested in disorders of the brain, cord, or nerves. Brain syphilis is usually a late phe- nomenon (from one to thirty years), and is more apt to ap- pear after light secondaries. The lesion may be gumma of the membranes (tumor), gummatous meningitis, arterial atheroma, or obliterative endarteritis. A gumma may eventuate in a scar, a cyst, or a calcareous mass. The symptoms of brain syphilis depend on the nature, seat, and rate of development of the lesions. It is to be noted that syphilitic palsy is apt to be limited, progressive, and incomplete. Epilepsy appearing after the thirtieth year is very probably specific if alcohol as a cause can be ruled out (Wood). Persistent headache, tremor, insomnia or som- nolence, transitory, limited, and erratic palsies ; unnatural slowness of utterance, amnesia, vertigo, and epilepsy are very suggestive. Sudden ptosis is very significant ; so is sudden palsy of one or more of the extrinsic eye-muscles. In syphilitic insomnia the patient cannot get to sleep at night for a long while, but when he once gets to sleep he reposes well. The more usual type of insanity is a likeness or counterpart of general paralysis. Spinal syphilis may cause sclerosis, a condition like Landry's paralysis, softening, and tumor. Neuritis is not uncommon in syphilis. Treatment of Primary Stage. — A chancre should not be excised. The disease is constitutional when the chancre appears, and excision and cauterization inflict needless pain and do no good. The initial lesion should never be cauter- ized unless it is phagedenic or becoming so. Order the patient to soak the penis for five minutes twice daily in warm salt water (a teaspoonful of salt to a cupful of water), and then to spray the sore by an atomizer with peroxid of hydrogen (14-volume solution of peroxid diluted with an equal bulk of water). The ulcer is then dried with absorbent cotton and on it is dusted a powder of equal parts of bismuth and calomel. The buboes in the groin require no local treatment unless they tend to suppurate. If they persist or become large, paint them with iodin or smear ichthyol oint- ment over them, and apply a spica bandage of the groin. Ichthyol and lanolin make an excellent application for the enlarged glands, and so does mercurial ointment. Some authorities give mercury in this stage, claiming that it pre- vents secondaries. The younger Gross opposed this strongly, 200 MODERN SURGERY. and affirmed a wish to see the secondary eruption — first, because it proves the diagnosis ; and, second, because it affords valuable prognostic indications (an erythematous eruption means a light case ; an early pustular eruption means a grave case with serious complications). White will not order mercury until constitutional symptoms de- velop. If phagedena arises, place the patient at once upon stimulants and nutritious diet. Give him quinin, iron, strych- nin, and whiskey. Secure sleep. Destroy the ulcer by the use of nitric acid or the electric cautery while the patient is anesthetized. Dust with iodoform and dress with wet antisep- tic gauze. Several times a day change the dressings, and at each change spray with peroxid of hydrogen, irrigate with bichlorid of mercury solution, and dust with iodoform. It may be necessary to cauterize several times. These cases are sometimes fatal and usually produce great destruction of tissue. Treatment of Secondary Stage. — In the secondary stage the aim is to cure the disease. That it can be cured is known from the fact that reinfection occurs in some persons. The old axiom, " Syphilis once, syphilis ever," is not true. Mercury must be used, the form being a matter of choice. Fournier first advocated intermittent treatment. In this plan give gr. \ of protiodid of mercury daily for six months, then stop a month ; then give mercury for three months, then stop two months. During the first year the patient is under treatment nine months, and during the second year eight months. Some prefer the intermittent and others the continuous plan of treatment. White greatly prefers the continuous plan. The rule in most cases is to give mercury for two years. Find the patient's dose of tolerance, and keep him on this amount. Gross' rule for continuous treatment was to order pills of the green iodid of mercury, each pill containing gr. \. The patient was ordered one pill after each meal to begin with ; the next day he took two pills after breakfast ; the following day, two after dinner, and so on, adding one pill every day. This advance was continued until there was slight diarrhea, griping, a metallic taste, or tenderness on snapping the teeth together, whereupon one pill was taken off each day until all unfavorable symptoms disappeared. This experi- mentation finds a dose on which the patient can be kept with entire safety for a long time ; but if it is found that colic or diarrhea is apt to recur, there must be added to each pill gr. ^ of opium. The patient is given mercury in this way SYPHILIS. 20 1 for two years. Every time new symptoms appear the dose is raised, and as soon as they disappear it is lowered to the standard. If the protiodid is not tolerated, give the bichlorid : R. Hydrarg. chlor. corros., gi"- j '? Syr. sarsaparillae comp., fSi'j- — M. Sig. f^j, in water, after meals. Mercury with chalk in i -grain doses four times a day, with or without Dover's powder in ^-grain doses, can be used. Mercurial inunctions produce a rapid effect, but irritate the skin. There can be used once a day \ dram of oleate of mercury (10 per cent.) or i dram of mercurial ointment, rubbed in, one day on the inside of one thigh and the next day on the inside of the other thigh ; next, the inside of one arm and then the other arm ; next, one groin and then the other groin, and so on. After the rubbing the patient puts on underclothes and goes to bed, and in the morning takes a bath. The ointment may be smeared on a rag, which is then worn between the stocking and sole of the foot during the day. Fumigation is performed by volatilizing each night 3j of calomel. The patient sits naked on a cane-seat chair, the calomel is put upon an iron plate under the chair and is heated by an alcohol lamp beneath the plate, and wrapped around the patient is a blanket which drops tent-like to the floor. The skin becomes coated with calomel, and the sub- ject, after putting on woollen drawers and an undershirt, gets into bed. Hypodermatic injections of mercury are used by some physicians. They cause an eruption to disappear rapidly, but may produce abscesses, and relapses are prone to occur. The usual plan is to give daily a hypodermatic injection of corrosive sublimate deep into the back or but- tocks, the dose being gr. \ of the drug. Thirty such injec- tions are used unless some indication points to their discon- tinuance sooner. The treatment is then stopped. If the symptoms recur, however, the patient is given another course, the daily dosage being gr. \, the treatment being again stopped after thirty injections, but continued anew in ^-grain doses if the symptoms recur. Orville Horwitz has recently made thorough trial of this method, and arrives at the following conclusions : it will not abort the disease ; it should never be a routine treatment ; in suitable cases it is very valuable for symptomatic use, as when lesions on the face or in important structures make a rapid impression de- 202 MODERN SURGERY. sirable or necessary ; in cases which obstinately relapse under other treatment, and in syphilis of the nervous system. Some physicians use the gray oil. J. William White, after a large experience with this method, says that hypodermatic injections of corrosive sublimate are painful and are strongly objected to by many patients ; that this method of treatment is occasionally dan- gerous and even fatal ; that it is liable to be followed by local complications (erythema, nodosities, cellulitis, abscess, slough- ing) ; that it cannot be carried out by the patient, but requires the surgeon's constant intervention. This distinguished syph- ilographer concludes that hypodermatic medication does not offer advantages justifying its use as a systematic method of treatment, and that it encourages insufficient treatment — those " short heroic courses " which Hutchinson shows are followed by the gravest tertiary lesions. " The claim that by a few injections the time of treatment can be measured by months or even by weeks, instead of by years, would seem, as Mauriac has said, to involve the idea that mercury given hypodermatically acquires some new and powerful curative property which, given in other ways, it does not possess." ^ Some surgeons employ intravenous injections of mercury. Lane injects, at first every other day and later daily, 20lfTl of a I per cent, solution of cyanid of mercury. The injection is made in a vein in front of the elbow, the skin is rendered aseptic, a fillet is tied around the arm, the needle is inserted, the fillet is loosened, the fluid is injected, and the needle is withdrawn. This method of using mercury is painless and produces a rapid effect. It may be used in nervous syphilis, but is not used as a routine. In whatever way mercury is given, do not let it salivate (hydrargyrism). Always remember that mercury may cause albuminuria. Examine the urine at regu- lar intervals. If albumin appears in urine, cut down the dose or stop the drug for a time. In the beginning of a case of syphilis, if the kidneys are found to be diseased, give the mercury cautiously, and never fail to examine the urine at regular intervals. Acute Ptyalism, or Salivation. — In acute ptyalism the saliva becomes thick and excessive in amount ; the gums be- come tender (found first by snapping the teeth), spongy, and tend to bleed; a metallic taste is complained of; the breath becomes fetid ; all the oral structures swell ; the teeth loosen ; the saliva is produced in great quantity ; and there are purging, ^ J. William White, in Morrow's System of Genito-winary Diseases, Syph- ilology, and Dermatology. SYPHILIS. 203 colic, and exhaustion. Sometimes there is fever and a diffuse scarlitiniform eruption upon the skin. A chronic hydrargy- rism may be shown by gastro-intestinal disorder, emaciation, mental depression, weakness, albuminuria, and tremor. To. avoid salivation cautiously advance the dose and instruct the patient as to the first signs. He should use a soft toothbrush and an astringent mouth-wash (gr. xlviij of boric acid to 5iv each of Listerin and water). When ptyalism begins, stop the drug. Employ the above mouth-wash or one composed of a saturated solution of chlorate of potassium. Order gr. yI^^ of atropin twice a day, and in bad cases spray the mouth with peroxid of hydrogen and use silver nitrate locally (gr. XX to sj). Give stimulants and nutritious food — iron, quinin, and strychnin. A weekly Turkish bath is of great use. In chronic hydrargyrism stop the drug, use tonics, stimulants, open-air exercise, Turkish baths, and good food. The chlo- rid of gold and sodium forms a good substitute drug. The use of iodid of potassium is of questionable value. Treatment of Complications in the Secondary Stage. — The complications of the secondary stage usually require local applications in addition to general remedies. Mucous patches in the mouth should be touched with bluestone every day, an astringent mouth-wash being employed several times daily. If the patches ulcerate, they should be touched twice a day with lunar caustic ; if these areas proliferate, they should be excised and burned. Vegetations or growing papules on the skin must, if calomel powder fails to remove them, be cut away with scissors and be cauterized with chromic acid or with the Paquelin cautery. Condylomata demand washing with ethereal soap several times daily, thorough drying, dust- ing with equal parts of calomel and subnitrate of bismuth or with borated talcum, and covering with dry bichlorid gauze. If these simple procedures fail, excise and cauterize. For psoriasis of the palms and soles diachylon ointment, mercurial plaster, or painting with tincture of iodin should be employed. Ulcers of paronychia are dressed with iodo- form and corrosive-sublimate gauze. Deep cutaneous ulcers are cleaned once a day with ethereal soap, then sprayed with peroxid of hydrogen, dressed with iodoform and corrosive- sublimate gauze, and bandaged. When granulation is well established dress with i part of unguent, hydrarg. nitratis to 7 parts of cosmolin. In sarcocele mercurial ointment should be used or the testicle be strapped. Alopecia requires that the hair be kept short and every night the scalp be cleaned with equal parts of green soap and alcohol rubbed into a 204 MODERN SURGERY. lather with water. After the soap is washed out some hair tonic should be rubbed into the scalp with a sponge. A favorite preparation of Erasmus Wilson's consisted of the fol- lowing ingredients : R. 01. amjgd. dul., Liq. ammonice, ad. f ^j ; Spt. rosemarini, Aquse mellis, aa. f^iij. M. Ft. lotio. One part of tincture of cantharides to 8 parts of castor oil may be rubbed into the scalp. Solutions of quinin are esteemed by some. In treating persistent skin-lesions, inunctions, injections, or fumigations may be used ; some prefer mercurial baths. Baths are suited to patients with delicate skins, to those whose digestion fails from mercury by the stomach, and to those whose lungs will not tolerate fumigations. Half an ounce of corrosive sublimate with 4 scruples of sal ammoniac are mixed in about 4 ounces of water ; this is added to a bath at a temperature of 95°. The patient gets into this bath, covers the tub with a blanket, leaving only his head exposed, and remains in the bath an hour or so. These baths may easily cause salivation. In every case of syphilis, no matter what constitutional or local treatment is used, the general health of the patient must be watched and the use of tobacco be stopped, as its use ren- ders certain the development of mucous patches and causes them to persist. Alcohol as a beverage must be cut off: it is to be used only as a medicine for debility and weakness of assimilation. An open-air life to a great degree must be in- sisted upon, and care be observed as to protection from damp and cold. Flannels must be worn in winter. Have the patient sponge the chest and shoulders every morning with cold or with tepid water and then with alcohol, dry himself with a rough towel, and take a hot bath twice a week or a Turkish bath once a week. He should wash the anus and nates after every stool, and ought to dust the axillae, scrotum, perineum, and internatal region once a day with borated talc. The teeth are to be looked to and put in perfect order, a soft brush being used twice a day and an astringent mouth-wash being fre- quently employed. Meat and milk are largely to be used. The patient should be weighed weekly : any falling off in weight is an indication for tonics, concentrated food, and cod- liver oil. If a patient's health continues to fail on mercury, SYPHILIS. 205 the drug should be stopped for some time and the patient be treated with iron, chlorid of gold and sodium, baths, fresh air, cod-liver oil, and nourishing foods. In treating secondary syphilis, give mercury for at least eighteen months and bet- ter for two years. Reminders require mixed treatment (mer- curials and iodids). Tertiary Stage. — If at any time during the case there appear tertiary symptoms, the patient should be put on mixed treatment. In any case, after two years of mercury add iodid of potassium to the treatment. White's rule is to use this mixed treatment for at least six months (if any symptoms ap- pear), the six-months course dating from their disappearance. This emphasizes the fact that the iodids alone will not cure tertiary syphilis. In obstinate tertiaries or in nervous syph- ilis the iodids should be run up to an enormous amount (from 30 to 250 grains per day). An easy way to give iodid is to order a saturated solution each drop of which solution equals one grain of the drug. Each dose of the iodid is given one hour after meals and in at least half a glass of water. If the iodid disagrees, it may be given in water containing one dram of aromatic spirits of ammonia or in milk. The iodid of sodium may be tolerated better than the potassium salt, or the iodids of sodium, potassium, and ammonium may be combined. In giving the iodids begin with a small dose. During a course of the iodid always give tonics and insist on plenty of fresh air. Arsenic tends to prevent skin-eruptions. The iodids when they disagree produce iodism — a condition which is first made manifest by running of the nose and the eyes. In some subjects there is an outbreak of acne, vesicu- lar eruptions or even bullae, or hemorrhages. Iodism calls for a reduction in dosage, and, if severe or persistent, for the abandonment of the drug. Some patients who cannot take the alkalin iodids may take syrup of hydriodic acid. After the patient has been for six months under mixed treatment without a symptom, stop all treatment and await develop- ments. If during one year no symptoms recur, the patient is probably cured ; if symptoms do recur, there must be six months more of treatment and another year of watching. Fournier has insisted that it is a great wrong to tell a syph- ilitic that he can never marry. He must not marry until he is cured, and he is not cured until, after the cessation of the use of iodid, he goes one year without treatment and without symptoms. Hereditary Syphilis. — Transmitted cong-enital syph- ilis is a hereditary syphilis manifest at birth. Acquired syph- 2o6 MODERN SURGERY. ilis (except in the case of a Avoman who obtains the disease from a fetus) always presents the chancre as an initial lesion ; hereditary syphilis never does. Hereditary syphilis may pre- sent itself at birth, and usually shows itself within, at most, the first six months of extra-uterine life. In rare cases (tardy hereditary syphilis) the disease does not become manifest until puberty. Rules of Inheritance. — According to Von Zeissl,^ the rules of inheritance are as follows : 1. If one parent is syphilitic at the time of procreation, the child may be syphilitic. 2. Syphilitic parents may bring forth healthy children. 3. If a mother, healthy at procreation, bears a child syph- ilitic from the father, the mother must have latent pox or must be immune, having become infected through the pla- cental circulation. She often shows no symptoms, having received the poison gradually in the blood, and having thus received, it may be said, preventive inoculations. Certain it is that mothers are almost never infected by suckling their own syphilitic children (Colles's law). 4. If both parents were healthy at the time of procreation, and the mother afterward contracts syphilis, the child may become syphilitic, and the earlier in the pregnancy the mother is diseased, the more certain is the child to be tainted. This is known as "infection in utero." 5. The more recent the parental syphilis, the more certain is infection of the offspring. The children are often stillborn. 6. When the disease is latent in the parents it is apt to be tardy in the children. 7. The longer the time which has passed since the dis- appearance of parental symptoms, the more improbable is infection of the children. 8. In most instances parental syphilis grows weaker, and after the parents beget some tainted children they bring forth healthy ones. Syphilis in the mother is more dangerous to the offspring than syphilis in the father. The frequent immunity of the mother is due to the fact that her tissues produce antitoxins under the influence of the virus. Many women who labor under hereditary syphilis are sterile. Many syphilitic women abort, usually before the eighth month. The fetus very often dies at an early period of gestation. This may be due to a gummatous placenta or to a degeneration of placental follicles. 1 Pathology and Treatment of Syphilis. SYPHILIS. 207 Evidences of Hereditary Syphilis (manifest at, or oftener soon after, birth). — Hutchinson says that at birth the skin is almost invariably clear. In from six to eight weeks "snuffles" begin, which are soon followed by a skin-eruption, by body-wasting, and by a chain of secondary symptoms (iritis, mucous patches, pains, condylomata, etc.). The child looks like a withered-up old man. Eruptions are met with on the palms and soles. Intertrigo is usual. Cracks occur at the angles of the mouth, and leave permanent radiating scars. The abdomen is tumid, and there is apt to be exhaust- ing diarrhea. The secreting and absorbing glands of the intestinal track atrophy.^ Enlargement of spleen and liver occurs. Sometimes synovitis or arthritis arises. Atrophic lesions may appear in the bones. In the skull the bone may be softened by removal of its salts or be thinned by the pressure of the brain. In the long bones the epiphyseal ends suffer, the attachment of epiphysis to shaft is weak, and sepa- ration is easily induced. Epiphysitis is common and rarely causes pain. Epiphysitis rarely suppurates unless in chil- dren who are old enough to walk (Coutts). Osteophytic lesions of the skull are shown by symmetrical spots of thickening upon the parietal and frontal bones (natiform skulls). In the long bones osteophytes are frequently formed. A child with precocious hereditary syphilis is apt to die, but if it lives from six months to one year the symptoms for a time disappear and for years the disease may be latent. Diagnosis is difficult after the third or fourth year, especially if the disease be associated with rickets or tuberculosis. When the disease begins again the symptoms are various, namely : noises in the ears, often followed b}^ deafness ; interstitial keratitis ; dactylitis (specific inflammation of all the struc- tures of a finger) ; synovitis in any joint ; ossifying nodes ; de- velopmental osseous defects ; suppurative periostitis ; ulcera- tions ; death of bone ; falling in of nose ; nervous maladies ; occasionally sarcocele, etc. In hereditary syphilis the eye- symptoms are of great diagnostic importance. In 212 cases of congenital syphilis Fournier found eye-trouble in loi. Keratitis and choroiditis are the most usual forms (Silex). Bone-trouble occurs in almost half of the cases, but is not often severe enough to cause symptoms. The tongue often shows a smooth base (Virchow's sign). Hirschberg believed choroiditis to be pathognomonic. Diagnosis. — In the diagnosis of hereditary' syphilis the condition of the teeth is of much importance : the temporary ^ Coutts, in Brif. Mid. Jour., 1894, No. 1843. 208 MODERN SURGERY. teeth decay soon, but present no characteristic defect. If the upper permanent central incisors are examined, they are found defective. Other teeth may show defects, but in these alone are defects almost sure to appear. In hereditary syphiHs they present an appearance of Fig. 38. — Hutchinson teeth. i j i • >_• c 1 i.l1 marked deviation irom health, and are called " Hutchinson teeth " (Fig. 38). If they are dwarfed, too short and too narrow, and if they display a single central cleft in their free edge, then the diagnosis of syphilis is almost certain. If the cleft is present and the dwarfing absent, or if the peculiar form of dwarfing be pres- ent without any conspicuous cleft, the diagnosis may still be made with much confidence. In early infancy the diagnosis is made by the snuffles, broad nose, skin-eruptions, wasted look, sores at the mouth-angles, tenderness over bones, con- dylomata, and history of the parents. The diagnosis at a later period is made by the existence of symmetrical inter- stitial keratitis, choroiditis, smooth base to tongue, deafness which comes on without pain or running from the ear, ossi- fying nodes, white radiating scars about the mouth-angles, sunken nose, natiform skull, deformity of long bones, pain- less inflammation of epiphyses, and Hutchinson teeth. It must be remembered that a child born apparently healthy and presenting no secondary symptoms may show bone-dis- ease, keratitis, or syphihtic deafness at puberty. Treatment. — In infants inunctions are to be used until the symptoms disappear, but mercury must not be forced or con- tinued too long after the symptoms are gone. There must be rubbed into the sole of each foot or the palm of each hand 5 grains of mercurial ointment every morning and night. Brodie advised spreading the ointment (in the strength of sj to the ounce) upon flannel and fastening it around the child's belly. If the skin is so tender that mercury must be given by the mouth, White and Hearn advise that gr. -^ to gr. \ of mer- cury with chalk, with i grain of sugar, be taken three times a day after nursing. If tertiary symptoms appear, or in any case when the secondaries disappear, give gr. ss to gr. j or more of iodid of potassium several times a day in syrup. White advocates the continuance of the mixed treatment in- termittently until puberty. Local lesions require local treat- ment, as in the adult. A syphilitic child must be nursed by its mother, as it will poison a healthy nurse. If the baby has a sore mouth, it must be fed from a bottle; and if the mother TUMORS OR MORBID GROWTHS. 209 cannot nurse the child, it must be brought up on the bottle. For the cachexia use cod-liver oil, iodid of iron, arsenic, and the phosphates. XVII. TUMORS OR MORBID GROWTHS. Division. — Morbid growths are divided into (i) neo- plasms and (2) cysts. Neoplasms. — A neoplasm is a pathological new growth which tends to persist independently of the structures in which it lies, and which performs no physiological function. A hypertrophy is differentiated from a tumor by the facts that it is a result of increased physiological demands or of local nutritive changes, and that it tends to subside after the withdrawal of the exciting stimulus. Further, a hypertrophy does not destroy the natural contour of a part, while a tumor does. Inflammation has marked symptoms : its swelling does not tend to persist, it terminates in resolution, organ- ization, or suppuration, and the microscope differentiates it from tumor. Inflammation, too, has an assignable excit- ing cause. A new growth is a mass of new tissue ; hence it is improper to designate as tumors those swellings due to extravasation of blood (as in hematocele), or of urine (as in ruptured urethra), to displacement of parts (as in hernia, floating kidney, or dislocation of the liver), or to fluid distention of a natural cavity (as in hydrocele or bursitis). Classes of Tumors. — There are two classes of tumors : the first class includes those derived from or composed of ordinary connective tissue or of higher structures. These all originate from cells which are developed from the meso- blast. There are two groups of connective-tissue tumors : {a) the typical, benign, or innocent, which find their type in the healthy adult human body ; and (^) the atypical or malig- nant, which find no counterpart in the healthy adult human body, but rather in the immature connective tissues of the embryo. The second class of tumors includes those which are deriv^ed from or composed of epithelium : {a) the typical, composed of adult epithelium ; and {b) the atypical, com- posed of embryonic epithelium. Mliller's La^w. — Miiller's law is that the constituent ele- ments of neoplasms always have their types, counterparts, or close imitations in the tissues of a normal organism^ either embryonic or mature. 14 2IO MODERN SURGERY. Virchow's Law. — Virchow's law is that the cells of a tumor spring from pre-existing cells (hence there is no spe- cial tumor-cell or cancer-cell). The term " heterologous " is no longer used to signify that the cellular elements of a tumor have no counterpart in the healthy organism, but is employed to signify that a tumor deviates from the type of the structure from which it takes its origin (as a chondroma arising from the parotid gland). Tumors when once formed almost invariably in- crease and persist, though occasionally warts, exostoses, and fatty tumors disappear spontaneously. Tumors may ulcerate, inflame, slough, be infiltrated with blood, or un- dergo mucoid, calcareous, or fatty degeneration. Causes. — The causes of tumors are not positively recog- nized, those alleged being but theories varying in probability and ingenuity. The inclusion theory of Cohiiheim supposes that more embryonic cells exist than are needful to construct the fetal tissues, that masses of them remain in the tissues, and that these may be stimulated later into active growth. This embryonic hypothesis seems to receive a certain force from the facts that exostoses do sometimes develop from portions of unossified epiphyseal cartilage, and that tumors often arise in regions where there was a suppression of a fetal part, closure of a cleft, or an involution of epitheHum (epithelioma is usual at muco-cutaneous junctures). This theory, which does not explain the origin of most neoplasms, cannot suc- cessfully be maintained even as a common predisposing cause. Hereditation is extremely doubtful. S. W. Gross found hereditary influence by no means frequent in cancer of the breast. It is affirmed by some, denied by others, and doubted by a number. At most, hereditary influence may only pre- dispose. Nevertheless, cases have occurred which cannot be explained by the term coincidence. In the celebrated " Middlesex Hospital case," a woman and five daughters had cancer of the left breast. A. Pearce Gould had charge of a woman for cancer of the left breast. The mother of this patient, the mother's two sisters, and two of the mother's cousins had died of cancer. Injury and inflammation may undoubtedly prove exciting causes. A blow is not infrequently followed by sarcoma ; the irritation of a hot pipe-stem may excite cancer of the hp ; the scratching of a jagged tooth may cause cancer of the tongue ; chimney-sweeps' cancer arises from the irrita- TUMORS OR MORBID GROWTHS. 211 tion of dirt in the scrotal creases ; and warts often arise from constant contact with acrid materials. Pliysiological activity favors the development of sarcoma, and pliysiological decline favors the development of cancer. Parasitic Liflticnce. — This theory does not maintain that the tumor is the parasite, but that it contains the parasite, although Pfeiffer and Adamciewicz did at one time assert that a cancer-cell is not a body-cell, but a parasite resem- bling an epithelial cell. Some facts render a parasitic origin of malignant growths not improbable ; as, for instance, the likeness of some tumors to infective granulomata, their occa- sional secondary development in distant parts of the body, the resemblance of the secondary to the primary growths, and the tenacity of their persistence. A parasitic origin of cancer is pointed to by its geographical distribution, the dis- ease being very common in low and marshy districts (Havi- land). Some surgeons believe that cancer is contagious, but most observers deny it. Guelliott, of Rheims, believes that cancer is primarily a local infection. He believes this because Morea and Hanau have inoculated it from one animal to another of the same species, and if this can be brought about experimentally he sees no reason why it cannot happen accidentally. This surgeon says that cancer is very unequally distributed, that genuine cancer-centers and " can- cer-houses " exist, and that numerous cases of accidental infection have occurred.^ Mayet, of Lyons, holds that can- cer can be reproduced by grafting or by the injection of can- cer-fluid. Graf could not find " cancer-houses " after a care- ful search.^ Geissler claimed to have produced the disease in a dog by planting fragments of cancer in the subcutaneous tissue and vaginal tissue, but Czerny, Rosenbach, and others disputed the claim. Hauser disputes the assertion that can- cer must be an infectious disease because it is followed by secondary growths. Secondary growths in an infectious disease are caused by the bacterium ; secondary growths in cancer are caused by the transferrence of cells of the growth.^ Hauser says with truth that the close connection between innocent and malignant growths renders the parasite view untenable, because to hold it we would be forced to believe that every tumor has a special parasite or that one parasite may cause many kinds of tumor. ^ Am. Jour. Med. Sci., June, 1895. '■* Archiv. f. klin. Chir., 1895, 1., p. I44. ^ Hauser, in Biolog. Centralbl., Oct. I, 1895. 212 MODERN SURGERY. There seems to be no doubt that autotransference of can- cer can occur, although it rarely does so. Sippel has re- ported a case in which vaginal carcinoma developed at the point where the vagina was in contact with a pre-existing cancer of the portio/ Cornil has seen it transferred from one side of the labia majora to the other, and from one lip to the other. Geissler was unable to transplant cancer, and Gratia also failed in his attempts. Duplay and Bazin say that transmissibility is possible, but only under conditions which are not practically realized. Haviland believes strongly in " cancer-houses." ^ Tillmanns elaborately discussed the subject of cancer in the Congress of 1895. His conclusions seem most sound and scientific. He says there is no evidence of a bacterial origin of cancer. The parasitic origin has not been proved, and protozoa have not certainly been found. Cancer can be transferred from one part to another part of the same indi- vidual, or from one individual to another of the same species, but never to one of a different species. It is possible that cancer can spread by contagion ; this is very rare, but can happen (as when penile cancer is followed by cervix cancer in a wife). Because it is sometimes possible to transfer can- cer, this does not prove that the disease is parasitic or infec- tious ; it simply shows that tissue has been successfully transplanted. Actinomycosis, long thought to be a true tumor, is now known to arise from the ray-fungus. There can be no doubt that changes in the liver which practically constitute a new growth can arise from the growth of a cell called by Darier the " psorosperm." A disease due to psorosperms is called a "psorospermosis." It is affirmed by some that molluscum contagiosum, follicular keratosis, cancer, and Paget's disease are due to psorosperms. Some claim to find the parasite in all cases of cancer, while others can find it in only 4 or 5 per cent, of the cases. Heneage Gibbes affirms ^ that dilatation of the bile-ducts of a rabbit's liver is caused by the chronic irritation arising from multiplication of the coccidium oviforme in them, and not in the columnar cells of the bile-ducts, as has been stated ; and, further, that the large majority of glandular cancers show nothing that can be considered parasitic, the suspicious appearances noted in some few cases being due to endogenous cell-formation. This coccidium oviforme is 1 Cent rail) I. f. Gyndk., No. 4, 1894. ^ Lancet, April 27, 1894. ^ The Aine7-ican Journal of Medical Sciences, July, 1893. TUMORS OR MORBID GROWTHS. 213 a genus of the sporozoa, class protozoa, the lowest division of the animal kingdom. To this class belong the monera and infusoria. Malignant and Innocent or Benign Tumors. — Malignant growths infiltrate the tissues as they grow ; benign tumors only push the tissues away ; hence malignant tumors are not thoroughly encapsuled, while innocent tumors are encapsuled. Malignant tumors grow rapidly ; innocent tumors grow slowly. Malignant tumors become adherent to the skin and cause ulceration ; innocent tumors rarely adhere and rarely cause ulceration. Many malignant tumors give rise to secondary growths in adjacent lymphatic glands (cancer, except in the stomach, gullet, and upper jaw, always so tends) ; sarcoma does not cause them, unless it be mel- anotic or unless it arises from the testicle or tonsil. Inno- cent tumors never cause secondary lymphatic involvement, although the glands near the tumor may enlarge from acci- dental inflammatory complications. The malignant tumors, especially certain sarcomata and soft cancers, may be followed by secondary growths in distant parts and various structures (bones, viscera, brain, muscles, etc.) ; innocent tumors are not followed by these secondary reproductions, although multiple fatty tumors or multiple lymphomata may exist. Malignant tumors destroy the general health ; innocent tumors do not. Malignant tumors tend to recur after removal ; innocent tu- mors do not if operation was thorough. The special histo- logical feature of a malignant growth is the possession by its cells of a power of reproduction which knows no limit, the cells of the tumor living among the body-cells like a par- asite, and invading and destroying the body-cells. Classification. — Tumors may be classified as follows : I. Connective-tissue tumors. 1. Innocent tumors, or those composed of mature con- nectiv^e tissue : Lipomata^ or fatty tumors ; fibromata, or fibrous tu- mors ; cliondrouiata, or cartilaginous tumors ; ostco- inata, or bony tumors ; odontomata, or tooth-tumors ; inyxomata, or mucous tumors ; myomata, or muscle- tumors ; neuromata, or tumors upon nerves ; aiigcio- mata, or tumors formed of blood-vessels; lympJian- gciomata, or tumors formed of lymphatic vessels ; and lympJwmata, or tumors of lymphatic glands. 2. Malignant tumors, or those composed of embryonic connective tissue : Sarcomata. 214 MODERN SURGERY. II. Epithelial tumors. 1. Innocent tumors, or those composed of mature epi- thelial tissue : Adenomata, or tumors whose type is a secreting gland ; and papillomata, or tumors whose type is found in the papillae of skin and mucous membranes. 2. Malignant tumors, or those composed of embryonic epithelial tissue : Carcinomata, or cancers. I. Innocent Connective-tissue Tumors. — The growths mimic or imitate some connective tissue or higher tissue of the mature and healthy organism. I/ipomata are congenital or acquired tumors composed of fat contained in the cells of connective tissue, which cells are bound together by fibers. If the fibers are excessively abundant, the growth is spoken of as a " fibro-fatty tumor." A fatty tumor has a distinct capsule, tightly adherent to sur- rounding parts, but loosely attached to the tumor; hence enucleation is easy. Fibrous trabeculse run from the capsule of a subcutaneous lipoma to the skin ; hence movement of the integument over the tumor or of the tumor itself causes dimpling of the skin. Lipomata are most frequent in middle life, and their commonest situations are in the subcutaneous tissues of the back or of the dorsal surfaces of the Hmbs ; they usually occur singly, but may be multiple and some- times symmetrical. Senn has described the case of a woman who had a fatty turnor in each axilla. A lipoma is soft, doughy, mobile, lobulated, of uniform consistence, and may give on tapping a tremor or pseudo-fluctuation. It may grow to an enormous size (in Rhodius's case it weighed sixty pounds), and the growth may be progressive or may be at times stationary and at other times active. The skin over a fatty tumor sometimes atrophies or even ulcerates ; the tumor itself may inflame or partly calcify. When a lipoma has once inflamed, it becomes immovable. The commonest situation for lipomata is in the subcutaneous layer of fat. Subcutane- ous lipoma of the palm of the hand or sole of the foot re- sembles a compound ganglion, and it is apt to be congenital. Lipomata of the head and face are rare. In the subcutane- ous tissues of the groins, neck, pubes, axillae, or scrotum a mass of fat may form, unlimited by a capsule and known as a " diffuse lipoma." A nevo-lipoma is a nevus with much fibro-fatty tissue. A very vascular fatty tumor is called lipoma telangiectodes. If the tumor stroma contains large veins, the growth is called a cavernous lipoma. A tumor TUMORS OR MORBID GROWTHS. 215 containing much blood can be diminished in size by pressure. Fatty tumors may arise in the subserous tissue, and when arising in either the femoral or inguinal canals or the linea alba they resemble omental hernia and are spoken of as " fat-hernia." In the retroperitoneal tissues enormous fibro- fatty tumors occasionally grow, and these neoplasms tend to become sarcomatous. Lipomata may arise from beneath synovial membranes and will project into the joints, being still covered by synovial membrane. Fatty tumors occasion- ally arise in submucous tissues, between or in muscles, from periosteum, and from the meninges of the spinal cord (J. Bland Sutton). A fatty tumor may undergo metamorpho- sis. The stroma may be attacked by a myxomatous process or a calcareous degeneration. The fat-cells themselves may become calcareous. Oil-cysts sometimes form (Senn). Treatment. — A single subcutaneous lipoma is to be re- moved. Open the capsule, tear out or dissect out the mass, and always drain for twenty-four hours, as butyric fermenta- tion will be apt to occur, and necrosis of small particles of fat predisposes to infection. Multiple subcutaneous lipomata, if very numerous, should not be interfered with unless troublesome because of their size or situation, when they should be removed. Diffuse lipomata cannot be removed entirely, and operation is useless. Liquor potassae has been recommended to limit growth ; it may be taken internally for a considerable time, but it seems to be useless. Subperi- toneal lipomata are rarely diagnosticated until the belly has been opened or the growth has been removed. Fibromata are tumors composed of wavy fibrous bundles of adult fibrous tissue. Senn tells us that benign endothe- lial tumors belong under this head. A fibroma has no dis- tinct capsule, though surrounding tissues are so compressed as to simulate a capsule. Fibromata are occasionally con- genital, are most usual in young adults, but they may occur at any period of life, in any part of the body containing con- nective tissue, and are hard and movable. Pure fibromata, which are rare, are generally solitary, grow slowly, are of uniform consistence, and have not much circulation. Soft fibromata grow more rapidly than the hard, may become quite large, are apt to have distinct pedicles, and arise gen- erally from the skin of the scrotum, labia, uterus, and on the inner surface of the arm or the thigh, and from the belly- wall of a pregnant woman. There may be several of these growths (the author has seen seven on one person). Hard fibromata grow slowly ; they may form upon nerves, they may arise in 2l6 MODERN SURGERY. the mammary gland, they may develop in the lobe of the ear in a person who wears earrings, and they may spring from various fibrous membranes, from the periosteum of the nasal bones (fibrous polypi), and from the gums (fibrous epulides). Fibromata may become cystic, calcareous, osseous, colloid, or sarcomatous, and may become inflamed, ulcerated, or even gangrenous. A painful siibciitaneoiis tubercle, which is a form of fibroma commonest in females, arises in the subcutaneous cellular tissue, usually of the extremities. It is firm, very tender, movable, rarely larger than a pea, and the skin over it seems healthy. \"iolent pain occurs in parox}-sms and radiates over a considerable area of which the tubercle is the center. These paroxysms may occur only once in many days or many times in one day. Pain may always be dev^eloped by pressure, and may be linked with spasm. Nerve-fibrillae were never found in these tubercles until a recent period. A mole is a congenital fibroma of the skin (Senn). It is rounded or flat, is usually pigmented, is apt to have hairs growing from it, and varies in size from a pin's head to several inches in diameter. The tumor rarely grows after the thir- teenth or fourteenth year. A mole may become malignant, a melanotic carcinoma may arise from its epithelial structures, a melanotic sarcoma from its connective-tissue elements. Fibrous epulis is a fibroma arising from the gums or peri- odontal membrane (J. Bland Sutton) in connection with a cari- ous tooth or retained snag ; it is covered by mucous mem- brane, grows slowly, may attain a large size, and sometimes has a stem, but is more often sessile. It may undergo myx- omatous change or may become sarcomatous. Fibrous tumors may arise from the ovar}-, the intestine, and the lan,-nx. Pure fibromata of the uterus are ver>^ rare, but fibromyomata are ver}* common (see Myomata, p. 222); hence the term " uterine fibroid" should be abandoned. Molluscuni fibrosinn is an overgrowth of the fibrous tissue of both skin and subcutaneous structure. Senn excludes this form of growth from consideration with fibromata, be- cause of its infective origin. It may be limited or widely ex- tended ; it may appear as an infinite number of nodules scat- tered over the entire body or as hanging folds of fibrous tissue in certain areas. Keloid is a hard fibrous vascular growth, with a broad base, arising in scar-tissue ; it is crossed by pink, white, or discolored ridges, and is named from a fancied likeness to the crab. It is more common in negroes than in whites, and is most frequent in the cicatrices of burns, TUMORS OR MORBID GROWTHS. 21/ though it may arise in the scar of any injury, as the scar from piercing the ears, and in the scars of syphiHtic lesions, tubercular processes, small-pox, or vaccination. It is rare in early childhood and in old age. It grows slowly, lasts for many years, and may eventually undergo involution and disappear. iMoj'pIua, or spontaneous keloid, is a name used to desig- nate a growth of this description which does not arise from a scar; but it seems certain that scar-tissue was present, though possibly in small amount from trivial injury. Fibrous and papillomatous growths of a serous membrane may occur. They are covered with endothelium. Such a growth of the choroid plexus calcifies early and constitutes a psammoma. Cholesteatoma is a fibrous growth covered with endothelium and containing layers of crystalline fat. It occurs especially in the pia mater, and is called a pearl tumor. Treatment. — Enucleate fibromata when in accessible regions; do not let them remain, as any fibrous tumor may become a sarcoma. Epulis requires the cutting away of the entire mass, the removal of the related snag or carious tooth, and sometimes the biting away of a por- tion of the alveolus with rongeur forceps. Keloid should not be operated upon : it will only return, and will also recur in the stitch-holes. Trust to time for inv^olution, or use pressure with flexible collodion, by which method J. M. DaCosta cured a case following small-pox. The administration of thyroid extract may be of benefit (a gr. v tablet 3 or 4 times a day). This drug must be given cau- tioush\ as it may cause attacks characterized by fever, dyspnea, and rapid pulse. A mole ought to be excised, because, if allowed to remain, it may become malignant. Chondromata (enchondromata) are tumors formed either of hyaline cartilage, of fibrocartilage, or of both. Chondro- mata are apt to occur in certain glands, in the long bones, the pelvis, the rib-cartilages, and the bones of the hands or feet, and often spring from unossified portions of epiphyseal cartilage. They may be single or multiple, are often nodu- lated, and are most commonly met with in the young. They have distinct adherent capsules ; they grow slowly, progressively hollowing out the bones by pressure ; they cause no pain ; they impart a sensation of firmness to the touch, unless mucoid degeneration forms zones of softness or fluctuation ; they are inelastic, smooth or nodular, im- movable, and often ossify. Chondromata may grow to an 2l8 MODERN SURGERY. enormous size. A chondroma of the parotid gland or testi- cle always contains sarcomatous elements, and any chon- droma may become a sarcoma. Chondromata are notably frequent in persons who had rickets in early life. Ecclion- droses, which are " small local overgrowths of cartilage " (J. Bland Sutton), arise from articular cartilages, especially of the knee-joint, and from the cartilages of the larynx and nose. Loose or floating cartilages in the joints may be broken-off ecchondroses or portions of hyaline cartilage which are entirely loose or are held by a narrow stalk, and which arise by chondrification of villous processes of the synovial membrane ; only one or vast numbers may exist ; one joint may be involved, or several ; they may produce no symptoms, but usually produce from time to time violent pain and immobility by acting as a joint-wedge. Treatment. — Remove chondromata whenever possible, for, if allowed to remain undisturbed, they are apt to resent this hospitality by becoming sarcomatous. Incise the cap- sule and take away the growth, using chisels and gouges if necessary. Incomplete removal means inevitable recur- rence. Amputation is very rarely demanded. Loose bodies in the joints, if productive of much annoyance, are to be removed, the joint being opened with the strictest antiseptic care. Osteomata. — J. Bland Sutton says that osteomata are ossifying chondromata. Compact osteomata, which are iden- tical in structure with the compact tissue of bone, occur in the frontal sinus, mastoid process, external auditory meatus, and in other regions in those beyond middle life ; they are small, capped with cartilage, smooth, round, with small, occasionally cartilaginous bases, and are densely hard. Cancellous osteomata, which comprise the great majority of bone-tumors, are similar in structure to cancellous bone. They spring from and are crusted with cartilage ; they may have fibrous capsules, and are often movable when recent, but soon become fixed ; they have broad bases, are angled, nodular, firm (but not so hard as are the compact osteomata), painless except when pressed, occur particularly at the ends of long bones, may grow to large size, and are commonest in youth. Osteomata near joints become overlaid by bursae which in rare instances communicate with their related joints. The term exostosis has been used as being synonymous with osteoma, but wrongly so, as an exostosis is an irregu- lar, local, bony growth which does not tend to progress TUMORS OR MORBID GROWTHS. 219 beyond a certain point, and which is hence not a tumor. A true exostosis is seen in the ossification of a tendon-inser- tion, in a limited growth from the maxillary bones, and in a local growth from the last phalanx of the big toe, which growth is known as a " sub-ungual exostosis." Exostoses of the retrocalcaneal bursa occasionally arise when this bursa is inflamed. Inflammation of this bursa is known as Achillo- dynia or Albert's disease. The bony masses sometimes found in the brain, lungs, testicle, various glands, and tumors are not true osteomata. Treatment. — Osteomata which are nonproductive of pain or trouble do not demand removal. If they produce pain by pressure, if they press upon important structures, if they cause annoying deformities, or if they grow rapidly, then remove them by means of chisels, gouges, or by the sur- gical engine. Exostosis of the toe should always be re- moved, to do which the nail should be split and part of it taken away, and the bony mass be gouged away or be cut off with forceps. Odontomata ' are tumors composed of tooth-tissue and springing from the germs of teeth or from developing teeth. J. Bland Sutton divides them into (i) those springing from the follicle ; (2) those springing from the papilla ; and (3) those springing from the whole germ. Epithelial odontoraes, or multilocular cystic tumors, arise from the follicle, occur oftenest in the lower jaw, dilate the bone, have capsules, and are made up of masses of cysts which are filled with brown fluid. These cysts are met with most frequently before the age of twenty. Follicular odoutoiiics, or dcntigcrous cysts, oftenest spring from the follicles of the permanent molars. In a dentigerous cyst there exists an expanded follicle which distends the bone, the follicle being filled with thick fluid and containing a portion of a tooth. K fibrous odontojiic is due to thickening of the tooth-sac, thus preventing eruption of the tooth ; fibrous odontomes are usually multiple, and are apt to occur in rickety children. A ceinciitoinc is due to enlargement, thickening, and ossification of the capsule, the developing tooth being encased in cement. A compound follicular odon- tomc is due to ossification of portions only of an enlarged and thickened capsule, and the tumor contains bits of cementum, portions of dentine, or small misshapen teeth. A radicidar odontonie springs from the papilla and arises ^ This section is abridged from J. Bland Sutton's stril^ing chapter upon odon- tomes in his recent work on Tumors. 220 MODERN SURGERY. after the crown of the tooth is formed and while the roots are forming ; hence it contains dentine and cement, but no enamel. Composite odontomes are formed of irregular, shape- less masses of dentine, cement, and enamel. All the above forms occur in man. They present themselves as hard tumors associated with teeth or in an area where teeth have not erupted. They may distend the jaw. Occasionally an odontome simulates necrosis ; it is surrounded by pus, and a sinus forms. Treatment. — The diagnosis is scarcely ever made until after incision ; hence, be in no haste to excise large por- tions of bone for a doubtful growth ; incise first and see if it be an odontome, which requires only the removal of an implicated tooth, curetting with a sharp spoon, and packing with iodoform gauze. Myxomata are tumors composed of mucous tissue. They are rare as independent growths, although myxo- matous change is frequent in the stroma of other tumors. The tissue type of these tumors is found in the vitreous humor of the eye and in the perivascular tissues of the umbilical cord (Wharton's jelly). Bowlby states that myxo- mata are in reality soft fibromata whose intercellular sub- stance has been replaced by mucin. The myxomatous state may be a stage in the formation of a fibroma, a stroma not having developed. Myxomata may result from myxomatous degeneration of cartilage, of muscle, or of fibrous tissue. These tumors are soft, elastic, usually pedunculated, tremu- lous, and vibratory. The stroma is very delicate and carries minute blood-vessels. Cutting into them causes a straw- colored, clear jelly to exude ; they grow slowly, are encap- suled, have but little circulation, and their diagnosis may be impossible before removal. Some pathologists place myxo- mata among the malignant tumors, but most consider them as benign tumors, though they tend strongly to become sarcomatous (myxosarcomata). A sarcoma may undergo myxomatous degeneration. Myxomata may arise from the skin ; from the mucous membrane of the nose, the frontal sinus, the antrum, the womb, auditor}^ meatus, and the tympanum (gelatinous polyps) ; from the parotid and mammary glands ; from the subcutaneous tissue, the nerve-sheaths, the intermuscular septi, the rectum, and the bladder (polyps). They may be congenital, but occur most often in young adults, as a result of inflammation. A sudden increase of growth indicates be- ginning malignancy (sarcomatous change). When a tumor Ti'MORS OR MORE ID GROWTHS. 221 begins to undergo myxomatous transformation we give to it a compound name ; for instance, chondromyxoma, fibro- myxoma, etc. Nasal polypi grow from the mucous membrane over the turbinated bones ; they are soft and jelly-like, of a grayish color, and have stems or pedicles ; they may be seen through the anterior nares. may project behind the veil of the palate, and may bulge out from the passages of the nose ; the}' may be, and usually are, multiple ; they may be present in one nasal fossa or in both ; and they occur most commonly in young adults. Hydatid moles of pregnancy are due to myxomatous changes in the chorion. Treatment. — In treating myxomata, remove them prompt- ly and thoroughly, because of the danger of sarcomatous change. Nasal polyps may usually be twisted off or be re- moved by the wire snare or galvano-cautery ; but occasion- ally extensive operations are required for their removal. A soft myxoma breaks up when remov^al is attempted, and the base must be cauterized. I/jntnphomata are tumors composed of lymphatic-gland structure, and are due to multiplication of pre-existing ade- noid tissue (idiopathic lymplipmata). Lymphomata are most frequently encountered in the neck and axillae, but are not unusualh' met with in the groins. One gland or many may be involved ; they grow rapidly and attain a large size ; they are painless, are encapsuled, and are freely movable beneath the skin ; they do not infiltrate surrounding tissues, and pre- sent no thickening from inflammation ; they are commonest between the ages of twenty and thirty-five, but they may occur in early life. Gross states that the enlargement usually begins upon one side of the neck, gland after gland being successively attacked ; in from four to eighteen months the glands of both sides of the neck, the axillae, the bronchi, and the mesentery become involved, the patient's health fails, and death soon ensues. These tumors are said not to be malig- nant, but certain it is that they tend to recur after removal. It is impossible to distinctly separate this disease from lymph- adenoma : they probably are related, or possibly are iden- tical. Sarcoma of a lymphatic gland arises later in life than does lymphoma ; it infiltrates surrounding structure, render- ing the growth immovable, and implicates the related glands gluing them together ; the tumor is painful and the skin ulcerates. Lymphoma differs from tubercular lymphadenitis in many ways. It originates in an apparently healthy person ; 222 MODERN SURGERY. it has no tendency to caseation or suppuration ; the growths do not infiltrate, but remain movable ; and the overlying skin retains a healthy appearance. Treatment. — If possible, entirely extirpate a lymphoma; but if complete removal is impossible, perform no operation. In inoperable cases order cod-liver oil and nutritious diet, insist on open-air exercise, employ inunctions of ichthyol, give courses of arsenic in advancing doses, and from time to time administer iodid of potassium and iron in some form. Fowler's solution as an injection into the growth finds some advocates. Myomata are tumors composed of unstriped muscle-fiber mixed often with fibrous tissue (leiomyomata). Tumors com- posed of striated muscle-fiber (rhabdomyomata) are very rare and are always sarcomatous. Leiomyomata are found in the womb, in the prostate gland, in the walls of the gullet, vagina, stomach, bladder, and bowel, in the broad ligament, ovary, and round ligament, in the scrotum, and in the skin. Myomata usually begin during or after middle age ; they are encapsuled, they grow slowly, they are firm and hard, and they produce annoyance by their size and weight or by ob- structing a viscus or channel. A leiomyoma of the posterior and middle of the prostate forms " a middle lobe." The so-called " uterine fibroid" is a myoma or fibromyoma. Uterine myomata may originate within the walls of the womb (intramural myomata), from the muscular structure of the mucous lining (submucous myomata), or from the muscular tissue of the serous covering (subserous myomata). Intra- mural uterine myomata may be single or be multiple and may grow to an enormous size. Submucous myomata pro- ject into the cavity of the womb (fleshy polyps). Submucous myomata distend the uterus and are often accompanied by menorrhagia or metrorrhagia ; they may project into the vagina. In some rare cases the projecting tumor is detached by nature and the patient is cured ; in other cases the myoma becomes gangrenous. This form of tumor may produce in- version of the fundus of the womb. Subserous uterine myo- mata cause trouble only by the inconvenience of weight or the discomfort of pressure. Uterine myomata may undergo fatty, calcareous, or myxomatous change, and may be infected by septic organisms as a result of the use of a uterine sound or of infection of the pedicle after oophorectomy. Infection of a uterine myoma causes great enlargement, elevated tem- perature, sweats, and exhaustion. Uterine myomata, which are commonest in single women (J. Bland Sutton), arise most TUMOFS OR MORBID GROWTHS. 223 frequently between the ages of twenty-five and forty-five. They may never produce any symptoms ; some, by enlarg- ing until they ascend above the pelvic brim, produce abdom- inal distention ; some become jammed or impacted in the pelvis, and produce by pressure retention of urine, obstruc- tion to passage of feces, or hydronephrosis. Impaction may occur temporarily at each menstrual period. Many myomata produce uterine hemorrhage ; some cause retroversion of the womb ; some protrude from the cervical canal ; some are so large that they cause disastrous pressure upon the colon (ob- struction), upon the iliac veins (intense edema), or upon the ureters (hydronephrosis). Uterine myomata usually shrink after the menopause. Pregnancy in a myomatous womb usually ends in abortion. The symptoms of myomata of the alimentary canal are similar to or identical with the symptoms of malignant growths. Myomata of the skin are rare growths ; they are encapsuled, firm or elastic, and painless. Treatment. — Cutaneous myomata are removed in the same manner as fibrous tumors. Uterine myomata are treated by rest and the administration of ergot, barium chlorid, and di- lute sulphuric acid. If this treatment fails to arrest serious bleeding due to a fleshy polyp, dilate the cervical canal and remove the growth. If there be dangerous bleeding in a woman who has some years to wait for the menopause and who has not a removable polyp as the cause, perform oophorectomy in order to bring on an artificial menopause. When a myoma becomes impacted at each menstrual period remove the ovaries and Fallopian tubes. Hysterectomy is indicated for some very large tumors, for tumors that grow after the menopause, and for infected myomata. If the abdo- men be opened to perform oophorectomy, and the tubes and ovaries are found so implicated in the growth that they can- not be removed completely, or the broad ligament is found so drawn out that a safe pedicle cannot be secured, perform a hysterectomy.^ A recent suggestion for the shrinkage of uterine myomata is to ligate both the uterine and ovarian arteries. If a myoma of the prostate cause severe obstruc- tion, effect a suprapubic cystotomy and remove the major portion of the enlarged gland ; or make both a suprapubic and a perineal opening, push the gland into the perineum and shell it out with the finger, or perform White's operation (double castration). 1 See J. Pjland Sutton's admirable article on " Uterine Myomata " in his work on Tumors. 224 MODERN SURGERY. Neuromata. — A true neuroma springs from nerve-tissue (brain, cord, or nerve-trunks) ; it is composed of medullated or non-medullated nerve-fibers which form a plexus or net- work and which are not continuous with the fibers of the nerve-trunk or other area from which the tumor grows. True neuromata, which are rare growths, arise during mid- dle life ; they are small in size, are due to injury or hered- itary tendency, and they may be single or multiple. There is usually around the tumor, rather than in it, severe neu- ralgic pain, which is greatly intensified by dampness, by blows, or by rough handling. The parts below a neuroma are cold, swollen, often anesthetic, and frequently present motor paralysis or trophic disorder. A false neuroma or neurofibroma is a tumor growing from a nerve-sheath, and is identical in structure with the sheath. False neuromata may be single, but they are often multiple ; they may be as small as peas or as large as oranges ; they are smooth and movable, and may cause great pain or may only hurt when pressed or struck ; they may spring from roots, trunks, or branches, and they may be hnked with the disease known as " molluscum fibrosum." In plexiform neuroma some branches of a nerve enlarge and lengthen like an artery in a cirsoid aneurysm ; the mass feels like beads or like a bag of worms ; it is mobile, and no pain is felt on moving it ; and it is generally congenital. In plexiform neuroma the nerve-sheath undergoes myxomatous change. Malignant neuroma means primary sarcoma of a nerve-sheath, though any neuroma may become sarcomatous. Traumatic neuromata are occasionally well exhibited after nerve-section or amputation. On nerve-section the distal end shrinks and atrophies, the proximal end enlarges and becomes bulbous. These traumatic neuromata are composed of fibrous tissue which contains nerve-fibres ; they are usu- ally, but not always, painful on pressure or during damp- ness, and they are commonest in stumps which did not heal by first intention. Painful subcutaneous tubercle is consid- ered under the head of Fibromata. In performing an ampu- tation cut the nerves high up, and thus keep them out of the scar and prevent a tender stump. A tender stump may be simple, due to anchoring the nerve in a scar, and thus preventing gliding when the individual moves the ex- tremity. Treatment. — A false neuroma is to be removed, if possi- ble, without destroying the nerve-trunk. If, in removing a neuroma, it is necessary to exsect a portion of a nerve-trunk, TCMORS OR MORBID GROWTHS. 22$ always endeavor to suture the ends so as to facilitate resto- ration of function. For multiple neuromata — at least should the number be large or should molluscum fibrosum exist — surgery can do nothing. Plexiform neuromata may often be removed, but amputation may be required. Painful neuro- mata in stumps should be excised. Angfiomata. — These vascular or erectile tumors are growths composed of blood-vessels. Simple or capillary angiomata, nevi, or " mother's marks," which affect the skin or subcutaneous tissue, are composed of enlarged and twisted capillaries and of anas- tomosing vessels surrounded by fat. These growths are congenital or appear in the first few weeks of life ; they are flat and slightly raised, and are of a bright-pink color if composed chiefly of arterioles, and are bluish if composed mainly of venules ; they are but little elevated ; they can be almost completely emptied by pressure ; they occasion- ally pass away spontaneously, but usually grow constantly and may become cavernous ; they may ulcerate and occasion violent or fatal hemorrhage. One or several large vessels join a nevus to adjacent blood-vessels. Port-wine or claret stains are pink or blue discolorations due to superficial nevi of the skin ; they may be small in extent or they may involve a very large area, are not elevated, and do not usually spread. Telangiectasis is a form of nevus involv- ing the skin and subcutaneous tissue in which many arte- rioles and venules exist. Simple angiomata are common on the forehead, the scalp, the face, the neck, the back, and the extremities. They may appear on the labia, the tongue, or the lips. Cavernous angiomata, or venous nevi, resemble in structure the corpora cavernosa of the penis ; there are large spaces with thin walls carrying blood, and there may be distinct vessels as well. Arteries send blood into the spaces, and veins receive it from the spaces. These chan- nels and sinuses are enormously distended capillaries. Cav- ernous angiomata arise in the skin and subcutaneous tis- sues ; they are usually congenital, but may develop from simple angiomata. These cavernous angiomata are purple or blue in color, are more distinctly elevated than the capil- lary nevus, may be either cutaneous or subcutaneous, swell when the child cries, and are apt to pulsate ; they may be emptied by pressure, and often look like cysts with very thin walls. Cavernous angiomata may arise in the breast, the tongue, the lip, the subcutaneous tissues, or the mu.scles. If 15 226 MODERN SURGERY. an angioma contains an excess of fat, the growth is called a " nevoid lipoma." Plexiform angiomata are known as " cirsoid aneurysms " or aneurysms by anastomosis (p. 256). Treatment. — These growths if large or growing must be treated. A capillary nevus can often be quickly cured by touching it with fuming nitric acid. A second appHcation of acid may be required. The growth may be destroyed by heat — " a knitting-needle at a dull-red heat or the galvano- cautery " (Wharton). The application of ethylate of sodium or the employment of electrolysis will destroy the growth. Small port-wine stains may be removed by electrolysis or multiple incisions, but extensive stains are ineffaceable. Small nevi may be ligated under harelip pins ; larger nevi may be strangulated in sections by the Erichsen suture or may be completely excised. Excision is usually the best plan for the cure of the cavernous variety of angeiomata. When a large cavity is left by excision a plastic operation must be performed. Do not use astringent injections. I/ytnphang"ioinata are tumors composed of dilated lymph-vessels, and are often, though not invariably, con- genital. The lymphatic nevus is a colorless or faintly pink elevation ; if it is punctured with a needle, lymph flows from the puncture. One or several nevi may be present in the same individual. The dilatation is due to blocking of the lymph-channels. Local lymphangioma of the tongue is manifested by a cluster of papillary projections containing lymph. Macroglossia is a congenital enlargement of the anterior portion of the tongue, which enlargement grows more and more marked until finally the tongue is forced far out of the mouth. This condition of tongue-enlargement is due to lymphangioma of the mucous membrane. Lymph scrotum is due to a similar growth. A collection of these warty-looking dilatations is called lymphangiectasis. Just as there occur cavernous angiomata among blood-vessel tumors, there occur cavernous lymphangiomata among lymph-vessel tumors, and the spaces are filled with lymph instead of with blood. Areas affected with lymphangiectasis are liable to repeated attacks of erysipelas-like inflammation. Whether this inflammation is causative or secondary is not known. Certain it is that in tropical countries blocking may be brought about by the filaria sanguinis hominis, a parasite which lurks in the lymph-vessels during the day and is found in the blood only at night. Lymphangiectasis is often the first stage of an elephantiasis (p. 747). TUMORS OR MORBID GROWTHS. 22/ Treatment. — Lymphatic nevus requires excision. In macroglos-sia remove the bulk of the mass by a V-shaped cut and so stitch the mucous membrane as to close the stump. In conditions due to the filaria, anilin-blue has been gi\-en internally with advantage. Malig^nant' Connective-tissue Tumors, or Sarco- mata. — The sarcomata are composed of embryonic tissue. They develop from connective tissue, have no definite stroma, and contain no lymphatics. The rapidly growing forms are very vascular, the blood flowing in vessels whose walls are very thin or running in canals whose boundaries are sarcomatous cells. These tumors may pulsate and have a bruit, and hemorrhages often take place in their substance. Slow-growing sarcomata have but few vessels. Sarcoma disseminates by means of the blood and the vessel-walls, particles of sarcoma being carried by the venous blood to the heart and from this organ to the lungs, where they lodge and form secondary^ growths. Emboli from these secondary foci are sent out by the arterial blood to various portions of the body, as the bones, kidneys, brain, liver, etc. This process is known as " metastasis." Sarcoma follows the vein-walls for considerable distances and builds elongated masses inside the veins. Sarcoma tends strongly to infil- trate adjacent parts. The tumor may possess a capsule when it is in an early stage, but soon loses this except in very slow-growing or mixed forms growing by central proliferation. Sarcomata may arise at any age from birth to extreme senility, but they are commonest during youth and early middle age. They are not hereditary, and often follow contusion. They may be primar}' or may arise from malignant change in an innocent connective-tissue growth (chondrosarcoma, fibro- sarcoma, etc.). A sarcoma does not tend to affect lymphatic glands except by the accident of its position ; and if it does implicate them, the sarcomatous elements are carried rather by the vein-walls and blood than by the lymph (melanotic sarcoma implicates adjacent glands, and so does sarcoma of the tonsil or of the testicle). The skin over the tumor may giv^e way, a bleeding fungus-mass protruding (fungus haematodes), and suppuration may cause septic enlargement of adjacent glands. After remov^al of a sarcoma the growth tends to recur, and the recurrent tumor may be either more or less malignant than its predecessor, the degree of malignancy being in direct ratio to the number and smallness of the cells. A sarcoma is malignant by local tissue-infection and by dis- semination. Sarcomata rarely cause pain when they are not 228 MODERN SURGERY. ulcerated. Sarcomata are commonest in the skin and con- nective tissue of the extremities, but they arise also from bone, neuroglia, periosteum, in the lymphatic glands, the breast, the testicle, the eye, the parotid, and in other parts. Hemorrhages into a sarcoma often occur, with the result of suddenly increasing its size and forming blood-cysts. Sarcomata are subject to partial fatty degeneration, to myxomatous changes which produce cavities filled with fluid, to calcification, and occasionally to necrosis of large masses. Species of Sarcomata. — The following species of sarco- mata are recognized : 1. Round-cell, in which the matrix is soft and vascular. The cells may be small or may be large. The smaller the cell the more malignant the growth. A small round-cell sarcoma is the most malignant variety of sarcoma and is soft in consistence. 2. Spindle-cell, which is composed of bundles of spindle- cells lying in a matrix which may be homogeneous, but which- may show some attempt at fiber-formation. Rhabdomyoma is a variety of spindle-cell sarcoma containing striated mus- cle-cells. These spindle-cell sarcomata often contain carti- lage. 3. Mixed-cell sarcoma, containing both of the above varie- ties of cells. 4. Giant-cell or myeloid, which contains some round-cells, some spindle-cells, and large cells with many nuclei, like the cells of bone-marrow. It is maroon-colored on section. This is the least malignant form of sarcoma, and it sometimes ad- mits of complete extirpation and cure. It tends to occur in the long bones as a central sarcoma. 5. Alveolar, in which the cells are collected in alveoli as are the cells of cancer. It arises usually from a mole. 6. Melanotic, which may be composed of either round- cells or spindle-cells containing a black pigment. 7. Lymphosarcoma, which is composed of small round- cells held in a delicate network, the tissue somewhat resem- bling that of a lymphatic gland. Clinical Varieties of Sarcoma. — The following are the clinical varieties of sarcoma : Melanotic or black sarcoma, the color of which is due to pigment in the cells or matrix. These growths are usually composed of round-cells, but may consist of spindle-cells ; they are sometimes alveolar, and spring from parts which contain pigment (skin and choroid coat of the eye) ; they are TUMORS OR MORBID GROWTHS. 229 apt to arise from pigmented moles ; they are very malig- nant ; they implicate related lymphatic glands, and during their existence the urine contains pigment. GliosarcoDia is a sarcoma of neuroglia. A pure glioma is composed of adult connective tissue ; but, as a matter of fact, pure glioma almost never arises, and the growth practically always contains numerous small round-cells and is properly a sarcoma. It springs from the neuroglia of the central ner- vous system, and is usually of about the consistence of the cortex of the brain; it is generally single, and does not cause secondary growths. A gliomatosis of the cord produces that remarkable disease known as " syringomyelia." The symptoms of glioma of the brain depend upon its situation. Hcnioryhagic sarcoma is a sarcoma containing blood- cysts, the results of parenchymatous hemorrhages. Cyliudroma, or Plcxiforin Sarcoma. — In this variety the cells adjacent to vessels have undergone hyaline degenera- tion ; the cells distant from vessels are unchanged. Section shows the normal cells apparently contained in spaces with h}-aline walls. Mixed tumors consist partly of mature and partly of embryonic tissue, the cellular elements exceeding the adult elements in amount. Among these mixed tumors are fibro- sarcoma or the recurrent fibroid tumor, myxosarcoma, chondrosarcoma, and osteosarcoma. Treatment of Sarcomata. — Remove a sarcoma at once if it is in an accessible spot. Never delay removal. Cut well clear of it. The rapidly growing soft sarcomata will almost inevitably return, and the very malignant variety, if uninter- fered with, may terminate life in six months ; but operation postpones the evil day and renders it possible that death will occur from metastasis in an organ, and that the patient will escape the horrors of ulceration and hemorrhage from the original tumor. Slowly growing and hard tumors offer some prospects of cure. The mixed tumor (as a recurrent fibroid) may repeatedly recur, and yet the patient may be cured at last by a sixth, an eighth, or a tenth operation. In sarcoma of a long bone amputation should, as a rule, be performed, though in some cases of giant-cell sarcoma excision may be employed. In sarcoma of the jaw-bone, excision ; of the eye, enucleation-; and of the testicle, castra- tion, is demanded. Sarcoma of the ovary in adults demands removal, but in children the operation is useless. Sarcoma of the kidney in adults calls for nephrectomy, but in chil- dren the operation is of little avail. In melanotic sarcoma 230 MODERN SURGERY. remove the growth and adjacent lymph-glands, or in some cases amputate. Removal of a sarcoma when there is no hope of a cure is often justifiable to prolong life, to relieve the patient of a foul, offensive, bleeding mass, and to permit of an easier road to death by means of metastasis to an internal organ. Wright advocates internal treatment for sar- coma' and for cancer. He advises that bromid of arsenic be given for a long period of time, the dose being gr. -^ to gr. yV ^^"I^^^ ^^^^ meal. Before meals gr. x of carbonate of lime are advised. This treatment, Wright holds, should be used before, and for many months after, operation, as an aid to surgery. In inoperable cases it may be tried.^ It has been observed that an attack of erysipelas occasion- ally greatly benefits a sarcoma, causing large masses of the growth to soften or to slough and expose a granulating sur- fece. Busch noticed this in 1866. It has been suggested that in inoperable cases of sarcoma these conditions might be established artificially. Fehleisen inoculated tumors with cultures of erysipelas. Lassar in 1891 employed the toxins (cultures rendered sterile by heat and filtration). In 1892 Coley began his observations. The first plan was as follows : a bouillon-culture is made of the streptococci ; this culture is filtered through porcelain and an injection is given once a day into and about the sarcoma. The first dose is TTlx, and it is increased ; it should cause a febrile reaction, and sometimes establishes softening or suppuration. Coley's present method is as follows : make cultures of erysipelas cocci in cacao-broth ; after three weeks inoculate them with the bacillus prodigiosus, and cultivate the mixed growth for four weeks. They are maintained at 58° C. until they become sterile. This sterile fluid contains the toxins. The dose is from i to 8 minims. The material is very powerful and may cause high fever. Begin with a small dose and gradually increase until the proper amount of reaction ensues (103°- 104° F.). The injection may be about the sarcoma or at a distant point. The exact status of this plan is not determined ; it has improved and even cured some cases, but is not free from danger. Coley believes that the value of the agent is proved, but Senn, Keen, Kocher, and others are very doubtful of its value. Emmerich and Scholl claim good results from the injection of erysipelas serum. A sh'eep is injected with cultures of erysipelas, the blood is drawn, the serum separated, filtered to remove cocci, and injected about the sarcoma. Results are not definite. Among other agents which have been used 1 Annals of Surgery, April, 1893. TUMORS OK MORBID GROWTHS. 23 1 to inject inoperable sarcoma we may mention alcohol, chlo- rid of zinc, arsenic, corrosive sublimate, thiosinamin, pepsin, alkalies, etc. The injection of anilin-products into the sar- coma, which has received a qualified commendation from some observers, has been abandoned by most surgeons after careful trial. Innocent Bpithelial Tumors. — These growths imi- tate an epithelial tissue of the mature and healthy organ- ism. Papillomata, or Warts. — These growths are formed upon the type of cutaneous and mucous papillae. A papil- loma consists of a fibrous stroma which contains blood- vessels and lymphatics and is covered by epithelium of the variety appertaining to the diseased part. Warts grow from the skin and from mucous membranes ; they may be single or multiple ; they may be painless or may be ulcerated and bleeding ; great masses may gather around the anus, the vagina, or the penis during the existence of a filthy discharge, and crops appear on the hands of those who work in irritant material (as petroleum). A large crop of warts may disappear in a single night ; hence the popular belief in the efficacy of charms. A single wart may reach a large size and become pigmented. The squa- mous epithelium covering a skin-wart may become horny (a wart-horn). Other cutaneous horns arise from the nails, from the scars of burns, or from ruptured sebaceous cysts. Villous papillomata grow chiefly from the bladder ; they form tufts like the villous processes of the chorion ; they may be single or multiple, and may be sessile or peduncu- lated ; they are very vascular, and are apt to bleed freely. Papillomata may arise in cysts of the paroophoron, in cysts of the mammary gland, from the choroid plexuses of the ventricles of the brain, and from the spinal membranes Any papilloma may become a cancer. Treatment. — Venereal warts are treated by repeatedly washing with peroxid of hydrogen, drying with cotton, and dusting with a powder composed of equal parts of calomel and subnitrate of bismuth, or oxid of zinc and iodoform, or borated talcum. If they do not soon dry up, cut them off with scissors and burn with the Paquelin cautery. Ordi- nary warts may usually be destroyed in a short time by daily applications of lactic or chromic acid. In multiple warts of the face Kaposi applies daily for several days a por- tion of the following combination : sublimed sulphur, .^5 ; gly- cerin, 31^; acetic acid, .32|-. Keeping a wart constantly 232 MODERN SURGERY. moist with castor oil will often cause it to drop off. Warts, and even extensive callosities, may be removed by painting once a day for five days with pure carbohc acid and cover- ing with lint kept wet with boric acid. A convenient plan is to paint a wart daily with a solution containing i part of corrosive sublimate to 30 parts of collodion (hydrarg. chlor. corros., z\\ collodion, 315). Large warts should be freely excised. Villous papillomata of the bladder demand the performance of a suprapubic cystotomy in order to remove them. Adenomata. — These glandular tumors are composed of tissue identical with that of normal glands, and they may contain acini and ducts like racemose glands or tubes like tubular glands. They grow from secreting glands, but can- not produce the secretion of the glands from which they spring, or, if they do secrete, the fluid is retained, and not discharged by the gland-duct. Adenomata occur in the mammary gland, the parotid, the ovary, the thyroid gland, the liver, the sweat-glands, and the prostate, and as pedun- culated growths from the mucous lining of the intestine and uterus. They are encapsuled, are usually single, but may be multiple, are of slow growth, but may attain a great size ; they do not tend to recur after thorough removal, do not involve adjacent glands, and do not disseminate ; they are firm to the touch ; they tend to become cystic (especially in the thyroid), the fluid which distends the ducts being due to mucoid liquefaction of the proliferating epithelium. In the breast a fibro-adenoma has a distinct capsule ; it is elastic and movable, is usually superficial, and one occasion- ally exists in each gland. They are most common before the age of thirty, and are often painful, especially during men- struation. Cystic adenomata of the breast attain a large size ; they are encapsuled and grow slowly, are most common after the thirtieth year, and are rarely painful. Both fibro- adenoma and cystic adenoma may arise in the male breast. Young unmarried women not unusually develop in the breast small, very tender, and painful bodies, most usually around the edge of the areola, which bodies increase in size and become more tender during menstruation ; they are only cysts of the mammary tissue. Adenomata of the thyroid gland begin before the fifteenth year (Gross). Adenomata may arise in the prostate if that gland be already the seat of senile hypertrophy. Adenomata of mucous glands may arise in the young or the middle- aged. rC'MORS OR MORBID GROWTHS. 233 Treatment. — Adenomata require extirpation. By confus- ing adenomata of the mammary gland with .small cyst.s of that structure an erroneous belief has arisen that the former, as well as the latter, may sometimes be cured by the local use of iodin, mercury, and ichthyol and the internal use of iodid of potassium. The treatment is excision. Malignant Epithelial Tumors, Carcinomata, or Cancers. — Cancers are tumors growing from epithelial surfaces, and are composed of epithelial cells which are clustered in spaces, nests, or alveoli of fibrous tissue. The cells of a cluster are not separated by any stroma, and the walls of the alveoli carry blood-vessels and lymphatics. The growth may be cancerous from the start, or may have begun as an innocent epithelial tumor. Cancers are always derived from epithelium (of glands, of skin, of mucous mem- brane, etc.), and if found in a non-epithelial tissue must be secondary. They have no capsules, rapidly infiltrate sur- rounding tissues, and are firmly anchored and immovable. In the beginning a cancer is a local lesion, but it soon attacks related lymph-glands and by means of the lymph, and very rarely by the blood (Thiersch and Waldeyer), is dissemi- nated throughout the system, secondary growths arising which are identical with the parent growth. Cancer is rare before the age of forty, and never occurs before puberty ; seems occasionally to be hereditary ; and is sometimes linked with continued irritation as a cause (cancer of the penis in phimosis ; cancer of the lip from the hot stem of a clay pipe ; chimney-sweeps' cancer from soot in the scrotal folds ; cancer of the gall-bladder when gall-stones exist). The weight of opinion is opposed to the theory that cancer is of parasitic origin. Tillmanns says that the presence of protozoa has never been proved.^ The same author says that transplantation has taken place, but only by auto-infec- tion or by transplantation to an animal of the same species. The facts that transplantation can be sometimes carried out, and that contagion is a possible occurrence under excep- tional circumstances, do not prove that cancer is a para- sitic disease, but simply prov^e that it can be transplanted. It is not that the cancer carries a parasite which will cause the disease in sound tissues, but rather that the cells of the cancer may themselves take root and grow in sound tissues (p. 211). Dennis says that all clinical evidence points strongly to the view that inflammatory changes following 1 Verhandlungen der deutschen Gesellschaft fiir Chirtirgie, XXIV. Kongress, 1895- 234 MODERN SURGERY. irritation are responsible for cancer. Cancer is often the seat of pricking pain ; tends strongly to recur after removal ; is prone to ulcerate, causing pain, hemorrhage, and cachexia ; makes rapid progress, and is often fatal in from one to two and a half years. It is more common in women than in men, and rarely exists with tubercle. After a cancer has existed for a time in an important structure, or after a super- ficial cancer has ulcerated and become hemorrhagic, there are noted in the individual evidences of illness and exhaustion. We speak of this condition as the " cancerous cachexia," and in it the muscles are wasted, the body-weight is con- stantly diminishing, the complexion is sallow, the face is sunken, pearly white conjunctivae contrast strongly with the yellow skin, the pulse is weak and rapid, and night-sweats add to the exhaustion. The above condition is due to the absorption of toxic products from the diseased tissues, and also to pain, loss of sleep, bleeding, deprivation of exercise, malassimilation of food, and anxiety. Cancer may kill by obstructing a canal, by destroying the functions of a viscus or organ, by hemorrhage, by anemia, by sepsis, or by exhaustion. Classification of Carcinomata. — Carcinomata are classi- fied as follows : i. Squamous-celled cancer, or epithelioma; 2. Rodent ulcer, or Jacob's ulcer ; 3. Spheroidal-celled cancer {a, scirrhus ; b, encephaloid ; c, colloid) ; and 4. Cylindrical- celled cancer. Epitheliomata. — An epithelioma may arise wherever there is pavement-epithelium, and it is especially apt to appear at the junctions of skin and mucous membrane (as the lips) or the point of juxtaposition of different kinds of epithelium. These growths arise in the anus, vagina, penis, scrotum, lips, tongue, mouth, nose, and other situations. In epithelioma there is an ingrowth of surface-epithelium into the sub-epi- thelial connective tissue, colonies of cells growing inward and forming epithelial nests. It may arise without discoverable cause, it may follow prolonged irritation, or it may arise in a wart or fissure. In the nipple it is often, and in the scrotum and nose it is occasionally, preceded by a persistent eczema, due probably to psorosperms and known as Pagefs disease. Paget's disease is not a true eczema, but is rather a malig- nant dermatitis. A crust gathers on the part, and beneath this crust is a raw, red, and moist surface, the edge of which is slightly elevated and somewhat indurated. In the begin- ning there is a strong resemblance to eczema. The nipple is apt to retract. The parts are the seat of a constant itch- TUMORS OR MORBID GROWTHS. 235 ing and scalding sensation. The area may become cancerous in a few weeks, but may not for years. Epithelioma generally begins as a warty protuberance which soon ulcerates. The malignant ulcer has a hard, irregular base, uneven edges, a foul, fungus-like bottom, and gives off a sanious or ichorous discharge. This ulcer is the seat of sharp, pricking pain, sometimes bleeds, and extends over a considerable area, em- bracing and destroying all structures. Epithelioma affects lymphatic glands usually early, but its action may be delayed for eight or ten months. These glands break down in ulcer- ation, making frightful gaps and often causing fatal hemor- rhage. Dissemination is not nearly so common as in other forms of cancer, but it does sometimes occur. A rodent or Jacob's ulcer is scarcely ever met with except upon the face, though Jonathan Hutchinson saw one upon the forearm, and James Berry one upon the arm. It is especially common upon the nose and forehead. It begins after the age of forty as a little warty prominence which ulcerates in the center, the ulceration progressing at a rate equal to the new growth. It becomes deep ; is not crusted ; its edges are hard and everted ; and the parts about contain numbers of visible vessels. Jacob's ulcer grows slowly, may last for years, does not involve the lymphatics, produces no constitutional cachexia, and is rarely fatal. It is an ulcer with irregular edges and a smooth base of a grayish color, its discharge being thin and acrid, and is considered to be a malignant epithelial growth which springs from a sweat-gland, a sebaceous gland, or a hair-follicle, but Kanthack asserts that before ulceration the rete and the sweat-glands are nor- mal, but the sebaceous glands are destroyed. The base and edges of the ulcer are hard, which differentiates it from lupus, and from lupus the bacilli of tubercle may sometimes be cultivated (p. 152). Rodent ulcer begins below the skin, ordinary epithelioma begins in the skin (Butlin), and a rodent ulcer contains no cell-nests. Spheroidal-celled Carcinoviata. — {a) Scirrhous carcinoma is a white and fibrous mass which has no capsule, which infil- trates tissues, and which draws in toward it, by the contrac- tion of its outlying processes, adjacent soft parts, thus pro- ducing dimpling, or, as in the breast, retraction of the nipple. It is composed of spheroidal cells in alveoli formed of con- nective-tissue bands. The commonest seat of scirrhus is the female breast. It occurs also in the skin, vagina, rectum, prostate, uterus, stomach, and esophagus. It is most fre- quent in women after forty. It begins as a hard lump which 236 AIODERN SURGERY. is at first painless, but soon becomes the seat of an acute, localized, pricking pain. This lump grows and becomes ir- regular and adherent, causing puckering of the soft parts. After the skin or mucous membrane above it has become infiltrated ulceration takes place and a fungous mass pro- trudes which bleeds and suppurates. The adjacent lymphatics soon become involved, and the constitutional involvement is rapid and certain. {b) EncepJialoid carcinoma is a soft gray or brain-like mass. It is a rare growth, it has no capsule, and it may appear in the kidney, liver, ovary, testicle, mammary gland, stomach, blad- der, and maxillary antrum. An encephaloid cancer often contains cavities filled with blood, and this variety is known as a " hematoid " or a " telangiectatic " carcinoma. These growths are soft and semi-fluctuating, they infiltrate rapidly and soon fungate, and they terminate life in from a year to a year and a half If the cells of encephaloid become filled with melanin, we have the condition known as " melanosis " or " melanotic cancer." [c) Colloid carcino7na arises from either a scirrhus or an en- cephaloid cancer when the cells or stroma undergo colloid degeneration. On section we see in the center of the growth a series of cavities filled with a material resembling honey or jelly; the periphery often shows an ordinary scirrhus or encephaloid cancer. Colloid degeneration is most prone to attack cancers of the stomach, mammary gland, and intes- tine. Cylindrical-celled carcinoniata which occur in the rectum are known as "adenoid" or "glandular" cancers. They may occur in this region at a much earlier age than do can- cers elsewhere, being not uncommon between the ages of twenty-eight and forty. At first covered by mucous mem- brane, they soon ulcerate and involve the submucous and muscular coats in the growth. They grow rather slowly, and take usually from four to six years to kill. They usu- ally, but not always, cause lymphatic involvement and con- stitutional infection. They are composed of a stroma of fibers between which lie tubular glands lined with columnar epithelium and masses of epithelial cells. Treatment. — Carcinomata demand early and free excision, with removal of implicated glands. A certain proportion can be cured. Recurrent growths may be removed as a palliative measure, to lessen pain and to relieve the patient from ulceration and hemorrhage. If a growth does not recur within five years after removal, a cure has probably been at- TC'J/OA'S OH MORBID GROWTHS. 237 tained. A rodent ulcer should be excised or else be curetted and cauterized with the hot iron or the Paquelin cautery. In cancer of the lower lip, remove the growth by a V-shaped incision or cut away the entire lip and remove the glands beneath the jaw ; in cancer of the tongue, excise this organ and any enlarged glands ; in cancer of the breast, remove the breast and pectoral fascia and take away the fat and glands of the axilla ; in cancer of the rectum, if near the surface, excise the rectum from below ; if above five inches from the anus, do the sacral resection of Kraske and then remove the growth ; in cancer of the esophagus, perform gastrostomy ; in cancer of the pylorus, perform pylorectomy or gastro-enter- ostomy ; in cancer of the boivel, do resection with end-to-end approximation, side-track the diseased area by an anasto- mosis, or make an artificial anus ; in cancer of the penis, amputate and remove the glands of the groin. Erysipelas toxins and erysipelas serum have been tried in inoperable carcinoma, but without any positive benefit. The same is true of pyoktanin, thiosinamin, and of all other drugs that have been suggested. Cysts. — A cyst is a sac containing a fluid or a semi-fluid. Division of Cysts. — Cysts are divided into (i) Retention- cysts, which are due to blocking up of the excretory ducts of glands and accumulation of the glandular secretions. These comprise sebaceous cysts or wens, serous cysts, mucous cysts, salivary cysts, milk-cysts, oil-cysts, and seminal cysts. (2) Exudation-cysts, which are due to accumulations in closed cavities. These comprise synovial cysts (ganglions and bursse). Dentigerous cysts used to be considered under this head. (3) Dermoid cysts, which are congenital and arise from inversion of the cutis and imperfectly closed fetal clefts. (4) Cystomas, which are cysts of new forma- tion due to cystic degeneration of connective tissue. These cysts are found in the neck (hygroma), in the arm-pit, and in the perineum. An example of a cystoma is found in the bursa which develops from pressure. (5) Extravasation- cysts, that form around blood-extravasations. (6) Hydatid cysts, or cysts due to the echinococcus or tape-worm of the dog. A mother-cyst is formed, which becomes filled with daughter-cysts floating in a saline liquor containing hooklets. Sebaceous cysts arise when the excretory duct of a seba- ceous gland is blocked by dirt or occluded by inflammation. The orifice of the duct is often visible as a black speck over the center of the cyst. They are very common in the scalp, 238 MODERN SURGERY. being known as " wens," and upon the face, neck, shoulders, and back. Arising in the skin, and not under it, the skin cannot be freely moved over a sebaceous cyst. A sebaceous cyst is lined with epithelium and is filled with foul-smelling sebaceous material. A sebaceous cyst may suppurate. When a cyst ruptures and the contents become hard, a horn is formed. The other form of horn has been previously alluded to as due to horny transformation of a wart. Treatment. — To treat a sebaceous cyst, dissect it entirely away with scissors or an Allis dissector, trying not to rupture the sac. If even a small particle of it is left, the cyst will return. If it ruptures during removal and it is feared that some portion may remain, swab out the wound with pure carbolic acid. If acid is not used, close without drainage; but if acid is used, drain for twenty-four hours. If an abscess forms in a sebaceous cyst, open it, grasp the edges of the cyst-lining with forceps, dissect out this lining with scissors curved on the flat, cauterize with pure carbolic acid, and drain for twenty-four hours. Dermoid cysts, are lined with true skin. They contain sebaceous matter, hair, teeth, or other epiblastic products. They are always congenital, but may be so small at birth as to escape notice for years. They may be distinguished from sebaceous cysts by the fact that they always lie below the deep fascia, and hence the skin is freely movable over them. They are met with at the root of the nose, at the orbital angles, in the eyelids, upon the floor of the mouth, over the sacrum or coccyx, and in the ovaries, the testicles, the brain, the eyes, the mediastinum, the lungs, the omentum, the mesentery, and the carotid sheaths. They are due to imper- fect closure of fetal clefts and inclusion of epiblast. If a dermoid cyst contains bones, it shows that mesoblast was included as well as epiblast. Treatment. — To treat a dermoid cyst, excise, if accessible, the same as in the case of a sebaceous cyst. If it lies over bone, go down to the bone : the growth will be found ad- herent, so remove a portion of periosteum with the cyst. Hydatid cysts are especially common in Iceland, and are frequent in Australia, but are very rare in the United States. They are due to the echinococcus. The adult echinococcus is the tapeworm of the dog (taenia echinococcus), and its ova or larvae gain access to man's body by accompanying the food he eats and passing into the alimentary canal, from which canal they are transported to various organs by the blood. Osier says the embryo (which has six DISEASES AND IXJURIES OF HEART AND VESSELS. 239 booklets) burrows through the wall of the bowel and en- ters the peritoneal cavity or muscles ; it may enter the portal vessels and reach the liver, or may enter the systemic cir- culation and pass to distant parts. The danger depends on two factors : " the situation and the liability of the cyst to suppurate " (Sidney Coupland). The organs most usually attacked are the liver and lung. In 60 per cent, of cases the liver suffers, and in 12 per cent, the lung (Thomas). Cysts sometimes arise in the intestine, genito-urinary passages, brain, or spinal canal. When the embryo lodges the booklets dis- appear and the embryo is converted into a cyst. This cyst is composed of two layers, an outer capsule (cuticular mem- brane) and an inner layer (endocyst). The cyst contains clear fluid (Osier). As the cyst grows, daughter-cysts bud out from the wall of the mother-cysts, the structure of the daugh- ter-cysts being identical with that of the mother-cyst. From the lining membrane of all the cysts, after a time, growths arise known as scolices, which represent the head of the echinococcus and exhibit four sucking disks and a row of booklets (Osier). The fluid is not albuminous, is occasionally saccharine, is thin and clear, and may contain scolices or booklets. A hydatid cyst may calcify, may rupture, or may suppurate. These cysts are very firm, but usually fluctuate. Palpation with one hand while percussion is practised with the other gives a persistent tremor (hydatid fremitus). The fluid should be drawn and examined. When a cyst suppurates positive constitutional and local symptoms arise. Treatment. — In a hydatid cyst of a superficial part incise and dissect out the sac-wall (Gardner). Unruptured hydatid cysts of superficial structures should be dissected out. Abdominal cysts should be radically removed if possible ; if this is not possible, stitch to the peritoneum, incise, irri- gate, and drain with gauze. Bond advocated evacuating the cyst, closing it with sutures and dropping it back in the abdomen. Gardner says tapping is dangerous, as it may cause rupture of the cyst. If aspiration is performed to settle a diagnosis, operate at once after doing it. XVIII. DISEASES AND INJURIES OF THE HEART AND VESSELS. Heart and Pericardium. — In an acute pulmonary con- gestion the venous side of the heart is over-distended with blood, and the surgeon in desperate cases may tap the right 240 MODERN SURGERY. auricle (see Paracentesis Auriculi). Pericardial effusion, if severe, calls for tapping or aspiration, and purulent peri- carditis demands incision and drainage. Wounds and Injuries. — The heart may rupture and cause instant death, but slight wounds may not prove fatal. A wound of the heart causes hemorrhage, usually copious, but owing to the interlocking of muscular fibers the hemor- rhage is often slight ; the pericardium may be injured by frag- ments of a fractured rib. If bleeding into the pericardial sac takes place, the signs of a pericardial effusion become mani- fest. Pain is constant, and attacks of syncope are the rule. Death is apt to occur suddenly from shock, hemorrhage, and inability of the heart to contract because of the severed fibers, or inability of the heart to dilate because of the pressure of blood in the pericardial sac. If a wound of the pericardium or heart does not cause death in the first day or two, inflammation follows (traumatic pericarditis or carditis). Treatment. — The treatment of heart-wounds consists of recumbency and lowering of the head. The body is sur- rounded with hot bottles, opium is given in small doses, and stimulants are applied in moderation, but never to excess. An attempt must be made to suture the wounds in the heart and pericardium. Access can be gained by resecting one or more ribs. The wounds should be sutured with silk. Rahn sutured a wound of the heart and packed the pericardium with gauze, and the patient recovered. Parrozzani successfully sutured a wound of the ventricle. Williams reports recovery after a stab-wound of the heart, the pericardium having been sutured. Fareni sutured a stab-wound of the left ventricle, and the patient lived several days. Cappelan sutured a wound of the heart, and the patient lived two and one-half days. Traumatic carditis or pericarditis is treated in the same way as idiopathic cases. Pus in the pericardial sac should be evacuated by resection of the fourth left costal cartilage and incision of the pericardium (Von Eiselberg's case). Dalton has sutured the pericardium. Phlebitis, or Inflammation of a Vein. — Phlebitis may be plastic, or it may be piiriilcnt. Plastic phlebitis, while occa- sionally due to gout, to a febrile malady, or to some other constitutional condition, usually takes its origin from a wound or other injury, from the extension to the vein of a peri- vascular inflammation, or in the portal region from an em- bolus. Varicose veins are particularly liable to phlebitis. When phlebitis begins a thrombus forms because of the DISEASES AND INJURIES OF HEART AXD VESSELS. 24 1 destruction of the endothelial coat, and this clot may be ab- sorbed or organized. Suppurative phlebitis is a suppurative inflammation of a vein, arising by infection from suppurating perivascular tissues (infective thrombophlebitis). It is most frequently met with in cellulitis or phlegmonous erysipelas, may arise in the lateral sinus as a result of mastoid suppura- tion, or in the liver from appendicitis or phlebitis of the rectal veins. A thrombus forms, the vein-wall suppurates, is softened and in part destroyed, and the clot becomes puru- lent. No bleeding occurs when the vein ruptures, as a barrier of clot keeps back the blood-stream. The clot of suppura- tive phlebitis cannot be absorbed and cannot organize. Septic phlebitis causes pyemia, and the infected clots of pyemia cause phlebitis. Symptoms. — The symptoms of phlebitis are pain, tender- ness in and around a vein, discoloration over it, and solid edema below the seat of the disease. ' Suppurative phlebitis causes the constitutional symptoms of pyemia (p. 138). Treatment. — The treatment of aseptic phlebitis comprises rest in bed, bandaging and elevation of the part, and the local use of lead-water and laudanum or ichthyol. Hot fomenta- tions are used later in the case. The danger is embolism ; hence massage and movement are dangerous. When a vein is involved in pyophlebitis or septic thrombophlebitis ligate, if possible, above and below the clot, open the vessel, and wash out the purulent mass. This plan of treatment is always to be applied in infective thrombophlebitis of the lateral sinus (p. 564). The constitutional treatment is that of pyemia. Varicose Veins, Phlebectasis, Phlebectasia, or Varix. — Definition and Causes. — Varicose veins are un- natural, irregular, and permanently dilated veins which elongate and pursue a tortuous course. This condition is very common, and 20 per cent, of adults exhibit it in some degree in one region or another. The causes of varicose veins are obstruction to venous return and weakness of cardiac action, which lessens the propulsion of the blood- stream. Varicose veins may occur in any portion of the body, but are chiefly met with on the inner side of the lower extremity, in the spermatic cord, and in the rectum. Varix in the leg is met with during and after pregnancy and in persons who stand upon their feet for long periods. It especially appears in the long saphenous, which, being subcutaneous, has no muscular aid in supporting the blood-column and in urging 16 242 MODERN SURGERY. it on. The deep as well as the superficial veins may become varicose. Verneuil maintained that varix of the superficial veins was almost always secondai'y to varix of the deep veins. By the term " caput medusae " are meant varicose veins radiating from the umbilicus. The veins of the esopha- gus may become varicose, and this malady is rarely recognized. Varicose veins are in rare instances congenital ; they are most often seen in the aged, but usually begin between the ages of twenty and forty. They are more common in women than in men because of the influence of pregnancy. Varix of the spermatic cord is known as " varicocele." It is apt to appear about the time of puberty, and most adult men have at least a slight varicocele. Varix is more likely to appear in the left spermatic vein than in the vein of the right side, because the left spermatic vein has no valves (Brinton). Varix of the veins of the rectum is known as " hemor- rhoids " or " piles," which are caused by obstruction to the upward flow in the hemorrhoidal veins, either by obstructive liver disease, enlargement of the uterus or prostate, or the presence in the rectum of fecal masses in a person habitually constipated. A vein under pressure usually dilates more at one spot than at another, the distention being greatest back of a valve or near the mouth of a tributary. The valves become incom- petent and the dilatation becomes still greater. Callender has pointed out that varix is apt to begin where the deep vessels join the superficial veins. At this point Treves says three forces meet, the blood-column above, the valve below, and the force of the blood-current. At this point the vein-wall dilates, and from this dilatation the blood-current is affected and causes another dilatation higher up (Agnew). The vein-wall may become fibrous, but usually it is thin and often ruptures. The veins not only dilate, but they also become longer, and hence do not remain straight, but twist and turn into a characteristic form. Varicose veins are apt to cause edema, and the watery elements in the tissues cause eczema of the skin. When eczema is once inaugurated ex- coriation is to be expected. Infection of an excoriated area produces inflammation, suppuration, and an ulcer. The skin over varicose veins in the leg is often discolored by pigmentation due to the red blood-cells having escaped from the vessel and been broken up. The tissues around a vari- cose vein become atrophied from pressure, and there is often met with a very large vein whose thin walls are in DISEASES AND INJURIES OF HEART AND VESSELS. 243 close contact with skin. In this condition rupture and hemorrhage are probable. V^aricose veins are apt to inflame, and thrombosis frequently occurs. Treatment. — The treatment of varix may be palliative or curative, but whichever is followed endeavor first to remove the exciting cause. In palliative treatment, attend to the general health, keep up the force and activity of the circu- lation, and prevent constipation. Recommend the patient to exercise in the open air and to lie down, if possible, every afternoon. Locally, in varix of the leg, order a flannel roller or a Martin rubber bandage to support the veins and drive the blood into the deeper vessels which have muscular sup- port. The use of a rubber pad filled with glycerin and applied over the saphenous vein so as to support the blood- column and act as a valve, has been recommended. Locally, in varicocele, pour cold water upon the scrotum twice a day and order the patient to wear a suspensory bandage. Lo- cally, in hemorrhoids, use astringent suppositories (p. 715). The curative or radical treatment of varix of the leg com- prises ligation with exdsion of part of the vein, exposure and ligation of the vein, multiple subcutaneous ligatures of catgut, acupressure-pins with twisted sutures, injection of pure carbolic acid into the perivascular structures, circular incision around the leg (see Operations upon Vessels). Nevus. — (See Tumors.) Arteritis, or inflammation of an artery, is acute or c/ironic. Acute arteritis may result from injury or from extension of inflammation from the perivascular tissues. This latter mode of origin is uncommon, as arteries are very resistant to the spread of inflammation, but we meet with it some- times in suppurating areas. In a suppurating acute arteritis the coats ulcerate through, but hemorrhage rarely occurs unless a considerable portion of the vessel sloughs. Septic emboli lodging in the arterial system produce acute arte- ritis. This is seen during the progress of ulcerative endo- carditis. Chronic arteritis produces "atheroma." It is due to increase of blood-pressure from hard work, strains, heart- disease, or contracted kidney. It is especially common in drunkards in the larger arteries. It is often met with in drunkards, but occurs in aged men who never drank. It is a true saying that " A man is as old as his arteries." In chronic arteritis exudation of serum and migration of leuko- cytes take place beneath the intima, and a like exudation soon becomes manifest in the media, in the adventitia, and even in 244 MODERN SURGERY. the sheath. Embryonic tissue is formed, which may undergo resolution, may become fibrous tissue (arterial sclerosis), or may undergo fatty degeneration (atheroma). When fatty de- generation occurs the endothelium is destroyed, the vessel- wall is damaged, and the blood obtains access to the deeper coats. Calcareous change may follow fatty degeneration. An atheromatous artery is rigid and inelastic, and the parts it supplies are cold, congested, and ill-nourished. Atheroma is a frequent cause of thrombosis, aneurysm, senile gangrene, and apoplexy. Syphilitic arteritis is characterized by an enormous growth of granulation-tissue from the inner coats (obliterative arteritis) of arteries of small size. Calci- fication of an artery may be secondary to fatty change, or may occur primarily from deposit of lime salts in the middle coat. Periarteritis is inflammation of the sheath and outer coat. An acute arteritis is always local, but a chronic arteritis may be general. Treatment of acute arteritis consists of rest, elevation and relaxation, the application of tincture of iodin, and the use of lead-water and laudanum.* Hot fomentations are applied later. Abscesses are opened and drained. Inter- nally, treat any diathesis (rheumatic, gouty, or syphilitic), maintain kidney secretion, quiet the circulation, and employ a non-stimulating diet. The part must be kept quiet, as rough movement would tend to rupture the vessel. Treatment of Chronic Arteritis. — In treating chronic arteritis, endeavor to antagonize the dangers to which the patient is obviously liable. Stop alcohol as a beverage, though a little whiskey may be taken at meals to aid di- gestion. Maintain the activity of the skin by daily baths, and of the kidneys by diuretic waters. The contents of the bowels are to be kept soft. The diet is to be plain and is to contain a minimum of nitrogen. If syphilis has existed, occasional courses of iodid are to be urged. If the arterial tension at any time becomes inordinately high, give nitro- glycerin. One danger is apoplexy ; hence excitement and violent exercise are to be avoided. Another danger is senile gangrene ; hence the patient should wear woollen stockings, put a hot bottle to his feet at night, and be careful to avoid injuring his toes or feet, especially when cutting his corns. When a patient with atheroma has dyspnea and is of a livid color, or when the arterial tension is very high, a moderate bloodletting (sixteen to eighteen ounces) does good. Still another danger is aneurysm, which may appear suddenly from rupture or gradually from progressive distention. DISEASES AND INJURIES OF HEART AND VESSELS. 245 Aneurysm. — An aneurysm is a pulsating sac containing blood and communicating with the cavity of an artery. Some restrict the term " true aneurysm " to a condition of dilatation involving all the coats of the vessel. We shall consider, with Heath, a true aneur>^sm to be one in which the blood is included in one or more of the arterial coats, and a false aneurysm to be a condition in which the vessel has ruptured or has atrophied and the aneurysmal wall is formed by a condensation of the perivascular tissues. Forms of Aneurysm. — The following forms of aneurj'sm are recognized : 1. True aneurysm — one whose sac is formed of one or more arterial coats. 2. False aueurysin — one whose sac is formed of condensed perivascular tissues and contains no arterial coat. 3. Traumatic aneurysm — a false aneur>'sm due to traumatic rupture some time before, the blood being in a sac of tissue and all wound being healed. 4. Fusiform aneurysm — a variety of true aneurysm, the sac being spindle-shaped. 5. Consecutive aneurysm — a sacculated aneur)^sm diffused by rupture, or a false aneurysm due to gradual destruction or atrophy of a true aneurysmal sac or to vascular rup- ture. 6. Sacculated aneurysm — a common form of aneurysm, in which the dilatation is like a pouch, arising from a part of the arterial circumference and joining the lumen of the vessel by an aperture. 7. Dissecting aneurysm — a pouch-like dilatation, due to the blood which, passing through an aperture in the intima, enters between the media and adventitia and dissects them apart. It may or may not join the lumen of the artery at another point by a fresh aperture in the intima. 8. Arteriovenous aneurysm, which is divided into aneur- ysmal varix, or Pott's aneurysm, where there is direct com- munication between a vein and an artery, and varicose aneur- ysm, where there is communication between an artery and a vein by means of an interposed sac. 9. Acute aneurysm — a cavity in the walls of the heart, which cavity communicates with the interior of this organ, and which is due to suppuration in the course of acute endo- carditis or myocarditis. 10. Aneurysm by anastomosis (see Angeiomata). 1 1. Aneurysm of bone — an inaccurate clinical term used to designate a pulsatile tumor of bone. 246 MODERN SURGERY. 12. Circumscribed aneurysm — when the blood is circum- scribed by distinct walls. 13. Cirsoid aneurysm — a mass of dilated and elongated arteries shaped like varicose veins and pulsating with each heart-beat. 14. Cylindrical aneurysm — a dilatation of the same dimen- sions for a considerable space. 15. Embolic or capillary aneurysm — dilatation of terminal arteries due to emboli. 16. Spontaneous aneiwysm — non-traumatic in origin. 17. Miliary aneurysm — a minute dilatation of an arteriole. 18. Secondary aneurysm — one which, after apparent cure, again pulsates, the blood entering by means of the anasto- motic circulation. 19. Verminous aneurysm — one containing a parasite. This form of aneurysm is met with in the mesenteric artery of the horse. The sac of a sacculated aneurysm is at first composed of at least two of the arterial coats, reinforced by the sheath and perivascular tissues. After a time the blood-pressure distends the sac, and the inner and middle coats either stretch with interstitial growth or — what is more common — are worn away and lost. When all the coats are lost, and the blood is sustained only by the sheath and surrounding tissue, a true aneurysm becomes a diffused or consecutive aneurysm, the limiting tissues and sheath being condensed, thickened, and glued together. This limiting process is deficient in the brain ; hence cerebral aneurysms break soon after their formation. When all the arterial coats are lost, the blood- pressure, acting on the tissues, finds some spots less resistant than others, the blood follows the lines of least resistance, the aneurysm grows with great rapidity, and soon ruptures. An aneurysm may rupture into a cavity (pleura, pericar- dium, or peritoneum), into the perivascular tissues, or through the skin. Rupture into the tissues may produce pressure- gangrene. When rupture occurs through the skin, the hem- orrhage is not often instantly fatal, but during several days constantly recurs in larger and larger amounts. The pressure of an aneurysmal sac causes atrophy of tissues, hard and soft, bones and cartilages being as easily destroyed as muscles and fat. Sometimes the perivascular tissues inflame and suppu- rate, and the sac is opened rapidly by sloughing. An aneurysm usually progresses toward rupture, the slowest in this progres- sion being the fusiform dilatations, which may exist for many years, but which finally eventuate in the sacculated variety. DISEASES AND INJURIES OF HEART AND VESSELS. 247 In some rare instances there takes place spontaneous cure, which may result from laminated fibrin being deposited upon the walls of the sac as the blood circulates through it. This laminated fibrin is known as an " active clot," and eventually fills the sac. The weaker and slower the blood-stream, the greater is the tendency to the formation of an active clot ; hence any agent impeding, but not abolishing, the circulation aids in the deposition. This weakening and slowing of cir- culation may be brought about by great activity of the col- lateral circulation deviating most of the blood away from the area of disease. Sometimes a clot breaks off from the sac- wall and plugs the artery beyond the dilatation, and the an- astomotic vessels, enlarging, divert the blood-stream. A large aneurysm, falling over by its own weight upon the vessel above the mouth of the sac, may diminish the blood-stream. The development of another aneurysm upon the same vessel nearer to the heart weakens the circulation in and may cure the older one. Inflammation occasionally forms a clot. The tissues about an aneurysm tend to contract when arterial force is lessened ; hence tissue-pressure may more than counteract blood-pressure when the circulation is feeble. Clotting of the blood contained within a sac, circulation through the aneurysm having ceased, causes a passive clot. A passive clot, which occasionally cures, may arise from a twisting of the neck of the sac, preventing the passage of blood ; from the lodgement of a clot in the mouth of the sac ; and from inflammation. Spontaneous cure is, unfortu- nately, very rare. Causes of Aneurysm. — Gradual distention of arterial coats which are in a condition of arterial sclerosis, or local loss of resisting power due to atheroma, may cause aneurysm. Hence the causes of sclerosis and atheroma are also causes of aneur- ysm. The principal cause of aneurysm is increased blood- pressure. This increase may be brought about by severe labor ; by sudden strains, as in lifting ; by violent efforts, as in rowing in a boat-race ; by chronic interstitial nephritis ; by hypertrophy of the heart ; by alcoholic inebriety ; and by syphilis. Arterial disease is commonest in the larger vessels and in the aged, but it may occur in youth. When an aneur- ysm follows a strain, it may be due to laceration of the media and loss of resistance at a narrow point. The intima may lacerate, permitting the blood to come in contact with the media or causing blood to diffuse between the coats (dissect- ing aneurysm). An embolus which lodges may cause an aneurysm on its proximal side. The embolus, if infective. 248 MODERN SURGERY. causes softening, and if calcareous causes laceration (Osier). Colonies of micrococci may cause aneurysm/ The parasite strongyltis armatiis causes aneurysm of the mesenteric arteries in horses. Suppuration around a vessel weakens its coats and tends to aneurysm by inducing acute arteritis and softening. Sometimes an individual develops multiple aneurysms the origins of which are absolutely unknown. TJic constituent parts of ait aneurysm are (i) the wall of the sac ; (2) the cavity ; (3) the mouth ; and (4) the contents. Symptoms of Aneurysm. — An oval or globular, soft, elastic, and pulsatile protrusion, develops in the Hne of an artery. It is usually quite evident to the touch that the sac contains fluid, but sometimes in old aneurysms it feels firm or even hard, because of the deposit of fibrin upon its inner surface. In a partially consolidated aneurysm pulsation may be slight or even inappreciable. This protrusion in- stantly ceases to pulsate and almost disappears on making firm pressure on the artery above. On relaxing the pressure the pulsatile enlargement at once reappears. Direct pressure upon the tumor may cause it to almost disappear. Pressure upon the artery below causes the tumor to enlarge. The pulsation is expansile — that is, it expands in all directions — and if an index finger be laid on each side of the tumor so that their points nearly touch, each pulsation not only lifts the fingers, but it also separates them. On placing a stetho- scope over the aneurysm or over the vessel below the aneur- ysm there is imparted to the ear a distinct bruit which travels in the direction of the blood-stream, is systolic in time, and is usually blowing in character. In some cases bruit is absent (when a sacculated aneurysm has a very small mouth, when the circulation is tranquil, or when the sac is full of blood and clot). When bruit is absent it may sometimes be de- veloped by muscular exercise or raising the affected limb (Hollo way). In rare cases there may be a double bruit. Occa- sionally in fusiform aortic aneurysm linked with aortic regur- gitation a diastolic bruit exists. A bruit is arrested by press- ing upon the artery between the aneurysm and the heart.^ The skin over an aneurysm may be normal or discolored, and may slough or ulcerate. Aneurysm of an extremity is apt to produce edema and varicose veins, because of pressure upon large veins and loss of vis a tergo in circulation. The muscles feel tired, and sometimes there is pain. In internal aneurysms pressure-symptoms are marked. Thoracic aneur- 1 See Osier on Malignant Endocarditis. 2 Holloway on " Aneurysm," in Park's Siti-gery by American Authors. DISEASES AND INJURIES OF HEART AND VESSELS. 249 ysm causes intercostal pain ; iliac aneurysm causes pain in the thigh. Aneurysm of the aorta presses upon the pneu- mogastric nerve, causing spasmodic dyspnea, and upon the recurrent laryngeal, causing loss of voice and paralysis of all the muscles of the larynx except the cricothyroid. The pulse below an aneurysm is weaker than the pulse of the cor- responding part of the opposite limb. This is well shown by the sphygmograph, the tracings being rounded without a sudden rise or an abrupt fall (Fig. 39). The evidences of Fig. 39. — Radial pulse-tracings in aneurysm of right brachial artery : i, left radial pulse ; 2, right radial pulse (after Mahomed). rupture are loss of distinctness of outline and increase in area of the tumor, weakening or disappearance of both bruit and pulsation, severe pain, edema and coldness of the surface and possibly syncope. External hemorrhage may arise ; the tissues may become extensively infiltrated with blood ; slough- ing or gangrene may ensue. Death is frequent, and only in very, rare cases does spontaneous cure take place. Diagnosis. — A cyst or abscess over a vessel may show transmitted pulsation which is not expansile, and the tumor does not disappear on pressure above it. The pulsation ceases when the growth is lifted off the vessel, or when the position is changed so as to permit it to fall away from the vessel. There is no true bruit, and the history is widely dif- ferent. A growth under a vessel may lift the vessel and simulate an aneurysm, but the pulsation is not noted in the entire growth, the growth does not disappear on proximal pressure, and there is only a false, and never a true, bruit. The larger the growth the less is the pulsation due to press- ure upon the vessel. A sarcoma, especially a soft sarcoma attached to the bone, and also a nevoid mass, pulsate and often have a bruit ; the tumor never disappears from proximal press- ure, though it may slowly diminish in size, to gradually en- large again when pressure is withdrawn. These growths do not feel fluid, and are rarely circumscribed. An aneurysm may cease to pulsate from consolidation leading to cure, or from rupture. Rupture of a large aneurysm into a cavity 250 MODERN SUR GER V. induces deadly pallor, syncope, and rapid death. Rupture of an aneurysm of an extremity into the tissues is made mani- fest by a sensation of something breaking, by pain, by sud- den increase in size, by diminution or absence of bruit and pulsation, by absence of pulse below the aneurysm, by swell- ing and coldness of the limb, and by shock. Treatment. — In inoperable aneurysms gejieral, medical, and dietetic treatment must be tried. It consists chiefly in rest in bed to diminish the rapidity and force of the circu- lation and favor fibrinous deposit. Tuffnell's plan is to reduce the heart-beats by rest and mental quiet, and to rigidly restrict the diet so as to diminish the total amount of blood and render it more fibrinous. Liquids are re- stricted in amount, and the patient lives for twenty-four hours upon four ounces of bread, a very little butter, eight ounces of milk, and three ounces of meat. Pursue this plan for several months if possible, or employ it for several weeks at a time over and over again. There can be no doubt that Tuffnell's treatment sometimes cures by decidedly lowering the blood-pressure. Valsalva long ago suggested rest, occasional bleeding, and a diet just above the point of star- vation. In many cases of aneurysm the patient may be permitted to go about, taking his time about everything and avoiding work, worry, and excitement. The diet is low and non-stimulating, and the bowels must be maintained in a loose condition. lodid of potassium in doses of 20 grains undoubtedly does good, and not only in syphilitic cases. It seems to lower the blood-pressure. Balfour taught that it thickened the sac. Osier says it relieves the pain. Iron, acetate of lead, and ergotin are prescribed by some. Digitalis is contraindicated, as it raises the blood-pressure. S. Solis Cohen has used with some success the hydrated chlorid of calcium. Morphin and bromid of potassium are occa- sionally useful to tranquillize the circulation, allay pain, or secure sleep. Aconite and veratrum viride have long been employed. Other expedients are : the kneading of the sac to release a clot, in the hope that it will plug the mouth of the sac or the artery beyond it — this is dangerous ; elec- tricity ; electrolysis ; the injection of an astringent liquid ; the insertion of a fine aspirating-needle and the pushing through it into the sac of a large quantity of silver wire, in the hope that it will aid in whipping out fibrin. Some physicians have inserted needles and horse-hair. Even in an operable case diet and rest are of importance. D/SE.-iSES AND IXJURIES OF HEART AND VESSELS. 25 1 The patient should be in bed for a number of days before operation, the daily diet consisting of ten or twelve ounces of solid food with a pint of milk. If the circulation is very active, use aconite and allay pain by morphin. Treatment by Pressure. — Iiistrinnental pressure is made by applying two Signorini tourniquets or some specially devised apparatus to limit the flow of blood through an aneurysm without entirely stopping it, the aneurysmal sac being felt to still slightly pulsate. In some situations Lister's abdom- inal tourniquet is applied ; in other regions we may use Tuff- nell's compress, which is like a spring truss and is strapped in place. A weight suspended over the artery and resting part of its weight upon the vessel has occasionally brought about cure. These instruments can be worn for from twelve to sixteen hours at a time ; usually they are removed to permit sleep and reapplied the next day, and so on for several days. Before applying the compress be sure the sac is full of blood, and render this certain by applying for a few minutes distal compression. This method may cure, but it is very painful. It cannot be used successfully in treating aneurysm of the axillary, subclavian, or carotid. It aids in the formation of an acti\-e clot. Digital pressure, made with the thumb aided by a weight, and maintained for many hours by a relay of assistants, has cured many cases. This method may be used alone or may be used as an accessory to instrumental pressure. Its chief field is in the treatment of aneurysm for which other methods are inapplicable (orbit and root of neck). It entirely cuts off the blood and promotes the formation of a passive clot. If cure does not take place in three days, abandon pressure. It must often be abandoned because of pain. Direct pressure upon the sac has been used in aneurysm of the popliteal arter}-, the pressure being obtained by flexing the leg ; and in aneur>'sm of the brachial artery pressure has been applied at the bend of the elbow by flexing the elbow. The pressure of a hollow rubber ball has been used in aneur- ysm of the subclavian. Rapid pressure completely arrests the passage of blood through the sac for a limited time, and is applied while the patient is under the influence of an anesthetic. Take, for example, a case of popliteal aneurj^sm : the patient is placed under ether ; two Esmarch bandages are used, one being put on the limb from the toes to the lower limit of the aneurysm, and the other from the groin down to the upper limit of the sac, and the Esmarch band is fastened above the upper 252 MODERN SURGERY. bandage. This procedure stagnates the blood both in the veins and in the arteries, the sac remaining full of blood. Pressure is thus maintained for three or four hours, and on removing the Esmarch apparatus a tourniquet is put on the artery above the aneurysm and partly tightened to limit the amount of blood passing through and thus prevent the washing away of clot. This method of rapid pressure sometimes cures by forming a passive clot, but it sometimes results in gangrene. It was devised by John Reid. Operative Treatment: By the Ligature. — Ligation of the main artery is, as a rule, the best procedure. The methods of ligation are — (i) the method of Antyllus; (2) the method of Anel ; (3) the method of Hunter ; (4) the method of War- drop ; and (5) the method of Brasdor. In the method of Antyllus the sac itself is attacked. Hemorrhage is controlled by the Esmarch bandage, the sac is opened, its contents turned out, and the artery ligated immediately above and below the sac. This method is chiefly employed for traumatic aneurysms, as its use in aneurysms from diseased vessel-walls would mean that the ligatures were probably applied upon diseased areas (Fig. 40). Syme suggested many years ago that extirpation was the proper operation for aneurysm of the gluteal, iliac, car- otid, and axillary arteries. In some cases it is the best method. The Metliod of Anel. — In Anel's method the artery is ligated close to and above the sac (Fig. 41). It is only used Fig. 40. — Old operation of Antyllus foraneur- Fig. 41. — Anel's operation for aneurysm (.^wz. ysm (/4?K. Text-Book of Surgery). Text-Book of Stirgeryi). for traumatic aneurysms, and is never employed when the vessel is diseased. TJie Metliod of Hunter. — This operation, which is the modern method of ligation, was devised by the illustrious John Hunter. He recognized the fact that the vessel adja- cent to an aneurysm was apt to be diseased, and he discov- ered the anastomotic circulation. Putting together these two facts, he devised the operation which goes by his name. It consists in applying a ligature between the heart and the DISEASES AND INJURIES OF HEART AND VESSELS. 253 aneurysm, but so far above the sac that collateral branches are given off between it and the point of ligation (Fig. 42). This operation, which is done upon a healthy area, does not at once cut off all blood, but so diminishes the force and frequency of the circulation that an active clot forms within ci^s: Fig. 42. — Hunter's operation for aneurysm [Avicrican Text-Book of Surgery). the sac. Thus is lessened the danger of secondary hemor- rhage and of gangrene. It is, as a rule, the proper opera- tion for aneurysm. In some cases pulsation does not return after tightening the ligature ; in most cases, however, it reappears for a time after about thirty-six hours, but is weak and constantly diminishing. Previous prolonged compres- sion by enlarging the collateral branches permits strong pulsation to soon recur after ligation, and thus militates against cure ; hence it is a bad plan to use pressure in cases where its success is very uncertain. Occasionally after Hun- ter's operation the sac suppurates, producing symptoms like those of abscess. When rupture takes place there may be no hemorrhage, or profuse hemorrhage may rapidly kill the patient, or hemorrhage may recur again and again until death ensues. Suppuration may occur between the first and thirty- second week after ligation.^ When pus forms open freely as we would open an abscess, and, if no blood flows, treat as an abscess, but have a tourniquet loosely applied for sev- eral days ready to screw up at the first sign of danger. If hemorrhage occurs, tie the vessel above and below and pack with iodoform gauze, having the tourniquet ready to tighten. If bleeding recurs, there is no use reapplying the ligature and there is little use tying higher up. If dealing with an extrem- ity, amputate at once. Distal Ligation. — When an aneurysm is so near the trunk that Hunter's operation is impracticable, or when the artery on the cardiac side of the tumor is greatly diseased, distal ligation may be employed. Distal ligation forms a barrier to the onflow of blood, collateral branches above the aneur- ysm enlarge, the blood-current is gradually diverted, and a clot is formed. Distal ligation is used in some aneurysms * See the famous case of Sir Astley Cooper. 254 MODERN SURGERY. of the aorta, iliacs, innominate, carotids, and subclavians. It occasionally causes rupture of the sac of the aneurysm. The operation of Brasdor consists in tying the main trunk some little distance below the aneurysm (Fig. 43). It com- pletely arrests circulation in the sac. The operation of War drop consists in tying one of the branches of the artery below the aneurysm (Fig. 44). It partially arrests the circulation in the sac. After ligating for aneurysm by any of these methods, elevate the limb, keep it warm, and subdue arterial excite- FiG. 43. — Brasdor's operation (Holmes). Fig. 44. — Wardrop's operation (Holmes). ment. When moist gangrene follows ligation, amputate early, above the ligature. When dry gangrene takes place, await a line of demarcation. Rupture of the sac after liga- tion may produce gangrene or suppuration, the first condition demanding amputation, and the second incision for drainage. Injection of agents to produce coagulation (ergot, per- chlorid of iron, etc.) is very dangerous and is to be utterly condemned. It may lead to suppuration, gangrene, rupture, or embolism. Manipulation to break up the clot was sug- gested by Sir Wm. Fergusson, and has been practised. The object aimed at is to have a fragment of clot block up the vessel upon the peripheral side of the artery and act like a distal ligature. The method is dangerous and should never be employed. Amputation for aneurysm is performed in some perilous cases of subclavian aneurysm, instead of distal ligation. Electrolysis. — An attempt may be made to coagulate the blood at once, or from time to time an endeavor may be made to produce fibrinous deposits, but the first method is the better. It is, however, rarely possible to at once occlude DISEASES AND IXJURIES OF HEART AND VESSELS. 255 a sac, and pulsation, which is for a time aboHshed, recurs as the gas present is absorbed. Use the constant current. Take from three to six cells which stand in point of size between those used for cautery and those used for ordinary medical purposes. A platinum needle is attached to the positive pole and a steel needle to the negative pole, both needles being insulated by vulcanite at the points where the skin will touch them. The asepticized needle are plunged into the sac where it is thick and they are kept near together. The current is passed for a variable period (from half an hour to an hour and a half). This operation is not dangerous. Pressure stops the bleeding. Electrolysis often ameliorates, and sometimes cures, aortic aneur>^sms.^ Acupressure consists of the partial introduction of a num- ber of ordinary sewing-needles into an aneur>'smal sac and leaving them in it for five or six days or more. Introduction of Wire. — Insert into the sac a hypodermatic or small aspirating-needle, and push through the needle or cannula a considerable quantity of aseptic gold wire, which is allowed to remain permanently. Loreta combines elec- trolysis with the introduction of wire. Cases have been benefited, and several have been apparently cured by this method. Traumatic aneurysm is a condition in which, after punc- ture or rupture of an artery, a sac has formed of tissue and if any wound previously existed, it has healed. The treat- ment consists in ligation by the method of Antyllus, or com- plete excision. When an artery ruptures and a large mass of blood is extravasated no sac exists, and it is an error to designate this condition as a diffuse traumatic aneurj^sm. In this condition a large, oblong, fluctuating swelling is found. If the rent is large, there are bruit and pulsation. There is no pulsation in the arteries below the aneurysm, and the limb is cold and swollen. The skin is at first of a natural color, but becomes thin and purple. If the main vein is also ruptured, or if the rupture has occurred into a large joint, amputate ; otherwise perform the operation of Antyllus. Arteriovenous aneurysm is an unnatural passage-way between a vein and an arter}', through which passage blood cir- culates. There are two forms : {a) aneurysmal varix, or Pott's aneurysm, where a vein and an artery directly communicate ; and [b] varicose aneurysm, where vein and artery communicate through an intervening sac. These conditions arise usually from punctured wounds, the instrument passing through one ^ See John Duncan, in Heath's Dictionary . 256 MODERN SURGERY. vessel and into the other, blood flowing into the vein, the subsequent inflammation gluing the two vessels together, and the aperture failing to close (aneurysmal varix, Fig. 45). After the infliction of the wound the two vessels may sepa- rate ; the blood still flows from artery into vein, and the blood-pressure, by consolidating tissue, forms a sac of junction (varicose aneurysm. Fig. 46). Aneurysmal varix is a far less grave disorder than varicose aneurysm. Symptoms. — In aneurysmal varix a swelling exists with the characteristic pulsation, and a loud whirring bruit is transmitted along the veins. The veins above and below the tumor are enlarged, tortuous, and pulsating. A distinct thrill is felt. Pressure over the tumor stops the thrill and greatly lessens the bruit. The extremity is apt to be swollen and the parts are usually painful. When pressure on the main artery causes the entire disappearance of the tumor, Fig. 45. — Plan of an aneurysmal varix. Fig. 46. — Varicose aneurysm (Spence the case is one of aneurysmal varix ; but if on applying this pressure the veins collapse and a distinct tumor remains which may be emptied by direct pressure, the case is one of varicose aneurysm. If light pressure on one spot stops both murmur and thrill, it is aneurysmal varix. The diagnosis between the two is often impossible. Treatment. — Aneurysmal varix often requires only palli- ative measures, as it does not tend to rupture, the veins becoming thick and resistant and after a time ceasing to enlarge. Some form of support is used. If the part is painful or the vein is in danger of rupture, tie the artery above and below the opening, or excise both vessels for som.e little distance each side of the point of trouble. Vari- cose aneurysm requires the use of the plans ordinarily adopted in treating aneurysm (compression, etc.). If these fail, tie the artery above and below the opening without opening the sac, or excise the involved areas of vein, artery, and sac. Cirsoid aneurysm, or aneurysm by anastomosis, consists in great dilatation with pouching and lengthening of DISEASES AND INJURIES OF HEART AND VESSELS. 257 one or several arteries. The disease progresses and after a time involves the veins and capillaries. The walls of the arte- ries thin and the vessels tend to rupture. Cirsoid aneurysm is met with upon the forehead and scalp of young people, where it sometimes takes origin from a nevus. Symptoms. — A pulsating mass, irregular in outline, com- posed of dilated, elongated, and tortuous vessels that empty into one another. The mass is soft, can be much reduced by direct pressure, and is diminished by compression of the main artery of supply. A thrill and a bruit exist. Pregnancy and puberty cause rapid growth of a cirsoid aneurysm. Treatment. — In treating a cirsoid aneurysm the ligation of the larger arteries of supply is a wretched failure. Sub- cutaneous ligation at many points of the diseased area has effected a cure in some cases, but it has failed in most. Direct pressure is also entirely useless. Ligation in mass has been successful. Destruction by caustic has its advocates. Electro- puncture with circular compression of the arteries of supply has once or twice effected a cure. Injection of astringents has been recommended. Verneuil ligated the afferent ar- teries, incised the tissues around the tumor, and sunk a constricting ligature into the cut. The proper method of treatment is excision after subcutaneous ligation of every accessible tributary of supply.' Wounds of arteries are divided into contused, incised, lacerated, punctured, and gunshot wounds, and vascular ruptures. Contused and Incised Wounds. — A contusion may de- stroy vitality and be followed by sloughing and hemorrhage. A contused wound may do little damage, or it may produce gangrene from thrombus, or it may cause secondary hemor- rhage. In an incised wound there is profuse hemorrhage. The artery after a time is apt to contract and retract, and thus arrest bleeding. A transverse wound causes profuse bleeding, but there is a better chance for natural arrest than in an oblique or in a longitudinal wound. In a partially divided artery, cut it entirely through and tie both ends. The clot which forms in a cut artery is known as the " in- ternal clot ;" it reaches as high as the first collateral branch, and subsequently becomes organized permanently, obliter- ates the vessel, and converts it into a shrunken fibrous cord. Between the vessel and its sheath, over the end of the vessel, and in the surrounding perivascular tissues is the " external clot." ^ Anderson, in Heath's Dictionary. 17 258 MODERN SURGERY. Lacerated -wounds cause little primary hemorrhage. The internal coat curls up, the circular muscular fibers of the media contract upon it, and the external coat is so pulled out as to cap the orifice of the vessel — all of which conditions favor clotting. The vessel-wall is so damaged that secondary hemorrhage is usual. Punctured "Wounds. — In punctured wounds primary hem- orrhage is slight. Secondary hemorrhage is not usual. Dif- fuse aneurysm and arteriovenous aneurysm are not unusual results. Gunshot-^wounds are apt to be contusions which may eventuate in sloughing and secondary hemorrhage or throm- bosis and gangrene. A shell-fragment makes a lacerated wound. A modern rifle-bullet makes a clean-cut division of an artery. Secondary hemorrhage after gunshot-wounds tends to occur during the third week. Partial rupture of an artery may cause sloughing and secondary hemorrhage, thrombosis and gangrene, and aneurysm. Complete rupture is a lacerated wound, and is a condition accompanied by dif- fuse traumatic aneurysm. "Wounds of veins are classified as are wounds of arteries. The symptom of any vascular wound is hemorrhage. I. Hemorrhage, or Loss of Blood. HemoiTliage may arise from wounds of arteries, veins, or capillaries, or from wounds of the three combined. In arte- rial hemorrhage the blood is scarlet and appears in jets from the proximal end of the vessel, which jets are synchronous with the pulse-beats ; the stream, however, never intermits. The stream from the distal end is darker and is not pulsatile. Venous hemorrhage is denoted by the dark hue of the blood and by the continuous stream. In capillary hemorrhage red blood wells up like water from a sponge. In subcutaneous hemorrhage from vascular rupture (diffuse aneurysm) there are great swelling, cutaneous discoloration, and systemic signs of hemorrhage. If a main artery ruptures in an extremity, there is no pulse below the rupture, and the limb becomes cold and swollen. At the seat of rupture a large fluctuating swelling forms, and sometimes there is bruit and pulsation. If a vein ruptures in an extremity, intense edema occurs. Profuse hemorrhage induces constitutional symptoms, and death may occur in a few seconds. Loss of half of the blood will usually cause death (from four to six pounds), though women can stand the loss of a greater rela- DISEASES AND INJURES OF HEART AND VESSELS. 259 tive proportion of blood than men. Generally, after the bleed- ing has gone on for a time syncope occurs, which is Nature's effort to arrest hemorrhage, for during this state the feeble cir- culation and the increased coagulability of blood give time for the formation of an external clot. When reaction occurs the clot may hold and be reinforced by an internal clot, or it may be washed away with a renewal of bleeding and syncope. These episodes may be repeated until death supervenes. Nausea and vertigo are present, black specks float before the eyes (muscae volitantes), tinnitus aurium exists. The patient is restless and tosses to and fro, and great thirst is complained of Delirium is not unusual, and convulsions often occur. After a profuse hemorrhage an individual is intensely pale and his skin has a greenish tinge ; the eyes are fixed in a glassy stare and the pupils are widely dilated ; the respirations are shallow and sighing ; the skin is covered with a cold sweat ; the legs and arms are extremely cold ; the pulse is soft, small, compressible, fluttering, or often cannot be detected ; the heart is very weak and fluttering; there is muscular tremor; the patient tosses about, and asks often for water. In hem- orrhage the hemoglobin is greatly diminished in amount. When such a dangerous condition is due to a visible hem- orrhage, temporarily arrest bleeding by digital pressure in the wound, or the application of an Esmarch band above the wound (if the bleeding is arterial). In some cases forced flexion is used. Lower the head, and have compression made upon the femorals and subclavians, so as to divert more blood to the brain. Apply artificial heat. Inject by hypodermoclysis the normal salt solution (10 to 16 ounces) into the cellular tissue of the buttock, or transfuse the salt so- lution into a vein, inject ether hypodermatically, then brandy, and then strychnin in doses of gr. 2^. Atropin, digitalis, and morphin are recommended. Give enemata of hot coffee and brandy. Apply mustard over the heart and spine. Lay a hot-water bag over the heart. As soon as reaction is estab- lished, arrest the bleeding permanently by the ligature. A severe hemorrhage is apt to be followed by fever — hem- orrhagic fever — due to the absorption of fibrin ferment from extravasated blood and its action upon a profoundly debil- itated system. In this form of fever there are most intense thirst, violent headache, dimness of vision, great restlessness, often mental wandering, with a very frequent, weak, and flut- tering heart. After a severe hemorrhage leukocytes are increased, not only relatively but absolutely. Red corpuscles are diminished both relatively and absolutely. Hemoglobin 260 MODERN SURGERY. diminishes ; many of the corpuscles become irregular and microcytes are noticed. In treating a patient who has reacted after a severe hem- orrhage, apply cold to the head to prevent serous effusion into the brain. Aconite, morphin, and neutral mixture are given by the mouth. Fluids and ice are grateful. Fre- quently sponge the skin with alcohol and water (S. W. Gross). Milk punch, koumiss, and beef-peptonoids are given at fre- quent intervals. If the hemorrhage is- from a spot inacces- sible to ligation, such as the lung, give the patient 3 grains of gallic acid, i grain of powdered digitalis, i grain of ergotin, and \ grain of powdered opium every three or four hours. Hemostatic agents comprise (i) the ligature; (2) torsion; (3) acupressure ; (4) elevation ; (5) compression ; (6) styptics ; (7) the actual cautery ; and (8) forced flexion of hmbs. The ligature may be made of silk, floss-silk, or catgut, but it must be aseptic. The Hgatures should be about ten inches long. The vessel is drawn out with forceps and separated from surrounding tissues. The forceps are better than the tenaculum in most cases, because the tenaculum makes a hole through which blood may subsequently exude. When the ar- tery lies in hard tissues or is retracted deeply in muscle or fascia, the tenaculum is best. Tie with a reef-knot. The tightening of the first knot cuts the internal and middle coats. The second knot must not be tied too tightly, or it will cut the lig- ature. Do not jerk the ligature in tying, and cut off closely. Both ends of the vessel are tied. If an artery is incompletely divided, tie on each side of the cut and entirely sever the ves- sel between the ligatures. If a large vein is slightly torn, try pinching up the vein-walls around the rent and apply a liga- ture (lateral hgature) (Fig. 48). If a vein is longitudinally torn, sew up with a Lembert suture of silk (Ricard and Niebergall have done this successfully). In extensive tears tie both ends of the vein ; cut the vein between the ligatures. If the bleeding comes from an artery very close to its point of origin, tie the main trunk as well as the bleeding branch, otherwise the clot formed will be too short and secondary hemorrhage will be inevitable. When the parts about an artery are so thickened that the artery cannot be drawn out, arm a Hagedorn needle (Fig. 47) with catgut and so pass the latter around the vessel that the catgut will include the vessel with some of the sur- rounding tissue, and tie the ligature. This method is pursued in necrosis, atheroma, scar-tissue, sloughing, etc. Never in- clude a nerve. If this mode of ligation fails, try acupressure. Murphy of Chicago has recently shown that longitudinal DISEASES AND INJURIES OF HEART AND VESSELS. 26 1 wounds or small lateral wounds of either veins or arteries can be closed successfully with silk sutures, and if a trans- verse wound includes more than one-third of the circum- FiG. 47. — Hagedorn needles. Fig. 48. — Method of controlling hemorrhage by liga- ture (after Esmarch) : a, artery ligated ; b, lateral ligature of vein. ference of the vessel, after the vessel is completely divided the ends can be successfully united.^ Torsion. — By means of torsion the internal and middle coats are ruptured and the external coat is twisted. It is a safe procedure, and is practised upon vessels as large as the femoral by many surgeons of high standing. Torsion has Fig. 49. — Method of controlling hemorrhage by torsion. the signal merit of not introducing possible infection in liga- tures. The vessel is drawn out by one pair of forceps, and another pair is applied transversely half an inch above the cut end and twisted six or eight times (Fig. 49). 1 See Med. Record., Jan. 16, 1897. 262 MODERN SURGERY. . Acupressure is pressure with a pin. The arrest of hemor- rhage by acupressure was devised by Sir James Y. Simpson. A pin is simply passed under a vessel (transfixion), leaving a little tissue on each side between the pin and vessel. A needle can be passed under a vessel, and a wire be thrown over the needle and twisted (circumclusion). The needle can be inserted upon one side, passed through half an inch of tissues up to the vessel, be given a quarter-twist, and be driven into the tissues across the artery (torsoclusion). Some tissue is picked up on the needle, folded over the vessel, and pinned to the other side (retroclusion). Acupressure is used for inflamed or atheromatous vessels, in sloughing wounds, and where a ligature will not hold. Elevation is used as a temporary expedient or as an asso- ciate of some other method. It is of use in wounds of the bursae, in bleeding from a ruptured varicose vein, and is fre- quently used with compression. Compression is either direct or indirect — that is, in the wound or upon its artery of supply. In the removal of the upper jaw arrest bleeding by plugging. In injury of a cere- bral sinus, plug with gauze. Compression and hot water (120°) will stop capillary bleeding. A graduated compress is often used in hemorrhage from the palmar arch. A com- press will arrest bleeding from superficial veins. The knotted bandage of the scalp will arrest bleeding from the temporal artery. Long-continued pressure causes pain and inflam- mation. Styptics. — Chemicals are now rarely used. In epistaxis we may pack with plugs of gauze saturated in antipyrin. In bleeding from a tooth-socket freeze with chlorid of ethyl spray, and then pack with gauze soaked in 10 per cent, solu- tion of antipyrin or with styptic cotton (absorbent cotton soaked in Monsel's solution and dried). In bleeding from an incised urinary meatus pack with styptic cotton. Cold water, chlorid of ethyl spray, or ice acts as a styptic by pro- ducing reflex vascular contraction. Hot water produces contraction and coagulates the albumin. The temperature should be from 115° to I2Q° F. A mixture of equal parts of alcohol and water stops capillary oozing. Paul Carnot has recently shown that a solution of gelatin in normal salt solution (i : 16) will arrest capillary oozing even in a hemo- philiac. We have recently employed this mixture with satis- factory results for capillary oozing from an incised wound in a victim of leukemia, and for the arrest of epistaxis. Tlie actual cauteiy is a most ancient hemostatic. It is DISEASES AND INJURIES OF HEART AND VESSELS. 263 still used in some cases after excising the upper jaw, in bleeding after the removal of some malignant growths, in continued hemorrhage from the prostatic plexus of veins, after lateral lithotomy, and to stop oozing after the excision of venereal warts. We are driven to it in " bleeders " — that is, those persons who have a hemorrhagic diathesis, and who may die from having a tooth pulled or from receiving a scratch. It will arrest hemorrhage, but sloughing is bound to occur, and when the slough separates secondary hemor- rhage is apt to set in. The iron for hemostatic purposes must be at a black heat. Forced flexion is a variety of indirect compression intro- duced by Adelmann. It will stop bleeding, but soon be- comes intensely painful. Forced flexion can be maintained by bandages. Brachial hyperflexion is maintained by tying the forearm to the arm. It is often associated with the use of a pad in front of the elbow. Genuflexion is kept up by tying the foot to the thigh. It is increased in efficiency by placing a pad in the popliteal space. Golden Rides for Procedure in Primary Hemorrhage. — I. In arterial hemorrhage tie the artery in the wound, enlarging the wound if necessary. In tying the main artery of the limb in continuity for bleeding from a point below we fail to cut off the bleeding from the distal extremity, and hemorrhage is bound to recur. If we fail to look into the wound, we cannot know what is cut : it may be only a branch, and not a main trunk. The same rule obtains in secondary hemorrhage (Guthrie's rule).^ 2. We can safely ligate veins as we would arteries. 3. In a wound of the superficial palmar arch tie both ends of the divided vessel. 4. In a wound of the deep palmar arch enlarge the wound, if necessary, in the direction of the flexor tendons, at the same time maintaining pressure upon the brachial artery. Catch the ends of the arch with hemostatic forceps and tie both ends. If the artery can be caught by, but cannot be tied over the point of, the forceps, leave the instrument on for four days. If the artery cannot be caught with forceps, try a tenaculum. If these means fail, insert a small piece of gauze in the depth of the wound, put over this a larger piece, and keep on adding bit after bit, each one larger than its predecessor, until there is constructed a conical pad the apex of which is against the extremities of the cut arch and the base of which is well external to the palm. Bandage ^ For Murphy's observations on anastomosis of vessels, see page 2^1. 264 MODERN SURGERY. each finger and the thumb, put a piece of metal over the pad, wrap the hand in gauze, place the arm upon a straight splint, apply firmly an ascending spiral reverse bandage of the arm. starting as a figure-of-8 of the wrist, and hang the hand in a sling. Instead of applying a splint, we may place a pad in front of the elbow and flex the forearm on the arm. The palmar pad is left in place for six or seven days unless bleeding keeps on or recurs. If bleeding is maintained or begins again, ligate the radial and ulnar. If this maneuver fails, we know that the interosseous arter}' is furnishing the blood and that the brachial must be tied at the bend of the elbow. If this fails, amputate the hand. A plan which might obviate these radical procedures is to incise on a line with the injur}- from the web of the fingers to above the carpus, separating the metacarpal and carpal bones until the arten,' is exposed (this is really Mynter's incision for excision of the wrist). 5. In primar}- hemorrhage, if the bleeding ceases, do not disturb the parts to look for the vessel. If the vessel is clearly seen in the wound, tie it ; otherwise do not, as the bleeding may not recur. This rule does not hold good when a large artery is probably cut, when the subject will require transportation (as on the battle-field), when a man has delirium tremens, mania, or delirium, or when he is a hea\y drinker. In these cases always look for an arter}' and tie it. 6. When a person is bleeding to death, arrest hemorrhage temporarily by digital pressure in the wound and apply above the wound a tourniquet or Esmarch bandage. Bring about reaction and then ligate, but do not operate during collapse if the bleeding can be controlled by pressure. 7. If a transverse cut incompletely divides an artery, it may be found possible to suture the cut if it does not in- clude more than one-third of the circumference of the ves- sel. Longitudinal cuts can be sutured (Murphy). If sutur- ing is impossible, or if the surgeon prefers not to attempt it, apply a ligature on each side of the vessel-wound and then sever the arter\- so as to permit of complete retraction. 8. If a branch comes oiT just below the ligature, tie the branch as well as the main trunk. 9. If a branch of an arter)' is divided ver>' close to a main trunk, tie the branch and also the main trunk. If the branch alone be tied, the internal clot, being ver}^ short, will be washed away by the blood-current of the larger vessel. 10. If a large vein is shghtly torn, put a lateral hgature DISEASES AND INJURIES OF HEART AND VESSELS. 265 upon its wall. Gather the rent and the tissue around it in a forceps and tie the pursed-up mass of vein-wall. It is a wise plan to pass the suture through the two outer coats by^ means of a needle and tie the knot subsequently. This expedient Fig. 50. — Application of lateral ligature to a vein. prevents slipping. If a longitudinal wound exists in a large vein, take an intestinal needle and fine silk and sew it up with a Lembert suture. 1 1. When a branch of a large vein is torn close to the main trunk, tie the branch, and not the main trunk. Apply practically a lateral ligature. 1 2. If, after tying the cardial extremity of a cut arter}', the distal extremity cannot be found even by a careful search after enlarging the wound, firmly pack. 13. In bleeding from diploe or cancellous bone, use Hors- ley's antiseptic wax or break in bony septa with a chisel. 14. In bleeding from a vessel in a bony canal, plug the canal with an antiseptic stick and break the wood, or fill up the orifice of the canal with antiseptic wax ; or, if this fails, ligate the arter}^ of supply. 15. In bleeding from the internal mammar\' artery the old rule was to pass a large curved needle holding a piece of silk into the chest, under the vessel and out again, and tie the thread tightly, but it is better to ligate the artery. 16. In bleeding from an intercostal artery make pressure upward and outward, or throw a ligature by means of a curved needle entirely over a rib, tying it externally, or, what is better, resect a rib and tie the artery. 17. In collapse due to puncture of a deep vessel, the bleed- ing having ceased, do not hurry reaction by stimulants. Give the clot a chance to hold. Wrap the sufferer in hot blankets. If the condition is dangerous, however, stimulate to save life. 18. In punctured wounds, as a rule, try pressure before using" lisration. 266 MODERN SURGERY. 19. After a severe hemorrhage always put the patient to bed and elevate the damaged part (if it be an extremity or the head). 20. A clot which holds for twelve hours after a primary- hemorrhage will probably hold permanently ; but even after twelve hours be watchful and insist on rest. 21. If recurrence of a hemorrhage from a limb is feared, mark with anilin or iodin the spot on the main artery where compression is to be applied, put on a tourniquet loosely, and order the nurse to screw it up and to send for the physician at the first sign of renewed bleeding. This must often be done in gunshot-wounds. 22. When the femoral vein is divided high up the advice commonly given is to ligate the vein and also the femoral artery. Branne taught that because of the venous valves there is no collateral circulation, and to tie the vein alone renders gangrene inevitable. Niebergall shows that the valves may be overcome by moderate arterial pressure, and thus collateral circulation is established. Hence, when the femoral vein is divided tie the vein, but leave the artery un- tied, so as to furnish the necessary pressure.^ 23. In extradural hemorrhage trephine. The side to be trephined is determined by the symptoms, and not by the situation of the injury. The opening is made on a level with the upper orbital border and one and a quarter inches be- hind the external angular process. This opening exposes the middle meningeal and its anterior branch (Keen). If this does not expose a clot, trephine over the posterior branch, on the same level and just below the parietal eminence. When the clot is found enlarge the opening with the ron- geur, scoop out the clot, and stop the bleeding by passing catgut ligatures on each side of the injury in the vessel through the dura, under the artery and out again, and then tying them. If the artery lies in a bony canal, plug the canal with Horsley's wax. 24. In hemorrhage from a cerebral sinus catch the edges of the opening with forceps if possible and apply a lateral ligature, or leave the forceps on forty-eight hours or com- press firmly with one large piece of iodoform gauze. 25. In extrameduUary spinal hemorrhage rapidly advanc- ing and threatening life perform a laminectomy and arrest the hemorrhage. 26. In bleeding from a tooth-socket use chlorid-of-ethyl spray or ice. If this treatment fails, plug with gauze infil- 1 Niebergall, in Deut. Zeit.f. C/iir., vol. xxxvii., Nos. 3, 4. DISEASES AND INJURIES OF HEART AND VESSELS. 267 trated with tannin or soaked in antipyrin solution of a strength of 10 per cent., or in Carnot's solution of gelatin, close the jaws upon the plug, and hold them with Barton's bandage. If this expedient fails, soak the plug in Monsel's solution, and if this is futile, use the cautery. Pressure on the carotid and ice over the jaw and neck are indicated. It may be necessary to tie the external carotid artery. 27. In intra-abdominal hemorrhage open the belly. In intra-abdominal hemorrhage it is necessary to operate dur- ing shock. If the blood accumulates so rapidly as to prevent the location of the bleeding point, compress the aorta or pack the abdominal cavity with large sponges. In seeking for the bleeding point remove the sponges one by one, or have the pressure momentarily relaxed from time to time. In paren- chymatous hemorrhage try packing with iodoform gauze. In the liver, if this fails, suture the torn edge or use the cau- tery. Severe wounds of the spleen demand splenectomy. Wounds of the kidney may be sutured; many require par- tial or complete nephrectomy. Mesenteric vessels are ligated en masse with silk (Senn). Wounds of stomach and intes- tines causing hemorrhage require stitching of their edges. When there are an infinite numbei: of points of bleeding take a number of sponges, tie a piece of iodoform gauze firmly to each one, pack many places in the belly with the sponges, bring the gauze out of the wound, and remove the sponges from below upward one at a time, securing the bleeding points as they come into view. 28. In abdominal section for disease of the female pelvic organs bleeding is limited by the clamp or by pressure-for- ceps. Ligation en masse is often practised. Use silk. A large mass can be transfixed and tied in sections. Bleeding edges are stitched. Areas of oozing are treated with tem- porary pressure and hot water, or, if this fails, by the cautery. Packing can be used as a tamponade, which is a gauze pouch, pieces of gauze being packed into this pouch after its inser- tion into the belly. 29. A ruptured varicose vein requires a compress, a band- age from the periphery up, and elevation. 30. For capillary hemorrhage use hot water and compres- sion, gelatin dissolved in salt solution, or, if these expedients fail, the cautery. Understand that capillary bleeding does not so much mean bleeding from genuine capillaries as it does bleeding from arterioles and venules. 31. Pressure above a wound stops arterial hemorrhage, but aggravates venous bleeding. Pressure below a wound stops 268 MODERN SURGERY. venous hemorrhage, but increases arterial bleeding. Remem- ber these facts when applying pressure. 32. In severe epistaxis, or bleeding from the nose, examine the nose by means of a head-mirror and a speculum.. If a little point of ulceration is found, touch it with the hot iron. If the bleeding is a general ooze, if it is high up, or if the cautery does not arrest it, pack the nares. It may be neces- sary to pack one nostril or both. Pass a Bellocq cannula (Fig. 50) along the floor of one nostril into the pharynx, Fig. 51.— Plugging the nares for epistaxis (Guerin). project the stem into the mouth, tie a plug of lint or gauze to the stem, and withdraw it. Carry out the same procedure upon the other nostril, pull the strings firmly forward, pack the nostrils from before backward, and tie the strings around the plug. If one nostril is packed, tie the string ends around the plug. Soaking the lint or gauze in antipyrin solution or gelatin solution is a good plan. Do not use subsulphate of iron, as it forms a disgusting, clotty, adherent mass. If a Bellocq cannula is not obtainable, push a soft catheter into the pharynx, catch it with a finger, pull it forward, and tie the plug to it. Remove the plug in three or four days. Pick out the front plug first, hold the string of the second plug in the hand, push the plug back into the pharynx, catch it with forceps, and withdraw plug and string through the mouth. 33. In gunshot-wounds the primary hemorrhage is sHght DISEASES AND INJURIES OF HEART AND VESSELS. 269 unless a large vessel is cut. The bleeding may be visible or may be internal (concealed), the blood running into a natu- ral cavity or among the muscles. Capillary oozing is arrested by very hot water and compression. Venous bleeding is usually arrested by compression. If a large vessel is the source of bleeding, enlarge the wound and tie the vessel. If the artery cannot be found in the wound, tie the main trunk. 34. In prolonged bleeding from a leech-bite tr\^ compres- sion over a plug saturated with alum or with tannin. If this fails, pass under the wound a harelip-pin and encircle it with a piece of silk. If this fails, use the actual cautery-. 35. In severe bleeding from the ear elevate the head, put an ice-bag over the mastoid, give opium and acetate of lead, and, if blood runs into the mouth, plug the Eustachian tube with a piece of catheter. 36. Umbilical hemorrhage in infants requires pressure over a plug containing tannin, alum, or gelatin solution. If compression fails, pass harelip-pins under the navel and apply a twisted suture. If this fails, use the actual cautery. 37. Rectal bleeding requires elevation of the buttocks, insertion of plugs of ice, ice to the anus and perineum, astringent injections (alum), and the internal use of opium and acetate of lead. If these means fail, plug the bowel over a catheter, or insert and inflate a Peterson bag or a colpeurynter, or tampon and use a T-bandage. If the bleed- ing persists or if a considerable vessel is bleeding, stretch the sphincter, catch the bowel and draw it down, seize the vessel, and tie it if possible ; if not, leave the forceps in place. Failing in this, the actual cautery must be used. 38. Subcutaneous hemorrhage, if severe, demands that an incision be made and ligation be performed, 39. Bleeding from a cut urethral meatus requires the insertion of styptic cotton and the application of pressure. Moderate bleeding from the urethra can usually be arrested by a hot bougie, by hot injections, or by tying a condom over a catheter, and, after inserting it, inflating the condom by blowing through the catheter and plugging the orifice of the instrument, thus using pressure. Sitting with the perineum on a thickly folded towel is useful. Ice to the perineum does good. The patient can lie down, have a folded towel applied to the perineum and a crutch-handle pushed upon the towel, the lower end of the crutch being jammed against the foot of the bed. If a solid bougie has been first introduced, firm pressure can be made by this 270 MODERN SURGERY. method. If these means are futile, perform an external urethrotomy and reach the bleeding point. 40. Hemorrhage from the prostate requires hot injec- tions, the introduction of a large bougie first dipped in very warm water, and the retention of a catheter for two days. Perineal section may be required, or suprapubic cystotomy with packing which does not occlude the ureteral orifices. 41. Vesical hemorrhage usually ceases spontaneously, in which case the urine must be drawn off and the viscus be washed out frequently with a solution of boric acid to pre- vent septic cystitis. If blood-clots prevent the flow of urine, break them up with a catheter or a lithotrite and inject vin- egar and water, a 2 per cent, solution of carbolic acid, or a solution of bicarbonate of sodium. Perfect quiet is to be maintained, cold acid drinks to be given, ice-bags to be put to the perineum and hypogastric region, and opium with acetate of lead, ergot, or gallic acid to be given by the mouth. If the hemorrhage is severe or persistent, perform a suprapubic cystotomy. 42. In hemorrhage after lateral lithotomy, ligate if pos- sible. If the vessel can be caught but cannot be ligated, leave the forceps in place. If we cannot catch the vessel with forceps, try a tenaculum. If the tenaculum fails, pass a threaded curved needle through the tissues around the vessel and tie the ligature. Plugs of ice and injections of hot water may be tried. These means failing, pressure is indicated. Take a cannula, fasten to it a chemise (Fig. 52), empty clots from the bladder, insert the instrument into the viscus, and pack gauze between the sides of the cannula and the chemise. The chemise is bulged out and pressure is made. Tie the cannula by means of tapes to a T-bandage. Pressure is thus combined with vesical drain- age. Buckstone Brown makes press- ure by inflating a rubber bag with air. The hot iron may occasionally be demanded. 43. Renal bleeding requires ice to the loin, tannic acid and opium, gallic acid and sulphuric acid, and perfect quiet. If the bleeding threatens life and the dis- FlG. 52. — Cannula i chemise. DISEASES AND IXJURIES OF HEART AND FESSELS. 2/1 eased organ is identified, make a lumbar incision, and suture or perform nephrectomy ; if not sure which organ is diseased, perform an abdominal nephrectomy. The use of a cysto- scope will show from which ureter blood is emerging. 44. Vaginal hemorrhage requires the ligature or the tampon. 45. Severe uterine hemorrhage (unconnected with preg- nancy) requires the tampon. Persistent hemorrhage due to morbid growths may require removal of the tubes and appendages, ligation of the uterine and ovarian arteries, or hysterectomy. 46. Hematemesis, or bleeding from the stomach, is treated by the swallowing of ice, giving tannic acid (dose, 20 or 30 grains) or Monsel's solution (3 drops). Never give tannic acid and Monsel's solution at the same time, as they mix and form ink. Opium is usually ordered. Acetate of lead and opium and gallic acid are favorite remedies, and ergot is used by many. Give no food by the stomach. If life is threatened by bleeding from an ulcer, open the belly and excise the ulcer. If severe hemorrhage follows injury, make an explorator}^ laparotomy. 47. In bleeding from the small bowel give acetate of lead and opium, sulphuric acid, or Monsel's salt in pill form (3 grains), allow no food for a time, and insist on liquid diet for a considerable period. If hemorrhage threatens life, do a celiotomy and find the cause. If ulcer exists, excise it. If violent hemorrhage follows injury, explore to discover the cause. 48. In bleeding from the large bowel, use styptic injections (10 grains of alum or 5 grains of bluestone to sj of water). If bleeding is low down, use small amounts of the solution ; if high up, large amounts. Do not use absorbable poisons. In dangerous cases perform an exploratory operation to find the cause. (For rectal bleeding see 37, p. 269.) 49. Hemoptysis, or bleeding from the lung, is treated by morphin hypodermatically, by perfect rest, by dry cups or ice over the affected spot if it can be located, and by gallic acid, which drug aids coagulation.' Of late nitrite of amyl by inhalation has given good results. 50. In hemorrhage from wound of the lung do not open ' The use of ergot is a general but questionable practice. Bartholow and others hold that this drug does harm ; it contracts all the arterioles, and hence more blood flows from an area where there is damage. Purgatives do good in bleeding from the lung by taking blood to the abdomen and lowering blood- pressure. 2/2 MODERN SURGERY. the chest unless life is threatened. If life is endangered, resect several ribs, find the bleeding point, ligate or employ forcipressure. A small cavity may be packed with gauze. If a large surface is bleeding, fill the pleural sac with gauze and pack more gauze against the oozing surface.^ Reactionary or Recurrent Hemorrliage (called also Consecutive, Intermediate, or Intercurrentj. — This form of hemorrhage comes on during reaction from an accident or an operation — that is, during the first forty-eight hours, but usually within twelve hours. It is bleeding from a vessel or vessels which did not bleed during the shock which accompanied operation, but were overlooked and were not tied. It may be due to faultily applied ligatures. It is favored by vascular excitement or hypertrophied heart. The bleeding is not sudden and severe, but is a gradual drop or trickle. The Esmarch apparatus is not unusually the cause. The constricting band paralyzes the smaller arteries, which do not bleed during shock and do not con- tract as shock departs ; hence bleeding comes on with reac- tion. To lessen the danger of-the Esmarch apparatus use a broad constricting band rather than a rubber tube. During reaction after an amputation, if slight hemorrhage occurs, elevate the stump and compress the flaps. If the hemor- rhage persists or at any time becomes severe, make pressure on the main artery of the limb, open the flaps, turn out the clots, find the bleeding point, ligate, asepticize, close, and dress. In any severe reactionary hemorrhage open the wound at once and ligate. Secondary hemorrhage may occur at any time in the period between forty-eight hours after the accident or opera- tion and the complete cicatrization of the wound. Secondary hemorrhage may be due to atheroma, to slipping of a lig- ature, to inclusion of nerve, fascia, or muscle in the liga- ture, to sloughing, to erysip- elas, to septicemia, to pyemia, to gangrene, and to ov^eraction of the heart. The great ma- jority of cases of secondary ^'''•"■"fnrasutre-Hgaturf.'^''^^'' hemorrhage are due to infec- tion, and the application of modern surgical principles has rendered secondary bleeding a rare calamity. If during an operation the vessels are found 1 See author's case, Aitnals of Surgery, Jan., 1898. DISEASES AND INJURIES OF HEART AND VESSELS. 273 atheromatous, acupressure had best be used, or a thread should be passed, by means of a Hagedorn needle, around the vessel, including a cushion of tissue in the loop of the ligature (this prevents cutting through) (Fig. 53). One great trouble with atheromatous arteries is that their coats can- not contract ; another trouble is that the ligature cuts en- tirely through them. If after an operation the pulse is found to be forcible, rapid, and jerking, give aconite, opium, and low diet. The bleeding may come on suddenly and furiously, but is usually preceded by a bloody stain in wound-fluids which had become free from blood. Treatment of Secondary Hemorrhage. — The method of treatment, supposing a case of leg-amputation in which, sev- eral days after the operation, a little oozing is detected, is to elevate the stump, apply two compresses over the flaps, and carry a firm bandage up the leg. If the bleeding is profuse or becomes so, make pressure on the main artery, open and tear the flaps apart with the fingers, find the bleeding vessel and tie it, turn out the clots, asepticize, close, and dress. If the bleeding begins at a period when the stump is nearly healed, cut down on the main artery just above the stump and ligate. In secondary hemorrhage from a blood-vessel in nodular tissue throw a ligature around the vessel by a curved needle or tie higher up, or, if this fails, amputate. When secondary hemorrhage arises in a sloughing wound apply a tourniquet or an Esmarch bandage, tear the wound open to the bottom with a grooved director, look for the orifice of the vessel, dissect the artery up until a healthy point is reached, cut it across, and tie both ends. If this fails, include tissue in the ligature or use acupressure. In secondary hemorrhage from atheromatous vessels use acu- pressure or include surrounding tissue in the ligature. Secondary hemorrhage may occur after ligation in con- tinuity, the blood usually coming from the distal side. If the dressings are slightly stained with blood, put on a gradu- ated compress. If the bleeding continues or is severe, make pressure on the main artery of the limb, open the wound and ligate, wrap the part in cotton, deviate, and surround with hot bottles. If this re-ligation is done on the femoral and fails, do not ligate higher up, as gangrene will certainly occur, but amputate at once, above the point of hemorrhage. If dealing with the brachial artery, do not amputate, but ligate higher up and make compression in the wound. In a secondary hemorrhage from the innominate tie the innominate again and also tie the vertebral. IS ^74 MODERN SURGERY. 2. Operations on the Vascular System. Paracentesis auriculi, or tapping the heart-cavity, has been suggested for the rehef of an over-distended heart from pulmonary congestion. The right auricle should be tapped. Push the aspirator-needle directly backward at the right edge of the sternum, in the third interspace. This operation is not recommended, as it is highly dangerous and is of question- able value. Paracentesis pericardii, or tapping the pericardial sac, is only done ,when life is endangered. Introduce the needle two inches to the left of the left edge of the sternum, in the fifth interspace, and push it directly backward (thus avoiding the internal mammary artery). Operation for Varix of I/Cg. — In this operation make, at several points in the course of the long saphenous vein, skin incisions each two inches long and in the long axis of the vessel. Clear the vessel at each incision, apply two liga- tures an inch apart, and excise the vein between them. Never operate if the slightest phlebitis exists (Barker). This method of multiple ligation is the plan of Phelps. Another method is as follows : the patient stands for a time before a fire to enlarge the veins. A harelip-pin is pushed into the tissues an inch from the vein, at the upper end of its varicose por- tion ; the pin is passed under the vein and emerges an inch outside of it. A bit of catheter wrapped in gauze is laid over the vein, and a twisted suture is carried around the pin and over the pad. This operation is done lower down in one or two positions ; but it is unsatisfactory, and offers grave dan- ger of infection. Trendelenburg, at a point below the saph- enous opening, ties the vein in two places and divides it be- tween his ligatures. Some surgeons have advised the removal of the entire length of the long saphenous vein. Madelung cuts down over the varices and ligates. Schede makes a cir- cular cut completely around the leg at the junction of the upper and middle thirds, the incision reaching to the deep fascia. All bleeding points are ligated and the edges of the incision are sewn together. Fergusson ties the saphenous vein near the femoral and removes a section from it. This makes the varices clearly evident. A semilunar incision is made to surround the varices, which incision reaches to the deep fascia. The flap is raised and dissected up, the vessels are tied, and the flap is sutured in place. The author of this operation claims that it is most satisfactory and certain. Open Operation for Varicocele. — The open operation DISEASES AND INJURIES OF HEART AND VESSELS. 275 is by far the best procedure for varicocele. The instruments used are a scalpel, an aneurysm-needle, curved needles, a grooved director, a dissecting-forceps, an Allis dry dissector, hemostatic forceps, and scissors^. Operation. — The patient is recumbent. He may be anes- thetized or Schleich's fluid may be injected. The operator stands on the diseased side. The assistant stands on the sound side and makes pressure over the inguinal ring of the affected side. A fold of skin is pinched up on the scrotum, and the surgeon transfixes it in the line of the cord, so that he will have an incision about one and a half inches long run- ning downward from below the external ring. The skin and fascia are cut with a scalpel, the veins are well exposed by means of an Allis dissector, and the cord is located and held aside. A double ligature of strong catgut or chromicized gut is passed under the veins by an aneurysm-needle. The threads are separated one inch, tied tightly, and the ends are left long. The veins between the ligatures are excised. The two gut ligatures are tied together and cut. This shortens the cord. The scrotum is sewed up with silkworm-gut, a small drainage-tube being used for twenty-four hours. Heal- ing is complete in one week. Subcutaneous I/igature for Varicocele. — In this ope- ration employ every antiseptic precaution. The patient stands, and the operator, sitting in front of him, holds the veins in a fold of skin away from the vas deferens by means of the thumb and index finger of the left hand. A large straight needle carrying a double piece of strong silk is passed en- tirely through the scrotum, between the veins and the vas. The needle is again inserted at the puncture from which it emerged, is carried around under the skin and in front of the veins, and emerges at its original point of entry. The veins are thus surrounded by the silk. The patient, who now lies down, is placed under the first stage of ether, and the double ligatures are separated as far as possible from each other, tied, and cut off, the knots slipping in through the puncture. This operation presents certain dangers. The veins may be wounded and the vas or other structures may be included. In an operation it is always best to be able to see what we are doing ; and the open operation, being safe, is preferred to the subcutaneous. Phlebotomy, or Venesection. — The instruments used in venesection are a lancet or bistoury, a fillet or tape, an antiseptic pad, and a bandage. A stick should be at hand for the patient to grasp. 2/6 MODERN SURGERY. Fig. 54. — Superficial veins Fig. 55.— Incisions for in front of elbow. venesection. (Bernard and Huette.) Operation. — The patient sit.s on a chair " with the arm abducted, extended, and incHned outward " (Barker). The parts are asepticized and a tape is tied around the arm just above the elbow. The surgeon stands to the right of the arm, holds the elbow with his left hand, and puts his thumb upon the vein below the intended point of punct- ure. A tape is tied above the elbow. The patient grasps a stick firmly and works his fingers to swell the veins. Either the me- dian cephalic or median basilic can be punctured (Fig. 54). The median basilic is the more dis- tinct, and is the vein usually selected. In puncturing it, do not go too deep, as nothing but the bicipital fascia separates it from the brachial artery. The median cephalic may be selected (we thus avoid endangering the brachial artery) ; under this vein lies the external cutaneous nerve (Fig. 54). Steady the vein with the thumb and open it by transfixion, making an oblique cut which divides two-thirds of it. Remove the thumb and allow bleeding to go on, instructing the patient to work his fingers. When faintness begins remove the fillet, put an antiseptic pad over the puncture, apply a spiral reverse bandage of the hand and arm and a figure-of-8 bandage of the elbow, and place the arm in a sling for several days. Transfusion of Blood. — This operation has been a recognized procedure since 1824, though it has certainly been known since 1492, when transfusion in the case of Pope Innocent VIII. was made. Its chief use was in severe hemorrhage, especially post-partum, in which it served to re- place the blood lost and supplied something for the heart to contract upon until new blood formed. Senn insists that the operation has proved an absolute failure. It does not prevent death from hemorrhage, and the transferred blood-elements do not retain vitality. Von Bergmann showed us that after severe hemorrhage we do not need to inject nutritive ele- ments, but do need to restore the greatly diminished intra- cardiac and intravascular pressure. At the present day a saline fluid is transfused rather than blood. In fact, the ope- DISEASES AND INJURIES OF HEART AND VESSELS. 277 ration of transfusion has become all but extinct. It exposes the patient to the danger of embolism and infection, its employment requires material often hard to obtain, and it has no single element of value beyond that secured by the use of salt solution. Transfusion of saline fluid is used after severe hemor- rhage, in shock, in diabetic coma, in post-operative suppres- sion of urine, and occasionally in sepsis. After a hemor- rhage its beneficial effects are often prompt and obvious. This saline fluid increases the arterial tension, gives the heart enough matter to contract upon, and so restores the activity of the circulation. We may use a simple apparatus consist- ing of a rubber tube, a funnel, and an aspirating-needle. Some employ an Aveling syringe, and others Collin's apparatus Fig. 56. ^Intravenous injection of saline fluid. (Fig. 56). The last-named instrument can be used without any danger of air entering with the fluids. Normal salt solu- tion is the fluid usually employed, salt solution of a strength of 0.7 per cent, (about a teaspoonful of common salt to a pint of boiled water). Some surgeons employ an artificial serum which contains 50 grains of chlorid of sodium, 3 grains of chlorid of potassium, 25 grains of sulphate and 25 grains of carbonate of sodium, 2 grains of phosphate of sodium in a pint of boiled water.^ Szumann's solution consists of 6 parts of common salt, i part of sodium carbonate, and looo parts of water. The following solution is used by Locke and Hare : calcium chlorid, 25 gm. ; potassium chlorid, i gm. ; sodium chlorid, 9 gm. ; sterile water sufficient to make i liter. One ^ A. Pearce Gould, in Treves' System of Surgery. 2/8 MODERN SURGERY. bottle of the commercial fluid when diluted to i liter gives a solution of the above composition. Whatever fluid is used, it should be at a temperature of ioo° F. From ^ pint to 2 pints or even more are slowly injected, the condition of the patient determining the amount given. In one case of violent hemorrhage the author used 2 quarts. In order to transfuse this fluid tie a fillet well above the elbow, and expose by dissection the median basihc vein, or the basiHc vein in the portion of its course where it is superficial to the deep fascia. Tie the vein. Incise it above the ligature, insert a fine can- nula, and hold the cannula firmly in the lumen by tightening a second ligature (Fig. 56). Slowly and gradually introduce the fluid, carefully watching the pulse. When the tension of the pulse returns withdraw the cannula, tie the second ligature tightly, sew up the wound, and dress it aseptically. In very severe operations an assistant can do transfusion while the surgeon is operating. It may be necessary to repeat the transfusion if the circulation fails again. Arterial Transfusion. — Hueter preferred the arterial method of transfusion, in order to send the blood more gradually to the heart, and thus prevent sudden disturb- ance of the circulation. A little air in an artery will do no harm, and the danger of venous embolism is avoided. Saline fluid can be thrown into an artery. The radial artery is exposed and surrounded by three ligatures, and the thread toward the heart is at once tied. The distal ligature is slightly tightened to cut off anastomotic blood-supply. The artery is cut transversely half through ; the syringe is inserted, pointed toward the periphery, and fastened by the third ligature ; the second ligature is loosened and the blood is injected. On finishing, the peripheral thread is tied tightly and that portion of the artery which held the cannula is excised. 3. Ligation of Arteries in Continuity. The instruments used in this operation are two scalpels j^j^M Fig. 57. — Aneurysm-needle of Saviard. (one small, one medium), two dissecting-forceps, several hemostatic forceps, toothed forceps, blunt hooks or broad DISEASES AND INJURIES OF HEART AND VESSELS. 279 Fig. 58. -Dupuytren's aneurysm- needles. metal retractors, an Allis dissector, an aneurysm-needle, for superficial arteries the instrument of Saviard (Fig. 57), for deep vessels the needle of Dupuy- tren (Fig. 58), ligatures of catgut, of chromicized gut, or of silk, curved needles and needle-holder, and silkworm-gut, and the reflec- tor or electric forehead-lamp for deep vessels. The position varies according to the vessel, though the body is supine except when ligation is to be performed on the gluteal, sciatic, or popliteal. The opera- tor, as a rule, stands upon the affected side, cutting from above downward on the right side and from below upward on the left side. Operation. — Accurately determine the line of the artery, and make an incision at a slight angle to this line, avoid- ing subcutaneous veins, and holding the scalpel like a fiddle- bow or a dinner-knife while cutting the superficial parts, and like a pen while incising the deeper parts. On reaching the deep fascia make out the required muscular gap by the eye and finger, so moving the extremity as to bring indi- vidual muscles into action. Treves cautions us not to depend upon the yellow line of fat, which often cannot be seen in emaciated people or when an Esmarch bandage is employed ; nor upon the white line due to attachment to the fascia of an intermuscular septum. In opening the deep portion of the wound relax the bounding muscles by altering the posture. Open a muscular interspace with a sharp knife, not with a dissector. Make the depths of the wound as long as the superficial incision. Do not tear structures apart with a grooved director ; cut them. Arrest hemorrhage as it occurs. Try to find the situation of the artery with the finger. Pulsation is present, but it may be very feeble and hard to detect. The artery feels like a very thin rubber tube ; it is compressible, though not so easily as a vein, and when compressed feels like a flat band which is thinner in the center than at the edges (Treves). A nerve feels like a hard round cord. The veins are soft, larger than their related arteries, and so very compressible that they can scarcely be felt when pressed upon, compression causing distal distention. If the wound can be seen well into, it will 28o MODERN SURGERY. be noted, as Treves asserts, that " the nerves stand out as clear, rounded, white cords ; that the veins are of a purple color and of somewhat uneven and wavy contour ; that the artery is regular in outline and of a pale-pink or pinkish- yellow tint, the large vessels being of lighter color than the small." All the arteries of the upper extremity and all the arteries below the knee are accompanied by two veins, known as " venae comites." The arteries of the head and neck have each a single attending vein, except the lingual, which has vense comites. Most of the smaller arteries of the trunk (pudic, internal mammary, etc.) have venae comites. These companion veins may lie on each side of the artery or in front and back of it, and they communicate with one another by transverse branches crossing the artery. On reaching the sheath pick up this structure with toothed forceps so as to make a transverse fold, and thus avoid catching the artery or vein ; lift the fold to see that it is free, and open the sheath by cutting toward the edge of the forceps with a scalpel held obliquely with its back toward the vessel, thus making a small longitudinal incision (PL i, Figs, i, 2). Hold the edge of the incised sheath with the forceps ; pass an Allis dissector under the vessel and from the forceps ; this clears one-half of the vessel. Grasp the other edge of the sheath and pass the blunt dissector all the way around the vessel. Pass an aneurysm-needle under the cleared vessel away from the forceps holding the sheath. Thread the needle and withdraw it always from its most dangerous neighbor. If venae comites are in the way, try to separate them ; but if this proves difficult, include them in the ligature. In small ves- sels always include them if they are in the way, as this saves trouble. If, in passing the needle, a large vein is severely wounded (such as the femoral), Jacobson advises the em- ployment of digital pressure in the lower portion of the wound while the artery is being tied on a level above or below that of the vein-injury, and after ligation the main- tenance of pressure on the wound for a couple of days. A slight puncture in a vein merely requires a lateral ligature. A small longitudinal cut can be closed with Lembert sutures of fine silk. After getting a ligature under an artery press for a moment upon the artery over the ligature, which is held taut ; this pressure will arrest pulsation below if the ligature is around the main artery and there is not a double vessel. Tie the thread at right angles to the vessel with a reef-knot (Fig. 59), rupturing the internal and middle coats. As the ligature is tightened place the extended index fingers LIGATIONS. Plate i. 1. Opening the Sheath for Ligation of an Artery (Guerin). 2. Sheath of Artery Open (Guerin). 3. Tightening the Knot in Ligation (Guerin). 4. Anatomy of the Iliac Arteries, and showing the lines of incision for their ligation : i, Abernethy's incision (Guerin). 5, 6. Hallance and Ed mund's Stay-knots. DISEASES AND INJURIES OE HEART AND VESSELS 28 1 along the ligature up to the artery (PI. i, Fig. 3), using the middle joints as the fulcrum of a lever by placing them against each other. Ballance and Edmunds have recently claimed, as Scarpa and Sir Philip Crampton did long since, that it is not neces- sary to divide the internal and middle coats to insure oblit- eration. If this claim be true, the danger of secondary hemorrhage can be greatly lessened. Holmes, however, thinks the older method the more certain of the two. Ballance and Edmunds recommend that the artery be surrounded with a doubled ligature of floss-silk, that each ligature be tied with one turn of a reef-knot, and that Fig. 59. — Reef-knot. Fig. 60. — Diagram showing the action of the ligature. the final turn be made by gathering together as single pieces both ends on either side, and tying them to each other. This knot is known as the " stay-knot" (PI. i. Figs. 5, 6). The chief dangers after ligation are secondary hemor- rhage and gangrene. Rigid asepsis usually prevents the first ; rest, elevation, and heat antagonize the second. Radial Artery. — The line of the radial arter>' is from the middle of the front of the elbow-joint to the ulnar side of the styloid process of the radius. The line in the tab- atiere is from the apex of the styloid' process to the posterior angle of the first interosseous space. Anatomy (PL 2, Fig. 5). — The radial artery, though smaller than the ulnar, is the direct continuation of the brachial. It arises from the bifurcation of the brachial half an inch below the bend of the elbow, runs down the radial side of the forearm to the front of the styloid process of the radius, passes beneath the extensor muscles of the first metacarpal bone and of the first phalanx of the thumb, and over the carpus to the first interosseous space. It is crossed by the tendon of the extensor secundi internodii pollicis, enters into the palm between the heads of the first dorsal interosseous muscle, and forms the deep palmar arch. The artery in the 282 MODERN SURGERY. . upper two-thirds of its course is somewhat overlaid by the supinator longus muscle ; in the lower one-third of the fore- arm it is superficial. In the upper third of the forearm it lies between the supinator longus on the outside and the pronator radii teres on the inside ; in the lower two-thirds of the forearm it lies between the supinator longus on the outside and the flexor carpi radialis on the inside. Two venae comites attend the vessel. The radial nerve is to the outer or radial side of the artery, well removed from the artery in the upper third, nearer to the artery in the middle third, far external to the artery in the lower third, the nerve at this point passing beneath the supinator longus muscle. The radial artery, from above downward, rests upon the biceps tendon, the supinator brevis, the flexor sublimis, the pronator radii teres, the flexor longus pollicis, the pronator quadratus muscles, and the radius. It has two venae comites. The best guide to the radial artery in the forearm is the outer edge of the flexor carpi radialis muscle or the inner edge of the supinator longus muscle. The tabatiere anatomique of Cloquet, or the anatomical snuff-box, is a triangle whose base is the lower edge of the posterior annular ligament, the ulnar side being formed by the extensor secundi internodii pollicis tendon, the radial side by the extensor ossis metacarpi and the extensor primi internodii pollicis tendons ; the floor consists of the trape- zium, scaphoid, their dorsal ligaments, and the base of the first metacarpal bone. Operations. — Ligation in the tabatiere is a dissecting-room operation of but little practical use. The patient is placed in a recumbent position, the arm is abducted and the forearm is placed midway between pronation and supination (Barker). The surgeon stands upon the side operated upon. An in- cision two inches in length is made along the radial border of the extensor secundi internodii pollicis muscle. The skin and superficial fascia are cut and some venous branches are divided. The deep fascia is incised and the vessel is easily found and tied before it passes between the heads of the first dorsal interosseous muscle (Barker). Ligation in the Lower Third. — In this operation (PI. 2, Fig. 6) the patient is supine, the arm is abducted, the fore- arm is supinated and rested upon a table and held by an assistant. The surgeon stands on the side operated upon, and cuts from above downward on the right arm and from below upward on the left arm. The line of the vessel is determined, and can be marked with iodin or anilin. An DISEASES AND INJURIES OF HEART AND VESSELS. 283 incision one and a half inches long is made at a slight angle to this line and midway between the supinator longus and the flexor carpi radialis muscles, which incision must not extend below the level of the tuberosity of the scaphoid bone. In the superficial fascia watch for the superficial radial vein, and if it comes into view, push it aside. Incise the superficial fascia and locate each guide-tendon. Open the deep fascia in the length of the first cut; try to separate the veins, but if they strongly adhere, include them in the ligature. There is no special fascial sheath. The radial nerve will not be seen, but a division of the anterior cutaneous is frequently found in relation with the vessel. The needle can be passed in either direction. A high origin of the superficialis volae artery is confusing. Ligation in the Middle Third. — In this operation the posi- tion is the same as in the preceding. A two-inch incision is made. Veins- of the subcutaneous tissues are avoided. Lying upon the deep fascia is the anterior division of the musculocutaneous nerve. Open the fascia ; find the inner edge of the supinator longus muscle and draw it outward, flexing the elbow if necessary. Be sure not to get external to this muscle. Find the vessel where it is bound down by connective tissue to the pronator radii teres muscle, separate the veins, and pass the ligature from without in. The nerve is external. Ligation in the Upper Third (PI. 2, Fig. 6). — In this ope- ration the incision is like the last, only higher up. The artery is between the supinator longus and the pronator radii teres, which muscles are at once differentiated by the different direction of their fibers. The artery is usually cov- ered by the supinator longus muscle, which must be retracted externally. The nerve is not seen. The ligature is passed in either direction. Ulnar Artery. — No one lijie will overlie the entire ulnar artery. The line of the upper third runs from the middle of the front of the elbow-joint to the point of junction of the upper and middle thirds of the ulna. The line of the lower two-thirds runs from the tip of the internal condyle of the humerus to the radial side of the pisiform bone (PI. 2, Figs. 5, 6). Anatomy (PI. 2, Fig. 5). — The ulnar artery arises from the brachial bifurcation and runs obliquely inward under the median nerve and a group of muscles from the internal con- dyle ; it turns down the arm, being covered in the middle third of its course by the flexor carpi ulnaris muscle. In the 284 MODERN SURGERY. lower third it is superficial, between the tendons of the flexor carpi ulnaris on the inside and the flexor sublimis digitorum on the outside, the vessel being a little overlapped by the flexor carpi ulnaris. This vessel rests first upon the brachi- alis anticus muscle, next upon the flexor profundus, to which it is bound by a distinct process of fascia, and next upon the annular ligament, which structure it crosses to become the superficial palmar arch. Two venae comites attend the vessel. In the upper third the nerve is well internal, but in the lower two-thirds the nerve lies near the artery and to its ulnar side. The guide is the outer edge of the flexor carpi ulnaris. Operations (PI. 2, Fig. 6). — Ligation of the Lower Tliird. — The position in this operation is the same as for the radial artery. Make a two-inch incision to the radial side of the ten- don of the flexor carpi ulnaris, which incision is not taken lower than a point one inch above the pisiform bone. Avoid the superficial ulnar vein in the subcutaneous tissue. Open the deep fascia, find the tendon of the flexor carpi ulnaris, flex the wrist and draw the tendon inward, open a second layer of fascia, clear the vessel, separate the veins, and pass the ligature from within outward to avoid the nerve. On the artery is the palmar cutaneous branch of the ulnar nerve, and this branch must not be included in the ligature. Ligation of the Middle Third (PI. 2, Fig. 6). — In this opera- tion the position is the same as in the preceding one, the in- cision being three inches long. Avoid the anterior ulnar vein and the branches of the internal cutaneous nerve in the super- ficial fascia. Open the deep fascia a little external to the superficial cut (Treves). Find the space between the flexor carpi ulnaris and the superficial flexor, feeling with the index finger, and when the space is discovered flex the wrist, re- tract the flexor carpi ulnaris inward and the flexor sublimis digitorum outward, open the fascia, find the ulnar nerve, look external to it for the artery, clear the vessel, separate the venae comites, and pass the needle from within outward. The ulnar artery should not be ligated in continuity in the upper one-third of its course. Brachial Artery. — The line of the brachial artery is from the junction of the anterior and middle thirds of the outlet of the axilla, the arm being abducted and the forearm supi- nated, to the middle of the front of the elbow-joint. Anatomy (PI. 2, Fig. i). — The brachial artery is the pro- longation of the axillary, and extends from the lower edge of the teres major muscle to half an inch below the bend of the LIGATIONS. Plate 2. ntf'X^ DISEASES AND INJURIES OF HEART AND VESSELS. 285 elbow, where it divides into the radial and ulnar. It lies first to the inner side of the arm, but passes to the front of the elbov\^ It is crossed by no muscle, and is in fact superficial, barring its being somewhat overlaid in part of its course by the edge of the biceps muscle. The median nerve is outside above, crosses over it about the middle of the arm, and reaches the inside. The coracobrachialis and biceps mus- cles are external, and both often overlap the vessel. The ulnar nerve is internal above, and the median nerve below, the middle. The basilic vein is internal to the artery, being outside the deep fascia to near the middle of the arm, at which point it pierces it. The artery above is separated from the long head of the triceps by the musculospiral nerve and superior profunda artery and vein ; it rests from above down on the inner head of the triceps, the coracobrachialis, and the brachialis anticus. The artery is covered by skin and by superficial and deep fascia. The internal cutaneous nerve lies in front of the artery, upon the deep fascia, until it pierces the fascia along with the basilic vein. The artery has venae comites, and in its upper half has also the basilic vein to its inner side. The guide to the brachial is the inner edge of the biceps muscle. Just in front of the elbow-joint the artery lies in a triangle, the base of which is formed by an imaginary transverse line above the condyles, the apex by the junction of the pronator radii teres and the supinator longus. The outer line is the supinator longus, the inner line is the pronator radii teres, and the floor is formed by the brachialis anticus and the supinator brevis. From within outward the triangle contains the median nerve, brachial artery, tendon of the biceps, anastomosis of the superior profunda and radial recurrent arteries, and the musculospiral nerve. Operations. — Ligation at the Bend of the Elboiv. — In this operation (PI. 2, Fig. 2) the patient is supine, the arm is mod- erately abducted and extended, and is allowed to lie upon its posterior aspect. The forearm is supinated. The surgeon stands upon the side operated upon, and cuts from above downward on the right side and from below upward on the left side. Accurately locate the tendon of the biceps and the median basilic vein. An incision is made parallel with the inner edge of the biceps tendon and two inches in length, the center of this cut being in the crease of the elbow. On exposing the median basilic vein, retract it downward and in- ward, open the bicipital fascia, clear the artery of fat, separate the venae comites, and pass the ligature from within outward 286 MODERN SURGERY. to avoid the median nerve. The above operation is not fre- quently performed. Ligation in the Middle of the Arm. — In this operation the patient is placed supine and abduction of the arm and supi- nation of the forearm are brought about. An assistant holds the forearm, but the arm should not rest upon the table, because, if it be allowed to do so, the inner head of the triceps will be forced forward and may overKe the artery, and thus complicate the operation. Locate the inner edge of the biceps, which is the guide. Make an incision three inches long in the Hne of the artery. Incise the skin and fascia, flex the elbow slightly, retract the biceps outward, feel for the artery, open its sheath, separate its vense comites, and, having located the median nerve, pass the ligature from it. In the middle of the arm the nerve is in front of the vessel, above the middle it is external, and below the middle internal. High up the arm the inner edge of the coracobrachialis is the guide, rather than the biceps. Above the middle of the arm the basilic vein is beneath the deep fascia and runs along to the inner side of the artery ; hence, high up, the artery has three companion veins, the venae comites and the basilic vein, and there is seen the ulnar nerve to the inside of the artery. Axillary Artery. — To determine the line of the axillary artery place the arm at right angles to the body, with the patient supine, and lay down a line from the middle of the clavicle to the humerus near the inner border of the coraco- brachialis. The line of the third portion can be approximated by projecting the line of the brachial upward. Anatomy (PL 2, Fig. 3 ; PI. 3, Fig. i). — The axillary artery is the continuation of the subclavian, and runs from the lower margin of the first rib to the inferior border of the teres major muscle. It is divided into three portions by the pectoralis minor muscle. The first portion is above, the second por- tion is behind, and the third portion is below, the pectoralis minor. The position of the artery varies with the position of the limb. When the arm is parallel with the body the artery is far from the surface and forms a curve whose con- vexity is upward and outward. When the arm is at right angles to the body the vessel is nearer the surface and straight. When the arm is raised above a right angle the artery comes near the surface and forms a curve with the convexity downward. The first portion of the axillary artery is occasionally ligated. It lies upon the first intercostal muscle and the DISEASES AXD IXJURIES OF HEART AND VESSELS. 28/ first serration of the great scrratus muscle, and has behind it the posterior thoracic nerve ; the brachial plexus is external and posterior to the vessel ; on its inner side is the axillary vein ; in front of it are the clavicle, the great pectoral muscle, the subclavius muscle, the costocoracoid membrane, the cephalic and acromiothoracic veins, and the external anterior thoracic nerve. The branches of the first part of the axillary artery are the superior thoracic and the acromiothoracic. The second part of the artery is not ligated. The brachial plexus surrounds the second portion. The third part is covered in front, above, by the great pectoral, but is covered below by skin and fascia ; behind, it has the tendon of the subscapularis, the latissimus dorsi, and the teres major ; the coracobrachi- alis is on the outer side ; the axillary vein is on the inner side. It is important to remember that there may be three veins, one external and two internal. The axillary vein is formed by the venae comites of the brachial artery joining, and this new vein effecting a junction with the basilic vein. The median" nerve lies upon the axillary artery in the upper part of the third portion of the vessel's course, and passes to the outer side. The musculocutaneous nerve is external, but it is only seen high up ; the ulnar nerve is internal ; the lesser internal and the internal cutaneous nerves are internal ; the musculospiral and the circumflex nerv^es are behind. The branches of the third portion of the axillary artery are the subscapular and the anterior and posterior circumflex. Operations. — Ligation of the Third Portion (PL 2, Fig. 4). — The position in this operation is supine with the shoulders raised and the arm abducted to a right angle. The surgeon stands between the patient's arm and side, with his back to- ward the subject's feet. An incision is made three inches in length. It begins half-way up the axilla opposite to the head of the humerus, and comes downward parallel to the lower edge of the great pectoral muscle and crosses the junction of the anterior and middle thirds of the outlet of the axilla. Incise the integuments and fascia. The vein or veins will be prominent to the inner side and may overlie the vessel. To the inner side with the veins are the ulnar and internal cu- taneous nerves. The median is upon and the external cuta- neous nerve to the outer side of the artery. Feel for the pulsations of the artery, find the median nerve and draw it outward, draw the internal nerve and veins inward, clear the artery from the venae comites. and pass the ligature from within outward. Apply the ligature well below the cir- cumflex branches. 288 MODERN SURGERY. Ligation of tJie First Pm't. — This operation (PI. 3, Fig. 2) was first performed in 181 5 by Chamberlaine of Jamaica. The position is supine, the upper part of the body being raised, a sand-pillow being placed between the scapulae to insure carrying back of the point of the shoulder, and the arm being brought down along the side. In operating on the left side the surgeon stands on the outer side of the left arm ; in operating on the right side he stands to the right of the subject's head and leans over his shoulder. The incision, which is slightly curved downward, begins external to the sternoclavicular joint and ends internal to the margin of the deltoid, thus avoiding the cephalic vein. The incision is half an inch below the clavicle. Incise skin, platysma myoides muscle, superficial nerves, and deep fascia. In the outer angle of the wound watch out for the acromiothoracic artery and the cephalic vein. Incise the pectoralis major ; draw the pec- toralis minor down ; retract the lower margin of the wound, cut throup-h the costocoracoid membrane close to the cora- coid process and upper border of the lesser pectoral. Bring the arm to the side so as to relax the structures. Find the brachial plexus, feel for the artery internal to it, clear the vessel, draw the vein internally, and pass the needle from within outward. This avoids the dangerous neighbor, which is the axillary vein. This operation is difficult, dangerous, and unusual, and in its performance the axillary vein, which has a close attachment to the costocoracoid membrane, is apt to be torn. Subclavian Artery. — There is no line for this vessel. Anatomy (PI. 3, Fig. i). — The subclavian artery of the right side arises from the innominate ; of the left side, from the arch of the aorta. The subclavian is divided into three parts. The first part runs from the origin of the vessel to the inner border of the scalenus anticus muscle ; the second part lies behind the scalenus anticus muscle ; and the third part runs from the outer edge of the muscle to the lower border of the first rib. At the present day the first and second portions are not ligated. The third portion is contained in the subclavian triangle (Fig. 61), and is superficial. It rises, as a rule, to half an inch above the clavicle. The subclavian vein is below the artery, being separated from it by the scalenus anticus muscle. The brachial plexus is above and external to the artery. The vessel rests upon the first rib, and behind it is the scalenus medius muscle. The suprascapular and trans- versalis colli arteries and veins and branches of the cervical LIGATIONS. Plate 3. DISEASES AND INJURIES OF HEART AND VESSELS. 289 plexus lie in front of the artery, and the external jugular vein crosses it at its inner side. The third portion gives off no branches. Ligation of the Third Part. — This operation (PI. 3, Fig. 2) was first successfully performed in 181 7 by Post of New York. The position is as follows : place the patient upon his back, raise the shoulders, extend and turn the head toward the opposite side, pull down the arm, and hold it by pushing the forearm under the patient's back (Treves). This pulls down the clavicle, thus increasing the size of the subclavian tri- angle. The operator stands facing the shoulder, with his back toward the patient's feet. Draw the skin over the sub- clavian triangle, half an inch above the clavicle, down upon this bone, and incise. This maneuver avoids the external jugular vein and gives an incision half an inch above the collar-bone. The incision reaches from the anterior edge of the trapezius to the posterior border of the sternocleidomas- toid (PI. 3, Fig. 2), and is about three inches long. By this in- cision are divided the skin, the superficial fascia, the platysma myoides, the vein running from the cephalic to the external jugular, and some superficial nerves. Open the deep fascia. Draw the external jugular vein into the inner angle of the wound, and do not divide it unnecessarily ; if forced to do so, tie the vein with two ligatures and cut between them. Find the outer edge of the anterior scalene muscle, and run the finger down along it to the tubercule on the first rib. Draw up the posterior belly of the omohyoid muscle. With the finger on the tubercle recall the fact that the vein is in front of the finger and the artery is behind it, and that the sub- clavian vein is on a lower plane than the artery. The artery is felt beating as it lies upon the rib. Clear the artery and expose the lower cord of the brachial plexus. Guard the vein with the finger and pass the needle from above down- ward, as the plexus, which is in more danger than the vein, is to be avoided. In this operation never cut the transversa- lis colli or suprascapular arteries, as they are necessary to the future anastomotic circulation. If the field of operation is too small, incise the trapezius or sternocleidomastoid or both. The vertebral artery was first successfully ligated by Smyth of New Orleans. Anatomy. — This vessel is the largest branch of the sub- clavian, and is the first branch from the first portion of the subclavian. The vertebral artery ascends and enters the foramen in the transverse process of the sixth cervical vcr- 19 290 MODERN SURGERY. tebra (in rare cases the fifth or the seventh), and ascends through foramina in the cervical vertebrae, passes behind the articular process of the atlas and over the posterior arch of this first vertebra, pierces the posterior occipito-atloid liga- ment, and enters the skull by way of the foramen magnum (see Gray). It joins its fellow of the opposite side to form the basilar. At its point of origin it has in front of it the internal jugular vein and inferior thyroid artery. Gray says that near the spine it lies between the longus colli and scalenus anticus muscles, with the thoracic duct to the left and in front. Ligation. — Position as for ligation of carotid. Make an incision three inches in length along the posterior edge of the sternocleidomastoid muscle. This incision reaches the clavicle. In dividing the skin and superficial fascia watch for the external jugular vein and retract it inward. Divide the deep fascia. Retract the sternocleido inward. Open the space between the longus colli and scalenus anticus muscles, find the artery, clear it, and pass the needle from the inner side. Jacobson tells us to remember that the phrenic nerve Hes on the scalene muscle, the pleura is inter- nal, the internal jugular, inferior thyroid, and vertebral veins are over the vessel, and the thoracic duct on the left side crosses it from within outward. The Inferior Thyroid Artery. — Anatomy. — The infe- rior thyroid is a branch of the thyroid axis. It ascends the neck, passes back of the carotid sheath and the sympathetic nerve, and reaches the thyroid gland. The recurrent laryn- geal nerve lies behind the artery. The phrenic nerve is external to the artery and near to it in the first part of its course (up to the point of origin of the ascending cervical branch). The ascending cervical branch takes origin just before the artery begins to dip behind the carotid. In front of the beginning of the left artery the thoracic duct crosses. The artery is ligated in the second part of its course (between its distribution and the origin of the above-named branch). Ligation. — Position of patient and incision as for common carotid in triangle of necessity (p. 294). After exposing the sternocleidomastoid retract it outward, and then retract outward the carotid artery and also the internal jugular vein. The artery will be found a little below the carotid tubercle. It is cleared and ligated. Treves advises ligation close to the level of the carotid, so as to avoid the recurrent laryngeal nerve. Innominate Artery. — First successfully ligated by DISEASES AND INJURIES OF HEART AND VESSELS. 29 1 Smyth of New Orleans. It is an almost certainly fatal operation. Anatomy. — The innominate artery arises from the begin- ning of the transverse portion of the arch of the aorta, passes to the back of the right sternoclavicular joint, and divides into the common carotid and subclavian. It rests upon the trachea. It has upon its outer side the pleura, the right innominate vein, and the pneumogastric nerve. Upon its inner side the remnant of the thymus and the beginning of the left carotid artery. In front of it are the inferior thyroid veins of the right side, the left innominate vein, the sterno- hyoid and sternothyroid muscles, the remnant of the thymus gland, and sometimes a branch from the right pneumogastric nerve. Ligation. — Patient supine, shoulders a little raised, and head thrown back. An incision from the upper margin of the sternum three inches in length along the anterior mar- gin of the sternomastoid. Another cut of the same length is made along the upper border of the clavicle to meet the first cut. Dissect up the flap of skin and fascia. Divide the sternal origin and a part of the clavicular portion of the sternocleido, and cut the sternohyoid and sternothyroid just above their sternal origins (Joseph Bell). Retract the inferior thyroid veins. Divide the dense leaflet of cervical fascia. Find the common carotid, and trace back along this vessel until the innominate comes into view. Retract the left innominate vein downward. The needle is passed from without inward to avoid the right innominate vein and right pneumogastric. If the needle is kept close to the artery, the pleura and trachea will not be injured.' Region of the Neck. — Anatomy. — The side of the neck is that space between the median line in front and the ante- rior edge of the trapezius behind, which space is limited be- low by the clavicle and above by the body of the jaw and an imaginary line running from the angle of the jaw to the mastoid process. The sternocleidomastoid muscle divides this space into an anterior and a posterior triangle, and each of the triangles is subdivided by other structures, the ante- rior into four spaces and the posterior into two (Fig. 61). Anterior Triangle. — The anterior triangle is bounded in front by the median line of the neck, behind by the anterior margin of the sternocleidomastoid, and above by the body of the lower jaw and an imaginary line from the angle of ^ See the exceedingly clear and terse account in that excellent book, A Man- ual of Su7-gical Operations, by Joseph Bell. 292 MODERN SURGERY. Lower jaw. the jaw to the mastoid process. This space is subdivided into four smaller triangles, namely, the inferior carotid, the superior carotid, the submaxillary, and the submental. The inferior' carotid triangle is called the " triangle of necessity," because the common carotid in it is ligated, not from choice, but through force of necessity. It is bounded in front by the median line, above by the anterior belly of the omohyoid and the hyoid bone, and below by the anterior edge of the sternomastoid. The floor of this triangle is com- posed of the longus colli, the sca- lenus anticus, the rectus capitis an- ticus major muscles, the sterno- hyoid and sternothyroid muscles. The superior carotid triangle is known as the " triangle of elec- tion," because, whenever possible, it is elected to tie the carotid in this situation. In this region the carotid is superficial, and there can be tied either the external, the in- ternal, or the common carotid, as may be desired. The triangle is bounded behind by the anterior edge of the sternomastoid, above by the posterior belly of the digastric, and below by the anterior belly of the omo- hyoid. Its floor is composed of the inferior and middle constrictors of the pharynx and the thyrohyoid and hyo- glossus muscles. The siibmaxillary triangle is bounded above by the body of the jaw and an imaginary line from the angle of the jaw to the mastoid process, behind by the posterior belly of the digastric and the stylohyoid muscle, and in front by the anterior belly of the digastric. Its floor is composed of the mylohyoid and hyoglossus muscles. The submental triangle is bounded on either side by the anterior belly of one digastric muscle ; its base is the hyoid bone and its floor is the mylohyoid muscle. The posterior triangle is bounded in front by the posterior border of the sternomastoid, behind by the anterior edge of the trapezius, and below by the clavicle. The posterior belly of the omohyoid subdivides it into two smaller spaces, the occipital and subclavian triangles. Clavicle. Fig. 61. — The triangles of the neck, right-sided view (after Keen) : I. Submaxillary triangle ; 2. Triangle of election, or superior carotid tri- angle ; 3. Submental triangle; 4. Triangle of necessity, or inferior carotid triangle ; 5. Occipital trian- gle ; 6. Subclavian triangle ; 7. Hy- oid bone. D/SEASES AND INJURIES OF HEART AND VESSELS. 293 The subclavian triangle is bounded above by the posterior belly of the omohyoid, below by the clavicle, and in front by the posterior border of the sternomastoid. Its floor is formed by the first rib and the first serration of the serratus magnus muscle. The occipital triangle is bounded in front by the posterior edge of the sternomastoid, behind by the anterior border of the trapezius, and below by the posterior belly of the omohyoid muscle. Common Carotid Artery. — The line of the common carotid artery is from the sternoclavicular articulation to midway between the angle of the jaw and the mastoid process, the head being turned toward the opposite side. Anatomy (PI. 3, Fig. 3). — The right common carotid arises from the innominate opposite the sternoclavicular joint ; the left common carotid arises from the arch of the aorta. In the neck the two carotids possess identical relations. The common carotid runs upward and outward from behind the sternoclavicular articulation to a level with the upper border of the thyroid cartilage, at which point it divides into the external and internal carotid. The common carotid is contained in a sheath from the cervical fascia, which sheath also holds, though in separate compart- ments, the internal jugular vein on the outer side of the artery and the pneumogastric nerve between the vein and artery and behind them. The anterior edge of the sterno- mastoid muscle lies over the artery and is a guide. Low in the neck the common carotid is deep, being covered by skin, superficial fascia, platysma, deep fascia, and the sternomas- toid, sternohyoid, and sternothyroid muscles. Above the omohyoid the vessel is more superficial, being covered by the skin, superficial fascia, platysma, deep fascia, and the an- terior edge of the sternomastoid. Upon the sheath (occa- sionally within it), above the crossing of the omohyoid muscle, lies the descendens noni nerve — the descending branch of the ninth pair of Willis (the hypoglossal). This nerve is a valuable guide to the sheath in the triangle of election. The sternomastoid branch of the superior thyroid artery crosses the carotid a little below its bifurcation, and the supe- rior thyroid veins cross it in this region ; the middle thyroid vein crosses the middle of the line of the artery, and the an- terior jugular vein crosses low down. The carotid rests upon the longus colli and rectus capitis anticus major muscles, the sympathetic nerve lying between the last-named muscle and 294 MODERN SURGERY. the vessel, outside the carotid sheath. The recurrent laryn- geal nerve passes behind the carotid below the omohyoid muscle, and the inferior thyroid artery passes behind the carotid just above the omohyoid muscle. The carotid is in relation internally with the trachea, thyroid gland, larynx, and pharynx. On its outer side are the pneumogastric nerve (which is on a posterior plane) and the internal jugular vein. On the left side, low down in the neck, the jugular vein often lies in front, or partly in front, of the artery. Ligation of the common carotid was first successfully performed in 1806 by Sir Astley Cooper. Ligation in the Triangle of Necessity. — In this operation the position is supine with the shoulders raised, a sand pillow un- der the neck, and the head turned to the opposite side with the chin raised. The operator stands upon the side operated upon. The incision, three inches long, at an angle of five degrees to the arterial line, runs from the level of the cricoid cartilage downward and inward toward the sternoclavicular joint, following the inner border of the sternocleidomastoid. Open the deep fascia, draw the sternocleidomastoid outward, retract the sternohyoid and sternothyroid muscles inward, and feel for the carotid tubercle of Chassaignac. This tuber- cle is the costal process of the sixth cervical vertebra, and lies directly under the artery. The tubercle is found about the point at which the omohyoid crosses the carotid. When the tubercle is found we know the situation of the artery, and that the triangle of necessity is below, and the triangle of election above, the tubercle. Pull the omohyoid muscle up- ward. Open the sheath of the artery on its inner side, clear it, and pass the needle from without inward to avoid the in- ternal jugular vein, remembering that the pneumogastric nerve is in the same sheath as the artery and vein, pos- terior and external to the artery. In this operation the in- ferior thyroid veins are much in the way, the anterior jugular vein crosses low down, and on the left side, at the root of the neck, the internal jugular vein may be in front of the carotid artery. If the incision is not sufficiently wide, divide the sternocleidomastoid or the sternohyoid and thyroid muscles. In the triangle of necessity the descendens noni nerve does not serve as a guide to the sheath. (See PI. 3, Fig. 4.) Ligation in the Triangle of Election. — The position for this operation is the same as in the preceding one. An incision, three inches in length, is made along the anterior edge of the sternomastoid in the line of the artery, the middle of this in- cision being opposite the cricoid cartilage. In cutting the DISEASES AND INJURIES OF HEART AND VESSELS. 295 superficial fascia, avoid the external jugular vein, the course of which should be outlined before making the incision. The line of the external jugular is from the angle of the jaw to the middle of the clavicle. Open the deep fascia, retract the sternocleidomastoid outward, feel for the carotid tubercle, draw the omohyoid downward, find the descendens noni nerve upon the sheath, open the sheath at its inner side, and pass the needle from without inward. This incision permits ligation of either the superior thyroid or the external, inter- nal, or common carotid, and if it be extended up a little, there can be tied through it, the lingual, and even the facial and occipital, arteries. (See PI. 3, Fig. 4.) Kxternal Carotid Artery. — The li/ie of the external carotid artery is the upper portion of the common carotid line. Anatomy (PI. 3, Fig. 3). — The external carotid artery, which is one of the terminal branches of the common carotid, arises on a level with the upper border of the thyroid cartilage and runs to the level of the neck of the condyle of the lower jaw. At its point of origin it is covered only by skin, platysma and fascia, and the edge of the sternomastoid, but as it ascends it passes beneath the digastric and stylohyoid muscles and into the parotid gland. The glossopharyngeal nerve, styloid process, and stylophaiyngeus muscle lie between the external and internal carotid arteries. The hypoglossal nerve crosses the vessel just below^ the digastric muscle, and the facial and lingual veins cross it a little below the nerve. The first branch is the superior thyroid, which arises from the veiy beginning of the trunk. The lingual arises on a level with the greater cornu of the hyoid bone. The facial and occipital take origin above the lingual. Each of them can be ligated through the incision of this operation. Operation. — The position is the same as that for ligation of the common carotid. The point of election is between the superior thyroid and the lingual. Make an incision three inches long in the arterial line, from near the angle of the jaw to opposite the middle of the th}Toid cartilage, cut through the skin, superficial fascia, platysma, and deep fascia, and retract the sternocleidomastoid outward. Look for the digastric muscle, find the hypoglossal nerve, and feel for the greater cornu of the hyoid bone. Open the sheath a little below the hyoid cornu and pass the needle from with- out inw^ard. Ligation of the external carotid has been ne- glected because ligation of the common carotid is easier. Internal Carotid Artery. — The line- of the internal 296 MODERN SURGER V. carotid is parallel with and half an inch external to the line for the external carotid. Anatomy (PL 3, Fig. 3). — The internal carotid artery, the other terminal branch of the common carotid, arises on a level with the upper border of the thyroid cartilage and enters the carotid canal. The first inch of the artery is the only point where a ligature is ever applied, this point being covered only by skin, platysma, fascia, and the sternomastoid ; higher up it is more deeply placed. It rests upon the vertebrae and the rectus capitis anticus major muscle. The internal jugular vein is in the same sheath and exte^-nal to the artery ; the pneumogastric is in the same sheath, between the artery and the vein, but posterior to both. The superior cervical ganglion of the sympathetic lies behind the origin of the internal carotid, and between the ganglion and the artery is the superior laryngeal nerve. Operation. — In this operation the position is the same as in ligation of the external carotid. Incision as for the external carotid, except that it is half an inch external. The sterno- cleido-mastoid is drawn outward, the external carotid artery is found and drawn inward, the internal carotid is found and drawn outward, and the needle is passed from without inward. The internal carotid is known by its more external position and by the fact that it gives off no branches. Superior Thyroid Artery (PL 3, Fig. 3). — This branches off from the external carotid below the level of the greater cornu of the hyoid bone, in the triangle of election. It is at first superficial, runs first upward and inward, next downward and forward, passes underneath the omohyoid, sternohyoid, and sternothyroid muscles, and reaches the thyroid gland. Ligation. — Same position of patient and surgeon as in carotid ligation. May be reached through incision employed in ligation of external carotid. Gross employed an incision starting at the edge of the hyoid bone, and running down- ward and outward to the sternomastoid muscle. Cut the skin, superficial and deep fascia, and find the artery deeply placed in the triangle of election between the carotid sheath and the thyroid gland. I/imgual Artery. — Anatomy (PL 3, Fig. 3). — The lingual artery arises from the external carotid opposite the greater cornu of the hyoid bone, passes beneath the digastric and stylohyoid muscles, reaches the margin of the hyoglossus, passes under that muscle, and emerges from under it to run along the under surface of the tongue. The place of elec- tion for ligation is where the artery is beneath the hyoglossus DISEASES AND INJURIES OF HEART AND VESSELS. 297 muscle and rests upon the genio<^lossus. Its guide is the hypoglossal nerve, which lies upon the muscle, but at a slightly higher level than the artery. Operation. — In this operation the position of the patient is recumbent with the shoulders raised and the face turned away from the side to be operated upon. The surgeon should stand upon the affected side. A curved incision is made from a little external to the symphysis of the lower jaw, downward and outward, to just above the greater cornu of the hyoid bone, and upward and outward to just in front of the facial artery at the lower edge of the lower jaw. Incise the skin, the superficial fascia and platysma, and the deep fascia. Clear the submaxillary gland and retract it well up- ward. Divide the fascia below the gland by a transverse in- cision. Find the posterior edge of the mylohyoid and the bellies of the digastric. Catch one of the digastric tendons and have it hooked down and out (Treves). Clear the hyo- glossus muscle with a dissector ; find the hypoglossal nerve and ranine vein and draw them a little upward. Divide the hyoglossus muscle transversely a little above the hyoid bone and below the level of the hypoglossal nerve, find the artery, and pass the needle from above downward. Facial Artery. — Anatomy (PI. 3, Fig. 3). — Arises from the external carotid a little above the lingual, runs upward and forward beneath the body of the inferior maxillary bone, passes along a groove in the posterior and upper surface of the submaxillary gland, crosses the body of the lower jaw at the lower anterior edge of the masseter muscle, and passes for- ward and upward to the angle of the mouth and side of the nose. Ligation (PI. 3, Fig. 4). — Is rarely ligated in the cervical portion, but may be reached through the incision employed for ligation of the external carotid. The vessel may be tied before it crosses the submaxillary gland, the styloyhoid and digastric muscles being drawn up. The vessel is reached in the facial portion of its course by a one-inch cut at the an- terior edge of the masseter muscle. Branches of the facial nerve are pushed aside. The needle is passed from behind forward to avoid the vein (Jacobson). Temporal Artery. — The line of the temporal artery passes " upward over the root of the zygoma, midway be- tween the condyle of the jaw and the tragus " (Jacobson). Anatomy. — Arises from the external carotid behind the condyle of the jaw and in the parotid gland, passes over the zygoma and divides into two terminal branches. Ligation. — Patient recumbent and head turned to opposite 298 MODERN SURGERY. side. An incision an inch in length is made, the superficial structures and dense fascia are divided, the vein is retracted backward, and the needle is passed from behind forward. Occipital Artery. — Takes origin from the posterior sur- face of the external carotid, below the digastric muscle and opposite the point of origin of the facial artery. It ascends beneath the digastric and stylohyoid muscles and parotid gland; the hypoglossal nerve hooks around it from behind forward. It crosses the internal carotid artery, the internal jugular vein, the pneumogastric and spinal accessory nerves ; passes between the mastoid process of the temporal bone and the atlas ; grooves the temporal bones ; penetrates the trape- zius and ascends over the occiput. Ligation. — We can ligate low down through the same incision as is employed to reach the external carotid. The hypoglossal nerve is avoided. To tie back of the mastoid process employ the same position as in ligation of carotid. Carry an incision from the tip of the mastoid upward and backward, reaching a point midway between the mastoid and the occipital protuberance (Jacobson). Cut the skin, the fascia, the sternocleidomastoid, the splenius capitis and possibly a portion of the trachelomastoid. Bring the head toward the operator to relax the structures, retract the edges, and clear the artery where it lies between the mas- toid and the transverse process of the atlas (Jacobson). An electric forehead light is of great assistance in finding the vessel. Pass the needle away from the vein or veins (there are often several). Dorsalis Pedis Artery. — The line of the dorsalis pedis artery is from the middle of the front of the ankle-joint to the middle of the base of the first interosseous space. Anatomy (PI. 4, Fig. i). — The dorsalis pedis is a continua- tion of the anterior tibial arteiy, and it runs from the bend of the ankle to the proximal extremity of the first interosseous space, where it divides into the dorsalis hallucis and the com- municating arteries. The artery rests, from above downward, upon the astragalus, scaphoid, and internal cuneiform bones, and at its point of bifurcation lies between the heads of the first dorsal interosseous muscle. It may lie in some persons a little external to this course. It is held upon the bones by a distinct layer derived from the deep fascia. This artery is covered by skin, by superficial and deep fascia, and by the annular ligament above, and is sometimes partly overlaid by the extensor proprius pollicis muscle, and is crossed, just be- fore its bifurcation, by the innermost tendon of the extensor LIGATIONS. Plate 4. ■**Vi.>ij|^^jj^^ ■2 S < < DISEASES AND IXJURIES OF HEART AND VESSELS. 299 brevis muscle. The inner tendon of the extensor longus digitorum is to the outer side of the vessel ; the tendon of the extensor proprius pollicis is to the inner side, and is a guide. The artery is ligated in the dorsal triangle of the foot — a space which is bounded abov^e by the lower edge of the an- nular ligament, externally by the inner tendon of the extensor brevis, and internally by the tendon of the extensor proprius pollicis. The artery has venae comites ; the anterior tibial nerve lies, as a rule, to its inner side, but may be found upon the artery or to its outer side, and the inner division of the musculocutaneous nerve is external to the vessel in the superficial parts. Operation (PI. 4, Fig. 2). — In this operation the position of the patient is supine with the legs and feet extended. Heath flexes the leg partly and rests the sole of the foot directly upon the table. The surgeon stands below the extremity, cutting from above downward. Make an incision two inches in length along the arterial line, beginning opposite the lower edge of the annular ligament and running along by the tendon of the extensor proprius pollicis; cut through the skin and superficial and deep fascia ; have the toes extended ; retract the tendon of the extensor proprius pollicis inward, and the tendon of the extensor longus outward ; clear the artery, find the nerve, try to separate the venae comites, and pass the needle from the nerve. Anterior Tibial Artery. — To locate the line of the anterior tibial, find a point midway between the head of the fibula and the tuberosity of the tibia, drop one inch, and draw a line from the second point to the middle of the front of the ankle-joint. Anatomy. — The anterior tibial artery is one of the termi- nal branches of the popliteal. It arises opposite the lower border of the popliteus muscle, passes forward between the two heads of the posterior tibial muscle, comes to the front of the leg through an opening in the interosseous mem- brane, and runs down to the middle of the front of the ankle-joint. In the upper two-thirds of its course it rests upon the interosseous membrane, to which it is fastened by firm fascia ; in the lower third it lies first upon the front of the tibia and then upon the anterior ligament of the ankle- joint. For its upper two-thirds the artery has the tibialis anticus muscle just internal to it; at the junction of the middle and lower thirds the extensor proprius pollicis comes from the outside and lies either upon the artery or to its inner side for the rest of its course. Externally in its upper 300 MODERN SURGERY. third is the extensor longus digitorum, in the middle third is the extensor proprius polhcis ; in the lower third, the proprius pollicis, having crossed to the inner side, the ex- tensor communis digitorum again becomes the outer boun- dary. The artery is covered by skin and by superficial and deep fascia. In its upper third it is deeply set between the muscles ; in its middle third it is less overlaid by muscle ; in its lower third it is superficial except where it is crossed by the extensor proprius and where it is covered by the annular ligament. The artery has venae comites. In the lower three- fourths of its course it is accompanied by the anterior tibial nerve, which in its course in the upper third of the leg is external to the artery ; in the middle third it is external and a little in front of the artery ; and in the lower third it is ex- ternal to or upon the artery (PI. 3, Fig. 5). Operations. — The ligations of the anterior tibial (PI. 3, Fig. 6) are (i) in the lower third; (2) in the middle third; and (3) in the upper third. In all these ligations the sur- geon stands outside of the extremity, cutting from above downward on the right side and from below upward on the left side. Ligation in the Lower Third. — The surgeon stands to the outside of the extremity, cutting from above downward upon the right leg and from below upward on the left leg. Make an incision three inches long in the line of the artery and over the annular ligament. This incision is external to the tibialis anticus muscle and half an inch from the outer border of the tibia (Barker). Divide the skin and fascia, retract the tendon of the tibialis anticus inward, and the tendon of the extensor proprius polhcis outward, along with the tendons of the extensor longus. Flex the ankle-joint to relax the tendons, and clear the artery. Draw the nerve external and pass the ligature from without inward. In order to recog- nize the muscles in this as in other ligations, rely largely upon the finger while the muscles are being moved. Ligation in the Middle Third. — In this operation the pro- cedure is similar to the above. Remember that the nerve lies upon the vessel and that the extensor proprius pollicis muscle is external. The nerve is retracted outward and the needle is passed from the nerve. A good rule for detecting the artery is to find the outer edge of the tibia and by this locate the interosseous membrane, and then, by passing out along this membrane, discover the artery. Ligation in the Upper Third. — In this operation the posi- tion is the same as in the above. Make an incision three DISEASES AND INJURIES OF HEART AND VESSELS. 30I inches long in the arterial line. On opening the deep fascia, do not rely on the eye for finding the muscular interspace, as often the latter cannot be seen, and neither a white nor a yellow line is reliable. Place the index finger deep in the wound and have the tibialis anticus and extensor longus muscles successively rendered tense by an assistant. In opening the interspace use the handle of the knife. Relax the muscles, retract the tibialis anticus inward, and draw the extensor longus outward. Find the interosseous mem- brane where it is attached to the edge of the tibia, and the artery will be found upon this membrane, between the tibia and the nerve. Clear the vessel and pass the ligature from without inward to avoid the nerve. Posterior Tibial Artery. — The line of the posterior tibial is from the middle of the popliteal space to a point midway between the tip of the inner malleolus and the point of the heel (PI. 4, Figs. 5, 6). Anatomy. — The posterior tibial is the larger of the two terminal branches of the popliteal. It arises opposite the lower border of the popliteus muscle, runs down between the deep and superficial flexor muscles to midway between the tip of the malleolus and the point of the heel, and divides into the external and internal plantar vessels. In its upper third it is very deep and midway between the tibia and fibula; in its middle third it is less deep, having passed inward; and in its lower third it is superficial. At the ankle the artery is beneath the annular ligament. From above down- ward the posterior tibial artery rests upon the posterior tibial muscle, the flexor longus digitorum muscle, the posterior surface of the tibia, and the internal lateral ligament of the ankle-joint. For the first inch or two of the course of the artery the posterior tibial nerve is internal ; the nerve then crosses to the outer side, and remains on that side through- out the rest of its course. When the knee is partly flexed and the leg is laid upon its outer surface the artery is be- tween the operator and the nerve, and the nerve is between the artery and the table. Back of the malleolus, in the first compartment, lies the posterior tibial muscle ; in the next compartment is the flexor longus digitorum muscle ; in the next are the artery and nerve ; and in the most posterior is the flexor longus pollicis muscle. Operations. — Ligation back of the Malleolus. — In this ope- ration the position of the patient is recumbent with the thigh abducted and the leg flexed and resting upon its outer sur- face. The surgeon stands to the outside. Make a two-inch 302 MODERN SURGERY. semilunar incision corresponding in its curve to the malle- olus and half an inch posterior to its margin. Cut down to the annular ligament, incise it, and find the artery and venae comites. Clear the vessel and pass the needle from behind forward (to avoid the nerve, which is here posterior and external). Do not make the preliminary incision nearer the malleolus than half an inch, as the sheath of the tibialis posticus muscle would then surely be opened. In sewing up, suture the ligament by buried sutures (PI. 4, Fig. 6). Ligation in the Middle of the Leg. — In this operation the position is the same as in the abo\^e. Feel for the inner border of the tibia, and make an incision four inches long one inch behind the osseous border, parallel with it, and ex- tending through skin and superficial and deep fascia. Draw the gastrocnemius outward. Incise the soleus, but not the fascia beneath the soleus ; cut this fascia, after dropping the handle of the knife so that the blade is at right angles with the plane of the tibia. Clear the artery ; pass the needle from without inward (PI. 4, Fig. 6). The popliteal artery is almost never ligated in con- tinuity. It can be tied at the upper portion of the popliteal space, at the lower portion of the popliteal space, or at the inner side of the thigh. Anatomy (Fig. 62). — The popliteal artery is the continua- tion of the femoral, and runs from the opening in the adductor magnus muscle to the lower margin of the popliteus muscle. This vessel runs downward and outward behind the knee- joint and in the popliteal space. The ham or popliteal space is a lozenge-shaped space, which above the joint is bounded on the outside by the biceps, and on the inside by the semitendinosus, semimembranosus, gracilis, and sar- torius muscles, while below the joint it is bounded externally by the plantaris and outer head of the gastrocnemius muscles, and internally by the inner head of the gastrocnemius muscle. The floor of this space is formed by the surface of the femur, the posterior ligament of the knee-joint, the end of the tibia, and the popliteus fascia. The internal popliteal nerve runs down the middle of the popliteal space ; it is superficial to the vessels, in the upper half of the space external to them, in the lower half internal to them. The external popliteal nerve is in the outer side of the space. The popliteal vein is between the nerve and the artery. Above the knee-joint it is to the outside of the artery, but below the knee-joint it is to the inner side. The artery lies deeply in the space. Ligation in Upper Third. — Patient prone. The surgeon DISEASES AND hXJURIES OE HEART AND VESSELS. 303 Stands on the outside of the Hmb and makes a vertical incision three inches in length along the outer margin of the semi- membranosus muscle, exposes the popliteal nerve, retracts the muscle inward and the nerve outward, exposes the artery, Fig. 62. — Anatomy of popliteal artery (Bernard and Huette). Fig. 63. — Ligation of popliteal artery in its upper third (Bernard and Huetie). separates it from the other structures, and passes the needle from without inward (Fig. 6-^. Ligation in Lozver Tliii'd. — Make a three-inch vertical incision between the heads of the gastrocnemius muscle. Avoid the external saphenous vein and nerve, and retract them with the popliteal nerve. Separate the artery from the vein and pass the needle from within outward. Femoral Artery. — The line of the femoral artery is from midway between the anterior superior spine of the ilium and the symphysis pubis to the adductor tubercle on the inner condyle of the femur, the thigh being abducted and resting upon its outer surface (PI. 4, Fig. 3). Anatomy. — The femoral artery is the continuation of the external iliac trunk ; it extends from the lower border of Poupart's ligament to the opening in the adductor magnus muscle, and hence occupies the upper two-thirds of the thigh. The artery for its first five inches is superficial, lying in Scarpa's triangle, a space which is bounded externally by the sartorius musc:le and internally by the adductor longus. 304 MODERN SURGERY. its base being Poupart's ligament and its floor being com- posed of the psoas, iliacus, pectineus, and adductor longus muscles, and often the adductor brevis. The artery- enters the triangle as the common femoral, but after a two-inch course it divides into the profunda (which passes deeply), and the superficial femoral. The latter vessel is the one alluded to in this section. At the base of Scarpa's triangle the vein is internal, the artery is between, and the nerve is external (v. a. x.j. At the apex of the triangle the vein is internal and a little pos- terior. At the apex of the triangle the superficial femoral passes under the sartorious muscle and enters into Hunter's canal, which occupies the middle third of the thigh and which terminates at the opening by the adductor magnus muscle. Hunter's canal is bounded externally by the vastus internus, internally by the adductors longus and magnus, and its roof is fascia which stretches from the adductor longus to the vastus. In Hunter's canal the vein is behind the artery in the upper part, but external to it in the lower part, and is firmly attached to the artery. There may be two veins. Inside Hunter's canal, but outside the femoral sheath, is the long saphenous nerve, which crosses the arter>' from without inward. A way to remember the relation of the femoral vein to the femoral artery is to recall the fact that the relation of the vein to the arteiy is always contrary to the relation of the sartorius muscle to the artery : when the sartorius muscle is external to the arter}^ the vein is internal, as at the base of Scarpa's triangle ; when the sartorius muscle is cross- ing in front toward the inside of the artery the vein is pass- ing at the back to the outside, as at the apex of Scarpa's triangle ; when the muscle is over the artery the vein is back of it. as in the upper third of Hunter's canal ; and when the muscle is to the inside of the artery the vein is to the out- side, as in the lower two-thirds of Hunter's canal. In a ligation at the apex of Scarpa's triangle the inner edge of the sartorius is the guide. In a ligation in Hunter's canal the long saphenous nerve is the guide. Operations. — Ligation of the S^ipcrficial Femoral at the Apex of Scarpa's Triangle. — In this operation the position is supine with the thigh and leg partly flexed, the thigh abducted, everted, and rested upon its outer surface on a pillow. The operator stands to the outside of the leg. From a point cor- responding to the middle of the triangle, and two and a half inches below Poupart's ligament, make a three-inch incision DISEASES A. YD INJURIES OF HEART AND VESSELS. 305 in the arterial line. Cut the skin and superficial fascia. The saphenous vein will not be seen unless the incision is internal to the arterial line ; if this vein is seen, draw it inward. Open the fascia lata, find the inner border of the sartorius muscle, and draw it outward. The fibers of this muscle run downward and inward, thus distinguishing it from the ad- ductor longus, whose fibers run downward and outward. Open the common sheath for the artery and vein, and then incise the individual arterial sheath. Clear the artery and pass the ligature from within outward (PI. 4. Fig. 4). Ligation of the Superficial Femoral in Hunter s Canal. — In this operation the position is the same as in the above. Make a three-inch incision in the middle third, but above the middle of the thigh, parallel with the arterial line and half an inch internal to it (Barker). Incise the skin and superficial fascia, look out for the internal saphenous vein, open the fascia lata, and find the sartorius and retract it inward, thus exposing the roof of Hunter's canal, which is to be opened for an inch or more. Within the canal is seen the long saphenous nerve, usually upon the sheath. Open the sheath of the artery, clear the vessel, and pass the needle from without inward. Iliac Arteries. — The line of the common and external iliac is from half an inch below and half an inch to the left of the umbilicus to midway between the anterior superior spine of the ilium and the pubic symphysis. The upper third of this line represents the common iliac, and the lower two-thirds the external iliac (PI. i. Fig. 4). Anatomy. — The common iliac arteries arise from the aorta opposite the left side and lower border of the fourth lumbar vertebra, and extend to the upper margin of the right and left sacroiliac joints, where they each bifurcate into an exter- nal and an internal iliac. The common iliac arteries lie upon the fifth lumbar vertebra, are covered with peritoneum, and are crossed by the ureters. In women the ovarian arteries cross the common iliacs. The common iliac veins lie to the right side of their respective arteries. The right common iliac artery has in front of it, besides the peritoneum and ureter (in women also the ovarian artery), the ileum, branches of the superior mesenteric artery, and branches of the sym- pathetic nerve. The left common iliac artery has in front of it, in addition to structures common to both sides (ureter, ovarian artery, sympathetic branches), branches of the infe- rior mesenteric artery and the sigmoid flexure with its meso- colon. The internal iliac artery runs from the sacroiliac joint 20 3o6 MODERN SURGERY. to the upper margin of the great sacrosciatic foramen. It is very rarely Hgated (only in gluteal aneurysm, uncontrollable hemorrhage from the gluteal or sciatic arteries, or to pro- duce atrophy of the prostate gland). The external iliac runs from the sacroiliac joint along the pelvic brim, upon the inner edge of the psoas muscle, to Poupart's ligament. The exter- nal iliac vein is internal to the artery. On the right side high up, it passes behind the artery. The external iliac artery has in front of it peritoneum and subserous tissue (Abernethy's fascia). The ileum crosses the right, and the sigmoid flexure the left, external iliac. The genital branch of the genito- crural nerve crosses the artery low down, and the circumflex iliac vein crosses it just before it terminates in the femoral. The spermatic vessels and the vas deferens in the male, the ovarian vessels in the female, lie upon it, low down. Some- times the ureter crosses it high up. We find the spermatic vessels in the male and the ovarian in the female lying for a time upon the inner side of the artery. Ligation of the Iliac by Abdominal Section. — The best method for ligating the common, the external or the in- ternal iliac is by abdominal section. The patient is placed in the Trendelenburg position. The abdomen is opened in the midline below the umbilicus. The intestines are lifted toward the diaphragm, and are held up by gauze pads. The edges of the incision are retracted. Select the vessel you wish to tie and decide where you wish to apply the ligature. Open the peritoneum posteriorly and pass the aneurysm needle. In ligating either common iliac, pass the needle from right to left. In ligating the external iliac, pass the ligature from within outward. In ligating the internal iliac pass the needle from within outward. It is not neces- sary to suture the posterior layer of peritoneum. The abdo- men is closed without a drain. In these operations be sure and push the ureter out of the way. This method of oper- ating is endorsed by Dennis, Hearn, Marmaduke Shield, Mitchell Banks, and others. Ligation of the External Iliac by Abernethy' s Extraperito- neal Method (PI. I, Fig. 4).^The position of the patient is recumbent with the thighs extended during the first incisions, but in the latter stages of the operation they are flexed a little to relax the abdominal structures. The operator stands to the outside. The surgeon will find the artery along the psoas muscle. Mark a point one inch above and one inch external to the middle of Poupart's ligament, and another point one inch above and one inch internal to the anterior superior iliac DISEASES AND INJURIES OF HEART AND VESSELS. 307 spine (Barker). Join these two points by a curved incision four inches long and convex downward. Cut the skin, the fat, the two obhque and the transversaHs muscles ; open the transversalis fascia, draw the peritoneum inward by a broad Fig. 64. — A, Nephrotomy : a, last dorsal n. ; b, latissimus dorsi m. ; c, serratus post, in- ferior m. ; d, middle layer of lumbar fascia ; e, outer layer ; _/", ext. oblique m. ; g, int. oblique m ; /;, pennephritic (extraperitoneal) fat; i, quadratus lumborum m, ;_/', erector spinse m. B, Nephrotomy : a. first lumbar n. ; h, kidney : c, transversalis fascia. C, Ligature of the sciatic and internal pudic arteries, and exposure of the great sciatic, small sciatic, and inter- nal pudic nerves : a, glutseus maximus m. ; b, inf. gluteal n. : c, sciatic a. ; d, int. pudic a. and n. ; e , great sciatic n. ; /, small sciatic n ; g, pyriformis m. D, Ligature of the gluteal artery and exposure of the superior gluteal nerve : a, glutseus maximus m. ; b, gluteal a. ; c, superior gluteal n. ; d, pyriformis m. ; c, glutaeus medius m. (Kocher). retractor, and look for the artery along the pelvic brim. The anterior crural nerve is seen external to the artery, the vein is internal to the artery, and the genitocrural nerve is upon the artery. Clear the artery near its middle and pass the 308 MODERN SURGERY. ligature from within outward. In Sir Astley Cooper's ligation the inguinal canal is laid open. The Gluteal Artery. — This vessel is a continuation of the posterior division of the internal iliac. It emerges from the pelvis at the upper border of the pyriformis muscle. It rests upon the glutseus minimus and divides into three branches, and is covered by the glutseus maximus muscle. The superior gluteal nerve lies inferior to the artery (Fig. 64). Ligation. — Patient is prone. The surgeon stands to the outside. The incision corresponds to a line drawn from the posterior superior iliac spine to the upper border of the great trochanter. Divide the skin, fascia, glutaeus maximus muscle, and fascia over the glutaeus medius, retract the glutseus medius upward. Feel for the great sacrosciatic foramen, and at this point the artery is found above the pyriformis muscle. Clear the vessel and pass the needle from below upward (see Kocher). The Sciatic Artery. — This artery is the larger of the terminal branches of the anterior division of the internal iliac artery. It passes to the lower portion of the great sacrosci- atic foramen, lying back of the internal pudic artery, and rest- ing upon the sacral plexus and pyriformis muscle (Gray). It leaves the pelvis between the pyriformis and coccygeus muscles and passes downward between the ischial tuberosity and great trochanter. It is covered by the glutaeus maximus muscle, rests upon the gemelli, internal obturator and quad- ratus femoris muscles, and has the great sciatic nerve exter- nal to it, and the small sciatic nerve external and posterior (Fig. 64). Ligation. — Patient lies prone. Surgeon stands to outside. Incision " corresponds to the middle two-thirds of a line ex- tending from the posterior inferior iliac spine to the base of the great trochanter." ^ Cut the skin, fat, fascia, and glutaeus maximus muscle. Find the artery at the lower border of the pyriformis muscle and trace it to its point of emergence from the pelvis. Pass the ligature from without inward. Internal Pudic Artery. — Is one of the terminal branches of the anterior trunk of the internal iliac. It runs to the lower margin of the great sacrosciatic foramen, and leaves the pelvis between the pyriformis and coccygeus muscles, crosses the ischial spine and again enters the pelvis by the lesser sacrosciatic foramen. The vessel is accompanied by the internal pudic nerve (Fig. 64). Ligation. — Position and incision as in ligation of sciatic. 1 Kocher's Operative Surgery, by Stiles. DISEASES AND INJURIES OE BONES AND JO/NTS. 3O9 The artery is found below the ischial spine. Pass the needle from below upward to avoid the nerve. XIX. DISEASES AND INJURIES OF BONES AND JOINTS. I. Diseases of the Bones. Atrophy of bone is a diminution in the amount of bony- matter without change in osseous structure. It arises from want of use (as seen in the wasting of the bone of a stump) or from pressure (as seen in the destruction of the sternum by an aneurysm of the aorta). Eccentric atrophy is the thinning of a long bone from within, the outer surface being unchanged. It is usually a senile change. Concentric atrophy means a thinning of the outer surface of the shaft, causing a lessened diameter. It is usually linked with eccen- tric atrophy. Hypertrophy of bone may be due to increased blood- supply (as is seen in chronic epiphyseal inflammation), the bone growing much more than does its fellow. It may arise from excessive use or from strain, as is seen in the increased size of the fibula when the tibia is congenitally absent (Bowlby). Tumors of Bone. — Bones give origin to both innocent and malignant tumors. Myeloid sarcoma takes origin in the endosteum and expands the bone. The fasciculated sarcoma is a periosteal growth. Besides these growths we find osteomata, chondromata, and secondary deposits of can- cer and sarcoma. Primary cancer of bone does not exist. A bone may become cystic, and occasionally the cysts are due to hydatids. Gummata are the commonest growths found springing from bone. Actinomycosis of Bone. — Most usual in the jaw, but may attack the orbit, ribs, sternum, or limbs (p. 183). Tubercle of Bone. — Tends especially to appear in the cancellous ends of long bones. Is apt to caseate and destroy large amounts of bone. The bone does not sclerose, but undergoes alterations of an osteoporotic nature (see p. 154). Osteitis, Periostitis, and Osteoperiostitis. — Ostei- tis, or inflammation of bone, may be due to traumatism, to a constitutional malady or diathesis, to the extension of inflammation from some other structure, or to infection. In inflammation of bone the exudation flows into the Haver- sian canals and spaces and the canaliculi, the corpuscles of 310 MODERN SURGERY. the exudate and the bone-corpuscles proHferate, embryonic tissue forms, the bone undergoing thinning (rarefaction), not because of pressure, but because of absorption by voracious leukocytes and osteoclasts. This process of rarefaction en- larges all the bony spaces, and by destroying septa throws many of the spaces into one. If the surface of a bone in- flames, the periosteum will more or less be separated by the exudation and the bone will be covered with little pits or erosions. Inflamed bone is so soft that it can readily be cut with a knife. Osteitis may terminate in resoliitio7i or it may terminate in sclerosis, the exudate being converted first into fibrous tissue and next into dense bone with only a few small cancellous spaces. If the exudation is under the periosteum, the bone will be thickened at this point, bone stalactites marking the points of passage of the vessels. Osteitis may terminate in suppuration, this condition being known as " caries!' In tubercular osteitis caseation of the inflammatory products is very apt to arise (tubercular or strumous caries). Acute osteitis may terminate in necrosis. Osteitis is usually asso- ciated with more or less periostitis. A simple acute peri- ostitis without involvement of the bone can arise from trau- matism, but in all severe cases of periostitis, in all chronic cases, in all cases due to syphilis, rheumatism, measles, scar- latina, or enteric fever the bone is involved at the same time or subsequently. In syphilitic states gummatous de- generation frequently ensues. Symptoms of Osteitis and Osteoperiostitis. — As a chronic process the symptoms of osteitis are commonest in the femur. Its history usually exhibits a record of a cold or an injury. Pain is severe, boring or aching in character, deep- seated, worse at night, and aggravated by a dependent position of the part. The symptoms closely resemble those of perios- titis, with which disease it is almost sure to be hnked. Ten- derness exists on percussion, and sometimes on pressure. Subperiosteal swelling, fusiform in shape, is noted ; cutaneous edema and discoloration are observed if a superficial bone be involved. In syphilis, atrophic osteitis may attack the cranial bones and produce softening or even perforation, or osteophytic osteitis may arise, exostoses being formed. Osteoperiostitis may be acute or chronic, circumscribed or diffused, and may terminate in resolution, organization, or suppuration. It arises from cold, blows, wounds, strains, the spread of adjacent inflammation, specific febrile maladies, pyogenic infection, syphilis, rheumatism, or tubercle. The DISEASES AND INJURIES OF BONES AND JOINTS. 3 I I symptoms are pain (which is worse at night and which is aggravated by motion, pressure, or a dependent position), swelHng, edema, and discoloration of the soft parts. Pain in the syphiUtic form is not so severe as in other varieties. Acute ?iccrosis or diffuse periostitis, a septic inflammation of bone and periosteum, is commonest in boys about the age of puberty. It is usually due to cold, a specific fever, or injury, and generally affects the tibia or femur ; the symp- toms locally are severe ; redness, swelUng, and pain are marked ; constitutionally there are rigors, fever, or convul- sions. Necrosis is apt to result. Pyemia is common. Some fever always exists. In simple acute periostitis a swelling is felt upon the osseous surface. The swelling is firmly fixed and is very tender, but the bone itself is not enlarged. There is some local heat, discoloration, often fever, and the patient complains of an aching pain, which is worse at night. Treatment of Osteitis and Osteoperiostitis. — In syphilitic forms the treatment consists of rest, elevation of the part, the local use of iodin and mercurial ointment, and bandag- ing. Specific treatment is by the stomach or hypodermati- cally. Operation is rarely justifiable. In other forms, if the case be recent and severe, put the patient to bed, place the limb in a splint and elevate it, apply leeches, cold, and lead-water and laudanum, use a bandage, and order salines and iodid of potassium. Morphin is used for pain. If these means fail, order counterirritation by iodin and blue oint- ment or blisters, and use heat locally. In severe cases take a tenotome and slit the periosteum subcutaneously to reliev^e tension ; this procedure often instantly relieves the pain. Some cases demand a longitudinal osteotofny, which is performed by taking Hey's saw and dividing the bone longitudinally into the medullary canal. If pus forms, drain at once. Diffuse osteoperiostitis requires early and free incisions, antiseptics, drainage, rest and deviation of the limb, and strong supporting and stimulating treatment. Amputation is sometimes demanded, as when the patient grows weaker and weaker even after incision, and when a joint is seriously involved. If the necrosis affects the entire shaft, which separates from its epiphyses, and new bone has not yet formed from the periosteum, make a subperiosteal resection of the shaft. Chronic periostitis is usually syphilitic. A node is a chronic inflammation of the deep periosteal layers. Nodes occurring early in the secondary stage remain soft and soon 312 MODERN SURGERY. pass away, but those occurring two years or more after infection are apt to cause a bony deposit. A node may suppurate, leaving a sinus at the bottom of which is a piece of dead bone. Gumma of the periosteum is one form of node which is apt to produce caries or necrosis. Osteoplastic periostitis accompanies chronic osteitis and causes the deposit of new bone which undergoes sclerosis. The chief symptom is aching pain, which is worse when warm in bed, and is aggravated by damp and wet. A swelling is found at the seat of pain (often over the tibia, ulna, clavicle, or sternum). The soft parts are uninflamed and move freely unless softening or suppuration has occurred. Tenderness is manifest. Treatment. — For the nodes of early syphilis use mercurial treatment ; for the nodes of late syphilis give mercury and large advancing doses of iodid of potassium. Blisters, blue ointment, and iodin used locally, and subcutaneous division of periosteum, are of value. If suppuration occurs, open antiseptically. Abscess of bone is due to tubercular infection. It is always chronic, never acute. A very acute inflamma- tion, such as is induced by pyogenic organisms, causes acute necrosis rather than an acute abscess. After a chronic abscess begins mixed infection may take place, the seat of abscess being a point of least resistance. Chronic ab- scess of bone was first described by Sir Benjamin Brodie, and is often called " Brodie's abscess." It occurs in the cancellous structure of the ends of bones — usually in the head of the tibia, sometimes in the femur or humerus. The cause of bone-abscess is injury which induces osteitis ; bone- rarefaction forms a cavity, the inflammatory products case- ate and sometimes suppurate, and the surrounding bone thickens and hardens because of growth from the perios- teum. The abscess is apt to break into a joint, as the joint- surface is not covered by periosteum and no barrier of bone is there formed. Brodie's abscess may induce necrosis. Symptoms. — The symptoms are like those of osteo- periostitis, only they are localized and persistent. These symptoms are thickening of bone and soft parts, edema and discoloration of skin, tenderness, constant pain (sub- ject to violent exacerbations and made worse by motion, pressure, or a dependent position), and attack after attack of synovitis in the nearest joint. Fever and sweats may be noted. Treatment. — In treating bone-abscess, trephine the bone D/SEASES AND INJURIES OF BONES AND JOINTS. 313 at the point of the greatest tenderness, and if the abscess is missed, follow the advice of Holmes and perforate the wall of bone with the trephine, opening in several directions to discover the pus. It is often easy to open into the abscess with a chisel or gouge. If the abscess opens into a joint, trephine the bone and open and drain the joint. After opening the cavity gouge its walls clean, dry with gauze, touch with pure carbolic acid, and pack with iodoform gauze. Caries is suppurative osteitis, a molecular osseous de- struction. In some cases caries is a name given to sup- purative osteitis, in others to tubercular osteitis, in still others to gummatous osteitis. Osteitis is apt to become purulent when the bone is exposed to the air, when rest is not secured, when the health of the individual is below nor- mal, when a foreign body such as a bullet is in the bone, or when tubercle or syphilis exists. When caries arises, the softened and granulating bone breaks down and is dis- charged through a sinus. After drainage is secured or- ganization, sclerosis, and healing result. In these cases new bone usually forms, and a cure results. Tubercular caries, due to caseation of the products of an osteitis in a tubercular subject, shows no tendency to self- cure, no organization or sclerosis takes place and no new bone forms. The interior of bones, especially of the carpus and tarsus, being entirely softened and destroyed, thin shells only are left. Caries necrotica is a condition in which small but visible portions of soft and dead bone are cast off; caries sicca is molecular death of bone without suppuration. The caseating masses in tubercular caries contain the tubercle bacillus. If a tubercular collection is evacuated and infection with pus organisms occurs, genuine suppuration takes place, and constitutional infection causes suppurative fever, and may cause death. Purulent osteitis may affect any part of any bone, but caseous osteitis (tubercular caries) tends to arise especially in cancellous structures (heads of long bones, vertebral bodies, ribs and sternum, and bones of the carpus and tarsus). Tubercular osteitis of the shaft of a long bone occasionally, but rarely, arises. Tubercular osteitis is apt to cause tubercular disease in an adjacent joint. Cold abscesses are frequently due to tuber- cular osteitis. Symptoms. — In the beginning the evidences of caries are usually those of osteitis, but the first sign noted may be a fluctuating swelling due to pus or to caseated tubercles. 314 MODERN SURGERY. After a time, at any rate, a fluctuating swelling is discovered. If not opened, the abscess breaks, voids its contents, and leaves a sinus from which runs a purulent matter which after a time becomes thin, reddish, and irritating to the skin, contains small portions of gritty bone, and has a foul smell. The opening of the sinus fills up with edematous granu- lations. A probe introduced to the bottom of the sinus finds bone which is sieve-like (worm-eaten), and which on being struck gives a muffled note rather than the clear, sharp note of necrosis ; the bone is rough, is bared, and is so soft that the probe can usually be stuck into it. In old cases of caries amyloid disease may arise. Treatment. — If syphilis exists, give iodid of potassium in advancing doses and a mild mercurial course. If tubercle ex- ists, give iodid of iron, arsenic, cod-liver oil, and nourishing foods, and recommend a change of air. Locally, in all cases, insist on rest and at once secure drainage, enlarging the open- ing if necessary and inserting a tube, and even making addi- tional openings ; syringe often with antiseptic fluids and dress antiseptically. If the case is seen before the abscess has opened, open it under strict antiseptic precautions. When the case is found to be chronic there arises the question of opera- tion. Incomplete operations are worse than useless, for they may cause pyemia, and if the case be tubercular may inaugu- rate systemic diffusion of the infection. If the gouge is used, try to remove all carious bone. The diseased bone is white, crumbles up, and does not bleed ; the non-carious bone is pink and vascular. Scrape away all granulations ; swab out the cavity with pure carbolic acid and pack it with iodoform gauze. Instead of gouging away bone, there may be used the actual cautery, sulphuric acid, or hydrochloric acid. In severe cases excision is required, and in some very rare cases amputation may be necessary. Caries of the spine is con- sidered under Diseases of the Spine. Necrosis is the death of visible portions of bone from circulatory impediment. It is analogous to gangrene. The cause of necrosis is injury (such as the tearing off of perios- teum) which deprives the bone of blood. Inflammation of the periosteum further lessens the nutrition. Acute inflam- mation in bone causes necrosis, the excessive exudation in the canals and spaces obliterating the blood-vessels by pressure. The occlusion of vessels by septic thrombi may lead to necrosis, or the direct action of toxins may first inflame and finally destroy a portion of the bone. A thin shell of bone only may necrose from periosteal separa- DISEASES AND INJURIES OF BONES AND JOINTS. 315 tion, or an entire shaft may die from acute osteomyelitis or diffuse infective periostitis. Osteomyelitis is the most usual cause of necrosis. Necrosis is most frequently met with in the diaphyses of the long bones, caries in the heads of the bones. A sequestrum may form in a vertebral body, in the carpus, or in the tarsus, but rarely does ; hence, we conclude that sequestra do not often result from tubercular osteitis. A fragment of dead bone is a foreign body ; the healthy bone adjacent to it inflames, softens, and granulates, and this line of granulation, like the line of demarcation of gangrene, separates the dead part from the living, the white dead bone being surrounded by the red zone of granulation- tissue. A bit of dead bone is called a " sequestrum," and Nature tries to cast it off. A superficial sequestrum is known as an " exfoliation." Nature's method of casting off a sequestrum is as follows : suppuration takes place at the line of demarcation, osteitis extends for a considerable distance around this line, the peri- osteum shares in the inflammation, and new bone forms. A cavity thus forms within by suppuration, and a box or case forms without by ossification, the now entirely loosened se- questrum being so encased that it cannot escape. The pus finds its way through the new bone, and there is presented the condition so often seen by the surgeon — namely, a case of new bone known as the " involucrum," a cavity containing pus and the dead fragment or sequestrum, and a discharging Fig. 65. — Diagram illustrating the formation of a sequestrum : ^, sound bone; 5, new bone ; C, granulations lining involucrum ; D, cloaca ; E, sequestrum. sinus or " cloaca " (Fig. 65). Nature may eventually get rid of the fragment, but the surgeon should not wait. When a portion of the bone surrounding the medullary canal dies the condition is called " central necro.sis." In some rare cases necrosis occurs without apparent suppura- 3l6 MODERN SURGERY. tion, a painless swelling of bone simulating sarcoma. Mer- cury is a cause of necrosis. The fumes of phosphorus may cause necrosis of the lower jaw in those with decayed teeth. Osteomyelitis is the usual cause of necrosis. It may be pro- duced also by frost-bites and burns. Many fevers (measles, typhoid, scarlet fever^ etc.) are occasionally followed by ne- crosis. SyphiHs and tubercle are occasional causes. Symptoms. — The symptoms of necrosis are at first those of osteitis or osteomyelitis. The abscess, when formed, opens of itself or is opened by the surgeon, and a sinus or sinuses form in the soft parts as happens in caries. A probe intro- duced into the sinus strikes upon hard bone with a clear, ringing note, and often finds a sinus or sinuses in the bone. In superficial necrosis the discharge is slight and the probe shows the limitations of the disease. In extensive necrosis the discharge is profuse, much new bone forms, several sinuses form far apart, and the probe must pass a considerable thick- ness of new bone before it finds the bit of dead bone. The surgeon should not operate until the dead bone is separated from the living, until a line of demarcation forms, and until the sequestrum is loose. In youth dead bone loosens quickly, but in old age slowly. An exfoHation becomes loose sooner than the sequestrum of central necrosis. In diffuse periostitis the necrosed shaft loosens quickly. Necrosed portions of the upper extremity loosen more rapidly than those of the lower. Chilton states that in the young adult two or three months will be required to loosen a necrosed fragment in the lower extremity, and from six weeks to two months in the upper extremity. A loose sequestrum may be moved by the probe, and when struck gives a hollow note. In old cases there is always danger that amyloid disease may arise. Treatment, — An exfoliation is removed as soon as it is loose, the seat of trouble is touched with pure carbolic acid and packing of iodoform gauze is inserted. The treatment of central necrosis comprises free incisions for drainage, antiseptic dressing, frequent cleansing, rest, good food, stimulants, and tonics. When the sequestrum becomes loose, break through the involucrum with the chisel, gouge, and rongeur, remove the dead bone with the forceps, clean the cavity with pure carbolic acid and pack with iodoform gauze. This operation is known as " sequestrotomy." If much of a gap is left by the operation, try to fill this gap by taking flaps of skin and fastening them to the bottom, by breaking the edges of the involucrum and turning them in, or by inserting bone-chips. These chips, which are obtained DISEASES AND INJURIES OF BONES AND JOINTS. 317 from the compact part of the tibia or femur of an ox, are decalcified by being placed for a couple of weeks in a 10 per cent, aqueous solution of hydrochloric acid (which is renewed every day) ; they are well washed in a weak alkali and then in water, are cut into strips, are soaked for two days in a I : 1000 sublimate solution, and are kept in a saturated ethe- real solution of iodoform. The cavity is made sterile and is well dusted with iodoform, the bone-chips are dried and in- serted into the cavity, a capillar)^ drain is employed, the peri- osteum is stitched over the opening, and so are the soft parts; but if this cannot be done, iodoform packing is used to keep the chips in place. This method we owe to the genius of Senn. Attempts have been made to fill bone-cavities with gutta- percha, plaster-of-Paris, etc. (Martin). The difficulty is to completely asepticize the walls of the cavity. Dressman has advised for this purpose the use of boiling oil, but it is apt to cause superficial necrosis. Schleich uses formalin-gelatin to fill bone-cavities. In some cases of extensive necrosis due to diffuse infective osteoperiostitis or to osteomyelitis exten- sive resection or even amputation may be necessary. Acute difiuse osteomyelitis, a diffuse inflammation of bone and marrow, is due to infection with pyogenic organisms (staphylococcus pyogenes aureus and streptococcus pyo- genes), or to mixed infection of the pyogenic organisms with the organisms of typhoid fever, of tubercle, etc. It may arise from a wound, such as a compound fracture, a gunshot- injury, or an amputation. It may occur when the infection has been by way of the blood. The causative organisms may enter the circulation through the lymphatic system or may pass directly into the blood from a focus of suppuration in the skin, in the subcutaneous structures, or some deeper part. The organisms may have been taken into the system by the tonsil or respiratory organs (Kraske), the intestinal canal (Kocher), the genito-urinary tract, or from excoriations, bruises, or small wounds in the skin (Warren). The exan- themata strongly predispose to osteomyelitis. Typhoid fever, typhus fever, small-pox, and malarial fever, lessen the vital resistance of marrow. Some observers teach that the ty- phoid bacillus is pyogenic (Frankel), but others think that the toxins of the typhoid organism weaken the marrow and suppuration arises because of mixed infection with pyogenic bacteria (Park and Klemm). Keen insists that the typhoid bacillus has occasionally pyogenic power.^ In osteomyelitis from wound of the endosteum the medulla and cancellous 1 Surgical Complications and Sequels of Typhoid Fever, by \V. W. Keen. 3l8 MODERN SURGERY. tissue inflame and suppurate. The entire length and thickness of the shaft may be involved, and the periosteum becomes infiltrated, detached, and retracted from the edges of the bone-wound. The soft tissues around the bone also inflame and sometimes slough. More or less necrosis is inevitable. The symptoms of acute diffuse osteomyelitis from wound are — a very severe boring, gnawing, aching pain ; great ten- derness ; deep swelling of the soft parts over the bone ; the skin is healthy early in the case ; a profuse offensive purulent discharge containing bone-fragments and tissue-sloughs is poured out ; the periosteum is red, thick, and separated ; a fungating foul mass protrudes from the medullary canal ; rigors, sweats, and fever point to septicemia or pyemia. Treatment. — In treating acute diffuse osteomyelitis expose the interior of the bone, curet the medullary cavity, swab it out with pure carbolic acid, and pack it with iodoform gauze ; drain ; apply antiseptic dressings ; frequently cleanse ; and use strong supporting treatment. When the sequestrum loosens, it should be removed. Some cases require amputation. Acute Bpipliysitis. — Acute osteomyelitis without a wound is called " acute infantile arthritis " or " acute epiph- ysitis." It affects the young, especially children of from one to two years of age, but occasionally arises in older persons (ten to fourteen years). It begins at the epiphyseal line. A strain may occur at this point, inflammation follows, and a hospitable welcome is extended to micro-organisms which are contained in the body-fluids and which pass through this area. In some cases chilling of the body is the predisposing cause. In some patients no history of injury is obtainable ; a preceding illness, especially a specific fever, being responsible for the weakening of tissue-resistance. New tissues are always more susceptible to infection than old tissues, and one of the most susceptible of new tissues is the young bone at the end of the diaphysis. Septic organ- isms may lodge in this area, multiply there and produce systemic poisons. The femur and tibia are the bones most often attacked, the hip-joint or knee-joint being secondarily involved ; the humerus, tibia, radius, ulna, and other bones may be attacked ; the shoulder-, ankle-, or elbow-joint may become secondarily affected. The youngest bone around the ossific centre first inflames, necrosis takes place, a small sequestrum forms, and the pus around the sequestrum is apt to make a cloaca and empty into the adjacent joint, lighting up a suppurative inflammation of the articulation, and into the medullary canal, causing diffuse osteomyelitis. DISEASES AND INJURIES OF BONES AND JOINTS. 319 The symptoms of acute epiphysitis usually come on sud- denly and especially at night, and the attack may be so acute as to cause death by systemic poisoning before a diagnosis is arrived at. The disease is generally ushered in by a chill, which is followed by septic febrile temperature. The history will sometimes contain the statement that the patient was suddenly chilled after being overheated (sitting in a draft or in a cellar on a hot day, possibly swimming when very warm, etc.). There is violent, burning, aching pain in the bone and great tenderness near the joint ; the soft parts, which at first are healthy in appearance, after a time dis- color, swell, and present distended veins ; the neighboring joint swells, and may become filled with pus ; the peri- osteum and the shaft are involv^ed for a considerable dis- tance ; each epiphysis may become affected, the shaft be- tween being comparatively uninvolved, and the epiphyses may separate, displacement and shortening taking place. This disease is often mistaken for rheumatism because of the joint- swelling, occasionally for typhoid fev'er because of the fever, and in some cases for erysipelas because of the redness of the skin. It gives a voxy grave prognosis. Sometimes an epiphysitis shows milder symptoms and is slower in progress (subacute). These cases are \'ery often mistaken for rheu- matism. But in rheumatism the joint is the part involved from the beginning, while in epiphysitis the joint is involved secondarily after obvious evidence of inflammation well clear of the articulation. Further, the symptoms of rheumatism can be rapidly improved by the use of the alkalies or the salicylates. Treatment. — In treating acute epiphysitis do not wait for fluctuation, but incise at once ; break through the bone at one or more points with a gouge or chisel ; curet ; chisel away the diseased bone, and if necessar>^ curet the medul- laiy canal ; irrigate with corrosive-sublimate solution ; swab out with pure carbolic acid ; use iodoform plentifully ; pack ; drain the joint if it is involved ; employ rest, anod}aies, and strong supporting treatment. Remove dead bone subse- quently when it becomes loose. Amputation may be required. Chronic osteomyelitis is usually linked with osteitis. It ma\' e\-entuate in osteosclerosis with filling up of the medullary canal, or in limited suppuration, or in caseation of the cancellous tissue (Brodie's abscess), or in necrosis. A tubercular inflammation is one form of chronic osteo- myelitis. Syphilis, typhoid fever, etc., may cause it. 320 MODERN SURGERY. Osteomalacia, or Mollities Ossium. — In this disease the bones are partly decalcified, and consequently soften and bend. Many bones are usually involved. It is commoner beyond than before middle age, though it may occur in infancy ; it is commoner in women than in men, and preg- nancy seems to bear more than a casual relation to its pro- duction. In osteomalacia the medulla increases in bulk and becomes more fatty, and the osseous matter is absorbed gradually, first from cancellous tissue and then from the compact tissue. Some observers believe this curious con- dition is due to lactic acid in the blood. Symptoms. — The symptoms of osteomalacia are as fol- lows : many points of pain which are often thought to be due to rheumatism ; deformities from twisting and bending of bone ; and a large excess of calcium salts in the urine. This disease lasts a number of years, but usually causes death from exhaustion, though some few cases are arrested or cured. Fractures occur from very slight force. Treatment. — In treating osteomalacia in women insist that pregnancy must not occur. Put braces and supports upon distorted limbs to prevent fracture. Advise good air, hygienic surroundings, and nourishing food. Among the medicines that can be used may be mentioned cod-liver oil, lime salts, preparations of phosphorus, and bone-marrow. In women the removal of the ovaries sometimes cures. It has been asserted that the production of anesthesia by means of chloroform is of great benefit. Acromegfaly. — This is a disease which causes progres- sive and often great enlargement of both the bones and soft parts of the extremities, which enlargement is symmetrical. The lower jaw projects in advance of the upper jaw, the nose becomes prominent and thick, the supra-orbital ridges are accentuated, and the costal cartilages and inner ends of the clavicles become protuberant. Later the lar}.'nx, ribs, shoulder-blades, and vertebra become involved, and the back becomes markedly humped (cervicodorsal hump). The hands and feet are affected in advanced cases. As a rule, the thyroid gland is enlarged, and a postmortem examina- tion may detect an enlarged pituitary gland. Severe and uncontrollable headache is sometimes a distressing feature of the disease. Treatment is futile. The disease slowly but surely causes death. I^eontiasis Ossium (Virchow's Disease). — This is a hypertrophy limited to the facial and cranial bones, which is symmetrical, and which begins, as a rule, in the superior DISEASES AND INJURIES OF BONES AND JOINTS. 32 1 maxillse. The hypertrophy progressively increases, causes difficulty of mastication, and is accompanied by headache. It produces distinct deformity of the jaw like a tumor, whereas acromegaly enlarges all of the proportions of a bone. Treatment is not satisfactory, as a rule. Recently Horsley has obtained amelioration by operating and remov- ing masses of bone. 2. Fractures. Definition. — A fracture is a solution, by sudden force, of the continuity of a bone or of a cartilage. Clinically, under this head are placed epiphyseal separations and the tearing apart of ribs and their cartilages. Varieties of Fractures. — The varieties of fractures are as follows : Simple fracture is a subcutaneous fracture, or one in which no open wound admits air to the seat of bone-injury. This corresponds to a contusion of the soft parts. Compound fracture is an open fracture, or one in which an open wound admits air to the seat of bone-injury. This corresponds to a contused or lacerated wound of the soft parts. A primary cojupoiuid fracture is one in which the breach in the soft parts is occasioned at the time of the accident, either by the direct violence of the injury or by the forcing of a bone or bones through the tissues. A secondary compound fracture is one in which the breach in the soft parts occurs after the accident, either from slough- ing of damaged tissues, from ulceration because of the press- ure of ill-adjusted fragments, or from the forcing of a bone or bones through the soft parts because of rough handling, neglect, or the tossing of delirium. Complicated fracture is a fracture plus the complication of a joint-injury, arterial or venous damage, or injuiy to the nerves or soft parts. When a fractured rib injures the lung or when a broken vertebra damages the cord we have a complicated fracture. The term is a bad one, as it con- veys no definite meaning, and is no more justifiable than it would be to speak of "complicated pneumonia" or "com- plicated typhoid," for we should always give a name to the complication in any case. It should be remembered that damage to the soft parts not sufficient to admit air to the seat of fracture does not make the case a compound fracture, but rather complicates a simple fracture. Remember also 21 322 MODERN SURGE R V. that even superficial areas of tissue-destruction must be treated antiseptically, otherwise absorption of pus-elements and their deposition at the seat of injury may cause diffuse osteomyelitis. Complete fracture is that which extends through the whole thickness of a bone or entirely across it. Incomplete fracture is that which extends only partially through the thickness of a bone or only partially across it. A linear, hair, capillary, or fissured fracture, or a fissure, is a crack in a bone with very little separation of the edges. This is an incomplete fracture, but may be associated with a complete break. A green-stick, hie koiy -stick, zvillow, or bent fracture is a true incomplete break. It is commonest in the forearm or clavicle, it arises from indirect force, and it is very rare after the age of sixteen. It is called " green-stick " because the bone breaks like a green stick when forced across the knee, first bending and then breaking on its convex surface. The bone, being compressed between two forces, bends, and the fibers on the outer side of the curve are pulled apart, while those on its concavity are not broken, but are compressed. In correcting the deformity the fracture is apt to be made complete. The permanent bending of a bone without a break may possibly occur in youth. Depressionfracture occurs when a portion of the thickness of a bone is driven in by crushing. Fracture by depression is a result of the bending in of a bone (as the parietal), a fragment breaking off from the side toward which the bone is bending. A depressed fracture is complete, not incom- plete, and by this term is meant an injury in which a frag- ment of the entire thickness of the bone is driven below the level of the surrounding surface. Splinter- and Strain fracture. — The breaking off of a splinter of bone (splinter-fracture) or of an apophysis con- stitutes an incomplete fracture. A strain upon a ligament or a tendon may tear off a shell of bone, and this injury is the " strain-fracture " of Callender. Longitudinal fracture is a fracture whose line is for a con- siderable distance parallel, or nearly so, with the long axis of the bone. This is common in gunshot-injuries. Oblique fracture is a fracture whose line is positively oblique to the long axis of the bone. Most' fractures from indirect force are oblique. Transverse fracture is a fracture whose line is nearly trans- verse to the long axis of the bone (no fracture is mathemati- DISEASES AND INJURIES OF BONES AND JOINTS. 323 cally transverse). The cause is often but not invariably direct force. The ''fracture en rave " (radish-fracture, so cahed be- cause the bone brealvs as does a radish) is transverse at the surface, but not within. Toothed or dentate fracture is a form of fracture in which the end of each fragment is irregularly serrated and the frag- ments are commonly locked together ; hence the deformity is hard to correct. Most of the simple fractures from direct force are serrated. Wedged-shaped, V-shaped, cnneated, or cuneiform fracture (" fracture oblique spiroide," " fracture en V " of Gosselin, "fracture en coin") is a fracture whose line has the shape of a V, which may be entire or may want the point. It occurs at the articular extremity of a long bone, and a fissure usu- ally arises from its point and enters the joint. If complete, it is a "comminuted fracture." T-shaped fracture is a fracture which presents a transverse or oblique line and also a longitudinal or vertical line. It occurs at the lower end of either the humerus or femur, the transverse line being above, and the vertical line (intercon- dyloid) between, the condyles. If complete, it is in reality a form of comminuted fracture. Multiple or composite fracture is a condition in which a bone is broken into more than two pieces, the lines of frac- ture not intercommunicating, or a condition in which two or more bones are broken. Multiple fractures of one bone are divided into double, treble, quadruple, etc. Comminuted fracture is a condition in which a bone is broken into more than two pieces, the lines of fracture inter- communicating. The bone may be broken into many small fragments, may present much splintering, or may actually be ground up. Impacted fracture is one in which one fragment is driven into the other and solidly wedged. Fracture zvitJi crushing, or penetration, is a fracture in which one bone is driven into the other, the encasing bone bein": so splintered that the impacting bone is not firmly held. Pathological, spontaneous, or secondary fracture is one occurring from a very insignificant force acting on a bone rendered brittle by disease. Ununited fracture is a term used to designate a fracture in which bony union is absent after the passage of the period normally necessary for its occurrence. Direct fractiire \s one occurring at the primary point of the application of force. 324 MODERN SURGERY. Indirect fracture is one occurring at a point distant from the area of the primary application of force. Stellate, or starred fracture (fracture par irradiation) is one in which several fissures radiate from a center. If the frac- ture be complete, it is in reality a form of comminuted fracture. Helicoidal, spiral, or torsion fracture is a fracture resulting in a long bone from twisting. Fracture by contre-coup is a fracture of the skull which is on the opposite side of the head to that which was the re- cipient of the force. Epiphyseal Separation or Diastasis. — This injury occurs only before the age of twenty-five and is commonest at the lower end of the femur, but it is encountered also at the lower ends of the tibia and radius and at both extremities of the humerus. This injury induces deformity, which is often hard to reduce, and by damaging the cartilage may retard or inhibit a further lengthening by growth of the limb. Intra-uterine fractures are usually due to injuries of the mother's abdomen sustained toward the end of pregnancy. Some hold that they can arise as a consequence of the force of violent uterine contractions. Many so-called " intra-ute- rine " fractures are wrongly named, as they result from injury during delivery. In sporadic cretinism (misnamed congenital rickets) the bones are fragile and ill-ossified, and many frac- tures may occur in iitero. Designations According to Seat of Fractures. — Fractures are designated also according to their anatomical seats ; for instance, fracture of the upper third of the shaft of the femur, fracture of the olecranon process of the ulna, fracture of the middle third of the clavicle, and fracture of the body of the lower jaw. Intra-articidar fracture is one extending into a joint; intracapsidar fracture is one within the capsule of either the shoulder- or hip-joint; and extracapsular fracture is one just without the capsule of either the shoulder- or hip-joint. Causes of Fracture. — The causes of fracture are (i) ex- citing, immediate or direct, and (2) predisposing or indirect. Exciting causes are {a) external violence and {f) muscu- lar action. External violence is the most usual exciting cause. Two forms are noted: (i) direct violence and (2) indirect force. Fractures from direct violence occur at the point struck, as when the nasal bones are broken with the fist. In such frac- tures the soft parts are damaged ; they may be destroyed at DISEASES A'ND IXJ CRIES OF BONES AXD JOINTS. 325 once in part, they may be damaged so severely that a portion sloughs, or they may be damaged so slightly that they do not lose vitality ; hence fractures by direct violence may be compound from the start, may become so, or may remain simple. In fractures by direct force discoloration, due to effused blood, usually appears at the point struck soon after the accident. In compound fractures by direct violence the soft-part injury is so great that primary tissue-union cannot occur. Fractures from indirect force do not occur at the point of application of the force, but at a distance from it, the force being transmitted through a bone or a chain of bones, as when the clavicle is broken by a fall upon the extended hand. Such fractures tend to occur in regions of special predilection. If they are not compound, there is no injury of the surface over the fracture. If they become compound by projection of fragments, primary union may still occur. Discoloration over the seat of fracture is usually not present soon after the accident, but may occur later. Discoloration rapidly appears in soft parts at the point where the force was first applied. Muscular action is a rather rare cause. Fractures thus produced result from sudden or violent contraction. Bones so broken are usually diseased. Violent coughing may frac- ture the ribs ; attempting to kick may fracture the femur ; saving one's self from falling backward may fracture the patella ; throwing a stone may fracture the humerus ; and sudden extension of the forearm may fracture the olecranon process of the ulna. Predisposing Causes. — There are two classes of predis- posing causes, namely: (i) physiological, natural or normal, and (2) pathological or abnormal. Natural Predisposing Causes. — Under this head is consid- ered the liability to fracture possessed by individual bones because of their shape, structure, function, or position. Those predispositions occasioned by special ages are also consid- ered. In youth epiphyseal separation is commoner than frac- ture, and a fracture is apt to be incomplete. Fractures are commonest between the ages of twenty-five and sixty. From two to four years of age a child is more liable to fracture than later, because he is then learning to walk (Malgaigne). The bones of the old are easily broken, but the normal lack of activity of the aged saves them from more frequent injur\'. Thus the predispositions of age are in part due to habits and in part to bony structure. The bones of the young, being elastic, bend considerablv before the\' break ; the bones of 326 MODERN SURGERY. the old, being brittle and inelastic, break easily, but do not bend. In old age the bones become lighter and more porous, though they do not diminish in size. An absorption takes place from the interior of a bone, particularly at its articular head, the medullary canal increases in size, the cancellous spaces become notably larger, and portions of the remaining bone of the interior show a fatty change. There is no in- crease in the amount of mineral salts present, as was long taught. These alterations occur earlier in women than in men.^ The change of age is a diminution in the amount of bone present, and sometimes a fatty change in a portion of what remains. If the atrophy of bone is other than that normal to senility, it constitutes a pathological predisposing cause. of fracture. Normal predisposing causes include the person's weight (which determines the force of a fall), mus- cular development, habits, sex, occupation, and the season of the year. Pathological Predisposing Causes. — Hereditary fragility is a condition commonest among women, often existing in generation after generation, and in which condition fractures occur from an infinitely slight force. There exists in these cases bony rarefaction — in fact, a premature senility. Nervous Diseases. — Bony nutrition is dependent on the spinal cord, and the trophic influence is probably exerted through the posterior nerve-roots (Gowers). In diseases of the anterior cornua bony growth is much interfered with ; in diseases of the posterior columns, as in locomotor ataxia, a true bony atrophy bespeaks trophic disorder. Syringo- myelia causes brittleness of the osseous structures, and in paralysis agitans bones are thought to break easily. Trophic changes may occur in the bones of the insane, most com- monly when insanity is linked to organic disease. About one-quarter of paretic dements show undue brittleness or unnatural softness of bone.^ The bones of maniacs are fre- quently fragile. In asylum practice fractures are not neces- sarily an indication of abuse. Rickets. — Rickets predisposes to fracture because of altered bone-structure and the great liability to falls. Atrophy of Bone. — This condition, as has been seen (p. 309), is normal in senility. It may arise from want of use, as is observed in the bedfast, in the wasted femur of hip-joint disease, and in the bones of a stump. It may arise from pressure, as when an aneurysm compresses the ribs, sternum, or vertebrae. Among other of the patho- ' Humphrey on Old Age. ^ Spitzka's Manual of Insanily. DISEASES AND INJURIES OF BONES AND JOINTS. 327 logical predisposing causes are to be mentioned cancer, sarcoma, and hydatid cysts of bone, caries, necrosis, gout, scrofula, syphilis, mollities ossium, and scurvy. Symptoms of Fracture. — History of an Injury. — In spontaneous fracture there may be no record of violence ; for instance, when a bone breaks while turning in bed. In investigating the history, not only seek for a record or for evidences of violence, but try to determine exactly how the accident happened. A sound of cracking is occasionally audible to a bystander at the time of the injury. The patient may have heard it, but very rarely does. A rupture of a tendon or a ligament produces a similar sound. Pai)i is usually, but not invariably, present (absent often in rickets). Malgaigne says that in some fractures the pain is slight or absent, in others it is torturing, and in most it is severe for a time after the injury, but gradually abates unless reinduced by movement. Pain developed at the time of the accident is far less important as a symptom than that which can subsequently be produced by movement. In indirect fracture there is an area of pain at the point of application of the force, and another at the seat of fracture. Pain at the seat of fracture can be greatly aggravated by pressure or movement and is rather narrowly localized. Deformity or alteration in length or outline is due in part to swelling and in part to a change in the mutual relation of the fragments (displacement). The deformity of swelling is no aid to a diagnosis, as the same thing occurs in contusion, and it often hides some positive symptomatic distortion. The swelling is due first to blood and next to inflammatory prod- ucts and pressure-edema, and is very great in joint-frac- tures. The deformity of displacement may be produced by the violence of the injury (as is the depression in a skull- fracture), by the weight of an extremity (as is the falling of the shoulder in a fracture of the clavicle), or by muscular action (as is the pulling upward of the superior fragment of a fractured olecranon process). The varieties of displacement are (i) transverse or lateral, where one fragment goes to the side, front, or back, but does not overlap the other ; (2) angular, the bony axis at the point of fracture being altered and the fragments forming with each other an angle ; (3) rotary, one fragment rotating in the bony circumference, the other remaining stationary. As a rule, it is the lower fragment which turns on its long axis, rotating with it the limb below the level of 328 MODERN SURGERY. the break ; (4) overlapping or overriding, when the upper level of one fragment is above the lower level of the other fragment. It is usually the lower fragment which is drawn by the muscles above the upper, but the body-weight and sliding down in bed may push the upper below the lower. In overriding the ends are near together and the bones are usually in contact at their periphery. It is obvious that overlapping is associated with transverse displacement, as one fragment must go front, back, or to the side ; (5) pene- tration or impaction is when one fragment is driven into the other, thus producing shortening ; (6) separation of the two fragments occurs in fracture of the patella, olecranon, os calcis, certain articulations, and in some breaks of the hume- rus when the arm is not supported. It is important to remember that a dislocation may produce displacement, but these two conditions may be differentiated by the observation that the displacement of fracture tends to reappear after complete reduction, while that of dislocation does not reappear. A displacement is hard to detect in a flat bone and when one of two parallel bones is broken. Loss of function may be shown by inability to move the limb because of the break, but it is not always markedly present, though some degree invariably exists. It is slight in " green-stick " and impacted fractures (unless the loss of power arises from pain or nerve-injury). A person can walk when the fibula alone is broken, and likewise in some cases of intracapsular fracture of the femur, and can often put the hand on the head in fractured clavicle (Malgaigne). The pain of any injury or the loss of power from nerve-trauma- tism may cause loss of movement in the limb. This symp- tom is of slight diagnostic value in most fractures. Extravasation of Blood. — A contusion of the surface ac- companied by skin-abrasion indicates merely the point of application of direct external violence. If contusion is exten- sive over a superficial bone, as the tibia or parietal, after a few hours it often simulates fracture by presenting a soft, compressible center surrounded by a ring of hard, condensed tissues and coagulated blood. Direct external violence may merely occasion ecchymosis, and in fracture from indirect force ecchymosis may occur in a considerable area. In regard to this symptom, note that even great external violence may occasion no evident contusion or ecchymosis, and in any fracture this symptom may be present or absent. In old people, anemic subjects, and drunkards, extravasa- tion of blood is frequently marked and persistent. By sug- DISEASES AND INJURIES OF BONES AND JOINTS. 329 gillation is meant an extrav^asation of blood which slowly invades wide areas of tissue and which appears at the sur- face only after some time, and then usually as a yellowish discoloration. Linear ecchymosis has been esteemed by some as a sign of fissure, and it often follows fracture of the fibula. Linear ecchymosis over the line of the poste- rior auricular artery was pointed out by Battle as a valuable sign of fracture of the posterior fossa of the base of the cranium. Preternatural mobility is a most important symptom, which is pathognomonic when surely found. The unbroken bone is nowhere mobile in continuity. By preternatural mobility is meant that a bone is mobile in continuity or that there is abnormality in the direction or extent of joint-mobility. In some fractures this symptom does not exist (impacted, green- stick, and locked serrated fractures) ; in others it cannot be found (fractures of tarsus, carpus, vertebral bodies) ; in others it is difficult to obtain, but at times can be developed (fractures near or into many joints). To develop this symp- tom, try, when the case admits, to grasp the fragments and to move them in opposite directions. In fractures of the shafts of the femur or humerus fix the upper fragments and carry the knee or elbow in various directions to develop bend- ing at the point of fracture. In fractured clavicle push the shoulder downward and inward. In fractures of either bone of the forearm grasp the opposite bone w^ith four fingers of each hand and make pressure on the suspected bone alternately with either thumb, the same proceeding being used in fract- ures of the leg. In fractures of the neck of the femur note the rotation-arc of the great trochanter (Desault). In fract- ures of the lower end of the radius bend the hand back, and in those of the lower end of the fibula evert the foot (Mai- sonneuve). In seeking preternatural mobility, remember that the elastic ribs when being forced in give a sense of bend- ing, and that the fibula at its middle is " normally flexible " (Dupuytren). Some rachitic bones may be bent. Crepitus or erepitation is both a sensation and a sound, which indicates the grating together of the two rough sur- faces of a broken bone. This symptom is of great value, but it is not always present. It is absent in locked serrated fractures, in impacted fractures, in cases where the broken ends cannot be approximated (as in overlapping), and is rare when a fractured surface is against the side, and not the broken face, of the other fragment, and is unusual in incom- plete fractures. Crepitus is often absent in epiphyseal sepa- 330 MODERN SURGERY. ration, in softened bones, and in fractures in or near joints, and it may be prevented from occurring by blood-clot, fascia, or muscle between the broken surfaces. The grating found in tenosynovitis must not be mistaken for the crepitus of fract- ure : the former is diffused, large, soft, and moist ; the latter is limited, small, harsh, and dry. The clicking of an inflamed or eroded joint and the crackling of emphysema must also be separated from bony crepitus. Crepitus of fracture may be present at one moment, but absent the next. It is often not detected during the time swelling is marked, and cannot be discovered after organization of the callus begins. In but few fractures is it needful to try to hear crepitus with the naked ear or with a stethoscope upon the part, but in doubt- ful cases of fractures of ribs and joints it should be tried. The above-named symptoms are known as " direct." There are other symptoms known as " circumstantial," such as the flow of blood and cerebrospinal fluid from the ear after some fractures of the middle fossa of the skull ; emphysema of the face and epistaxis after fractures of the nasal bones ; hemoptysis and emphysema after crushes of the chest ; dis- coloration following the line of the posterior auricular artery after fractures of the posterior fossa of the skull ; and sub- conjunctival ecchymosis after fractures of the anterior fossa of the skull. Diagnosis. — Examine as soon as practicable after the injury — before the onset of swelling, if possible. Expose the part completely, taking off the clothing, if necessary, by clip- ping it along the seams. Compare the part, by attentive scrutiny, with the corresponding part on the opposite side. If any deformity be present, it must be ascertained that it did not exist before the accident. If the nature of the in- jury be uncertain, if the patient be very nervous, or if the part be acutely painful, it is better to give ether to diagnos- ticate, and set and dress. In injuries of the elbow-joint always anesthetize before examination, unless an .r-ray appa- ratus is accessible to settle the diagnosis. A fracture is distinguished from a dislocation by its preter- natural mobility, its easily reduced but recurring displace- ment, and its crepitus, as against the preternatural rigidity, the deformity, difficult to reduce, but remaining reduced, and the absence of crepitus of a dislocation. Further, in disloca- tion the bone, when rotated, moves as one piece, whereas in fracture it does not so move ; in dislocation the bony pro- cesses are felt occupying their proper relations to the rest of the same bone, while in fracture some of them present altered DISEASES AND nVJCR/ES OF BONES AND JOINTS. 33 1 relations ; in dislocation the head of the bone is found out of its socket, but in fracture it is felt in its place. It is impor- tant to remember, moreover, that a fracture and a dislocation may occur together, and that the rubbing of a dislocated bone against an articular edge, when the joint has been roughened by inflammation, simulates crepitus. Great contusion, by inducing extreme tumefaction, may mask characteristic deformity and obscure crepitus. When only a contusion exists pain is apt to be diffused ; but if a fracture has occurred, the pain is accentuated at some narrow- spot. In many cases, before he can give a certain opinion, the surgeon must wait some days until the swelling has largely subsided. In such a case it is best to assume in our treatment that a fracture exists until the contrary is known. Combat swelling by rest and the use of lead-water and laud- anum and moderate compression. In impaction the diagnosis is difficult. The moderate de- formity is concealed by swelling ; crepitus and preternatural mobility do not exist unless the fragments are pulled apart, and there is not necessarily much loss of function. A con- clusion is reached largely by considering the nature, direc- tion, and extent of the violence, the seat of the pain, and by a careful study of the most minute deformity. Fissures are hard to recognize. They rarely present any evidence of their existence except a localized pain and possibly a linear ecchy- mosis appearing after a few days. In green-stick fractures the age, the deformity, and possi- bly crepitus during reduction, help in the diagnosis. Epiphy- seal separations are diagnosticated by the age, the preternat- ural mobility, the deformity, the situation of the injuiy, and the absence of crepitus or the presence only of a soft crepitus. Fractures are often hard to recognize when occurring in a group of bones like those of the carpus and tarsus (w hich are firmly joined by dense ligaments) or in one of two paral- lel bones. There is not always a certainty that a fracture exists, and when, after a careful examination, there is still an uncertainty, do not prolong the efforts or use great force, but treat the case as a fracture until a cure ensues or the diag- nosis becomes apparent. We have recently had added to our resources a method of incalculable value in diagnosticating fracture ; that is, the use of the force known as the A'-ray or the Rontgen ray. We can look through a part with a fluoroscope and see the bones as shadows, or we can take a negative of the shadows and print skiagraphs from it. This method is applicable even 332 MODERN SURGERY. when the parts are swollen, and even when a limb is clothed or wrapped in dressings. It is possible to obtain a picture of a fractured skull after long exposure ; fractured ribs and ver- tebrae can be detected ; and the process is of the greatest use in detecting fractures of the limbs. In order to obtain certain results the ;ir-rays must be used by an expert. This method should, if possible, be resorted to in all cases. Complications and Consequences. — Some of the con- sequences and complications of fractures are — sloughing of the soft parts, thus making the fracture compound ; extrav- asation of blood, causing swelling or even gangrene ; rupt- ure of the main artery or vein of the limb ; dislocation ; edema from pressure of extravasated blood, from inflamma- tory exudation, from tight bandaging, from thrombosis, or, later, from the pressure of callus ; stiffness of joints from synovitis with adhesion, from displaced fragments, or from intra-articular callus ; stiffness of tendons from adhesive the- citis or from the presence of callus ; paralysis from traumatic neuritis or the pressure of callus upon nerve-trunks ; muscu- lar spasm ; painful callus ; exuberant callus ; embolism ; fat- embolism ; pulmonary congestion ; gangrene ; shock ; septi- cemia; pyemia; tetanus; delirium tremens; urinary retention ; extensive laceration of the soft parts ; rupture of large nerves ; and involvement of joints. Repair of Fractures. — Simple Fracture. — In a simple fracture the bone is broken, the medullary contents are lacer- ated, the periosteum is torn, and the overlying soft parts are damaged to a considerable degree. The periosteum is stripped more or less from each fragment, but it is rarely completely torn through, an untorn portion known as the periosteal bridge remaining. The amount of blood effused is usually considerable, and it forms a decided prominence at the seat of fracture; it gradually gathers because of oozing, and soon clots. This clot lies in the medullary canal, be- tween the fragments, under the periosteum at the ends of the fragments, and in the tissues outside of the periosteum. Very rapidly after the accident the damaged parts inflame (bone, endosteum, periosteum, and other peri-osseous struct- ures). The inflammatory exudate enters into the blood- clot and destroys it. The clot is simply dead material and in no way contributes to repair, and it is replaced by em- bryonic tissue which quickly becomes vascularized (granula- tion-tissue). This granulation-tissue passes into fibrous tissue and then into bone, only the tissue springing from the periosteal DISEASES AND INJURIES OF BONES AND JOINTS. 333 bridge going through a cartilaginous stage. The mass of new tissue around and between the bone-ends is called callus. It will be observed that the name is applied succes- sively to embryonic tissue, granulation-tissue, fibrous tissue, and bone. Warren tells us that callus has no well-defined outline, and " involves not only the bone and periosteum, but also the connective tissue and some of the surrounding mus- cular tissue." Even a few days after the injury the inflam- matory mass is much firmer than follows inflammation in- volving other structures, and the bone-ends are deeply im- bedded in a dense mass. During the second week the callus is greatly strengthened by the formation of dense fibrous tissue in and below the periosteum, of less dense fibrous tissue outside of the peri- osteum, and of cartilage from the periosteal bridge. This new tissue contracts decidedly. During the third week ossi- fication begins at the points farthest from the fracture, and in the course of a short time (from three to six weeks) is com- plete. The ossified callus or new bone is spindle-shaped and spongy. The term intermediate, definitive, or permanent callus is used to describe the material which forms between the fract- ured ends. The name provisional or temporary callus is given to the material within the canal (central callus) and external to the bone (ensheathing callus). The amount of provisional callus depends directly on the extent of sepa- ration and the amount of motion between the fragments. It is Nature's splint, and when the break is not well im- mobilized a large amount is formed. The greater the amount of motion the larger the amount of provisional callus. The ensheathing callus is after a time largely absorbed, and the central callus in the course of a long time may also be absorbed, with the restoration of the medullary canal, although this latter result is rare. An excessive amount of provisional callus may ossify nearby tendons, may unite two parallel bones (radius to ulna — tibia to fibula — a rib to its neighbors), may block a joint just as a stone in the crack of a door will block a door, or may absolutely abolish a joint. Fragments, even if entirely detached, often unite, but they may be surrounded by provisional callus ; sometimes they do not cause trouble, but sometimes they lead to suppuration. It takes about one year to remove the temporary callus. If callus does not get beyond the fibrous state, there exists that form of ununited fracture known as " fibrous union." 334 MODERN SURGERY. The definitive or permanent callus after a time ceases to be porous and becomes very dense bone. Compound, fractures without much destruction or bruis- ing of soft parts, if treated antiseptically, become at once simple fractures and unite as such. If the wound is not drained and asepticized, septic inflammation occurs, pus forms, and union by granulation is the best that can be obtained. Compound fractures by direct violence will not heal by first intention because of the extensive loss of vitality of a large area of the soft parts. Delayed union may be due to ill-health, want of ap- proximation, etc. (any of the causes mentioned under the heading Non-union). It is not non-union, but may eventuate in non-union. Non-union of Fractures. — An ununited fracture is a fracture in which the fragments are not held together by bone. The causes are local and constitutional. The local causes 2,x& (i) want of approximation of fragments (a frequent cause of want of approximation is interposition of soft tissues, especially muscle) ; (2) want of rest ; (3) want of blood- supply (as seen in the heads of humerus and femur, or when a nutrient artery is torn, or when a thrombus forms in a vein near the fracture); (4) defective innervation; and (5) bone-disease. The constitutional causes are debility, scurvy, Bright's disease, syphilis, etc. In this condition the broken ends of the bone round off and the medullary canal in each fragment becomes closed by bone. The fragments may not be held together by any material, or they may be held by very thin and much-stretched fibrous tissue {inembranous union), or by strong, thick, fibrous tissue {ligamentous or fib7'ous union). When the ends of the bones come together, are held by a fibrous capsule, and move on each other, there is presented a false joint or pseiidartlirosis. Such a joint may after a time secrete serous fluid for lubrication. Vicious union is union with great deformity, and is often productive of pain and loss of function. It arises from failure to coaptate the fragments, from a recurrence of displacement after reduction, or from yielding of callus after the removal of splints. Treatment of Fractures. — If a man is found in the street with a fracture, further injury must be prevented by applying, after cutting off the clothing over the fracture, some temporary support. If an ambulance 'or patrol-wagon can- not be obtained, move the patient by hand. If the lower ex- tremity be involved, an improvised stretcher (a board or a DISEASES AND INJURIES OF BONES AND JOINTS. 335 shutter) is placed on the ground beside the patient, who is placed on the stretcher, the surgeon lifting the injured limb, and the patient is then carried to the hospital and carefully transferred to a fracture-bed, or, if taken home, to a small ordinary bed, a board being placed beneath a rather hard but even mattress. The temporary appliances are now removed and a diagnosis by the methods before given is proceeded with. After determining the injury the fragments must be adjusted. This should, if possible, be done at once, because a fracture remaining unreduced may become compound, the fragments may injure important structures, and they are sure to cause intense pain. Reduction is easily effected during shock, as the muscles are in a state of relaxation. If there is great swelling, reduction may be impossible, and the part must then be supported and antiphlogistics, sorbefacients, and moderate pressure be used, avoiding ice and tight band- aging, which predispose to gangrene. Set the fracture at the first possible moment. Velpeau's axiom was to reduce fractures at once, regardless of pain, spasm, or inflammation, as reduction is their cure. If the patient is very nervous, if the pain is severe, or if rigid muscles antagonize the efforts, then reduce the fracture under anesthesia. In some fractures (as those of the clavicle) adjustment is effected by altering the position, and in others (as those of the femur) by extension and counterextension ; in some by tenotomy, and in some by kneading, bending, and coaptation. When extension is employed, always en- deavor to get a point of counterextension. The extension is to be made on the broken bone (if possible, in the axis of the bone), and is to be steady, not jerky nor violent. In some cases complete reduction is impossible. This may be due to spasm, to swelling, to the catching of soft parts between the fragments, to the existence of a loose fragment, to locking, or to impaction. An impaction by rotation can generally be released, but it is sometimes undesirable to reduce it. If the fragments cannot be adjusted without violence, retain them in the best attainable position, combat the antagonistic cause, and set them properly as soon as possible. After adjusting the fragments they must be maintained in position by some retentive apparatus. Avoid pressure over joints or bony prominences, and particularly guard against tight or improper bandaging. The circulation in the fingers or the toes must be observed as an index of circulation in the limb ; hence leave those digits exposed. 336 MODERN SURGERY. A retentive apparatus should prevent the re-occurrence of de- formity, and not be itself productive of pain or harm. For the first few days of treatment of a simple fracture the dress- ing is removed every day, to make sure that deformity has not recurred, and if it does recur the fragments must at once be reset. The splints should be padded thoroughly, especially when over joints or bony prominences, and they should, if possible, fix the joints immediately above and below the break. A primary roller should never be used. Some surgeons at once apply an immovable dressing. This proceeding is safe in simple fractures without much displacement or soft-part injury. This apparatus is used also in military practice, with the old and feeble whom we fear to put to bed, with the young who are very restless, and with the insane or the delirious. If, however, there is great deformity, much soft-part injury, or marked swelling, im- movable dressings may induce sloughing, edema, gangrene, or faulty union. In the above-named cases use splints for the first few days ; then, if it is desirable, the immovable dressing can be applied. It is dangerous to keep old or feeble persons long in bed, as they are prone to develop bed-sores and hypostatic pulmonary congestion. The period for the artificial retention of the fracture varies with the seat of the fracture and the age and the condition of the patient. Passive motion is to be made in most fractures in from two to three weeks, though it is sometimes made earlier to prevent ankylosis. Landerer strongly advocates massage, believing that it hastens union and prevents wasting. He applies it as soon as there is no danger of the callus bending (in from eight to fourteen days). Massage should not be used when great edema points to the possibility of venous thrombosis. The movements might break up a clot and cause fatal em- bolism.^ Very early massage may cause fat-embohsm. In fracture of the patella, Barker and many others believe in wiring, and some surgeons advocate the same procedure in fracture of the clavicle and fracture of the tibia. The plan known as the ambulatory treatment of fractures of the lower extremities has many advocates. Its aim is not only to get the patient about on crutches, but also to cause him to use the limb. It is held that this plan of treat- ment greatly lessens the patient's sufferings and actually favors union by the stimulation of walking. Bardeleben, in his report to the German Surgical Congress, gave the records of 116 fractures of the lower extremity thus treated ^ Cerne's case, in Norniandie nied. ; Bull, med., 1895, No. 44. DISEASES AND INJURIES OF BONES AND JOINTS. 337 {jy simple and 12 compound fractures of the leg; 17 simple and 5 compound fractures of the thigh). The patients were gotten about a few days after the accident, were able to attend to business, had excellent appetites, digested their food perfectly, slept well, and were saved from muscular atrophy. Pilcher has warmly advocated the method. It can be used in fractures as high up as the middle of the femur. The apparatus which we should em- ploy in the ambulatory treatment reaches below the sole of the foot, and is supported firmly above the seat of fracture, the weight of the body being transferred from above the fracture to the firm pad below the sole of the foot on which the patient walks (Fig. 66). This ap- pliance in a fractured thigh is put on about one week after the inflic- tion of the injury. While the pa- tient sits on the ischial tuberosities extension is made upon the leg. The seat of fracture is encircled with a thin plaster cast. The sole of the other foot is raised by a cork sole. Albers uses plaster-of- Paris strengthened by bits of wood, running from below the sole of the foot to the iliac crest, when he treats a fractured thigh. Krause says in fracture of the ankle carry the dressing to the head of the tibia ; in fracture of the leg carry it to the middle of the thigh ; in fracture of the lower end of the femur carry it to the pelvis.* Bradford warmly advocates the use of Thomas's splint often combined with plaster-of-Paris. Prevention and Treatment of Complications. — In every case of fracture feel for the pulse below the injury in order to be sure the artery is not ruptured. If the soft parts are badly contused, try to prevent sloughing by rest, re- laxation, and lead-water and laudanum. If superficial slough- ing occurs, treat antiseptically, remembering that a super- ficial excoriation can admit bacteria which, carried by the Fig. 66. — Ambulatory dressing (Harting). ' Centralbl. f. Chir., vol. xxii., 1895. 22 338 MODERN SURGERY. blood or lymph, may infect the bones. If a slough leads down to the fracture, treat the case as one of compound fract- ure. If there be great blood-extravasation, the danger is gangrene, and the foot of the bed is to be elevated, or the extremity, to which splints and bandages are to be loosely applied, is to be raised ; lead-water and laudanum is applied if there be much inflammation, and cotton-wool and hot bottles if the surface be cold. If a bleb forms, it is to be opened with a needle and dressed antiseptically. If gangrene occurs, treat by the usual rules. The appearance of buUai when the circulation is good does not mean gangrene. Edema may be due to tight bandaging. If it is due to phlebitis, there is danger of pulmonary or cerebral emboHsm. In phlebitis elevate the Hmb, remove all constriction, and employ locally tincture of iodin, blue ointment, and lead- water and laudanum, and internally strong stimulation. In edema due to weak circulation or venous relaxation use daily frictions and firm bandaging. If the fracture involves a joint, carefully adjust the fragments, make passive motion early, and inform the patient that he will have a stiff joint. A dislocation occurring with a fracture is reduced at once if possible. To do this, splint the limb and give ether, and try to reduce while the limb is managed with the splint as a handle. If this fails, it is best to incise and pull the sepa- FiG. 67. — Fracture-hook (McBurney and Dowd). rated end in place by the hook of McBurney and Dowd (Figs. 67-69) ; but some surgeons say, get the bones in the best pos- sible position, set them, await union, and then treat the unre- duced dislocation. Allis is often able to reduce a dislocation accompanied by a fracture. He uses the untorn portion of periosteum as a hinge, pulls upon the fragment, and forces it in place by manipulation. A rupture of the main artery of the limb presents the symptoms of absent pulse below the rupture, a pulsating tumor, and often an aneurysmal thrill DISEASES AND INJURIES OF BONES AND JOINTS. 339 and bruit. This condition demands that the surgeon should apply an Esmarch bandage, cut down upon the tumor, turn out the clot, and ligate each end of the vessel. If these Fig. 68.— Fracture-hook applied at base of acromion process (McBurney and Dowd). measures fail or if gangrene appears, amputate at once above the seat of the fracture. Inflammation is to be treated by compression, rest, lead- water and laudanum, and later by a 50 per cent, ichthyol ointment. Muscular spasm requires morphin internally, Fig. 69. — Fracture-hook inserted in displaced fragment (McBurney and Dowd). firm bandaging, or even tenotomy. Fat-embolism is treated by stimulants and artificial respiration. Shock, delirium tremens, urinary retention, etc. are treated according to the ordinary rules of surgery. Treatment of Compound Fractures. — It must first be decided, in a case of compound fracture of a limb, if ampu- tation is necessary, and the x-rays are of great value in de- termining the condition of the bones in a crushed part. Amputation is demanded when the limb is completely crushed or pulpefied through its entire thickness ; when extensive pieces of skin are torn off; when an important joint is badly splintered ; w^ien the main arter}^, vein, and nerve are torn through ; and sometimes when there is vio- lent hemorrhage from a deep-seated vessel. What is to be done is to some extent determined by the patient's age and general health. In a healthy young person, if in doubt, 340 MODERN SURGERY. give the limb the benefit of the doubt and try to save it : if the artery alone is ruptured, cut down upon it and tie both ends; if the nerve is severed, suture it; if a joint is opened, drain and asepticize. If an attempt is made to save the limb, be ready at any time to amputate for gangrene, secondary hemorrhage (if re-ligation at original point and compression high up fail), extensive cellulitis, and profuse and prolonged suppuration.^ When it is determined to try to save the limb, the part must be cleansed thoroughly by the antiseptic method (in no injuries is this more important). The frag- ments are reduced, the ends are resected if necessary, and are usually held together by silver wire, copper wire, chro- micized catgut, or kangaroo-tendon. Thorough through- and-through drainage is established and tubes are inserted. The extremity is put in a proper position, the damaged area and its neighboring parts are enveloped in corrosive-subli- mate gauze, plaster is at once appHed over brackets or over a well-padded stick of wood, and in the plaster a trap-door is cut before it sets, over each end of, and around, the drainage- tube (Fig. 70). These trap-doors are covered with corro- Fenestrated plaster-of- Paris dressing. sive-sublimate gauze, which is held in place by a roller. The drainage-tubes are usually removed, if suppuration does not occur, in from forty-eight to seventy-two hours. The wound is treated as any other wound. A compound fract- ure of the skull demands trephining. If a fracture of a rib ^ See Howard Marsh on "Fractures," in Heaths Dictionary of Practical Surgery. DISEASES AND INJURIES OF BONES AND JOINTS. 34 1 is compound internally, resect the rib ; if it is compound externally, dress antiseptically. Compound fractures may be followed by gangrene, slough- ing, periostitis, septicemia, pyemia, osteomyelitis, necrosis, etc. The treatment of these conditions is by well-known rules. Treatment of Delayed Union and Ununited Fracture. — When delayed union exists, seek for a cause and remove it, treating constitutionally if required, and thoroughly im- mobilizing the parts by plaster. Orthopedic splints may be of value. Use of the limb while splinted, percussion over the fracture, and rubbing the fragments together, thus in each case producing irritation, have all been recommended. Blistering the skin with iodin or firing it has been employed. If the case be very long delayed, forcibly separate the frag- ments and put up in plaster as a fresh break. If these means fail, irritate by subcutaneous drilling or scraping, or, better, by laying open the parts and then drilling and scraping at many places. Buechner advocates the induction of hyper- emia by a constricting band, just as Bier induces congestive hyperemia for tuberculous areas. At first the constriction is left on only a short time, but the period is lengthened every day, until in a it.w days it remains almost continuously day and night. He claims that ten days of almost contin- uous application cures most cases. Helferich devised this method in 1887. Lannelongue and Menard inject a i : 10 solution of zinc chlorid between the fragments. Leaving acupuncture-needles in for days is approved by some, and electropuncture is advocated by others. Cases of ununited fracture must be treated by excision of the bony ends and fibrous tissue, securing the fragments together by periosteal sutures, by pins, by screws and plates, by ivory pegs, by screws, by silver or copper wire, by kangaroo-tendon, by Senn's bone-ferrules, or by chromicized catgut. Delorme makes an incision, removes bone-splinters and fibrous tissue, smooths off one end, forces this into the bored-out medul- lary canal of the other fragment, and sutures the periosteum. Gussenbauer's clamp will often give a good result, and was used for years by Billroth. (See Osteotomy for Ununited Fracture, p. 482.) Treatmefit of Vicious Union. — If angular deformity results from faulty union, it can be corrected by moulding while the callus is soft. If the callus has become hard, the bone can be refractured. If faulty union occurs with overriding, an osteotomy can be performed. 342 MODERN SURGERY. Special Fractures. — Nasal Bones. — The nasal bones, because of their situation, are often broken. The commonest site of fracture is through the lower third, where the bones are thin and lack support. The fracture may be compound externally or internally. The cause is direct violence. Dis- placement may not occur at all, but when present it arises purely, from force, and never from muscular action, no mus- cle being attached to these bones. If the force is from the front, the nose is flattened ; if from the side, deflected and de- pressed. Displacement is soon masked by swelling. Crepitus can sometimes be elicited by grasping the upper part of the nose with the fingers of one hand and moving it below from side to side with those of the other hand. Preternatural mo- bility is valueless as a sign, because of the natural mobility of the cartilages. Nose-breathing is difficult because of blocking of the nostrils by blood-clot. Diagnosis is almost impossible when deformity is absent. The complications that may be noted are cerebral concus- sion, brain-symptoms from implication of the frontal bone or cribriform plate of the ethmoid, and extension of fracture to the superior maxillary or lachrymal bones. Emphysema of root of nose, eyelids, and cheeks, is common, and means either a rent in the mucous membrane of Schneider or a crack in the frontal sinus. There may be much discoloration because of subcutaneous hemorrhage. Epistaxis is usual, and is sepa- rated from the epistaxis in fractures of the base of the skull by the facts that the bleeding in the first condition is profuse, is, as a rule, soon checked, and is not followed by an ooze of cerebrospinal fluid; whereas in the second condition it is pro- fuse, continued, and followed by a flow of cerebrospinal fluid. Fracture of the bony septum occasionally complicates nasal fractures, and deviation of the cartilaginous septum often takes place. The prognosis is usually good. Treatment. — When there is no displacement, or when a displacement does not tend to be reproduced after reduction, use lead-water and laudanum for a few days if swelling exists, but employ no retentive apparatus of any kind. Order the patient not to blow his nose for ten days and to syringe it out daily with a solution of bicarbonate of sodium. If de- formity be noted, correct it at once, as the bones soon unite in deformity. If the attempts at reduction are very painful, or if the subject be a child, a woman, or a nervous man, give ether or spray the interior of the nose with a 4 per cent, solu- tion of cocain. Reduction is effected by a grooved director or steel knitting-needle, wrapped in iodoform gauze and DISEASES AND INJURIES OF BONES AND JOINTS. 343 Fig. 71. — Mason's pin. passed into the nostril ; the fragments are lifted up with this instrument, and the fingers externally mould them into place. A rubber dilator can be used in reduction. This is pushed into the nose and inflated by air or water. If hemorrhage is mod- erate, check it with cold ; if se- vere, by plugging. If flattening tends to recur, pass a Mason's pin (Fig. 71) just beneath the fragments, through the line of fracture and out the opposite side. Steady the fragments by a piece of rubber externally caught on each end of the pin, or with figure- of-8 turns around the ends with silk. Leave the pin in place for five days. This instrument of Mason's is a sharp, strong, nickel-plated pin, with a triangular point. If a lateral deformity tends to recur, hold a compress over the fracture or fix a moulded-rubber splint over the nose by a piece of rubber-plaster one and a half inches broad and long enough to reach well across the face, and use compres- sion for ten days. In neither of the above cases is the nose to be blown, but in both cases it is to be syringed daily. In both cases, after dressing, if the swelling be marked, use lead- water and laudanum. In fractures rendered compound by tears in the mucous membrane irrigate with normal salt solution or boracic-acid solution, holding the head so that the solution will not run into the mouth ; plug with iodo- form gauze around a small rubber catheter, which instrument permits nose-breathing ; carefully remove the gauze daily and syringe. In fractures compound externally cleanse anti- septically externally, and dress with a film of cotton soaked in iodoform collodion or com- pound tincture of benzoin, or apply sterile gauze. Fractures of the bony septum, if showing a tendency to reproduction of deformity, require packing as above explained, or the use of a special splint (Fig. 72). Fractures of the nasal cartilages are to be pinned in place. Fractures of the nose are entirely united in from ten to twelve days. Fractures of the Lachrymal Bone. — The lachrymal Fig. 72. — Jones's nasal splint. 344 MODERN SURGERY. bone may be broken when the nasal bones, a superior maxillary bone, or the lateral plate of the ethmoid are fractured. Treatment. — Treat the chief injury, which is the fracture of the other bone. Maintain the patency of the lachrymal duct by passing frequently a clean probe. Fractures of the Superior Maxillary Bone. — Although a fragile bone, the superior maxillary is rarely broken except through the alveolar border. It may be broken by transmitted force from blows on the chin, or on the head when the chin is fixed ; but direct violence is the usual cause, and the wall of the antrum may be crushed in. Comminution is the rule, and the injury is often compound. These fractures induce great swelling, pain, and inability to chew; mobility and crepitus may be detected. Deformity is due to the breaking force, and not to the action of any muscle. When a portion of the alveolar arch is fractured, as may occur in pulling teeth, the fragment is depressed back- ward, and there exist irregularity of the teeth (some of which may be loosened) and inability to chew food. Fracture of the nasal process is apt to injure the lachrymal duct. When the antrum is broken in there are great sinking over the fract- ure, depression of the malar bone, and emphysema. Trans- verse fracture of the upper part of the body of the bone may cause no deformity. The force sufficient to break the supe- rior maxillary bone is so great that fractures of other bones almost certainly occur, and concussion of the brain not infre- quently exists. Injury of the infraorbital nerve is not unusual, causing pain, numbness, or an area of anesthesia involving one-half of the upper lip, the ala of the nose, and a triangle whose base is one-half the upper lip and whose apex is the infraorbital foramen. There is also loss of sensation in the gums and upper teeth of the injured side. Fractures of the superior maxillary bone occasionally induce fierce hemor- rhage from branches of the internal maxillary artery, and if this occurs, watch out for secondary hemorrhage (these ves- sels being in firm canals). Treatment. — If the fracture does not implicate the alveolus, or if no deformity exists, apply no apparatus, but feed the patient on liquid food for four weeks. Reduce deformity, if it exists, by inserting a finger in the mouth. If the antrum is broken in, put the thumb in the mouth and push the malar bone up and back. In certain cases of deformity make an incision at the anterior border of the masseter muscle, insert a tenaculum or aneurysm-needle, and pull the bone into place DISEASES AND INJURIES OE BONES AND JOINTS. 345 (Hamilton). If the malar bone or malar process is driven into the antrum, Weir tells us to incise the mucous mem- brane above, and external to, the canine tooth of the upper jaw, break into the antrum with a bone gouge, insert a steel sound, lift out the malar bone, and pack the antrum with gauze. Loose teeth are not to be removed : they are pushed back into place and held by wiring them to their firmer neighbors. Hemorrhage is arrested by cold and pressure. If hemorrhage is dangerously profuse or pro- longed, tie the external carotid. If the line of the teeth, notwithstanding the wiring, is not regular, mould on an interdental splint. The usual splint for the upper jaw is the lower jaw held firmly against it by the Gibson, the Barton, or the four-tailed bandage. Ever}^ second day remove the bandage and wash the face with ethereal soap. The patient, who is ordered not to talk, is to live on Hquid food administered by pouring it into the mouth back of the last molar tooth by means of a tube or a feeding-cup. Never pull a tooth to get a space, but if a tooth is lost, utilize its space for this purpose. After ever}^ meal wash out the mouth with chlorate-of-potassium or boracic-acid solution to prevent foulness and the digestive disorders it may induce. Leave off the dressings in five weeks, and let the patient gradually return to ordinary diet. In fractures compound externally do not remove frag- ments, antisepticize, arrest bleeding as far as possible by ligature, by pressure, or by plugging, wire the fragments if feasible, dress with gauze, and wash the mouth with great frequency. Fractures compound internally are treated as simple fractures, except that the mouth is washed more frequently. The malar bone is rarely broken alone. Hamilton says no uncomplicated case is on record. The malar is a strong bone resting on a fragile support, and hence it can be used as a wedge to break other bones and yet itself be unfract- ured. The cmisc of fracture is violent direct force. A fracture of the orbital surface of this bone causes subcon- junctival hemorrhage like that encountered in fracture of the base of the skull. Protrusion of the eye may result either from hemorrhage or from crushing in of the malar bone. Chewing is apt to cause pain. Treatment. — If no deformity exists, there is practically nothing to be done. If deformity exists, try to correct it as in fractures of the superior maxillary. As these cases are almost invariably complicated by breaks of the upper jaw, 346 MODERN SURGERY. they are treated in the same manner as the latter injury. The union is complete in three weeks. Fracture of the zygomatic arch is very rare. The causes are (i) direct violence; (2) indirect force (from depres- sion of the malar) ; and (3) forcing of foreign bodies through the mouth. Direct violence is the usual cause. Direct vio- lence causes inward displacement, and indirect force may cause outward displacement. The usual seat of fracture is at the smallest portion of the process — that is, on the tem- poral side of the temporomalar suture (Matas). The symp- toms are pain, ecchymosis, swelling, displacement, and dif- ficulty in moving the jaw (because of injury to the masseter). Treatment. — In simple fracture give ether and try to push the arch in place. Many surgeons do not make an incision, as depression will do no harm and the functions of the jaw will be restored. Simply dress with compress, adhesive strips, and crossed bandage of the angle of the jaw (Fig. 267). Union will take place in three weeks. Matas ^ advises that an anesthetic be administered and the parts be asepticized. A long semicircular Hagedorn needle is threaded with silk, is entered one inch above the middle of the displaced frag- ment, is passed well into the temporal fossa, and is made to emerge half an inch below the arch. The silk is used to pull a silver wire through around the fracture, and this wire is employed to pull the bone into po.sition. A firm pad is applied externally and the wire is twisted over the pad. Matas dresses antiseptically, and on the ninth or tenth day removes the wire, splint, and dressings permanently. Fractures of the inferior maxillary bone may, and most usually do, affect the body, although they occasionally occur in the rami. Any part of the body may be fractured, the most usual seat being near the canine tooth or a little external to the symphysis (Pick). A portion of alveolus may be broken off. In fractures of the ramus either the angle, the condyloid neck, or the coronoid process may be broken. In fractures of the body the posterior fragment generally overrides the anterior. Fractures of the lower jaw are often multiple and are almost always compound, because the oral mucous membrane and alveolar periosteum are torn. The cause is usually direct violence. Indirect violence (lateral pressure) may fracture the body anteriorly. Fractures near the angle are always due to direct violence. Indirect violence may fracture the condyle (falls on the chin), and so may direct violence. Fractures of the coronoid are very rare, and they 1 New Oi'leans Med. and Surg. Jour., Sept., 1 896. DISEASES AND INJURIES OF BONES AND JOINTS. 347 arise from great direct violence (usually gunshot-wound or some other penetrating force). Symptoms. — In fracture of the body preternatural mobility and crepitus generally exist. There is bleeding because of laceration of the gums ; saliva dribbles constantly ; the jaw is supported by the hand ; great pain exists (possibly from in- jury of the nerve) ; and deformity is present, shown by inequal- ity of the teeth if the fracture is anterior to the masseter, the anterior fragment going downward and backward and the posterior fragment going upward and forward. The down- ward displacement is due to muscular action (action of the digastric, geniohyoid, and geniohyoglossus). The backward displacement is due to the violence. The temporal muscle draws the posterior fragment up and to the front. In fract- ure of the neck of the condyle the jaw is drawn toward the injured side, and the condyle goes inward and forward by the action of the external pterygoid. In fracture of the coronoid process the temporal pulls the small fragment up. Complications. — The complications are — digestive disorders and diarrhea from swallowing foul discharges ; loosening of the teeth ; loosened teeth be- tween fragments ; bleeding (usually only oozing from the gums, but there may be hemorrhage from the infe- rior dental) ; and suppura- tion. Necrosis may follow these fractures. Treatment. — Remove a tooth if between fragments, but replace it in its socket after reducing the fracture. Correct deformity. Push in loose teeth and put back de- tached ones. Wash out the mouth with hot water to clean it and to check bleeding. If bleeding is very severe, com- press the carotid for a time. The fracture can be dressed with a pad of lint over the chin and Hamilton's four-tailed bandage (Fig. ']^^ ; or put on a splint of paste-board, felt, or gutta-percha (cut as shown on PI. 5, Figs. 3, 4) moulded to the part, padded with cotton, and held in place by a Barton's or a Gibson's bandage (Figs. 264, 266). If apposition of the fragments cannot be maintained by the above methods, fasten Fig. 73. — Hamilton's bandage. 348 MODERN SURGERY. the teeth together with wire, wire the fragments themselves together, or have a dentist apply an interdental splint (Fig. 74). The patient is to be fed on liquid food (see Fracture of the Upper Jaw, p. 345), the mouth is to be washed out frequently, and the dressings are to be changed every second day. The union is complete in five weeks. Though these fractures Fig. 74. — Interdental splints. are usually compound, they do not endanger life. If they are compound, wash the mouth often with a solution of boracic acid or of chlorate of potassium. Fractures of the Hyoid Bone. — These fractures are rare injuries, and are caused by hanging, by the throat being grasped by an antagonist, and by falls in which the neck strikes some obstacle. If the bone breaks by throttling, it is its body which fractures (indirect force). Fractures by mus- cular action are most unusual. Symptoms. — The symptoms are — a sensation of something breaking; bleeding from the mouth if the mucous mem- brane be lacerated; pain, which is worse on opening the jaws or on moving the head or tongue ; difficulty in swal- lowing (dysphagia) ; muffled, hoarse, or absent voice ; swell- ing, and frequently ecchymosis, of the neck. There are observed occasionally, though rarely, harsh cough and dysp- nea, irregularity of bony contour, and crepitus. Always look into the mouth and see if there can be detected ecchy- mosis or laceration of the mucous membrane or projection of a bony fragment. The displacement is due to the middle constrictor of the pharynx contracting. This fracture may destroy life. Treatment. — For dyspnea be ready to perform intubation or tracheotomy at a moment's notice. Edema of the glottis is a great danger. Try to restore the fragments with one DISEASES AND INJURIES OF BONES AND JOINTS. 349 hand externally and with a finger in the mouth. Put the patient to bed and have him He back upon a firm rest so that his shoulders are elevated. His head is to be thrown between extension and flexion, a pasteboard splint or collar is moulded on the neck, and a bandage is applied around forehead, neck, and shoulders to keep the head immobile. The patient must not utter a word for a week ; he must at first be fed by enemata, and then for some time on liquid diet which is given through a tube early in the case. Endeavor to control the cough by opiates. A fractured hyoid bone requires about four weeks to unite. Fracture of laryngeal cartilages is caused by direct violence, as throttling, blows, or kicks. It is rare in young persons, and is commonest when the cartilages have begun to ossify. It is a very grave injury (80 per cent, die), death arising from obstruction to the entrance of air. Symptoms. — The symptoms, which are severe, are pain, aggravated by attempts at swallowing or speaking ; swelling, ecchymosis it may be, and emphysema of the neck ; cough ; aphonia ; intense dyspnea ; and bloody expectoration if the mucous membrane is ruptured. There can be detected in- equality of outline (flattening or projection) and perhaps moist crepitus. The usual seat of the injury is the thyroid cartilage. Treatment. — Cases without dyspnea require quiet, avoid- ance of all talking, feeding with a stomach-tube, compresses and adhesive strips over the fracture, and remedies to quiet cough. Be ready to operate at any moment. In most cases dyspnea exists, due to projection of the fragments or submucous extravasation. When there is dyspnea, emphy- sema, or spitting of blood, at once practise intubation, or, if unable to do this, open the larynx or trachea below the seat of fracture. If laryngotomy or tracheotomy is done, try to restore displaced fragments. If the fragments will not stay reduced, introduce a Trendelenburg cannula or a tracheot- omy-tube around which gauze is packed. Take out the packing in four days, and remove the tube as soon as the patient breathes well, when the opening is allowed to close. In these fractures feed with a stomach-tube and keep the patient absolutely quiet. Union takes place in four weeks. Fracture of the Ribs. — The ribs, owing to their shape, elasticity, and mode of attachment, readily bend and as read- ily recover their shape, thus standing considerable force with- out breaking. Notwithstanding these facts, the situation of the ribs so exposes them that in 16 per cent, of all cases of 350 MODERN SURGERY. fractures noted by Gurlt these bones were involved. In chil- dren this injury is rare and is most usually incomplete; it is common in adults and the aged, and in them is generally complete. It is more frequent among men than among women. The ribs commonly broken are from the fifth to the ninth, the seventh being the one that usually suffers. Fract- ure of the first rib alone is an excessively rare accident. The eleventh and twelfth ribs are seldom broken. A rib may be broken in several places, and several ribs are often broken at the same time. Fracture of a single rib is not nearly so com- mon as fracture of several ribs. These fractures may be compound either through the skin or through the pleura, a damaged lung permitting pneumothorax. Compound fract- ures are very rare, however, except from bullet-wounds. Causes. — Direct force, as buffer accidents, blows with heavy instruments, or being jumped on while recumbent, may pro- duce these injuries. A fracture from direct violence occurs at the point struck, and the ends, projecting inward, may damage the viscera. Indirect force, as great pressure or blows which exaggerate the natural bony curves, tends to produce fractures near the middle of the ribs or in front of their angles and to force the ends outward. A number of ribs are apt to be broken. Muscular action, as in coughing or parturition, occasionally, but very rarely, is a cause. Symptoms. — In connection with the history of the accident the symptoms are — acute localized pain (a stitch) on breath- ing, increased by pressure over the injury, pressure backward over the sternum, cough, and forcible inspiration or expira- tion ; respiration is largely diaphragmatic, the patient en- deavoring to immobilize the injured side; cough is frequent and is suppressed because of pain. Crepitus is often but not invariably found. It is sought, first, by resting the palm over the seat of pain while the patient takes long breaths ; second, by placing a thumb before and one behind the seat of pain and making alternate pressure ; and third, by auscultation. It should be remembered that incomplete fractures are the rule in children ; hence in them do not expect crepitus. Deform- ity is usually trivial unless several ribs are broken, because shortening cannot occur and the intercostal attachments pre- vent vertical displacement. Preternatural mobility may occa- sionally be elicited, when the region is not deeply covered with muscles, by pressing on one side of the supposed break and observing that a part of, and not the entire, rib moves. Cellular emphysema without a surface-wound is proof of rib- fracture. Bloody expectoration suggests lung injury; bloody DISEASES AND INJURIES OF BONES AND JOINTS. 35 I expectoration and emphysema prove injury of the lung. A simple, uncomplicated case in a young person gives a good prognosis. The complications are — additional injur>', making the fract- ure externally or internally compound ; laceration of pleura, pericardium, heart, lung, diaphragm, liver, spleen, or colon ; rupture of an intercostal artery ; hemothorax ; cellular em- physema ; pulmonary emphysema ; pneumothorax and pyo- thorax ; traumatic pleurisy ; pneumonia ; bronchitis ; con- gestion or edema of the lungs. Treatment. — In an uncomplicated case the patient is not put to bed, as breathing is easier when erect than when recumbent. Angular displacement outward is corrected by direct pressure. Displacement inward is soon corrected, as a rule, by the expansion of ordinary respiratory action ; but if it is not thus corrected, etherize, the deep breathing of the anesthetic state almost always succeeding. If ether fails and dangerous symptoms come on, incise under strict antiseptic guardianship, elevate, and drain, or sometimes resect the rib. After correcting any existing deformity immobilize the injured side. Direct the patient to raise his arms above his head, to empty his chest by a forced expiration, and to keep it empty until a piece of rubber plaster (two inches wide) is forcibly applied seven or eight inches below the fracture and reaching from the spine to the sternum. The patient is now allowed to take a breath and is directed to empty the chest again, another piece of plaster being applied, covering the upper two-thirds of the width of the previous strip. This process is continued until the side is strapped well above and well below the fracture (PI. 5, Fig. 13). Over the plaster light turns of an inelastic spiral bandage are carried, or pref- erably a figure-of-8 bandage of the chest, the turns crossing over the seat of injury. About once a week the plaster is removed and fresh pieces applied after rubbing off the chest with soap liniment, drying, and anointing excoriations with an ointment of oxid of zinc. The dressing is worn for three or four weeks. The patient avoids cold, damp, and draughts. The diet is to be nutritious but non-stimulating, and any cough is at once treated by opiates and expectorants. A person with this injury who has reached the age of sixty must take stimulant expectorants (ammonii carb., gr. x, in infus. senegae, oSs, t. i. d.) or employ a steam-tent several times a day. The old method of treatment, in which the chest was included in a forcibly applied broad rib-roller, is not to be used except as a temporary expedient ; it compresses the 352 MODERN SURGERY. entire chest, causes pain and dyspnea, and tends to loosen and slip. Fracture of the ribs complicated with visceral injury is highly dangerous, and requires confinement to bed. The treatment is that of the visceral injury. If there be bloody expectoration, apply adhesive strips as above indicated, put the patient to bed reclining on a bed-rest, keep him quiet, subdue the circulation, and employ opium, diaphoretics, and expectorants (a good mixture consists of squill, ipecac, am- monium acetate, and chloroform ; opium is given separately). Inflammations of the lung or the pleura, fortunately, are apt to be localized, and are treated as are ordinary inflammations of these parts. If signs of visceral injury are severe from the start or become worse under medical treatment, incise, re- sect a rib, arrest hemorrhage, and drain the pleura. In lacer- ation of an intercostal artery incise and try to ligate ; if un- able to ligate, resect a rib and apply a ligature. If the signs point to internal bleeding, resect a rib, search for the bleed- ing point, and ligate. Emphysema usually soon disappears; but if it does not, open the cellular tissue, dress antiseptically, and employ pressure. When there arises a sudden attack of dyspnea, which is prone to happen in these cases, and in which there are a blue face and a laboring pulse and suffoca- tion seems imminent, bleed the patient almost to syncope. Fracture of the costal cartilages is not a common occur- rence, even in the aged. Such fractures occur either through the cartilages or through their points of junction with the ribs. These injuries generally arise from direct violence, the carti- lage of the eighth rib being most prone to suffer. Indirect force (such as a blow upon the shoulder) is occasionally the cause, but when it is the cause some other injury is apt to be noted. Muscular action is a possible cause. Symptoms. — Displacement is often absent; but if present, it is forward or backward of either fragment, and is due chiefly to the force of the injury, but partly, it may be, to muscular action. When displacement is absent crepitus will not often be found ; in fact, crepitus is usually absent in these injuries. Localized pain, swelling, and ecchymosis are noted. Preter- natural mobility may or may not be detected. Union by bone is to be expected. Treatment. — If displacement exists, try to reduce it. If the fragment is displaced backward, reduce by deep inspira- tions ; if the fragment is displaced forward, reduce by pull- ing back the shoulders. In this attempt failure is the rule, and the surgeon should then adopt Malgaigne's expedient DISEASES AND INJURIES OF BONES AND JOINTS. 353 of applying a truss over the projection for a day or two. Dress and treat the case as if a rib were broken, removing the dressings in four weeks. Fracture of the Sternum. — The sternum may be broken, along with the ribs and spine, from great violence. Fract- ures of the sternum alone are infrequent, because the bone rests on a spring-bed of ribs. Fractures of the sternum may be simple or compound, complete or incomplete, single or multiple. The most usual injury is a simple transverse fract- ure at or near the gladiomanubrial junction, at which point dislocation may also occur. Both fracture and separation of the ensiform cartilage are very rare. The sternum may be broken along with the ribs or clavicle. Cajises. — The causes of fracture of the sternum are — direct force, as by falls of embankments or of walls, by car- crushes, or by the passing of a cart-wheel over the body ; indirect force, as by falls upon the head, thus driving the chin against the chest ; by falls upon the feet, the buttocks, or the shoulder ; by forced flexion or extension of the body over an edge or angle (as may occur during labor-pains). Syjnptojiis. — In fracture of the sternum displacement is not always present, but when it does occur the lower fragment is apt to go forward ; displacement may, however, be trans- verse or angular, or there may be overriding. The posterior periosteum, which rarely tears, limits displacement, but some deformity can, as a rule, be detected. The history of the nature of the accident has a valuable bearing upon the ques- tion of diagnosis. The position assumed by the patient is with the head and body bent forward, as attempts to straighten up cause much suffering. There is fixed and localized pain, increased by deep respiratory action, by body-movements, or by cough. Crepitus is sought for by auscultation and by placing the hand over the injury and directing the patient to make quick respirations. Mobility may become manifest on external pressure, during respiration, or while attempts are being made to bring the body erect. Respiration in these cases is usually much interfered with. It is not important to separate diastasis from fracture. Complications. — Other fractures generally complicate fract- ure of the sternum, and laceration of the pleura or peri- cardium and hemorrhage into the anterior mediastinum may exist. Abscess of the mediastinum and necrosis of the ster- num may appear as late consequences. The prognosis is good in uncomplicated cases. Treatment. — The deformity attending fracture of the ster- 23 354 MODERN SURGERY. num is to be corrected, if possible, by external pressure. If overriding is found, effect reduction by bending the body back over a firm pillow and ordering deep respiration ; if this method fails, give ether and then bend the patient back. The deformity, if reduced, tends to recur, but the bones unite well in deformity and no great harm results. The fragments need not be cut down on or hooked up unless there be inter- nal injury. After reducing the deformity, cover the front of the chest with adhesive strips extending laterally from one axillary line to the other, and vertically from well above the fracture down to the ensiform cartilage. Place over this covering an anterior figure-of-8 of the chest. In some cases, where deformity recurs after reduction, a circular bandage of the chest is applied and the shoulders are pulled strongly back with a posterior figure-of-8 bandage. The plaster is to be renewed once a week. Some surgeons treat these cases by means of a large compress held by adhesive plaster and a broad tight roller. The patient, however dressed, is put to bed and reposes erect or semi-erect on a bed-rest. This position favors easy respi- ration and antagonizes the tendency to displacement. The diet should be light, nutritious, and non-stimulating. The patient is convalescent in four weeks, and the plaster is per- manently taken off in five weeks. When the ensiform carti- lage is so bent in as to cause intense pain or injure the stomach, it should be incised and resected. Edema of the skin and fever, if they appear, indicate pus, in which case an incision is made at the edge of the sternum and the pus- cavity is irrigated, drained, and dressed antiseptically. Fractures of the Pelvis. — In some of the indicated fract- ures serious injury of the pelvic contents is apt to be found. Fractures of the False Pelvis. — Fractures of this region are seldom dangerous unless comminuted. There may be fracture of the iliac crest or of the anterior superior spine, or the line of fracture may traverse the entire length of the flanged-out ilium or the bone may be comminuted with the association of grave visceral damage. The anterior superior and posterior superior spines may be broken off. Causes. — The cause of fracture of the false pelvis is gen- erally violent direct force, as the passage of a wagon-wheel, the fall of a wall, the kick of a mule, or the force of car- crushes. Violent contraction of the rectus muscle may tear off the anterior inferior spine of the ilium. Symptoms. — In fracture of the false pelvis the history of violent force is noted. The patient leans toward the injured DISEASES AND INJURIES OF BONES AND JOINTS. 355 side. Pain exists, which is aggravated by movements (par- ticularly by bending forward), by coughing, or by straining to empty the bowels or the bladder. Ecchymosis and swell- ing are manifest. Crepitus and preternatural mobility are detected by moving the crest. Deformity is very rarely pres- ent. Cases uncomplicated by visceral injury make good recoveries. Coniplications. — The fracture may be, but rarely is, com- pound, as the parts are well protected with muscles. The colon may be injured when comminution has taken place. Treatment. — In treating fracture of the false pelvis put the patient on a fracture-bed, raise the shoulders, and put a binder about the pelvis, or encase the pelvis with broad pieces of rubber plaster, or employ the belt or girdle. Place the knees over two pillows so as to semiflex the legs and thighs, and tie the knees together. To restrain thigh-movements it may be necessary to encase a restless patient with splints or bind him to sand-bags. If the binder displaces the fragments or causes pain, abandon it and trust to position. The dress- ings can be removed in six weeks, and the patient is allowed to get up in eight weeks. In compound fractures of the false pelvis asepticize, drain and dress, put on a binder, and direct the same position to be maintained as for simple fractures. Fractures of the True Pelvis. — The most usual seat of these fractures is through the obturator foramen, the ascend- ing ischial and horizontal pubic rami being broken. A fract- ure may occur near the symphysis pubis, the symphysis may be separated, a break may run near to or into the sacro- iliac joint, the same fracture may occur on each side of the body of the pubis, and there may be multiple fractures. Fractures of the acetabulum and of the tuberosity of the is- chium may occur. Before the seventeenth year the innomi- nate bone may be broken into its three anatomical segments. These injuries are highly dangerous because of the damage which is apt to be inflicted on the pelvic contents. There may be rupture of the bladder or membranous urethra and injury of the vagina, the rectum, the uterus, or the small gut. The cause of pelvic fracture is violent force, direct or indirect. Front force tends to produce direct, and side force indirect, fracture. Symptoms. — In pelvic fracture there is a history of violent force. There are great shock, ecchymosis which is possibly linear, swelling, and intense pain increased by attempts at motion, coughing, and straining. There is also inability to sit or to stand. Mobility becomes obvious on grasping an 356 MODERN SURGERY. ilium in each hand and moving the hands. Crepitus may be noticed by this manoeuver or by moving an ilium with one hand, a finger of the other hand being inserted in the rectum or in the vagina. In making movements for diagnostic pur- poses be very gentle, as rough manipulation permits of injury by sharp fragments. There may be doubt as to whether crepitus is to be referred to pelvic fracture or to fracture of the neck of the femur; in this case follow the rule of John Wood : " The surgeon grasps the femur with one hand and places the other firmly upon the anterior superior iliac spine or crest or upon the pubes ; then, on moving the femur and abducting it freely, if a crepitus be detected, it will be felt the more distinctly by that hand which rests on or grasps the fractured bone." Injury of the bladder or urethra is made manifest by retention of urine, extravasation of urine, hematuria, etc. In some cases the urine is extravasated into the prevesical space. Bleeding from the vagina or the rectum points to a laceration of the part by a fragment. Intestinal injury induces septic peritonitis. Fractures of the brim of the acetabulum permit dorsal dislocation of the femur to occur, which dislocation will not remain reduced. The acetabulum may be broken by falls upon the feet. Fracture of the brim of the acetabulum causes shortening, which at once recurs when extension is abandoned — inversion and adduction, although the power of eversion and abduction is preserved (Stokes). There is crepitus, and the head of the bone goes with the fragment upward and backward (Stokes). If the head of the femur be driven through the acetabulum into the pelvis, the injury is very grave ; there are then found shortening, adduction, and semiflexion of the thigh, absence of the prominence of the great trochanter, and more capacity for movement than is noted in dislocation. Fracture of the ischium rarely occurs alone. Treatment. — In treating pelvic fractures endeavor to re- store the parts to a normal position, employing external manipulation and inserting a finger in the rectum or in the vagina. If reduction is difficult, give ether. Use a catheter before dressing, to detect any bladder-injury. Treat as in fractures of the false pelvis, attending carefully to visceral injuries. If urinary extravasation occurs, effect a perineal section. If peritonitis develops, perform a laparotomy. All visceral injuries are treated by general rules. Remove the dressings in six weeks, and allow the patient to be about in twelve weeks. In fracture of the acetabulum, if the limb DISEASES AND INJURIES OF BONES AND JOINTS. 357 be shortened, give ether and reduce. Treat these fractures in the same way as intracapsular fractures of the femur (p. 386). Fractures of the ischium are best treated by position, the pad, and adhesive plaster. Fracture of the Sacrum. — This injury may arise from direct force, such as a kick, but it is very rare. The sacral plexus is usually injured, and if it is there is paralysis in the territory of its branches. Symptoms. — The symptoms in fracture of the sacrum are pain, frequently incontinence of feces and retention of urine, irregularity of the sacral spines, ecchymosis, and crepitus. Crepitus may be sought for with one hand externally and a finger of the other hand in the rectum. The lower fragment goes forward and may obstruct or may tear the rectum. Paralysis may be found in the area of distribution of the sacral plexus. Treatment. — In treating fracture of the sacrum press the fragments into place with a hand externally and a finger in the rectum. Do not plug the rectum. Put a pad over the upper fragment, hold it with plaster or a binder, place the patient recumbent on a fracture-bed, and insert a large cushion underneath the pad. Some surgeons give opium to induce constipation, and allow a fecal support to accu- mulate in the rectum. Use a clean catheter regularly, and guard against bed-sores. Union occurs in about four weeks, when the dressing can be removed. The patient can get about again in six weeks. If urinary retention persists or if intractable bed-sores form after eight or ten weeks, cut down on the seat of injury and elevate or remove the portion of bone causing pressure. Fractures of the Coccyx. — The coccyx may be broken or be separated from the sacrum by a fall, a blow, a kick, or the straining of parturition. Its mobility is so great, however, that it does not often break. Symptoms. — The chief symptom of fracture of the coccyx is pain, which is much aggravated by sitting, walking, or straining at stool. If the index finger is inserted in the rectum, the displaced bone is felt ; if the thumb of the same hand is also placed externally, a rocking motion will develop crepitus and preternatural mobility. Treatment. — In treating fracture of the coccyx reduce by external pressure and by the manipulations of a finger in the rectum. Put the patient to bed and obstruct the bowels by opium for a number of days. In four weeks the fracture should be united. If union does not take place, defecation 358 MODERN SURGERY. and all movements of the coccyx will cause excruciating pain by pressure on the last sacral nerve. This condition, known as " coccygodynia," demands a subcutaneous division of the nerve or of the muscles which move the coccyx, or a resection of the bone. Fractures of the Vertebra. (See p. 592.) Fractures of the Skull. (See p. 549.) Fracture of the Clavicle. — The clavicle is more often fractured than any other bone. This fracture may occur at any age, but is notably common before the sixth year (Hulke says one-half of the recorded cases). It may be simple, mul- tiple, comminuted, oblique, transverse, complete, incomplete, or, very rarely, compound. Both clavicles may be broken. Fractures are most apt to occur just external to the middle, at the point where the inner or large curve meets the outer or small curve, at which junction the bone is at its smallest diameter. Fractures of the acromial end are more frequent than fractures of the sternal end, and less frequent than fract- ures of the shaft. The causes of clavicle-fractures are direct violence, indirect violence, and, very rarely, the contractions of " the deltoid and clavicular fibers of the great pectoral " (Treves, from Polaillon). Fractures of the shaft are usually due to indirect vio- lence, as falls upon the shoulder or upon the outstretched hand. In the latter, which is the usual mode of origin, the concussion of the fall travels up and the body-weight travels down, and these two forces compress the bone, which snaps at its weakest point. Fractures from indirect force are obhque, and in children are of the green-stick form. Fract- ures from direct force are usually transverse, and are occa- sionally comminuted. Fractures from muscular action have been recorded (Rubini the tenor, recorded by Melay). Syviptojns. — In fractures of the shaft the attitude of the patient is peculiar. He supports the elbow or wrist of the injured side with the hand of the sound side, and also pulls the extremity against the chest ; the head is turned down toward the shoulder of the damaged side, as if trying to listen to something in the joint, thus relaxing the pull of the sterno-cleido-mastoid muscle upon the inner fragment. The shoulder is nearer the sternum, on a lower level, and farther front than that of the sound side. Loss of func- tion is shown by inability to abduct the arm. Considerable pain exists, which is increased by motion, by pressure, and by hanging down the extremity without support. The deformity above noted is described by stating that DISEASES AND INJURIES OF BONES AND JOINTS. 359 the shoulder goes downward, inward, and forward (d. i. f.). The doivnzvard deformity is chiefly due to the weight of the arm, which pulls down the unsupported outer fragment, and is contributed to by the action of the pectoralis minor muscle. The imvard deformity is chiefly due to the con- traction of the pectoralis minor and subclavius muscles assisted by the action of the pectoralis major. The forward deformity is due to rotation of the outer fragment, which is brought about by the serratus magnus muscle carrying the scapula forward. In this deformity the inner end of the outer fragment is below and behind the outer end of the inner fragment, which overrides it. The inner fragment, though pulled on by the sternomastoid and relatively higher than the outer fragment, is really but little, if at all, elevated, marked elevation being prevented by the attachment of the rhomboid ligament. After noting the deformity, detect with the finger the irregularity of bony contour. Examine for preternatural mobility and crepitus by raising and throwing back the shoulder. In looking for these signs in children it is to be remembered that the fracture is probably incomplete. The prognosis is good, the bone uniting, but always with some shortening and inequality. Complications. — Fractures of the shaft are rarely com- pound, because the sharp end of the outer fragment goes back and because of the free play the skin makes over the bone (Pickering Pick). Both clavicles may be broken. In fractures from direct force deeper structures may be injured by fragments. Thus, injury of the brachial plexus will induce paralysis. Ribs may be broken at the same time. Treatment. — In treating fractures of the shaft reduce the fracture as soon as possible by throwing the shoulder upward, outward, and backward. If the patient is a girl, it is desirable to minimize the deformity. Place her upon her back on a hard bed, with a small pillow under her head, a firm and narrow cushion between the shoulders, a bag of shot resting over the seat of fracture, and the forearm lying on the front of the chest, the arm being held to the side by a sand-bag. In three weeks there will be union, practically without deformity. In a child with an incomplete fracture a handkerchief sling for the forearm, worn three weeks, is all that is needed. In complete fracture the Velpeau bandage is efficient (Fig. 273). Before applying it, place lint around the chest and cotton over the elbow. Change the bandage every day for the first week, and after that period every third day. Each time it is changed rub 360 MODERN SURGERY. the skin with alcohol, ethereal soap, or soap liniment, then dry it and examine for excoriations, which, if any are found, are anointed with zinc ointment before the dressing is reap- plied. The dressing is permanently removed at the end of four weeks, the arm being worn in a sling for another week. The classical apparatus of Desault is now rarely used (Fig. 276). The posterior fig- ure-of-8 bandage associ- ated with the second roller of Desault, some turns being made from the elbow of the injured side to the shoulder of the well side, can be used in cases in which the forward deform- ity is apt to return. The apparatus of Fox, which is very useful, consists of a pad for the axilla, a sling for the forearm, and a ring for the opposite shoulder, to which ring are tied the tapes from both the pad and the sling (Fig. 75). The dressinsf of Moore of Rochester is valuable in an emergency. It consists of a piece of cotton cloth, two yards long, and folded Hke a cra- vat until it is eight inches in width at the middle. The center of the bandage rests upon the elbow, the poste- rior tail is carried across the front of the shoulder of the injured side. The forearm is at an acute angle with the arm, and the other end of the bandage is car- ried across the forearm, across the back over the opposite shoulder, and around the axilla, where the extremities are stitched together. The forearm is sus- pended in a bandage sling (S. D. Gross). The four-tailed bandage is preferred by Pick. Sayre's dressing has many advocates (Fig. 76). For this there are required two pieces Fig. 75. — Fox's apparatus for fractured clavicle. Fig. 76. — Sayre's adhesive-plaster dressing for fracture of the clavicle (Stimson) : A, first piece; .5, second piece. DISEASES AND INJURIES OF BONES AND JOINTS. 36 1 of rubber plaster, each piece being three inches wide and sufficiently long to go around the chest one and a half times. The end of one piece encircles the arm of the injured side just below the arm-pit ; the plaster strip is pulled across the back to the other side, to the front of the chest, and returns again to the middle of the back. This procedure pulls the elbow back and throws the shoulder out. The hand of the injured side is placed on the breast of the opposite side, cotton being interposed, and the second strip of plaster runs from the elbow of the injured side and the opposite shoulder, front, around, and back, pressing the elbow forward, upward, and inward. If the fragments cannot be coaptated, incise, clear away the muscle from between them, saw the ends, bore each end and hold them in contact by means of kangaroo- tendon or silver wire. The same procedure should be pur- sued when a fracture is compound or threatens to become so. In any fracture, if signs indicate pressure upon vessels or nerves, incise, lift fragments into place and wire them. If the patient refuses this operation, put him to bed and abduct the arm. If a vessel is injured, operation is imperatively neces- sary. After removing the dressings, if the shoulder is found to be stiff, make passive movements daily ; if these fail, break up the adhesions after giving ether or nitrous oxid. Fracture of the acromial end of the clavicle is due to direct force. If the fracture is between the two coraco- clavicular ligaments, deformity is very slight, crepitus is elicited by manipulating with the fingers, and pain exists, but loss of function is not markedly manifest unless it is due to pain. These fractures are treated by binding the arm to the side with the second roller of Desault, interposing cotton between the arm and the side, and hanging the hand in a sling. In fractures external to the ligaments crepitus is manifest on moving the shoulder, the outline of the bone is irregular, severe pain exists on movement, and deformity is pronounced. The deformity is due to the serratus magnus muscle rotating the scapula forward, the inner end of the outer fragment of the clavicle often coming in contact with the anterior surface of the outer portion of the inner fragment. This fracture is reduced by pulling both of the shoulders strongly backward, and it is kept reduced by a posterior fig- ure-of-8 bandage. In fracture external to the ligaments the displacement frequently cannot be corrected by position and manipulation. Such cases demand incision and wiring. In either fracture the dressings are worn for four weeks. In children, if it is found difficult to immobilize the parts, 362 MODERN SURGERY. the most satisfactory result is obtained by the apphcation of the Velpeau bandage, which is to be overlaid by a plaster bandage. Fracture of the sternal end of the clavicle is very rare. It is caused by either direct or indirect force. There are found crepitus, projection at the seat of fracture, rigidity of the sternomastoid muscle, and shortening of the clavicle. The inner end of the outer fragment always goes forward, and often also downward and inward. Reduce these fract- ures by pulling the shoulders back, and treat them by means of the posterior figure-of-8 bandage worn for four weeks. Wiring may be necessary. Fracture of the Scapula. — This bone is not often broken, as it rests upon thick muscles and elastic ribs ; it is freely movable, and it has attached to it a bone which, easily breaks. Fractures of the body of the bone are due to direct violence. The symptoms are pain (which becomes agonizing on attempting to rotate the shoulder-blade), ecchymosis, and swelling. Crepitus is sought for by placing the hand over the bone and making movements of the arm ; also by hold- ing the point of the shoulder and lifting up the lower angle of the bone. The latter plan may display mobility. The spine of the scapula is uneven only when it itself is fractured. Examine for unevenness of the vertebral border. In fract- ures of the body of the scapula a shoulder-cap should be applied, a gutta-percha splint must be moulded over the scapula, the arm is bound to the side, and the hand is carried in a .sHng. The apparatus is worn for four weeks. Fractures of the spine of the scapula are treated as are fract- ures of the body of the bone, and for the same time. Fractures of the Neck. — Fracture of the anatomical neck has not been proved to exist. Fracture of the surgical neck is evinced by flattening of the shoulder, prominence of the acromion, and a lump in the axilla which gives crepitus on pressure upward and backward. The deformity is reduced with ease, but it at once recurs. It is treated by placing a pad in the axilla, a shoulder-cap on the shoulder, applying the second roller of Desault, and supporting the forearm and elbow in a sling. A Velpeau dressing can be used, associated with a folded towel in the axilla. The dressing is to be worn for five weeks. Fracture of the glenoid cavity, which is not very unusual, may occur with or without dislocation. It arises from direct force applied to the shoulder. The existence of this fracture is determined by excluding fractures of other bones and by DISEASES AND INJURIES OF BONES AND JOINTS. 363 detecting crepitus when the arm is at right angles to the body and the humerus is pushed against the glenoid cavity, the crepitus not being found when the arm hangs by the side. Tnatinciit here is by the second roller of Desault and a forearm sling for four weeks ; by careful passive movements limit ankylosis, but, if it occurs, it will have to be broken up while the patient is under ether or nitrous oxid. Fracture of the acromion is often met with as the result of direct violence. Its existence is indicated by pain, by in- ability to abduct the arm, by flattening of the shoulder, by sudden lowering of the point of the shoulder, by mobility, and by crepitus. To treat a case of this kind, put a large pad in the axilla with the base down, bind the arm over the pad with the second roller of Desault, lifting the elbow with turns of the roller carried over it and the opposite shoulder, thus splinting the bone in place by the head of the humerus pushing against the coraco-acromial ligaments. The dress- ing is to be worn for four weeks. Fracture of the coracoid, which rarely happens alone, may arise from direct force or from muscular action. But little displacement is found. Crepitus and mobility are usu- ally detected. Inability to shrug the shoulder inward was pointed out as a symptom by Byers. These cases are well treated by the Velpeau bandage, which is to be worn for four weeks. Fractures of the humerus are div^ided into (i) fractures of the upper extremity ; (2) fractures of the shaft ; and (3) fractures of the lower extremity. In examining any fracture of the humerus, feel at once for the pulse, so as to ascertain if the artery has been torn ; in any fracture near the head of the humerus be certain that there is no dislocation. I. Fractures of the upper extremity include {a) fractures of the anatomical neck ; (/?) fractures of the surgical neck ; {c) fractures of the head, oblique and longitudinal ; and {d) separation of the upper epiphysis. Fractures of the Anatomical Neck of the Humerus. — The anatomical neck is the constricted circumference of the articular surface, and fractures of it, though rare, do occur, especially in the aged. The line of fracture in some cases follows the insertion of the capsule, in others it is entirely within the capsule, but in most it is without the capsule above and within the capsule below ; hence the term " intra- capsular " is rarely correct as a designation. The cause is direct violence. Symptoms. — The symptoms in fracture of the anatomical 364 ' MODERN SURGERY. neck are pain, swelling, ecchymosis, slight irregularity of the shoulder (which irregularity is soon hidden by tumefaction), and inability to abduct the arm voluntarily. Deformity, as a rule, is slight or is absent, because the capsule is rarely en- tirely torn from the lower fragment. If deformity exists, it is due to the muscles inserted on the bicipital groove and to the coracobrachialis, which pull the lower fragment inward and forward. Treves says that a tear of the reflected fibers of the capsule leads to subsequent necrosis, because this joint has no ligamentum teres. In some cases impaction occurs, the upper fragment impacting in the lower. In this condition there is very sHght shortening and shoulder-flattening, no crepitus unless the tuberosity is broken off, and, as Erichsen says, the head of the bone, while it can be felt through the axilla, is not in the axis of the limb. The prognosis of this fracture is good for bony union (Ham- ilton, Pick, and R. W. Smith), but a stiff joint is apt to result. Treatment. — Some surgeons treat this fracture by simply hanging the wrist in a sling and suspending a bag of shot from the elbow to make extension. The usual plan of treatment is as follows : flex the arm to a right angle with the body, and carry up from the base of the fingers to above the elbow the turns of a spiral reverse bandage. Interpose lint between the arm and the side, and place a folded towel or a small pad in the axilla, tying the tapes over the opposite shoulder. Mould a shoulder-cap (PI. 5, Fig. 8) upon the outer aspect of the arm and upon the shoulder. This cap, which is made of paste- board or of felt, should reach below the insertion of the deltoid, cover one-half the circumference of the arm, and is to be padded with cotton. The arm with the shoulder-cap is fixed to the side by the second roller of Desault, and the hand is hung in a sling. The edges of the bandage had best be stitched. This apparatus is changed daily for the first few days, the body and arm being rubbed at each change with alcohol, soap liniment, or ethereal soap. After this period a change every third or fourth day is often enough. Passive motion is started at the end of four weeks, and the dressings are removed at the end of six weeks. In impacted fracture do not pull apart the impaction, but apply a cap to the shoul- der and fix the arm to the side for five weeks. No pad is used. The fracture unites with deformity. Fractures of the Surg-ical Neck of the Humerus. — The surgical neck is the constricted portion of bone between the tuberosities and the upper line of the insertion of the muscles on the bicipital groove. Fractures in this region are usually SPLINTS. Plate 5. I. Fracture-box. 2. Double IncHned Plane Fracture-box. 3. Jaw-cup (unfolded). 4. Jaw-cup (folded). 5. Anterior Angular Splint. 6. Internal Angular Splint. 7. Bond Splint. 8. Shoulder-cap. 9. Dupuytren Splint in Pott's Fracture. 10. Agnew Splint for Fracture of the Metacarpus. 11. Agnevv Splint for Fracture of the Patella. 12. Agnew Splint applied. 13. Strapping the Chest in Fractured Ribs. 14. Extension Apparatus in Fracture of the Femur. 15, 16. Adhesive Strips for Extension Apparatus. DISEASES AND INJURIES OF BONES AND JOINTS. 365 transverse, but they may be oblique. The causes arc — direct force almost always ; indirect force occasionally ; and mus- cular action in rare instances. SytiiptoJiis. — The symptoms in fracture of the surgical neck are — pain running into the fingers from pressure upon the brachial plexus ; crepitus and mobility on extension ; and flattening, which differs from the flattening of dislocation in that it occurs farther below the acromion and that this pro- cess is not so prominent. Shortening to the extent of an inch is noted. The head of the bone can be felt in the gle- noid cavity, but it does not move on rotating the arm. The upper end of the lower fragment is felt and moves on rotat- ing the arm. The displacement is pronounced. The lower fragment is pulled upward by the deltoid, biceps, coraco- brachialis, and triceps ; inward by the muscles of the bicipital groove ; and forward by the great pectoral ; thus, the upper end of the lower fragment projects into the axilla, and the elbow lies from the side and backward. Pean holds that the violence sends the lower fragment forward. The upper frag- ment is abducted and rotated outward, which position is due, it is generally taught, to the action of the supraspinatus, in- fraspinatus, and teres minor muscles. In some cases dis- placement is forward, and in other cases it is not obvious. The lower fragment may impact into the upper, in which case the symptoms are obscure and the diagnosis is made by ex- clusion. If the impaction is solid and complete, there are the his- tory of direct force, the impaired movements, the slight deformity, and the absence of crepitus. In all fractures of the upper end of the humerus the distinction can be made from dislocation by feel- ing the head of the bone under the acromion and by noting that it does not move on rotating the arm. The prognosis of these fract- ures is good. Treatment. — In treating a case of fracture of the surgical neck, reduce by traction and manipula- tion ; if there is an impaction, pull it apart. Take an internal angular sphnt (PI. 5, Fig. 6) and pad it well, putting on extra padding at the points that are to rest against the palm, the inner condyle, and the axillary Fig. 77. — Internal angular splint and shoulder-cap in fracture of the sur- gical neck of the humerus. 366 MODERN SURGERY. folds. Lay the arm and pronated forearm upon the spHnt. Apply a padded shoulder-cap. Fix the sphnt and cap in place with a spiral reverse bandage terminating as a spica of the shoulder, and hang the hand or forearm in a sling (Fig. jf). The dressing is to be worn for five weeks, and the rules to be followed in changing it are the same as in fractures of the anatomical neck. Motions are to be made after four weeks to amend stiffness. Another plan of treat- ment is the same as for fracture of the anatomical neck, sup- porting the wrist only in a sling so as to get the extending weight of the elbow, increasing this weight in some cases by hanging to the elbow a bag of shot. In rare cases — those with strong anterior pro- jection of the lower end of the upper fragment — apply an anterior angu- lar splint (Brinton). In some cases where the deformity strongly tends to recur support by a plaster-of-Paris trough on the back and sides of arm and shoulder (Fig. 78), and maintain ex- tension by weights and pulleys, the patient being kept in bed (Stimson). Longitudinal and Oblique Fracture of the Head of the Humerus. — By this term may be designated separation of the great tuberosity, or separation of a portion of the articular surface, together with the great tuberosity, from the shaft and lesser tuberosity (Pickering Pick, Guthrie, and Ogston). The cause is direct violence to the front of the shoulder. Symptoms. — The symptoms in longitudinal and oblique fracture of the head are broadening and flattening of the shoulder with projection of the acromion. The upper frag- ment passes up and out, and the lower fragment passes up and in to rest on the margin of the glenoid cavity below the coracoid. The elbow is drawn from the side, there is some shortening, and the patient cannot abduct his arm. If Fig. 78.— Apparatus for fracture of the humerus at any point above the condyles. DISEASES AND INJURIES OF BONES AND JOINTS. 2,6"/ the elbow be grasped and held to the side and the arm be rotated while the other hand grasps the upper fragment, crepitus is very positive. Examination develops wide sepa- ration of the fragments. The deformity cannot be entirely corrected, because the biceps tendon gets between the fragments (Ogston), but a useful limb can usually be obtained. Trcatmc7it. — The plan which gives the best result in treat- ing longitudinal and oblique fracture of the head is to place the patient on his back upon a hard bed with a small firm pillow under his head, and to abduct the arm above the head, rotate it outward so that the back of the hand rests on the bed, and hold it in place by sand-bags. This position should be maintained for three weeks, at the end of which period the fracture can be dressed for three weeks more as a fracture of the anatomical neck. If the patient refuses to go to bed, treat the injury as a fracture of the anatomical neck, padding well over the tuberosities. The dressings should be worn for six weeks, passive motion being made after four weeks. In all the abov-e injuries — in fact, in all fractures of the humerus — feel at once for the pulse, to see if the artery has been torn. Separation of the Upper Epiphysis. — The epiphysis is united during the twentieth year, its separation being a rare accident and being produced by direct force. Syviptoins. — The chief symptom in separation of the upper epiphysis is projection of the upper end of the lower frag- ment inward, forward, and upward beneath the coracoid, and consequently a projection of the elbow backward and from the side. If the lower fragment passes forward and not inward, the elbow simply passes back. The upper end of the lower fragment is smooth and convex. Rotation of the shaft develops soft crepitus when the fragments are in contact. The prognosis is good for bony union, though the future growth of the limb may be impaired. Treatment. — The treatment for separation of the upper epiphysis is a pad in the axilla, a shoulder-cap, binding the arm to the side, and hanging the hand in a sling. Wear the dressing for six weeks. 2. Fracture of the Shaft of the Humerus. — Fracture of the shaft of the humerus is a very common accident. The cause is usually direct violence, such as a blow. The fracture may arise from indirect violence, such as a fall upon the elbow. Muscular action is not rarely also a cause, as 368 MODERN SURGERY. in throwing a ball, in catching a tree-limb while falling, or in turning another's wrist as a test of strength (Treves). Symptoms. — The symptoms of a fractured shaft are pain, swelling, ecchymosis, inability to move the arm, mobility, and distinct crepitus. Shortening to the extent of three-fourths of an inch occurs. The displacement varies with the situ- ation of the fracture and the direction of the force. If the fracture is above the insertion of the deltoid, the lower frag- ment is pulled up by the triceps, biceps, and deltoid, and pulled out by the deltoid, and the upper fragment is pulled inward by the arm-pit muscles. In fracture below the del- toid this muscle is apt to pull the lower end of the upper fragment outward, while the lower fragment passes inward and upward because of the action of the biceps and triceps. The prognosis is good, but the fact should always be remembered that ununited fractures are commoner in the humerus than in any other bone. Treves believes this to be due to entanglement of muscle between the fragments, lack of fixation of the shoulder-joint, and imperfect elbow-support Hamilton believes that it is due to the facts that the elbow soon becomes fixed at a right angle, and that any movement of the forearm moves the seat of fracture, and not the elbow. Treatment. — Reduce the fracture by extension, counter- extension, and manipulation. Apply an internal angular splint without the shoulder-cap (Fig. 79). If deformity is not cor- rected, associate with this splint three short humeral splints in- stead of the shoulder-cap used in fractures near the shoulder-joint. Splints are to be worn for six weeks. Passive movements are not to be made until the fracture is well united (after six weeks), for, if made too soon, they pre- dispose to non-union, and, as no joint is involved, ankylosis will not occur. Many surgeons treat these fractures by applying plas- ter-of-Paris to forearm, arm, and shoulder (the elbow being flexed to a right angle), and hang- ing a weight to the elbow. Others apply a trough to the arm and forearm (Fig. 78). In any case in which it is im- possible to obtain and maintain correct apposition of the fragments cut down upon them, and apply sutures. Fig. 79. — Internal angular splint in fracture of the shaft of the humerus. DISEASES AND INJURIES OF BONES AND JOINTS. 369 3. Fractures of the Lower Extremity of the Humerus. — Tliesc fractures are spoken of as fractures in, or in the neighborhood of, the elbow-joint, and they include {a) fract- ure of the external condyle ; {b) fracture of the internal con- dyle ; {c) fracture of the internal epicondyle; {d^ fracture at the base of the condyles ; {/) T-fracture ; and (/) epiphyseal separation. In all injuries of the elbow-joint use ether while making diagnosis and applying first dressing. Fracture of the External Condyle of the Humerus. — A fracture of the external condyle runs into the joint and the capitellum is usually broken off. This injury occurs oftenest in children by falling on the hand, but it may occur from direct force, and may happen to adults. SyJiiptoms. — The symptoms of fracture of the external condyle are severe pain, great swelling, and crepitus (found on pressing or moving the condyle and on rotating the radius). Mobility may also be discovered. A projection is felt on the outer and posterior surface of the elbow. The hand is supinated and the forearm is semiflexed. The patient cannot use the joint. The first examination must be made under ether unless an A'-ray apparatus is accessible, but even when we have a skiagraph of the part the first dressing should be put on under ether. Fracture of the Inner Epicondyle of the Humerus. — The inner epicondyle is an epiphysis which unites during the seventeenth year. It not infrequently breaks from mus- cular action or from direct violence, the fracture not involv- ing the joint. Crepitus and mobility can be detected. Dis- placement is slight. The 02itcr epicondyle is never fractured alone. Fracture of the Internal Condyle of the Humerus. — The line of fracture of the internal condyle runs into the joint, to the trochlear surface of the humerus. The cause is always direct violence. Syinptoiiis. — In fracture of the internal condyle the frag- ment, accompanied by the ulna, goes upward and backward^ and when the forearm is extended the ulna projects poste- riorly, the lower end of the humerus being felt in front. The fragment forms a projection back of the elbow. Crepitus and preternatural mobility can be found if swelling is not too great. Crepitus is detected by flexing and extending the forearm. The space between the condyles is broader than normal and the forearm takes a bend toward the ulnar side, the " carrying function " of the forearm being lost. When a person carries a heavy object, such as a bucket, he instinc- 24 370 MODERN SURGERY. lively rests the inner condyle upon the pelvis, and the nor- mal deviation of the forearm outward keeps the bucket from striking the leg. This deviation outward when the inner condyle is against the ilium gives us the carrying function. Fig. 8o. — Diagram to exhibit the " carrying function " of the forearm, and the loss of this function in fracture of the inner condyle of the humerus : a and b show the normal relation of the parts when carrying; c shows the alteration of axis of the forearm when the inner condyle is fractured (after Allis). In fracture of the inner condyle the broken condyle ascends and the " carrying function " is lost (Fig. 80). Fracture at the Base of the Condyles of the Humerus. — This fracture is just above the olecranon and is on a higher level behind than in front. The caiLse is direct force upon the olecranon. The symptoms are loss of function and pain from injury of the median or ulnar nerves. Crepitus and mobility are readily found. The lower fragment goes backward and upward by the action of the triceps, biceps, and brachialis anticus. The lower end of the upper fragment projects in front of the joint. This lesion may be mistaken for dislocation of the bones of DISEASES AND INJURIES OF BONES AND JOINTS. 37 1 the forearm backward. In fracture the limb is mobile ; in dislocation, rigid. In fracture the deformity is easily reduced and strongly tends to recur ; in dislocation the deformity is reduced with difficulty and does not tend to recur. In dis- location there is shortening of forearm but not of arm ; in fracture there is shortening of arm but not of forearm. In dislocation there is a smooth large projection below the crease in front of the elbow ; in fracture there is a sharp projection above the crease. In fracture there is crepitus ; in dislocation there is no crepitus. The diagnosis can be set- tled by the Rontgen rays. T-fracture of the Humerus. — This is a transverse fracture above the condyles plus a vertical fracture between them. The cause is violent direct force applied posteriorly. Symptoms. — The symptoms are increase in breadth of the joint, preternatural mobility, crepitus, pain, and swelling, mounting up of the inner condyle back of the elbow on the inner side, and of the outer condyle back of the elbow on the outer side. The hand is supinated ; the forearm semiflexed ; the carrying function is lost. Prog-nosis and Treatm.ent of Fractures In or Near the Elbow -joint. — The prognosis for complete restora- tion of function is bad, and in most of these fractures some deformity and considerable stiffness are inevitable. Callus poured into a joint acts like a stone pushed into the crack of a door: it limits or prevents motion. Give ether for diagnosis and the first dressing. In all cases possible use the ;r-rays for diagnosis. After the dress- ings are applied the ,t'-rays will show if a displacement has recurred during the ap- plication of the splint. If swelling is so great that the surgeon dare not apply a splint, let him rest the arm, semiflexed, upon a pillow and apply lead-water and ■laudanum for a day or two. The position for splinting is to be full supination, which is obtained by so placing the hand of the patient that he could easily spit into the palm (Brinton). Apply a well-padded anterior angular splint (a right-angled splint; PI. 5, Fig. 5 ; Fig. 81). If posterior projection exists, -Anterior angular splint for fractures in or near the elbow-joint. 372 MODERN SURGERY. mould a pasteboard cup over the elbow and also use the anterior splint, or apply a posterior trough without the anterior angular splint (Fig. 78). In applying the anterior angular splint first fasten the upper end to the arm, then make extension of the elbow, and fasten the lower end of the splint to the extended forearm. This splint is to be worn for five weeks, removing it carefully every third day. Begin passive motion at the end of the third week. Some surgeons oppose the making of passive motion so early, believing that it leads to further formation of callus. After the dressings are removed employ passive motion, massage, hot and cold douches, inunctions of ichthyol or mercurial ointment, iodin locally, corrosive sublimate and iodid of potassium internally, and direct the patient to systematically use the arm. Many surgeons at the end of the second week apply a Stromeyer splint, which permits the patient and the surgeon to make some motion by means of the screw (Fig. 108) without removing the dressings. In children or in very stout people an anterior angular splint will not stay in place, in which case the arm should be put at a right angle and plaster-of- Paris be used. If in any case after four weeks non- union exists, put up the arm in a plaster splint for three or four weeks more. Allis warmly advocates treatment in extension. He holds that the extended position secures the best circulation, and if either condyle is unbroken gives us a natural splint. Fur- thermore, in fractures of the inner condyle, it restores the carrying function, which the flexed position does not do. For one week after the accident the patient stays in bed, with his arm extended upon a pillow. After swelling subsides the limb is wrapped firmly in a spiral flannel bandage and plaster is rubbed in or the bandage is covered with adhesive plaster. Some surgeons extend the limb and apply an ordinary plaster bandage, and in about three weeks substitute an ante- rior angular splint. The trouble with treatment in extension is that if ankylosis ensues the limb is nearly useless. Fur- thermore, it requires confinement to bed. Jones of Liverpool thinks that splints and bandages are largely responsible for the stiffness which so commonly en- sues upon an elbow injury. He advocates treatment by acute flexion in all elbow injuries except fracture of the olecranon.. In a fracture he extends, supinates, and flexes to reduce the displacement. He maintains flexion by fastening a bandage around the wrist and neck. The bandage around the neck passes through a rubber tube which serves to protect the DISEASES AND INJURIES OF BONES AND JOINTS. 373 neck. The ball of the thumb should rest against the neck. The bandage is fastened to a leather band around the wrist. This position is maintained from three to six weeks.' The author has treated a number of cases by Jones's method and now prefers it to any other plan. Separation of the lo^wer epiphysis of the humerus is a not unusual accident. The inferior extremity of the humerus may be separated, or the condyles may be separated from each other and from the shaft of the bone. Symptoms.— "WiQ symptoms are — prominence in front of the joint, caused by the lower end of the shaft of the hume- rus ; projection backward of the olecranon ; hand midway between pronation and supination. Epiphyseal separation may retard growth and produce deformity. Treatment. — Jones's position or anterior angular splint as above directed. Fractures of the ulna comprise the following varieties : (i) fracture of the coronoid process ; (2) fracture of the olec- ranon process ; (3) fracture of the shaft ; and (4) fracture of the styloid process. Fracture of the coronoid process of the ulna is a rare injury and practically occurs only as a complication of a backward dislocation of the ulna or in association with other fractures. Symptoms. — When fracture of the coronoid process is associated with a dislocation there is produced crepitus on reduction, and it is found that the deformity of the disloca- tion promptly returns on cessation of extension. The upper fragment may be pulled up by the brachialis anticus, and there exists an inability to flex the forearm completely. The position is one of extension with posterior projection of the olecranon. The broken piece is felt in front of the joint. Treatment. — The treatment is by an anterior splint whose angle is less than a right angle ; the splint is to be worn for four weeks, and passive motion is to be begun in the third week. Jones's position may be used in treating such a case. A stiff joint will probably follow. Fracture of the olecranon process of the ulna is not an uncommon injury in adults. Hulke states that it never occurs before the age of fifteen, but the writer has seen in the Jefferson Hospital a girl aged fourteen with a fractured olecranon. The cause is direct violence or muscular action. Only a small fragment may be torn away, or the greater part ^ Provincial Medical Jour., Dec, 1894, and Jan., 1895. 374 MODERN SURGERY. of the olecranon may be broken off, and the break may be comminuted or even be compound. Symptoms. — The symptoms of fracture of the olecranon are — swelling ; partial flexion of forearm ; separation of frag- ments, the upper piece being pulled up from half an inch to two inches by the triceps ; the space between the fragments is increased by forearm flexion and lessened by forearm ex- tension ; there is inability to extend the arm. Bulging of the triceps above the fragments and crepitus on approximating the fragments are observed. In some few cases there is no separation, the periosteum being untorn or the fascial expan- sions from the triceps holding the fragments in apposition. In such cases crepitus can be eHcited by rocking the upper fragment from side to side. The prognosis is fair, fibrous union being the rule. Some joint-stiffness usually occurs, and much ankylosis may be unavoidable. Treatment. — This fracture calls for a well-padded anterior splint, almost but not quite straight. A perfectly straight splint is uncomfortable, and, by opening a retiring angle be- tween the fragments and into the joint, favors non-union and ankylosis. The splint should reach from a level with the axillary margin to below the fingers. If the upper fragment does not come in contact with the lower, pull it down by ad- hesive plaster and fasten the strips to the splint. The author in one case employed a glove to which strings from the ad- hesive plaster were attached. After applying the splint keep the patient in bed for three weeks. The danger of ankylosis in this fracture is very great, and, in case it occurs in the posi- tion of extension, an almost useless arm results. Pickering Pick at the end of three weeks anesthetizes the patient, presses his thumb firmly down upon the top of the olec- ranon, puts the forearm at a right angle, and applies an anterior angular splint and directs it to be worn for two weeks, passive motion being made every other day. When the splint is removed try to obtain motion as previously directed. Non-union requires wiring of the fragments. Fracture of the shaft of the ulna alone is most apt to be near the middle, is always due to direct violence, and is not unusually compound. An injury which breaks the ulna is very apt to break the radius also. Symptoms. — By running the finger along the inner surface of the bone there are detected inequality and depression ; crepitus and mobility are easily developed ; there are pain and the evidences of direct violence. The long axis of the DISEASES AND INJURIES OF BONES AND JOINTS. 375 hand is not on a line with the long axis of the forearm, but is internal to it. If deformity exists, it is due to the lower frag- ment passing into the interosseous space because of the action of the pronator quadratus muscle ; the upper fragment, acted on by the brachialis anticus, passes a little forward. The forearm at and below the seat of fracture is narrower and thicker than normal. Trcatuioit. — In treating fracture of the shaft place the forearm midway between pronation and supination, so as to bring the fragments together and to obtain the widest pos- sible interosseous space ; this limits the danger of ankylosis in this space. The position midway between pronation and supination is marked by flexing the forearm to a right angle with the arm and pointing the thumb to the nose. Take two well-padded straight splints, one long enough to reach from the inner condyle to below the fingers, the other from the outer condyle to be- low the wrist ; place a long pad over the inter- osseous space on the flexor side of the limb, and another on the exten- sor side ; apply the splints and hang the arm in a tri- angular sling (Fig. 82). Passive motion is to be made in the third week, and the splints are to be Fig. 82.— Two straight splims in fracture of both ^ bones of the forearm. worn lor four weeks. Fractures of the ulna can be treated v^ery efficiently with plaster-of-Paris. Fracture of the styloid process of the ulna is due to direct force. The displacement is obvious. Treatment. — In treating fracture of the styloid process push the fragment back into place and use a Bond splint with a compress for four weeks, or a plaster-of-Paris dressing. Fractures of the radius include the following varieties : {a) fractures of its head ; (/?) fractures of its neck ; {c) fract- ures of its shaft; and {d) fractures of its lower extremity. Fracture of the head of the radius very rarely occurs alone, but it may complicate backward dislocation of the radius. Syniptoiiis. — The symptoms of fracture of the head of the radius are crepitus on passive pronation and supination, and loss of voluntary pronation and supination. 3/6 MODERN SURGERY. Treatment. — The treatment of a fracture of the head of the radius is the same as for a fracture in or near the elbow- joint — namely, an anterior angular splint for four or five weeks, or placing the extremity in Jones's position. Fracture of the neck of the radius rarely occurs alone. Symptoms. — In this fracture the forearm is pronated and the patient is found to have lost the power of voluntary pro- nation and supination. Under forced pronation and supina- tion it will be noted that the head of the radius does not move and crepitus is felt. The lower fragment, being pulled upward and forward by the biceps, can be felt in front of the elbow-joint. Treatment. — The treatment for fracture of the neck of the radius is the same as for fracture of the elbow-joint — namely, an anterior angular splint or Jones's position. Fracture of the shaft of the radius is far commoner than fracture of the shaft of the ulna. It may occur above or below the insertion of the pronator radii teres muscle. It may arise from either direct or indirect force. Fracture of the shaft of the ulna frequently exists as a result of the same accident. Fracture of the Radius above the Insertion of the Pronator Radii Teres Muscle. — Symptoms. — The upper fragment is drawn forward by the biceps and is fully supi- nated by the supinator brevis. The lower fragment is fully pronated by the pronator quadratus and pronator radii teres, and its upper end is pulled into the interosseous space. There are crepitus, mobility, pain, narrowing and thickening of the forearm below the seat of fracture, and loss of the power of pronation and supination. The head of the bone is motionless during passive pronation and supination. The hand is prone. Treatment. — In treating this fracture do not put the forearm midway between pronation and supination, as this position will not bring the fragments into contact, the upper fragment remaining flexed and supinated. To bring the lower fragment in contact with the upper, flex and fully supinate the forearm. Put the arm upon an anterior angular splint for four weeks, and make passive motion in the third week. Fracture of the Radius below the Insertion of the Pronator Radii Teres Muscle. — In this variety of fracture the upper fragment is acted on by the biceps, the supinator brevis, and the pronator radii teres, and it remains about midway between pronation and supination, passing forward DISEASES AND INJURIES OF BONES AND JOINTS. 377 and also into the interosseous space. The lower fragment is acted on by the supinator longus and the pronator quad- ratus, the latter being the more powerful of the two, and the lower fragment is moderately pronated, its upper extremity being thrown into the interosseous space. Other symptoms are identical with those of fracture above the insertion of the pronator radii teres. Treatment. — In treating fracture below the pronator radii teres the forearm is flexed and is placed midway between pronation and supination ; interosseous pads and two straight splints are applied as for fracture of the ulna (Fig. 82). The splints are worn for four weeks, and passive motion is made in the third week. Plaster-of- Paris is a most satisfactory dressing. Fracture of the shafts of both bones of the forearm is not frequently seen. It is caused by direct or indirect force. Symptoms. — In fractures of both bones of the forearm the hand is pronated and the lower two fragments come together and are drawn upward and backward or upward and forward by the combined force of flexor and extensor muscles, short- ening being manifest and the projection of the lower frag- ments being detected on either the dorsal or the flexor sur- face of the forearm. The upper fragment of the ulna is somewhat flexed by the brachialis anticus ; the upper frag- ment of the radius is flexed by the biceps and is pronated and drawn toward the ulna by the pronator radii teres. The forearm is narrower than it should be (the ends of the frag- ments having passed into the interosseous space) and is thicker than normal (the contents of the interosseous space having been forced out). Crepitus, mobility, pain, and inequality exist, the power of rotation is lost, and on pas- sive rotation the head of the radius does not move. The forearm is prone and semiflexed. Treatment. — The treatment requires two straight splints and two interosseous pads, the forearm flexed to a right angle and placed midway between pronation and supination (Fig. 82). The splints are worn for four weeks, and passive motion is made in the third week. Instead of this a plaster- of-Paris dressing can be used. Fracture of the Lo-wer Extremity of the Radius. — Bar- ton's fracture is oblique, starts A\'ithin half an inch of the joint, and runs into the joint. Colles's fracture is a trans- verse or nearly transverse fracture of the lower end of the radius, between the limits of one-quarter of an inch and one and a half inches above the wrist-joint, the lower fragment 378 MODERN SURGERY. mounting upon the dorsum of the upper fragment. Cones' s fracture, a very common injury, is met with most frequently in those beyond the age of forty, and oftener in women than in men. It is due to transmitted force (a fall upon the palm of the pronated hand), the force being received by the ball of the thumb and passing to the carpal bones and the edge of the radius ; a fracture begins posteriorly rather than ante- riorly, the force driving the fragment upon the dorsal surface of the radius, the carpus and lower fragment moving upward and outward. The fragments are not unusually impacted. In the author's experience dislocation of the lower end of the ulna is a frequent complication, which arises from a fract- ure of the ulnar styloid or tearing off of the internal lateral ligament of the wrist. Some hold that this fracture is due to sudden traction upon the anterior ligaments, which drag upon the bone and break it at the point where the cancellous end of the radius joins the compact shaft. Symptoms. — In Colles's fracture the hand is abducted (drawn to the radial side of the forearm) and pronated, the head of the ulna is prominent, the styloid process of the radius is raised, and the lower fragment, which mounts on the back of the lower end of the upper fragment, causes a dorsal projection, termed by Liston the " silver-fork de- formity." The lower end of the upper fragment can be felt beneath the flexor tendons above the wrist. The position in deformity is produced by the force. Some consider it is maintained by the action of the supinator longus and the flexor and extensor muscles, but particularly by the exten- sors of the thumb. Pilcher has demonstrated the fact that in this fracture a portion of the dorsal periosteum is untorn, and this untorn portion acts as a binding band to hold the fragments in deformity. Pronation and supination are lost. In this fracture the hand can be greatly hyperextended (Maisonneuve's symptom). Crepitus, which is best obtained by alternate hyperextension and flexion, can be secured unless swelling is great or impaction exists. Crepitus on side movements is rarely obtainable. Impaction may greatly modify the deformity, though displacement generally exists to some extent, and the fragments do not ride easily on each other. The styloid process of the ulna may be broken, or the inferior radio-ulnar articulation may be separated. This latter complication allows the lower fragment to roll freely upon the upper, and the characteristic silver-fork deformity does not appear. If the styloid process of the ulna is broken, pressure over it causes great pain. If a person in falling DISEASES A AD EV/CA'/ES OE BONES AND JOINTS. 379 Strikes the back of the hand and a fracture of the radius occurs, the lower fragment is driven upon the front surface of the upper fragment and is felt under the flexor tendons at the wrist. An elaborate study of fracture of the radius with forward displacement of the lower fragment has been recently published by John B. Roberts/ Trcatniciit. — In treating Colles's fracture reduce the de- FiG. 83. — Levis's radius-splints, right and left, for fracture of the lower end of the radius. formity by hyperextension to unlock the fragments and relax the dorsal periosteum, followed by longitudinal trac- tion to separate the fragments, and by forced flexion to force them into position. This formula was introduced many years ago by the late R. J. Levis. The extremity can be placed upon a Levis splint (Fig. 83), the position maintaining reduction and the tense extensor tendons giving dorsal support. Some surgeons use Gordon's pistol - shaped splint. The favorite splint in Philadelphia practice is Bond's. It places the hand in a natural position of rest (semiflexion of the fingers, semi-extension of the wrist, and deviation of the hand toward the ulna). Two pads are used : a dorsal pad ^ Am. Joitr. Med. Sci., Jan., 1S97. Fig. 84. — Bond's splint in Colles's fracture. 380 MODERN SURGERY. which oveHies the lower fragment, and a pad for the flexor surface which overHes the lower end of the upper fragment. A bandage is appUed, the thumb and fingers being left free (Fig. 84; PI. 5, Fig. 7). Passive motion is begun upon the fingers in three or four days, and upon the wrist during the second week. The splint is removed in three weeks, and a bandage is worn for a week or two more because of the swelling. In applying the Bond splint, do not pull the hand too much up on the block, or the fracture will unite with a projection upon the flexor surface of the extremity and the tendons of the wrist will be apt to be caught in the callus. If a stiff joint and limited tendon- motion eventuate from the fracture, use massage, frictions, sorbefacient ointments, tincture of iodin, electricity, and hot and cold douches, or give ether and forcibly break up ad- hesions. Undoubtedly more or less stiffness often follows Colles's fracture, and some very able surgeons have been so impressed with the frequency of its occurrence that they have dispensed with the use of a splint. Sir Astley Cooper long ago spoke of placing the arm in a sling as proper treatment for fracture of the radius. Moore of Rochester applied a cylindrical compress over the ulna, held in place for six hours with adhesive plaster, then cut the plaster, placed the forearm in a sling, and let the hand hang over the edge of the sling. Pilcher applies a band of adhesive plaster around the wrist and supports the wrist in a sling. Storp says that dispensary patients are apt to disarrange this dressing.^ He wraps a piece of rubber plaster four inches wide around the wrist, and places a second piece around the first so arranged as to form a fold over the radius ; an opening is made through the fold for the passage of a sling. In ten days the plaster is removed and the fore- arm is carried in a sling. Fracture of both the Radius and Ulna near the Wrist. — Colles's fracture may be complicated by a fracture of the ulna other than of its styloid process. Symptoms. — In fracture of the radius and ulna near the wrist the lower ends of the upper fragments come together, the upper fragment of the radius is pronated, and the lower fragment of the radius is drawn up. Pain, crepitus, mobility, shortening, and loss of function exist. Treatment. — A fracture of the radius and ulna requires the use of the Bond splint, as for Colles's fracture. Separation of the Lower Radial Epiphysis. — This acci- 1 Arch. f. klin. Chir., liii. DISEASES AND INJURIES OF BONES AND JOINTS. 38 1 dent occurs in children from falling upon the palm of the hand. It never happens after the twentieth year. Syniptojiis. — In separation of the lower radial epiphysis the lower fragment mounts upon the upper and produces a dorsal projection like Colles's fracture, but the hand does not deviate to the radial side. The deformity resembles that of a backward carpal dislocation, but is differentiated from dis- location by the unaltered relation in the fracture between the st}'loid processes and the carpal bones. Treatment. — The treatment in separation of the lower radial epiphysis consists of the use of a Bond splint, as in Colles's fracture. Fractures of the carpus are not frequent, and they are usually compound. The cause is violent direct force. Syjiiptcvns. — Fractures of the carpus are indicated by pain, swelling, evidences of direct force, sometimes crepitus, loss of power in the hand, and a very little displacement. Treatment. — Many compound comminuted fractures of the carpus require amputation. In an ordinary compound fract- ure, asepticize, drain, dress with antiseptic gauze and a plas- ter-of-Paris bandage, cutting trap-doors in the plaster over the ends of the drainage-tube. In a simple fracture use lead- water and laudanum for a few days. Dress the hand upon a well-padded straight palmar splint (PI. 5, Fig. 10) reaching from beyond the fingers to the middle of the forearm, and place the hand and forearm in a sling. The splint is worn for four weeks, and passiv'e motion of the wrist is begun in the second week. Fracture of the Metacarpal Bones. — Metacarpal fracture is very common. One or more bones may be broken. The first metacarpal bone is oftenest broken ; the third is rarely broken (Hulke). The cause is direct or indirect force. Symptoms. — The signs of a metacarpal fracture are — dorsal projection of the upper end of the lower fragment and the lower end of the upper fragment ; pain ; crepitus ; and often evidences of direct violence. Treatment. — To treat a fracture of a metacarpal bone re- duce by extension ; place a large ball of oakum, cotton, or lint in the palm to maintain the natural rotundity, and apply a straight palmar splint like that used in fractures of the car- pus (PI. 5, Fig. 10). It may be necessary to apply a compress over the dorsal projection. The duration of treatment is three weeks, and passive motion is begun after two weeks. A plas- ter-of-Paris dressing is often used. Fractures of the Phalanges. — The phalanges are often 382 MODERN SURGERY. broken. The fracture may be compound. The cause usually is direct force. Symptoms. — Fracture of the phalanges is indicated by pain, bruising, crepitus, and mobility, with very little or no displacement. Treatment. — If the middle or distal phalanx is broken, mould on a trough-like splint of gutta-percha or of paste- board, which splint need not run into the palm. If the proximal phalanx is broken, run the splint into the palm of the hand. Make the splint of gutta-percha, pasteboard, wood, or leather. The splint is worn three weeks. A sling must be worn, otherwise the finger will constantly be knocked and hurt. Some cases require a dorsal as well as a palmar splint. These cases are dressed most satisfactorily with a silicate- of-sodium or plaster-of- Paris bandage. Fracture of the femur is a very common injury. The divisions of the femur are (i) the upper extremity; (2) the shaft ; and (3) the lower extremity. I. Fractures of the upper extremity of the femur are divided into (a) intracapsular ; {b) extracapsular ; {c) of the great trochanter ; and (d) epiphyseal separation (either of the great trochanter or the head). Intracapsular Fracture of the Femur. — This fracture of the neck is transverse or only slightly oblique, and is not unusually impacted. The cause is often slight indirect force, of the nature of a twist, acting upon a person of advanced years (more often a woman than a man), but not unusually a fall upon the great trochanter is the cause. A fall upon the knees, a trip, or an attempt to prevent a fall may produce this fracture. It more often happens that the fall is due to the fracture than the fracture arises from the fall. Intracapsular fracture is never caused by direct force unless it is due to gunshot violence. The aged are more liable to intracapsular fracture than the young or the middle-aged, because, first, the angle which the neck forms with the axis of the femur becomes less obtuse with advancing years, and may even form a right angle ; this change is more pronounced in women than in men ; secondly, the compact tissue becomes thinned by absorption, the cancelli diminish, the spaces between them enlarge, the bony portions of the cancellous portion are thinned or destroyed, and the cancellous structure becomes fatty and degenerated. Sutton has shown that in very rare cases this fracture may occur in the young, even before the union of the epiphyses. Stokes follows Gordon of Belfast in classifying fractures of the femoral neck. He divides them DISEASES AXD INJURIES OF BONES AND JOINTS. 383 into intracapsular and extracapsular, and subdivides intracap- sular fractures into fracture with penetration of cervix into head ; fracture with reciprocal penetration ; intraperiosteal fracture at junction of cervix and head; intraperiosteal fract- ure of center of cervix ; extraperiosteal fracture, with lacera- tion of cervical ligaments. The last-named fracture is the most common. The first four forms may unite by bone, the fifth form will not because of non-apposition, lack of nutrition, effusion of blood, synovitis, or interstitial absorption.' Stokes claims that we may have penetration, but not impaction. Symptoms. — In intracapsular fracture there is usually shortening to the extent of from half an inch to an inch; but in some cases no shortening can be detected. Shorten- ing of a quarter of an inch does not count in diagnosis, for, as Hunt shows, one limb is often naturally a little shorter than the other. If the reflected portion of the capsule is not torn, the shortening is trivial in amount or is entirely absent. In some cases shortening gradually or suddenly increases some little time after the accident. This is due to separation of a penetration, tearing of the previously unlacerated fibrous synovial reflection, or restoration of muscular strength after a paresis. A gradually increasing shortening arises from ab- sorption of the head of the bone. Shortening is due chiefly to pulling up of the lower fragment by the hamstrings, the glutei, and the rectus. Pain is usually present in front, posteriorly, and to the side. The area of pain is localized, and motion or pressure greatly increases the suffering. Evcrsion exists, spoken of as " helpless eversion," though in a very few instances the patient can still invert the leg. This eversion is due to the force of gravity, the limb rolling outward because the line of gravity has moved externally. That eversion is not due to the action of the external rotator muscles, as was taught by Astley Cooper, is proved by the fact that when a fracture happens in the shaft below the in- .sertion of these muscles the lower fragment still rotates out- ward. This is further demonstrated by the considerations that the internal rotators are more powerful than the exter- nal, that some patients can still invert the limb, and that eversion persists during anesthesia.^ In some unusual cases inversion attends the fracture. Inversion, if it exists, is due to the fact that the limb was adducted and inverted at the time of the accident, and after the accident it remains in this 1 Stokes, in Brit. JMed. Jotir., Oct. 12, 1895. ^ Edmund Owens: A Manual of Anatomy. 384 MODERN SURGERY. position (Stokes). Besides shortening and eversion, the leg- is somewhat flexed on the thigh and the thigh on the pel- vis, the extremity when rolled out resting upon its outer sur- face. Abduction is commonly present. Loss of power is a prominent symptom : the limb can rarely be raised or inverted ; although in rare cases, when the fibrous synovial envelope is untorn, the patient may stand or even take steps. Pain is usually trivial except upon mo- tion, when it may be localized in the joint. In some cases the pain is violent. Crepitus often cannot be found, either be- cause the fragments cannot be approximated, because pene- tration exists, or because they are greatly softened by fatty change. To obtain crepitus the front of the joint must be examined while the limb is extended and rotated inward. But why try to obtain crepitus ? The diagnosis is readily made without it ; in many cases it cannot be detected, and the endeavor to obtain it inflicts pain and may produce damage. These fractures offer a not very flattering chance of repair, and efforts to find crepitus may produce serious damage. Altered Arc of Rotation of the Great Trochanter (Desault's sign). — The pivot on which the great trochanter revolves is no longer the acetabulum, and the great trochanter no longer describes the segment of a circle, but rotates only as the apex of the femur, which rotates around its own axis. It is need- less to try to obtain this sign ; to do so inflicts violence on the parts. Relaxation of the fascia lata (Allis's sign) simply means shortejting. The fascia lata is attached to the ilium and the tibia (iliotibial band), and when shortening brings the tibia nearer to the ilium this band relaxes and permits one to push more deeply inward on the injured side, between the great trochanter and the iliac crest, and near the knee above the outer condyle, than on the sound side. In this examination each limb should be adducted. Allis has pointed out another sign : when the patient is recumbent the sound thigh cannot be raised to the perpendicular without flexing the leg ; the injured thigh can be. Lagoria's sign is a relaxation of the extensor muscles. Ascent of the Great Trochanter above Nelaton's Line. — This line is taken from the anterior superior iliac spine to the most prominent part of the ischial tuberosity (Fig. 85). In health the great trochanter is below, and in intracapsular fracture it is above, this line. Relation of the Trochanter to Bryant's Triangle (Fig. 85). — DISEASES AXD IXJL'RIES OF BONES AND JOINTS. 385 Place the patient recumbent, carry a line around the body on a level with the anterior superior spines, draw a line from the anterior iliac spine on each side to the summit of the corre- sponding great trochanter, and measure the base of the tri- angle from the great trochanter to the perpendicular line from the spine to determine the amount of ascent. The dif- ference in measurement between the two sides shows the amount of ascent of the trochanter ; that is, shows the extent of shortening. Morris's mcasurcvicnt shows the extent of inward displace- ment. Measure from the median line of the body to a perpendicular line drawn through the trochanter on each side of the body. Diagnosis. — Intracapsular fracture without separation of the fragments may be mistaken for a mere contu- sion, and the diagnosis may continue obscure unless the fragments sepa- Fig. 85.— a c d, Bryant's iiio- . T c c t.' ■ J- • femoral triangle ; A B, Nelaton's rate. Loss ot tunction in contusion une (Owen). is rarely complete or prolonged, although occasionally the head of the bone is absorbed. Early in a contusion and possibly throughout the case, there is no alteration between the relation of the spine of the ilium and the trochanter, and no shortening. Contusion of a rheu- matic joint leads to much difficulty in diagnosis. Intracap- sular fracture may be confused with extracapsular fracture or with a dislocation of the hip-joint. Extracapsular fracture, which is common in advanced life, but is met with in middle life or even occasionally in the young, results usually from great violence over the great trochanter; if non-impacted, there are noted shortening of from one and a half to three inches, crepitus over the great trochanter, and usually, but not invariably, eversion ; if impacted, there is less eversion, crepitus is almost or entirely absent, and the shortening is limited to about an inch. Great tenderness exists over the great trochanter in both impacted and non-impacted fract- ures. The extensor muscles are relaxed. In dislocation on the dorsum of the ilium the patient is usually a strong young adult. There is a history of forcible internal rotation. There are inversion (the ball of the great toe resting on the instep of the sound foot), rigidity, ascent of the bone above Nela- ton's line, and shortening of from one to three inches. The head of the bone is felt on the dorsum of the ilium, and the trochanter mounts up toward the spine of the ilium, and 25 386 MODERN SURGERY. pressure upon it causes no pain. In dislocation into the thyroid notch there is possibly eversion, but it is Hnked with lengthening. \vl fracture of the brim of the acetabulum there is shorten- ing which occurs on the removal of extension, inversion, retained power of everting the limb, abduction, retained power of adduction, flexion of knee, head of bone drawn up and back with the acetabular fragment (Stokes). Crep- itus, which is most distinctly appreciated by a hand resting on the ilium. In fracture of the fundus of the acetabulum there is shortening, and the head of the bone enters the pel- vis (Stokes). Prognosis. — The prognosis is not very favorable. Old people not unusually die. Many surgeons have maintained that bony union never occurs, but it certainly does sometimes take place. Stokes holds that bony union is possible in fractures with penetration and even in fractures without penetration when the fracture is within the periosteum.^ Non-union is not unusual. Permanent shortening to some degree is inevitable, and the function of the joint is sure to be more or less impaired. It will be found necessary in many cases for the patient to always employ support in walking. Treatment. — In treating a very feeble person for intracap- sular fracture make no attempt to obtain union. Keep the patient in bed for two weeks, give lateral support by sand- bags, tie around the ankle a fillet, to which attach a weight of a few pounds, and hang the weight over the foot-board of the bed. When pain and tenderness abate, order the patient to get into a reclining-chair, and permit him very soon to get about on crutches. If hypostatic congestion of the lungs sets in, if bed-sores appear, if the appetite and diges- tion utterly fail, or if diarrhea persists, abandon attempts at ■cure in any case and secure for the sufferer sunshine and fresh air, simply immobilizing the fracture as thoroughly as possible by means of pasteboard splints. In the vast major- ity of patients, no matter how old, undertake treatment. We may be forced to abandon it, but should at least attempt to obtain a cure. If it is determined to treat the case, com- bine extension with lateral support by means of sand-bags and the extension apparatus originally devised by Gurdon Buck. The extension should be gentle, never forcible. It is not wise to pull apart a penetration. Place the subject on a firm mattress, and if the patient be a man, shave the leg. Cut a foot-piece out of a cigar-box, perforate it for 1 See the masterly paper of Stokes, before quoted. DISEASES AND INJURIES OF BONES AND JOINTS. 387 a cord, wrap it with adhesive plaster as shown on Plate 5, Figs. 15 and 16, run the weight-cord through the opening in the wood, and fasten a piece of plaster on each side of the leg, from just below the seat of fracture to above the malleo- lus (PI. 5, Fig. 14). The plaster is guarded from sticking to the malleoli by having another piece stuck to it at each of these points. Apply an ascending spiral reverse bandage over the plaster to the groin (Fig. 86). and finish the band- age by a spica of the groin. Slightly abduct the extremity. Put a brick under each leg of the bed at its foot, thus obtaining counter-extension by the weight of the body. Run a cord over a pulley at the foot of the bed, and get extension by the use of weights. From ten to fifteen pounds will probably be necessary at first, but after a day or two from six to eight pounds will be found sufficient (rememb'er that a brick weighs about five pounds). Make a bird's-nest pad of oakum for the heel. Take two canvas bags, one long Fig. 86. — Adhesive plaster applied to make extension. It should be carried up higher to a point just below the seat of fracture. enough to reach from the crest of the ilium to the malleolus, the other long enough to reach from the perineum to the malleolus. Fill the bags three-quarters full of dry sand, sew up their ends, cover the bags with slips, and put the bags in place in order to correct eversion. The slips may be changed everj^ third or fourth day. The bowels are to be emptied and the urine is to be voided in a bed-pan, unless using a fracture-bed. Maintain extension for five or six weeks, then mould pasteboard splints upon the part, and keep the patient in bed for three or four weeks more. In from eight to ten weeks after the accident the patient may get about on crutches. Union, if it takes place, is usually cartilaginous, but is sometimes bony, and there are bound to be some shortening and some stiffness of the joint. Pas- sive motion is not made until after eight weeks have elapsed. Senn claims that by his method of " immediate reduction and permanent fixation " bony union is obtained in fractures 388 MODERN SURGERY. of the neck of the femur within the capsule. He " places the patient in the erect position, causing him to stand with his sound leg upon a stool or a box about two feet in height ; in this position he is supported by a person on each side until the dressing has been applied and the plaster has set. " Another person takes care of the fractured limb, which in impacted fractures is gently supported and immovably held until permanent fixation has been secured by the dress- ing. In non-impacted fractures the weight of the fractured limb makes auto-extension, which is often quite sufficient to restore the normal length of the limb ; if this is not the case, the person who has charge of the limb makes traction until all shortening has been overcome as far as possible, at the same time holding the limb in position, so that the great toe is on a straight line with the inner margin of the patella and the anterior superior spinous process of the ilium. In applying the plaster-of-Paris bandage over the seat of fracture a fenestrum, cor- responding in size to the dimensions of the compress with which the lateral press- ure is to be made, is left open over the great tro- chanter. " To secure perfect im- mobility at the seat of fractures, it is not only necessary to include in the dressing the fractured limb and the entire pelvis, but it" is absolutely necessary to also include the opposite limb as far as the knee and to extend the dressing as far as the cartilage of the eighth rib. " The splint (Fig. 87) is incorporated in the plaster-of-Paris dressing, and it must carefully be applied, so that the com- press, composed of a well-cushioned pad with a stiff, unyield- ing back, rests directly upon the trochanter major, and the pressure, which is made by a set-screw, is directed in the axis of the femoral neck. Lateral pressure is not applied until the plaster has completely set. Syncope should be guarded against by the administration of stimulants. " As soon as the plaster has sufficiently hardened to retain Fig. 87. — Senn's apparatus. Fig. 88. — Senn's appa- ratus applied. DISEASES AND INJURIES OF BONES AND JOINTS. 389 the limb in proper position, the patient should be laid upon a smooth, even mattress, without pillows under the head, and in non-impacted fractures the foot is held in a straight position and extension is kept up until lateral pressure can be applied. " No matter how snugly a plaster-of- Paris dressing is applied, as the result of shrinkage it becomes loose, and without some means of making lateral pressure it would become necessary to change it from time to time in order to render it efficient. But by incorporating a splint in the plaster dressing (Fig. 88) this is obviated, and the lateral pressure is regulated, day by day, by moving the screw, the proximal end of which rests on an oval depression in the center of the pad." Extracapsular Fracture (fracture of the base of the neck). — The line of extracapsular fracture is at the junction of the neck with the great trochanter, and is partly within and partly without the capsule, the fracture being generally comminuted and often impacted. The cause is violent direct force over the great trochanter (as by falling upon the side of the hip). This fracture is most usual in elderly people, but is not very uncommon in young adults. Stokes has described six forms of extracapsular fracture : extracapsu- lar fracture with partial impaction posterior ; fracture with complete impaction ; fracture with partial impaction above ; fracture with partial impaction below, the shaft being split ; splitting of the neck longitudinally without impaction ; com- minuted non-impacted fracture.^ SyjnptojHS. — When impaction is absent there is marked crepitus, which is manifested most when the fingers are put over the great trochanter; there is great pain, pressure upon the great trochanter is very painful, swelling and ecchy- mosis are marked ; there is absolute inability on the part of the patient to move the limb, and passive movements cause great pain ; there is shortening to the extent of at least one and a half inches, and sometimes three inches, which short- ening is made manifest by noting the ascent of the trochan- ter above Nelaton's line, by comparison of the injured limb with the sound limb, and by measuring the base-line of Bryant's triangle on each side. Absolute eversion exists with slight flexion both of the leg and the thigh. In some rare cases inversion exists. This happens if at the time of the accident the limb was inverted and adducted (Stokes). Lagoria's sign and Allis's sign are present (p. 384). All these ' Brit. Med. Jour., Oct. 12, 1895. 390 MODERN SURGERY. symptoms follow violent direct lateral force. In the im- pacted form of extracapsular fracture, in addition to the aid given the surgeon by the history, there is severe pain which is intensified by movement or pressure ; shorten- ing exists to the extent of one inch at least, which is not corrected by extension ; there is also great loss of function ; and whereas the limb may be straight or even inverted, it is usually everted. Crepitus can be easily obtained when, there is no impaction, the trochanter moves in a large arc of rotation and is above Nelaton's line, the base-line of Bryant's triangle is shortened, and AlHs's sign is noted. Treatment. — In treating extracapsular fracture make ex- tension, raise the foot of the bed, and apply the extension apparatus with sand-bags for four weeks ; then apply a plaster dressing and get the patient up on crutches. Remove the plaster at the end of four weeks. In impacted extra- capsular fracture it is best to pull apart the impaction if the patient is in good physical condition. Southam of Manches- ter, in an impressive article, has recently insisted on the absolute necessity of pulling apart an impaction. He gives ether, and when the patient is anesthetized unlocks the fragments.^ Fracture of the Great Trochanter. — This process may be (i) broken off without any other injury, but in most cases (2) the line of fracture runs through the trochanter, and leaves one portion of the trochanter attached to the head and neck and the other part attached to the shaft. The cause is violent direct force over the great trochanter. Symptoms and Treatment. — The symptoms of the second form are similar to those of extracapsular fracture. On rotating the femur the lower part of the trochanter moves with it, but not the upper. The lower fragment goes upward and backward and projects by the side of the sciatic notch. There are shortening, eversion, crepitus, and altered position of the trochanter. The symptoms of the first form resemble those of epiphyseal separation. The treatment of the second form is like that in extracapsular fracture, and the first form is treated like separation of the epiphysis of the trochanter. Separation of the upper epiphysis of the femoral head is a very rare result of accident ; it occurs most often from disease and in youth. Symptoms and Treatment. — The symptoms are like those 1 Lancet, Dec. 21, 1895. DISEASES AXD LXJURIES OF BONES AND JOINTS. 39 1 of fracture of the neck, except that the crepitus is soft. The trcatDioit is extension as above directed. Separation of the epiphysis of the great trochanter is a very rare accident. The cause is direct violence, and the injury occurs only in youth. Symptoms. — The trochanter is found to have ascended and passed posteriorly ; there is no shortening ; all the motions of the hip-joint can be obtained ; if the thigh is flexed, abducted, and rotated externally, and the fragment pushed down and forward, crepitus is obtained — soft in epiphyseal separation, hard in fracture. Trcatmoit. — In treating separation of the epiphysis of the great trochanter flex the leg on the thigh and the thigh on the pelvis, place the extremity upon its outer surface, keep it fixed by some form of retentive apparatus, and try to draw the trochanter downward and forward by adhesive strips or by a pad and bandage. Some degree of lameness is inevi- table, even after Bryant's extension. Bryant's extension directly upward may admit of the trochanter being pulled downward upon the bone (Fig. 93). Extension must be applied for six weeks, and crutches and pasteboard splints are used for four weeks more. 2. Fractures of the shaft of the femur may affect any portion of the shaft, but especially the middle third, and may occur at any age. The cause of fractures in the upper third is usually indirect force ; fractures in the lower third are due to direct force ; and in fractures of the middle third these tw^o causes are about equally potential. Fracture from muscular action occasionally occurs. Oblique fracture is the usual variety. Symptoms. — The chief symptom in fracture of the shaft of the femur is great displacement, except when impaction occurs or when the break is in a child and the periosteum is untorn. As a rule, the lower fragment is drawn up and is posterior and somewhat to the inside of the upper fragment, and undergoes external rotation (the drawing up is due to the rectus and hamstrings ; the passing inward is due to the adductor muscles ; the rotation outward arises from the weight of the limb). In fracture of the upper third the upper fragment is apt to be thrown strongly forward and outward. Some attribute this to the action of the psoas, iliacus, and external rotator muscles, but Allis thinks it is due to the lower fragment pushing the upper fragment into this position. There is complete loss of function, the thicrh and lee beine semiflexed and everted. There are 392 MODERN SURGERY. shortening to the extent of two or three inches, pain on movement, preternatural mobility, crepitus, and obvious Fig. 89. — Dressing of fracture of the femur in the upper third with extension upon a double inclined plane (Agnew). deformity, and the ends of the fragments can be felt. In impaction there is shortening with altered axis of the limb. Treatinent. — In fractures of the shaft of the femur some amount of permanent shortening is almost inevitable. In fract- ures of the upper third use Agnew's plan — namely, a double inclined plane with extension in the axis of the partly-flexed thigh (Fig. 89). If, notwithstanding position and extension, the upper fragment pro- jects, push it into place and bind short splints upon the limb. Extension is continued for four weeks, a plaster-of-Paris bandage being used for four weeks more, the patient being then allowed to get about on crutches. Some sur- geons, in fractures of the upper third, apply a plas- ter-of-Paris bandage to the leg, thigh, and pelvis, ex- tension being made from the foot while the dressing is being applied. The anterior splint of Nathan R. Smith is much used in the South in treating fractures of the shaft and the upper ex- tremity (Fig. 90). In some fractures of the upper third no apparatus will maintain reduction. In such cases it is ad- visable to incise, separate the muscle from between the ends of the bone, and fasten the ends together with bone ferrules. Fig. go. — Smith's anterior splint. DISEASES AND INJURIES OF BONES AND JOINTS. 393 silver wire, kangaroo-tendon, steel screws, or steel pins. In fractures of the middle third and upper part of the lower Fig. 91. — Hodgen's suspending apparatus. third of the shaft, use the extension apparatus (PI. 5, Fig. 14) with the sand-bags, carrying the plaster to just below the seat of the fracture, and the roller bandage to a little above this point. Extension is to be continued for four weeks, and the plaster- of-Paris bandage is used for four weeks more. Many surgeons use Hodgen's splint in the Fig. 92. — Mclntyre's splint treatment of fractures of the thigh. The limb is suspended in a cradle and extension is obtained by strapping the foot 394 MODERN SURGERY. to the cross-bar of the frame and pulling upon the frame by cords (Fig. 91). In fractures of the lower part of the lower third of the shaft use a double inclined plane (PI. 5,. Fig. 2) alone. A Mclntyre splint (Fig. 92) is a useful form of double inclined plane. At the end of four weeks apply plaster, which is to be worn for four weeks. In children under three years of age the extension apparatus will not satisfactorily immobilize the fragments. Fractures of the thigh in children are reduced by extension and counter- extension ; a well-padded splint reaching from the axilla to below the sole of the foot is applied to the outer side of the limb and body. This splint is held in place by bandages which are overlaid with plaster of Paris. It is worn for four weeks, at which time it is removed and a plas- ter bandage, applied so as to include the entire limb, is worn for four weeks more. Bryant's extension is very satisfac- tory in treating a child (Fig. 93). Both the injured limb and the sound limb should be flexed to a right angle with the pelvis, fixed by light splints, and fastened to a bar above the bed. The weight of the body produces counter-extension and the child can be easily cleaned (Bryant's Practice of Siirgery). Fracture just above the Con- dyles. — The line of this fracture is well above the epiphyseal line. The femoral artery is in danger from the fragments. The cause, as a rule, is direct violence. Indirect force is sometimes responsible (falls upon the feet). The knee-joint may be opened. The fracture is sometimes compound. Symptoms. — The upper end of the lower fragment is drawn upward and backward, because of the action of the rectus, hamstrings, gastrocnemius, and popliteus. The upper frag- ment passes inward, and the deformity is very manifest. There are shortening, crepitus, and mobility. The ends of the fragments can be felt. If the force has been very great, a T-fracture results, and in this the knee is broadened and crepitus is got by moving the condyles, one up and the other down. Treatment. — In treating fracture at the base of the condyles, Fjg. 93. — Bryant's extension for fracture of the thigh in a child. DISEASES AND INJURIES OF BONES AND JOINTS. 395 place the limb on a double inclined plane for five weeks, then begin passive motion once every other day, restoring the limb to the splint after the movements are completed. At the end of eight weeks after the accident remove the dressings, and, if the knee-joint be stiff, use for some time massage, motions, hot and cold douches, ichthyol inunctions, etc. Bryant treats this fracture in extension, cutting the tendo Achillis, if necessary, to amend deformity. It is occa- sionally necessary to wire the fragments. Some cases de- mand amputation because of injury to the structures in the popliteal space. Fracture Separating- Either Condyle. — The cause of this fracture is direct force. SynnptoDis and Treatment. — The broken piece is drawn upward, the leg bends toward the injury, crepitus exists, the knee is much broadened, there is no shortening, and con- siderable swelling is sure to arise. In treating a fracture separating either condyle, use a double inclined plane as directed above. Longitudinal fractures run up from the knee-joint. The cause is a fall upon the feet or the knees. Symptoms and Treatment. — The symptoms of longitudinal fracture are often obscure. The femur is broadened when the knee is flexed. The split is detected between the con- dyles. The treatment is the straight position in plaster for eight weeks. Separation of the lower epiphysis occurs only before the twenty-first year. Symptoms. — The symptoms in separation of the lower epiphysis are like those of fracture, but crepitus is moist. The danger is that the growth of bone will be stunted. Treatment. — The treatment for separation of the lower epiphysis is a double inclined plane as above directed. Fracture of the patella is a very common accident. The ca?tse is direct force (producing vertical, star-shaped, or oblique lines of fracture) or muscular action (producing a transverse line of fracture). Fractures of the Patella by Muscular Action. — The knee-cap is more often broken by muscular action than is any other bone. When the knee is partly flexed the middle third of the patella rests upon the condyles of the femur and the upper third of the knee-cap projects above them ; when in this position a contraction of the quadriceps may easily cause a fracture near the center of the bone (Fig. 94). Both patellae may be broken at once. In this form of fracture the 396 MODERN SURGERY. joint, and often the prepatellar bursa, is opened. Fractures by muscular action are transverse. Symptoms. — The symptoms in fractures by muscular action are — rapid and enormous swelling, due to the effusion first of blood and then of synovia and inflammatory products into and around the joint ; absolute inability ^^^ p . to raise the limb from the bed. The frag- "^ Y I ments are widely separated, this separa- ' :>i«^.Wx^ ^^,.//\ I tion being distinctly manifest to the touch ''^- — J unless swelling is great. The separation 1 I is accentuated by flexion of the leg. \--'iWv\ Crepitus is detected if the upper frag- l^^J ment can be pushed down until it touches Fig. 94.— Mechanism of the lowcr piccc, but if swcUing is great ^scukrfct^n fxreves)'.^ this cannot be done. Union, if it occurs, will probably be ligamentous, and if the patient gets about too soon, apparently well-united fragments will by degrees stretch far asunder. Transverse Fractures of the Patella. — Treatment. — If the swelling in transverse fracture of the patella be so great as to prevent approximation of the fragments, reduce it by bandaging for a day or two, by using ice-bags and lead- water and laudanum, or by aspirating the joint. When the swelling diminishes, bring the two fragments into apposition, pull them together by adhesive plaster, and put on a well- padded posterior splint. Run a piece of adhesive plaster over the upper end of the upper fragment, draw the bone down and fasten the plaster behind and below the joint. Run another piece of plaster over the lower end of the lower fragment, draw the bone up, and fasten the plaster behind and above the joint. A third piece is run over the junction of the fragments to prevent tilting. Agnew's splint admirably accomplishes this approximation (PI. 5, Figs. 11, 12). A bandage holds the splint in place, and maybe carried around the knee by figure-of-8 turns. The heel is sometimes raised upon a pillow so as to extend the leg and to semiflex the thigh, but this is not essential. Remove and reapply the dressing every few days, as it inevitably becomes loose. At the end of three weeks remove the splint permanently and apply a plaster-of- Paris dressing from just above the ankle to the middle of the thigh. The dressing is to be worn for five weeks. At the end of eight weeks let the patient walk with canes, the joint being kept fixed for four weeks more by pasteboard splints or by a light plaster-of-Paris bandage. For one year after removing the splints and DISEASES AND INJURIES OF BONES AND JOINTS. 397 plaster a lacing knee-cap and a posterior splint should be worn to support the joint. The plan of prolonged retention renders more or less joint-stiffness a certain occurrence, but this is less of an impediment than the wide separation of the fragments that inevitably attends an early use of the joint. W. Barton Hopkins, of the Pennsylvania Hospital, has devised an excellent adhesive-plaster dressing, by means of which extension is maintained upon the upper fragment. Bryant of New York has devised an ambulatory dressing. Malgaigne's hooks (Fig. 95), if employed to treat these fractures, are to be inserted with the full antiseptic care of an ordinary surgical opera- tion. Insert the lower hooks just below the point of the patella, entering them under its edge, press the fragments together, draw up the skin over the upper fragment to prevent puckering, and insert the upper hooks with force just above the upper fragment, letting the points of the hooks bear upon the bone. Lock or screw the hooks to- gether, dress with antiseptic gauze, and apply a posterior sphnt Remove the hooks in three weeks, and treat with plaster as in the preceding case when the special splint was removed. Among other plans of treatment may be mentioned wiring the fragments (see Operations upon Bones) ; encircling the fragments with a subcutaneous silk ligature ; passing a pin Fig. 95. — Malgaigne's hooks. Fig. 96. — Needle specially designed to carry a thick wire. The eye is drilled obliquely, and should receive only a little loop on the end of the wire ; this little loop should be made previously {vide Figs. 97, 98, Barker). through the tendon of the quadriceps, another through the ligament of the patella, and approximating the two by figure- of-8 turns with a silk cord, thus drawing together the frag- ments. Barker believes strongly in wiring recent transverse fractures. He does it with antiseptic care soon after the accident, and permits passive motion or even slight active 398 MODERN SURGERY. motion immediately after the operation. Massage is begun the day after the operation and is continued for two weeks. Barker ^ uses a special needle (Fig. 96) and silver wire of the thickness of a No. i English catheter. This wire is straightened and softened in a spirit-flame. He rubs the fragments together in order to dislodge blood or fibrous material, and when marked grating occurs he introduces the wire. A puncture with a small knife is made through the middle of the upper attachment of the patellar ligament. Fig. 97. — Needle (a) introduced behind the fragments, and receiving one end {U) of the silver wire (b, c) (Barker). The needle, not carrying any wire, is made to enter through this opening into the joint, is passed back of the fragments, pierces the tendon of the quadriceps at the upper edge of the upper fragment, and its point is cut upon with a knife. The wire is inserted into the eye of the needle and the needle is withdrawn and unthreaded. The empty needle is pushed through the lower opening, is carried in front of the joint, is made to emerge at the upper opening, is threaded again and withdrawn (Figs. 97, 98). The wires are threaded into bars and twisted (Fig. 99). Fractures of the patella by direct force are vertical, stellate, oblique, or V-shaped, and are often incomplete. 1 Brit. Med. Jour., April ii, 1896. DISEASES AND INJURIES OF BONES AND JOINTS. 399 Symptoms. — Fractures of the patella by direct force are indicated by dis- coloration, swelling, great difficulty in movement, and much pain. There may or may not be crepitus, and rarely is there separation of the fragments. Bony union occurs in these fractures. Treatment. — F r a c t u r e by direct force requires a posterior splint, the local use of lead-water and laudanum, and the appli- cation of a bandage. If there is any separation, approximate the frag- ments by bandages and compresses. The dan- ger in these cases is not non-union, but ankylosis ; hence, Fig. 98. — Needle [a) passed in front of the fragments and receiving the other end (c) of the silver wire (b, c) (Barker). Fig. 99. — Wire in position round fragments and threaded through metal bars. The lower and posterior wire runs upward to the left of the upper, ready for twisting (Barker). begin passive motion of the knee-joint in the fourth week 400 MODERN SURGERY. after the accident. Remove the dressings at the end of six weeks, and let the patient at once get about. Fractures of the Leg. — In leg-fcactures both bones or only one bone may be broken. Fractures of the tibia are divided into (i) fractures of the upper end ; (2) separation of the upper epiphysis ; (3) fract- ures of the shaft ; (4) fractures of the lower end ; and (5) separation of the lower epiphysis. Fractures of the upper end of the tibia are uncommon. They may be transverse, oblique, or vertical, running into the joint. The cause is direct violence. Symptoms. — In fracture of the upper end of the tibia there is contusion of the soft parts. In a transverse fracture there are mobility and crepitus, but there is little displacement. In oblique fracture crepitus and mobility are marked and the axis of the limb is altered. In vertical fractures entering the joint there is great swelling of the knee-joint. In comminuted fractures, which exhibit marked signs, union is readily ob- tained, but if the joint has been damaged stiffness is sure to ensue. Treatmeytt. — In treating fractures of the upper end of the tibia employ a double inclined plane in the form of a Mcln- tyre splint (Fig. 92) or in the form of a fracture-box (PI. 5, Fig. i). Lead- water and laudanum are applied about the knee-joint. At the end of the fourth week begin passive motion, reapplying the splint after each daily seance. In six weeks let the patient get about, first with crutches, then with a cane, then without any artificial support. Separation of the Upper Epiphysis of the Tibia. — There is only one recorded case (Pick). Fractures of the Shaft of the Tibia. — The cause of these fractures is direct force. The fracture is generally transverse in the upper part of the bone and oblique in the lower part (Pickering Pick). Symptoms. — In transverse fracture of the shaft of the tibia there is no deformity, and the support of the fibula may even permit of walking ; there is fixed pain ; there may or may not be inequality of fragments felt by the finger ; and there are crepitus, mobility, and often linear ecchymosis. In oblique fractures there usually exist crepitus, a little mobility, and some deformity. The deformity depends on the direction of the line of fracture, and, as this line is usually from above downward, inward, and a little forward, the lower fragment usually passes behind the upper fragment and rotates inward. Treatment. — In treating fractures of the shaft of the tibia, DISEASES AND INJURIES OF BONES AND JOINTS. 4OI if there be much swelHng, put the Hmb in a fracture-box (PI. 5, Fig. I ; Fig. 100) and apply lead-water and laudanum. A silicate-of-sodium or a plastcr-of-Paris dressing is applied when the swelling subsides, or the dressing is used at once Fig. 100. — Fracture-box in fractures of the bones of the leg. if swelling is slight. The patient gets about on crutches. The dressing is removed in six weeks, and the patient goes about for one week on crutches, lightly using the foot, and then for one week with a cane. At the end of eight weeks the leg may be used, but not too much at first. Fractures of the Lo^wer End of the Tibia : Fracture of the Inner Malleolus. — The cause of fracture of the inner malleolus is direct force. Symptoms and Treatment. — The symptoms of fracture of the inner malleolus are some downward displacement, de- pression above the fragment, mobility, and crepitus. The treatment is to push the fragment into place and use side- splints or a fracture-box for two weeks, when a plaster-of- Paris or a silicate dressing may be substituted and the pa- tient be ordered to use crutches. Remove the plaster four weeks after it is applied, and direct the patient to gradually bear his weight upon the leg, as outlined above. Separation of the lo"wer epiphysis of the tibia is a very rare accident. The treatment is a fixed dressing for six weeks. Fracture of the fibula alone is commoner by far than is fracture of the tibia alone. Fractures in the upper two-thirds, which are rare, are usually due to direct force. Fractures in the lower third are frequent, and they arise from indirect force. 26 402 MODERN SURGERY. Fractures of the Upper Two-thirds of the Fibula. — In these fractures the cause is direct force. Syinpto7ns. — In fracture of the upper two-thirds of the fibula the patient can often walk. The bone is deeply situ- ated, and displacement cannot often be made out. There is a fixed pain, which is intensified by movement and by press- ure. Pressure upon the lower fragment does not move the upper fragment. Crepitus is sometimes felt, and a linear ecchymosis is apt to appear. The bone bends normally, hence slight mobility is of no value diagnostically. Treatment. — In treating a fracture of the upper two-thirds of the fibula apply a plaster-of-Paris or a silicate bandage and direct that it be worn for six weeks. Weight is not to be put upon the foot for six weeks after the accident. Fractures of the Lower Third of the Fibula. — In these fractures the cause is indirect force, especially twists of the foot. Forcible inversion of the foot pulls upon the external lateral ligament and the external malleolus, forces the fibula outward, and tends to break it, the lower fragment being dis- placed outward. Forcible eversion pulls the internal lateral ligament off from the inner malleolus (often breaks the mal- leolus) and fractures the fibula above the ankle, the bone being displaced inward. Symptoms. — In the lower third of the fibula the bone is superficial, and the irregularity of a fracture is manifest to the touch. There is localized pain, which is increased by pressure or by motion. Crepitus may exist. Deformity is often exhibited by the position of the foot. Pott's fracture, which is a fracture of the lower fifth of the fibula accompanied by outward dislocation of the foot, is due to powerful eversion of the foot. This outward dislocation is rendered possible by rupture of the deltoid ligament or — what is far commoner — by the tearing off of a portion of the internal malleolus. Treatment. — In fractures of the lower third of the fibula, after reducing displacement, place the limb in a fracture-box containing a soft pillow. A bird's-nest pad of cotton or oakum is made for the heel (Fig. lOo). A fillet around the ankle fastens the foot to the foot-piece of the box ; a pad of oakum rests between the foot-piece and the sole. If dressing Pott's fracture, put a compress above the inner malleolus and another compress below the outer malleolus. Close the sides of the box and tie them together with a bandage. Swing the box, if desired, on a gallows. Every day let down the sides of the box and rub the leg, the ankle, DISEASES AND INJURIES OF BONES AND JOINTS. 403 and the foot with alcohol. In ten days apply a plaster-of- Paris bandage and let the patient get about on crutches. Remove the plaster at the end of the fifth week after the accident, and let the patient go about with crutches for one week and with a cane for a week longer. Some surgeons dress Pott's fracture with a Dupuytren spHnt. This is a straight splint (PI. 5, Fig. 9) which reaches from the head of the tibia to or below the toes. This splint is padded, and a pyramidal pad with the base down is laid upon the inner surface of the leg, above the inner malleolus, the splint being put upon the inner surface of the leg, over the pad. The splint is fastened as shown on Plate 5 (Fig. 9), and the leg is semiflexed upon the thigh and is laid upon its outer surface on a pillow. After ten days apply the plaster- of-Paris bandage, which is to be worn as above directed. In Pott's fracture Biyant advises the use of a posterior splint, two lateral splints, and a swing. Fracture of both bones of the leg-, a very common in- jury, is often compound, and is not unusually comminuted. Fractures by direct force, such as blows or kicks, are com- monest in the upper half of the leg. Fractures by indirect force, as by falls, are commonest in the lower half of the leg. In fractures from indirect force the tibia breaks first, and then the fibula breaks at a higher level. The point of greatest liability to fracture from indirect force is the junc- tion of the low^er and middle thirds. Fractures of the leg are usually oblique, but they may be transverse if arising from direct force. Spiral, torsion, or V-shaped fractures and longitudinal breaks sometimes occur. In oblique fractures, as a rule, the line of fracture runs downward, inward, and a little forward. Symptoms. — Fracture of both bones of the leg is easy of recognition. The fibular fracture is detected as before de- scribed. By running the finger along the crest of the tibia displacement will be found, except in transverse fractures, when it may not occur. The common displacement is for the lower fragment to ascend and pass behind the lower end of the upper fragment and to rotate a little outward, and for the upper fragment to project in front. This ascent is due to the action of the gastrocnemius and soleus muscles. If the line of fracture is in a direction the reverse of that which is usual, the lower fragment ascends in front of the lower end of the upper fragment. In fracture of both bones there are marked mobility, crepitus, pain, and inability to walk. In fractures from direct force there is more or less 404 MODERN SURGERY. damage to the soft parts. A fracture near the ankle is dis- tinguished from a dislocation by the fact that the deformity is easily reduced, but tends to recur in the fracture, and, further, that in a fracture the relations of the malleoli to the tarsus are unaltered. Treatment. — If the fracture is near the ankle-joint, the action of the tendo Achillis may maintain deformity, and in such cases the tendon must be divided. In treating a simple fracture of the lower two-thirds of the bones reduce by ex- tension and counter-extension, and use a fracture-box (PI. 5, Fig. i) as in Pott's fracture (p. 402), though the compresses are not required. If the soft parts are bruised, use lead-water and laudanum ; if they are abraded, apply antiseptic dress- ings. The fracture-box may be swung upon a gallows. After three weeks apply plaster-of-Paris or silicate-of-sodium dress- ing and let the patient sit up in a chair daily for one week ; at the end of this time the patient may get about with crutches. At the end of six weeks after the accident re- move the plaster, and let the sufferer get about with crutches for two weeks and with a cane for two weeks more. Brinton dresses a fracture of both bones of the leg for two weeks in a fracture-box, for two weeks in side-splints, and for two weeks in an immovable dressing, allowing the patient to get about as soon as the plaster is put on. Instead of the fract- ure-box, we may use a posterior splint, two lateral splints, and a swing. Shrimpton of Paris uses Nathan R. Smith's anterior splint in fracture of the leg. Many surgeons apply plaster-of-Paris in the form of an ambulatory dressing. In this dressing a solid apparatus reaches up to the lower third of the thigh and below the sole of the foot. When the patient walks the weight is transmitted to the thigh. In fractures of the upper third of the leg the Mclntyre splint or the double inclined plane is used. If the fracture is com- pound, asepticize thoroughly, make a counter-opening, insert a drainage-tube, dress with bichlorid gauze, apply a plaster bandage, and cut trap-doors over the openings of the tube (see Fig. 70). Remove the tube, as a rule, in about forty- eight hours ; but the patient's temperature is a better guide than time. Fractures of the bones of the foot are rather rare acci- dents. Owing to the number of the bones and to the elasticity of their connections, the force of blows and falls is spread and dissipated. Fractures from direct force are often compound. The cause of fracture of either the scaph- oid, the cuboid, or any of the cuneiform bones is direct DISEASES AND INJURIES OF BONES AND JOINTS. 405 force. Fractures of the os calcis and astragalus arise, as a rule, from indirect force, such as falls, but the calcaneum may be broken by direct violence. In rare instances the OS calcis has been broken by contraction of the great calf- muscles. Symptoms. — In fracture of the os calcis there are severe pain, swelling, crepitus, mobility, often an apparent widening of the bone, not unusually a loss of the arch of the foot (Pick). In some cases the posterior fragment is drawn up by the calf-muscles, and in other cases there is deformity. In fracture of the astragalus displacement may occur which resembles that of a dislocation. Crepitus may or may not be detected. It can be elicited, as a rule, by rotating the foot while the heel is firmly held. If crepitus cannot be found, it is not certain that a fracture is present, though the patient may be unable to stand and there may be swelling and pain on pressure. Fractures of the other bones are hard to detect. There may or may not be crepitus, which, if it exists, is hard to localize ; there is pain on standing and on pressure, and there is bruising of the soft parts. Treatment. — To treat a fracture of the os calcis when no deformity exists, use a fracture-box for two weeks ; maintain the foot at a right angle to the leg ; apply lead-water and laudanum ; then put on an immovable dressing, and let it be worn for four weeks. In fracture of the os calcis with drawing up of the posterior fragment flex the leg upon the thigh, extend the foot, and maintain this position by means of a band around the thigh, the band being fastened by means of a cord to a slipper (PI. 6, Fig. 5), the leg resting upon its outer side. At the end of two weeks apply plaster, and let it be worn for four weeks. Many cases require incision and nailing or wiring the fragments together. If the projecting fragment of the os calcis cannot be forced into place, and if it makes dangerous pressure upon the skin, excise it ; if it does not make pressure which threatens sloughing, place the joint in a position favorable for anky- losis, and immobilize. In a fracture of the astragalus, use a fracture-box and then an immovable dressing, as in fracture of the OS calcis without deformity. Fractures of the other bones of the tarsus are almost invariably compound, and the injury may require drainage and immovable dressing, excis- ion, or even amputation. Fractures of the metatarsal bones are due to direct force and are almost always compound. Fractures from crushes usually demand excision or amputation. When 406 MODERN SURGERY. only one bone is broken displacement is slight, there is severe pain on motion and pressure, and crepitus can gener- ally be obtained. A simple fracture of a metatarsal bone is dressed in an immovable dressing for four vi'eeks. Fractures of the phalanges of the toes are due to direct force and are often compound. They may require imme- diate amputation. Treatment. — In a compound fracture where amputation is unnecessary, drain with strands of catgut for forty-eight hours and dress antiseptically ; at the end of this time apply over the bichlorid gauze a gutta-percha or a pasteboard splint extending from beyond the end of the toe to well up upon the sole of the foot, and fix the splint in place with a spiral bandage of the toe and instep. The splint is to be worn for four weeks. In a simple fracture fasten the injured toe to an adjacent toe or toes by a plaster bandage to be worn for three weeks. 3, Diseases of the Joints. Synovitis is a primary inflammation of the synovial mem- brane alone. If other structures besides the synovial mem- brane are involved, the condition is known as " arthritis." Two forms of simple synovitis exist — namely, acute and chronic. Some surgeons speak also of subacute cases. Acute Simple Synovitis. — The causes of acute simple synovitis are contusions, sprains, twists, and overuse. The causative influence of exposure to cold or damp has been much debated. It seems probable that in some cases cold produces vasomotor paresis of the vessels of the synovial membrane, a condition which may eventuate in inflammation. The membrane is red and swollen and the joint contains an excess of turbid fibrinous fluid. If the inflammation ad- vances, arthritis arises and sometimes blood is effused. Symptoms. — The symptoms of acute synovitis are — pain, which is increased by motion of the joint, by pressure upon the articulation, and by a dependent position of the limb, and which is worse at night. Pressure upon the cartilage does not cause pain, but friction of the synovial membrane at once develops it. The patient places the limb in the position which gives the greatest ease, and in this position the part becomes more or less fixed. A fluctuating swelling is noted, most marked between the ligaments, which swell- ing bulges out the synovial area and hides or obscures the articular heads of the bones. The swelling is due early to DISEASES AXD INJURIES OF BOXES AND JOIXTS. 407 extensive secretion of synovia, and later to effusion of liquor sanguinis. Bulging takes place at points where the capsule is thin, and at such points fluctuation may be detected. Fluc- tuation in the elbow is sought for posteriorly. Fluctuation in the knee is sought for on either side in front. A large effu- sion in the knee floats the patella up from the condyles. A small effusion in the knee can be detected by Fiske's plan ; that is, cause the patient to bend forward at the hips, resting each hand on the front of the corresponding thigh. The anterior structures of the joint are relaxed, and, by tapping the patella, even a small effusion can be discovered. The skin ov^er the joint is rarely reddened, but feels hot to the hand of the observer (over more superficial joints, but not over shoulder and hip) ; the joint is partly flexed ; fever exists, var>nng in degree with the size of the joint, the acute- ness of the attack, and the nature of the cause. Suppura- tion rarely follows simple synovitis, but if it does, rigors occur, there is a septic temperature, and the joint soon gives evidence of containing pus (periarticular edema). Traumatic synovitis without infection tends toward cure without suppuration if the patient is healthy, and after it ankylosis is rare. Trcatmoit. — In treating acute synovitis immobilize the joint. In sev^ere cases place it in such a position that the limb will still be useful even if ankylosis occurs. In mild cases we can immobilize in the position of rest (semiflexion), apply leeches, use the ice-bag or the Leiter coil, and follow the cold by lead-water and laudanum. After a day or two apply gentle pressure, intermittent heat, and iodin and ichthyol. If the effusion is ver}' great and persistent, and pressure, astringents, and sorbefacients fail, aspirate with antiseptic care. If effusion recurs, apply a plaster-of-Paris dressing or use flying blisters and massage. A rubber band- age is often useful toward the termination of a case. Chronic Synovitis. — Chronic synovitis follows acute synovitis or it may be chronic from the start. The syno- vial membrane looks nearly natural, but is edematous, and the joint contains an excess of fluid. If the quantity of fluid is large, the patella floats up and the disease is called " hydrops articuli " or " dropsy." In prolonged cases the synovial membrane is thickened in some places, softened in others, and is often adherent, and the villous processes of the synovial membrane are hypertrophied. If the membrane becomes extensively softened (pulpy degeneration), the soft- ened areas bulge and suppuration eventually occurs. In the 408 MODERN SURGERY. knee-joint a traumatic synovitis is sometimes linked with inflammation of the semilunar cartilages. Roux tells us that this inflammation may be produced by a squeeze, a twist, or a direct force, but a squeeze is the common cause. Hyper- extension of the knee may squeeze the cartilage, and so may attempting to rise from a stooping posture.^ If this injury has taken place, the condition of disability will be prolonged. Syjuptonis. — In chronic synovitis pain is absent or is only present during exercise or from pressure, and is slight even then ; there is some limitation of movement ; passive motion may develop creaking or crepitus ; fluctuation is apparent ; there is atrophy in the muscles about the joint; and the hypodermatic needle will draw out a viscid, straw-colored or bloody fluid. Treatment. — For hydrops use rest and pressure (a Martin rubber bandage or, better, a plaster dressing), massage, douches, frictions, passive movements, and flying blisters. Painting the joint with iodin and spreading over it blue ointment, and inunctions with ichthyol, may do good. The actual cautery is a valuable expedient. Aspiration and the subsequent use of a plaster-of- Paris bandage may be tried in some cases. Some surgeons advise aspiration, washing out with salt solution, injecting a 5 per cent, solution of carbolic acid, and immobilizing. Incision and drainage constitute a radical but proper plan. If pulpy degeneration exists, per- form an excision or an erasion. If pus forms, incise at once and drain. Internally, treat any existing diathesis and give good food, tonics, and stimulants. Chronic synovitis is often greatly benefited by the use of a hot-air apparatus. The affected part is placed in the apparatus every day, and is subjected to a temperature of from 250° to 300°. Arthritis. — By this term is meant not only inflammation of a synovial membrane, but also of other structures com- posing and surrounding a joint. It may follow a traumatic synovitis ; it may be due to pus organisms, to tubercle bacilli, to infectious diseases (gonorrhea and typhoid fever), to rheu- matism, to gout, to syphilis, and to lesions of the spinal cord. Arthritis may be either acute or chronic. Tubercular Arthritis (White Swelling ; Strumous Joint ; Pulpy Degeneration). — Patliology and Symptoms. — The ex- citing causes of tubercular arthritis may be strains, blows, twists, or cold. The primary infection with tubercle bacilli is usually in the bone, though it may be in the synovial membrane, the joint-capsule, or the structures about the 1 Gaz. des Hop., No. 125, 1895. DISEASES AND INJURIES OE BONES AND JOINTS. 4O9 joint. If the primary infective focus is in the bone, a portion of the cartilage is destroyed and the joint is opened, or a sinus forms and perforates the synovial membrane. When tubercular inflammation attacks the synovial membrane granulation-tissue is formed, and the capsule and periarticu- lar structures soon become involved in the process ; the parts thicken and soften from caseation, and they may be covered with tubercles, though but little fluid is usually effused into the joint. Some few cases present large joint- effusions. In the ordinary form of arthritis there occurs what is known as " gelatiniform degeneration ;" the embry- onic tissue is formed in large amount as fungous growths ; the structures are markedly edematous and softened ; the relaxed ligaments yield under pressure ; the natural contour of the joint is lost, and it becomes spindle-shaped ; all the structures, articular and periarticular, are glued into one mass ; the skin about the joint is white, thick, and adherent, and in it one or more large veins are seen ; fluctuation or pseudo-fluctuation is noted when caseation has occurred ; pain is not often severe, but it can usually be elicited by certain motions or by firm pressure (but the pain will always be severe when the epiphysis is involved) ; the temperature of the part is somewhat elevated ; deformity results from destruction of bone, cartilage, and ligament, from muscular spasms, and from the habitual assumption of certain attitudes to secure relief from pain; there is soon impairment of joint- motions. When the products of a tubercular arthritis caseate, the thick liquid seeks exit by forming sinuses from which caseous pus runs. If a sinus becomes infected with pyo- genic cocci, and the joint itself becomes their prey, acute suppuration arises in the joint, and constitutional involv^e- ment is pronounced and perilous to life. In pannous synovitis a large effusion is formed, there is but little granulation-tissue, though the tubercles are present in large numbers, and the ligaments and structures about the joint are slightly or not at all implicated. The diagnosis early in a case is difficult, often impossible, and the prognosis is grave. In only a very few cases, even when recognized early, is a cure obtained without impairment of joint-func- tion. The best that can usually be accomplished is a cure with more or less ankylosis, fibrous or bony ; but often ankylosis is complete. Long after the disease is apparently cured, it may break forth anew. Tubercular lesions may arise in a distant organ, or general tuberculosis may occur. Caseation is apt to produce severe constitutional disorder. 4IO MODERN SURGERY. Infection by pus organisms gives rise to grave danger of septicemia. Death is not unusual from exhaustion, from septicemia, from disseminated tuberculosis, from tubercle in an important organ, or from amyloid disease. Ti'eatment. — Constitutionally, the treatment is directed against the tubercular diathesis. Locally, rest is of the first importance, and it is maintained for many weeks, it being obtained by splints, by a plaster-of-Paris bandage, or by extension appliances. Bier's plan of inducing conges- tive hyperemia may do good (page 156). Aspiration can be used for fluid accumulations. Caseous masses are often let alone, or an aspirator is used and the joint drained, washed out with boiled water, and injected with an emulsion of iodoform and glycerin (10 per cent.). Injections of bal- sam of Peru or of iodoform emulsion about the joint once a week are efficient in some cases. If these means fail, if the patient gets worse, or if the condition of the sufferer renders dangerous the prolonged conservative course, then operate, removing the entire diseased area by erasion, by excision, or by amputation. Always remember that an incomplete operation, a partial removal, is worse than no operation, as it opens the portals to systemic infection, and may be responsible for a general tuberculosis, septicemia, or pyemia. Tuberculosis of Special Joints. — Tuberculosis of the Sacro-iliac Joint (Sacro-iliac Disease). — This is an uncom- mon affection, and is especially rare before the age of fifteen. The disease may begin in the joint, may arise in adjacent bones, or may result from a cold abscess burrowing into the joint. In some cases it is associated with extensive disease of the pelvic bones. The disease, if undetected, may lead to dissemination of tubercle, to abscess, even to death. Symptoms. — Are often obscure. The disease is usually confounded with vertebral caries or hip-joint disease. The patient limps on walking, but can stand on either leg ; there is pain in the sacro-iliac joint, about the hip, and down the thigh ; tenderness is manifest on pressure over the joint and on pushing the ilia together ; there is fulness over the sacro- iliac joint ; but no flexion of hip unless iliac abscess exists.^ Treatinent. — Rest in bed for months, using also a felt case for pelvis. Counter-irritation by blisters and actual cautery. In some cases injection of iodoform; in others incision and curetting. 1 See A. G. Miller, Edinburgh Med. Jour., May, 1895. DISEASES AND INJURIES OF BONES AND JOINTS. 4II Tuberculosis of the Hip-joint (Hip Disease ; Morbus Cox- arius ; Morbus Coxse ; Coxitis ; Hip-joint Disease). — The prim- ary lesion may be in the synovial membrane, but is more often in the bone. It may begin in the acetabulum ; it may begin in the femur. If it begins in the femur it usually starts on " the distal side of the epiphyseal cartilage " (Senn). In some cases primary tuberculosis arises in the trochanter major, and may never involve the joint. When the synovial is involved at one point spreading throughout the joint is rapid. In many • cases the articular cartilages are attacked, and in some cases the epiphyseal cartilage is destroyed. It is commonest in children, but it may arise in adults and even occasionally in those of advanced years ; 62 per cent, of cases arise in chil- dren under ten years of age and 80 per cent, of cases occur before the twentieth year (Bryant). Traumatism and cold may be exciting causes. The disease strongly tends to caseation and the formation of sequestra. S}nnptouis. — In tuberculosis of the hip-joint there are three stages: (i) the stage of microbic deposition and multiplication, the products of the bacilli causing irritation and new growth ; (2) the stage of progression, with forma- tion of embryonic-tissue masses and effusion into the joint ; and (3) the stage of caseation, with destruction of the joint and often of the structures about it. The symptoms of the first stage are slight and may be overlooked entirely. In a child there are night-terrors ; on getting about in the morning the child shows some lameness, which wears off during the day, and it soon grows tired while playing and lies down to rest. There may be a slight limp ; a slight adductor spasm may often be noted ; some pain may occur in the hip on tapping the sole of the foot while the patient is recumbent with the leg extended ; pain may be complained of at night in the hip, in the front of the thigh, or at the inside of the knee. The diagnosis in this stage is more or less problematical. In the second stage, or the stage of apparent lengthening, the symptoms are positive. The child limps ; the adductor muscles are rigid ; the hip is broadened by an effusion in the joint, and fluctuation may possibly be detected ; the thigh- muscles are atrophied ; the extremity is pushed forward, ab- ducted, and everted (the patient tilts the pelvis so as to rest his weight on the sound limb). In some few cases adduction exists rather than abduction. The abduction, w'hich is usual, releases tension of the fascia lata, and thus abolishes pressure upon the joint through pressure upon the trochanter (Allis). 412 MODERN SURGERY. The thigh is somewhat flexed. This flexion relaxes the psoas muscle and prevents pressure of its tendon upon the front of the joint (Allis). In very rare instances adduction is present. Pain exists, often sudden or starting, and is located in the joint, on the front of the thigh, and to the inner side of the knee in the course of the obturator nerve ; the pain is aggravated at night ; and full extension and complete abduc- tion are not possible. The gluteal muscles waste, and the gluteal crease is on a lower level than is that of the sound side. The gluteal crease may be nearly or quite effaced, because of hypertrophy of the subcutaneous layer (Alexan- drofif). Jarring of the heel when the extremity is in extension causes pain in the hip. The above symptoms arise chiefly from unconscious efforts to obtain ease, from joint-effusion, reflex irritation, and involuntaiy or spasmodic muscular contractions. Lengthening in the second stage is apparent, not real, but this stage is spoken of as the " stage of length- ening." The position is shown on Plate 6 (Fig. 4). The fluid effusion may be absorbed or may find its way externally by means of sinuses. The latter condition is known as " abscess of the hip." The absorption of the exudate or the rupture of the capsule permits the contracting muscles to bring the head of the femur into firm contact with the acetabulum or its brim ; the bones are worn away and destroyed, shortening results, abduction gives way to ad- duction, flexion is increased, shortening occurs, and the third stage is estabHshed. In the third stage the head of the femur goes upward and outward upon the rim of the acetabulum, the thigh is flexed and fixed, and attempts at extension when the patient is recumbent cause the pelvis to tilt forward and occasion a marked lumbar curve (PL 6, Fig. 2), which is due to the pelvis moving with the femur as if ankylosed, and which disappears on flexion. In the third stage adduction occurs because of the ascent and movement outward of the head of the bone. Shortening is marked. After a hip- abscess finds an external outlet pyogenic infection is very apt to take place and inflammation is liable to arise, followed by that state which is designated as " hectic." If a cure follows the third stage, partial or complete ankylosis takes place ; if death ensues, it may be due to septicemia, tuberculosis of the viscera, exhaustion, or amyloid degeneration. Diagnosis is very easy in well-established cases of hip dis- ease, but very difficult when the disease is incipient. Always make a systematic and thorough examination. Undress the HIP-JOINT DISEASE. Plate 6. I, 2, Effects on the Lumbar Spine of Flexing and Extending the Diseased Leg in Hip Disease (Albert). 3, 4. Positions in Coxalgia (Albert). 5. Strap-and-slipper Apparatus for Fracture of Pos- terior Portion of the Calcaneum (after Hamilton). 6. Extension in Hip Disease (Treves). 7. Exten- sion of the Limb in a Flexed and Adducted Position (Treves). 8. Extension of the Limb in a Flexed and Abducted Joint (Treves). DISEASES AND INJURIES OF BONES AND JOINTS. 413 patient and place him recumbent upon a table or a hard mattress, with the legs extended, and note if the heels are level and if the iliac spines are on the same level (depressed spine on the affected side means abducted extremity, the degree of which is determined by carrying the limb out until the spines are horizontal ; elevation of the iliac spine on the affected side means adduction, the amount of which is deter- mined by adducting the limb until the spines are horizontal Fig. loi); try all the movements belonging to the joint, to F:g. ioi. — Positions in hip-joint disease (after the plan of Howard Marsh and Treves). A. — e / lumbar spine ; b d, limb fixed in flexion and abduction — useless for wall;ing. B. — e/, lumbar spine. Patient corrects the condition in B'igure a by curving the lumbar spine for- ward and rotating the pelvis on its transverse axis, thus making the femur point downward. The lumbar spine is curved laterally, the pelvis ascending on the sound side and descending on the affected side (apparent lengthening), c. — h li, limb fixed in flexion and adduction. D. — e /, curve of lumbar spine to correct condition in Figure c (apparent shortening). detect any limitations ; try if bringing down the knee pro- duces lordosis (PI. 6, Figs, i, 2); look for sweUing and for muscular wasting ; feel if the head of the bone is enlarged ; observe if motion produces pain or if pressure causes tender- ness ; and always carefully elicit the history of the attack, of the person, and of the family. Hip disease may be confounded with spinal caries in which a psoas or a lumbar abscess has formed, with sacro-iliac dis- ease, with infantile paralysis, with congenital dislocation, with lordosis from rickets, with gluteal abscess, and with bursitis of the gluteal bursae. In hip disease there is always some lameness ; pain may be severe or may be absent entirely, and may be in the hip or be referred to the front of the thigh or to the inner side of the knee. Always remember that the pain is not characteristic, and that pain in the same localities may arise from aneurysm of the femoral or iliac arteries, from abscess in Scarpa's triangle, from caries of the lumbar vertebrae, from sacro-iliac disease, and from cancer of the rectum. Altered position of the limb, limita- tion of movement in the hip-joint, muscular w'asting, and swelling soon arise in hip-joint disease. In disease of the sacro-iliac joint examination shows that 414 MODERN SURGERY. the movements of the hip-joint are unlimited and produce no pain, and that pain is developed by pressure over the sacro- iliac articulation and by pressing the ilia together. In infan- tile paralysis there is no pain, but there is paralysis with great muscular atrophy, which comes on with considerable rapid- ity. In spinal caries with psoas abscess the evidences of dis- ease of the vertebrae are clear and the pus is located in the groin external to the femoral vessels. The pus of hip-abscess generally gathers under the tensor vaginae femoris muscle, but it may reach Scarpa's triangle by passing through the cotyloid notch or through the bursa under the psoas mus- cle ; it may appear under the glutei. Matter from a caseat- ing acetabulum may reach the inside of the pelvis and appear above Poupart's ligament. In gluteal bursitis the symptoms last for many months, and do not remit as the symptoms of early hip disease are apt to do. The pain is but moderate, and is aggravated by ex- ercise, but passes away on going to bed, and is felt back of the hip and back of the knee. There are a certain amount of limitation of motion and a positive Hmp, which arises early. In marked cases fluctuation can be detected in the upper gluteal region.^ Prognosis. — If the case of hip disease is seen early, the chances of cure are excellent in children, in whom the dis- ease may be arrested at any stage. The longer the duration of the disease and the older the subject, the more unfavor- able is the prognosis. The cure takes many months, and advanced cases only get well by means of ankylosis with shortening and deformity. Hip disease may recur years after apparent cure, and a person who has had hip disease runs a strong chance of developing visceral tuberculosis. Complications. — The complications that may accompany hip disease are the following : Abscess, as above noted. Tubercular meningitis, or the condition known as " acute hydrocephalus," or " water on the brain," may arise during the progress of the case or after apparent cure, and is apt to en- sue upon incomplete operations. It is almost inevitably fatal. Amyloid, lardaceous, or tvaxy degeneration of viscera, which condition follows upon profuse and long-continued suppura- tions, and which is apt to arise in the liver, spleen, kidneys, or intestinal mucous membrane. Tuberculosis is not the only cause, syphilis being responsible for at least 30 per cent, of all cases. In amyloid disease of the liver this organ is much 1 See E. G. Brackett's important paper on " Gluteal Bursitis," in The Trans- actions of the American Orthopedic Association, vol. x. DISEASES AND INJURIES OF BONES AND JOINTS. 415 enlarged, smooth, painless, and of increased consistency, there is no jaundice, the spleen is apt to be enlarged, and albuminuria is the rule. In amyloid kidney large amounts of pale urine of low specific gravity are voided ; albumin is usually present in large amount, but may be absent ; globu- lin may often be found, as ma)^ also hyaline, fatty, or granular casts ; the patient is anemic, and dropsy usually exists. Test the hyaHne casts with iodin for amyloid material. Amyloid changes are usually slow in onset, but they may be rapid ; they are commoner in men than in women, and are most frequently encountered in individuals between the ages of ten and thirty. Slight amyloid change may be recovered from, but an extensive degeneration brings about a fatal result. Dickinson's theory of how this tissue-change is caused is that the flow of pus drains off from the body the alkaline salts, especially the salts of potassium, which drainage re- sults in visceral depositions of de-alkalinized fibrin. Phthisis puhnonalis is a rare complication, but is a common sequence, being apt to arise, sooner or later, after the hip disease is cured. Treatment. — In the early stage of hip disease the treatment consists in rest. Place the patient upon a solid mattress and apply extension. In children under ten years of age, use a weight of from three to five pounds ; in children between ten and twenty, use a weight of from five to eight pounds. A long splint is often applied to the sound side to keep the patient recumbent and horizontal. Always use a cradle to hold up the bed-clothing. Apply the extension in the long axis of the limb, the extremity being placed in the line of the deformity due to disease and being supported by pillows. In lordosis from thigh-flexion, raise the limb until the iliac spine is straight (PI. 6, Fig. 6). If the spine is de- pressed on the affected side, abduct the limb (PI. 6, Fig. 8) ; if the spine is elevated, adduct the limb until the spines are horizontal (PI. 6, Fig. 7). The object in taking these precau- tions is to enable the extension to separate the femoral head and the acetabulum. Extension will remove flexion in two weeks in a recent case and in the course of some months in an older case. As flexion is relieved remove the pillows and lower the leg so as to keep up extension in the long axis of the thigh. Abduction and adduction cannot be removed by extension. Abduction demands no special treatment. In a movable joint it will disappear, and in an ankylosed joint it is an ad- vantage, compensating by apparent lengthening for the short- 4i6 MODERN SURGERY. ening due to bone-absorption or to stunted growth of the limb. Adduction requires an addition of several pounds to the extension weight, the use of a long splint on the sound limb, and the drawing up of the sound limb by a rope and pulley toward the head of the bed. The weight-used to pull the sound side toward the head of the bed is equal to that used to pull the damaged side to the foot of the bed. This expedient is used for a month or six weeks. In old cases where the weight will not bring about extension, anesthetize the patient, gent- ly straighten the limb a very httle, and reapply the weight. Extension in a mild case must be continued for three months after the symptoms have disappeared, and in a severe case the period must be six months. The weight is gradually taken off; if symptoms recur, the weight is reapplied ; if they do not recur, apply a traction splint or a plaster dressing, put a high-heeled boot on the sound limb, and send the patient out on crutches. In young children extension can be made in a wheeled carriage, thus enabling the patient to go out in the fresh air and sunlight. The general treatment is tonic and restorative. The joint is so deeply placed that it is useless to make In the treatment of hip disease 102) is used by many, and it may Fig. 102. — Thomas's posterior splint. external applications. Thomas's spHnt (Fig. be combined with weight extension ; or Sayre's splint (Fig. 103) may be employed. Wyeth's apparatus (Fig. 104) is a favorite with many American surgeons. If the limb is in good position, or has been brought into good position, either by weight extension or straightening under ether, plaster-of-Paris is a useful dressing. It is put on from the toes up, and includes the entire extremity and also the pelvis. A patient dressed by plaster may get about on crutches when the sole of the other foot is raised. If a case, in spite of treatment, does not improve or becomes worse, use " intra-articular and parenchymatous injections of iodoform." Always try these injections before doing a resec- tion. Sometimes they succeed and render resection unneces- sary. Asepticize the surface, carry a small aspirating-needle DISEASES AND INJURIES OE BONES AND JOINTS. 417 into the joint, irrigate the joint with salt solution, and inject a sterile pmulsion of iodoform and glycerin (10 per cent.). In one week, if reaction has ceased, repeat the injection. In another week repeat again. It may be necessary to give from ten to twenty injections. The spot for puncture is thus obtained : Draw a line from a point half an inch outside of the middle of Poupart's ligament to the outer edge of the great trochanter. Puncture at the middle of the outer half of this line (DeVos). If an abscess forms, incise it with the most thorough anti- septic care, let the fluid drain away, wash out with salt solu- FiG. 103. — Sayre's long splint. Fig. 104. — Wyeth's combination method. tion, remove any sequestra, inject with iodoform emulsion, insert a tube, and dress antiseptically. In some cases the sequestrum is extra-articular. In some cases no sequestrum is found. The old plan of not operating until rupture was seen to be inevitable was bad. To open early and antisepti- cally often means rapid healing, the prevention of burrowing, a lessened danger of visceral infection, and an earlier cure. 27 41 8 MODERN SURGERY. Hectic will not arise if the abscess is opened with antiseptic care. Excision of the hip is to be performed when the head of the femur is detached and lies loose in the joint ; when pro- fuse suppuration continues for a long time, and other methods fail to arrest it ; when amyloid disease is beginning ; or when very faulty position is inevitable without operation. Excision is an operation of considerable danger, and the older the person the greater the danger. Schede advocates arthrec- tomy in some cases as a substitute for resection. Senn tells us that opinion as to resection has greatly changed of late, and the operation is advisable in all cases where fixation, ex- tension, intra-articular and parenchymatous injections have failed to arrest the disease (see Tuberculosis of Bones and Joints). When there is extensive disease of the femur, when excision has been tried and has failed, and when the patient has not the recuperative power to stand the long siege following excision, amputate.^ Knee-joint Disease (White Swelling). — After the hip, the knee is, of all joints, the commonest site for tubercular dis- ease. Knee-joint disease can begin as a synovitis, but oftener begins as tubercular inflammation of the femoral or the tibial epiphysis. The disease rarely attacks the bone above the epiphyseal line ; a single focus only exists as a rule, and a sequestrum is rarely formed. In very rare instances the pa- tella is primarily attacked, or the semilunar cartilages. It may begin at any age, but is most common in children and young adults. If an acute synovitis ushers in the case, there may be large eflusion into the knee-joint and partial flexion, but swelling is usually slight in knee-joint disease. Pulpy de- generation of the .synovial membrane occurs ; the joint enlarges ; the ligaments soften ; the skin is edematous ; muscular spasm is marked ; the leg is flexed ; the bones are displaced backward and outward, the foot being everted; lameness exists, due chiefly to deformity; pain may be absent, is often slight, and is rarely severe. When the disease begins in the bone or an epiphysis ther6 are pain, tenderness, lameness, swelling, inability to extend the hmb completely, sudden spasmodic muscular contractions, and final involve- ment of the joint. When an abscess forms, it may destroy the joint very rapidly or it may break externally. Treatment. — In treating knee-joint disease employ general antitubercular treatment and locally apply iodoform oint- ment or guaiacol. Apply splints (Figs. 105, 106), extension 1 See the admirable article of Howard Marsh in Treves's Manual of Surgery. DISEASES AND INJURIES OF BONES AND JOINTS. 419 (Fig. 107), or a plaster-of- Paris bandage, and keep the patient in bed for a few weeks ; then permit him to go out upon crutches, with a high-heeled shoe upon the sound foot. In cases in which treatment is begun early the disease may often be arrested in from eight to twelve months. If the symptoms do not abate after a number of weeks, or if the condition grows worse and an abscess arises, aspirate, irrigate, and inject iodoform emulsion. Intra-articular in- jections are not unusually curative. Insert the needle in the angle between the outer edge of the patella and the ligament of the patella (DeVos). Repeat the injec- tion in one week if reaction has abated, and advance as directed for the injection of the hip-joint. Some surgeons incise the capsule, remove all fragments and tubercular foci, irrigate with normal salt solution, inject iodoform emulsion, and sew up without drainage (Neuber's plan). If these means fail, open the joint and perform an excision or an erasion (page 495). Some cases demand amputation, Fig. 105. — Sayre's Fig. io6. — Hutchinson's knee splint applied. knee-joint splint. Sayre's double extension of the knee-joint. which, if the patient's health is much impaired, is to be preferred to excision. Amputation is preferred to excision in very young children and aged people. Ankle-joint disease may begin in the synovial membrane, 420 MODERN SURGERY. in the tibial epiphysis, or in the tarsus, but the origin is usually synovial. The symptoms are pain, swelling, lame- ness, limitation of joint-movements, and atrophy of the calf- muscles. Suppuration often occurs, and sinuses form. Treatment. — The treatment of ankle-joint disease consists in the employment of antitubercular remedies, applications of guaiacol or iodoform ointment over the joint, and rest by means of splints or plaster. Caution the patient to avoid standing upon the diseased extremity. Injections of iodoform emulsion may do good. Insert the needle below the outer malleolus. When caseation occurs, it is often advisable to open, drain, wash out with normal salt solution, inject iodo- form emulsion, and put up the ankle-joint in plaster. When joint-disorganization occurs, perform an excision or an erasion. Some cases demand amputation (Syme's amputa- tion being preferred by some, amputation above the ankle being approved by many). Osteoplastic resection is some- times advised (Wladimiroff-Mikulicz operation). Shoulder-joint disease is not common ; it is rare in chil- dren and is commonest in adults ; it begins either in the synovial membrane or in the head of the humerus. The gle- noid cavity is rarely attacked. Pain is slight, atrophy of the deltoid and other muscles is noted, the joint is stiff, and the scapula follows the motions of the humerus. Caries sicca is the usual cause of destruction. In many cases swelling is not obvious, the joint shrinking because of destruction of the head of the bone and contraction of the capsule (Senn). If an abscess forms, it may open in the axilla under the deltoid, or at some far distant point, but abscess-formation is unusual. Treatment. — In treating shoulder-joint disease employ anti- tubercular remedies and apply over the joint guaiacol or iodo- form ointment. Put on a shoulder-cap, apply the second roller of Desault, and hang the hand in a sling. Maintain rest for at least four months. Aspiration and injection of iodoform emulsion are very valuable in synovial tuberculosis.. The needle is entered below the acromion, while the arm is held against the side and the forearm is at right angles to the arm and across the front of the chest (DeVos). If an abscess forms, open and drain it. In rare instances dead bone will have to be gouged away. Caries sicca may occur. Excision is sometimes required. Elbow-joint disease may begin in the humerus or the ulna. The head of the radius is rarely the primary focus. In some cases the synovial membrane is first attacked. It is most frequent in young adults. The joint is swollen, its DISEASES AND INJURIES OF BONES AND JOINTS. 42 1 movements are somewhat limited, the skin is usually hot, muscular wasting is pronounced, and pain is generally slight. Pus may form. Trcalmoit. — In treating elbow-joint disease, employ anti- tubercular foods, drugs, and hygienic measures ; iodoform ointment or guaiacol locally ; rest by means of an anterior angular splint (Fig. 108) and a triangular sling. Injection of Fig. 108. — Stromeyer's anterior angular splint. iodoform emulsion may be useful. Insert the needle for injection by the side of the olecranon. If caseation takes place, it is often necessary to open the joint and drain. Splints are to be worn for from four months to a year. If any considerable area becomes carious, perform an erasion or an excision. "Wrist-joint disease may arise at any age, and is some- times met with in late middle life, or even in old age. The joint presents a puffy swelling, loses its normal contour, and becomes spindle-shaped. Hand-movements are impaired, pronation and supination cannot completely or satisfactorily be performed, the joint is stiff and partly flexed, the grasp is enfeebled, pain may be severe or slight, the skin is usually hot, and muscular atrophy is marked. This form of tuber- culosis may begin in the synovial membrane, in the bones, or in the tendon sheaths. TrcaUncnt. — The essential treatment in wrist-joint disease comprises cod-liver oil, tonics, good food and fresh air, and the local application of guaiacol or iodoform ointment. Ap- ply a Bond splint and sling or put on a plaster bandage, and maintain rigid rest for from four to six months. Aspiration and injection of iodoform emulsion is often useful. Enter the needle at the dorsal edge of the radial, styloid process, and again at the upper edge of the pisiform bone (DeVos). In some cases it is well to incise, wash with salt solution, in- ject iodoform emulsion, and close without drainage. Severe cases demand incision and drainage with the maintenance of 422 MODERN SURGERY. rest. A moderate amount of caries is treated by drainage and rest. Necrosis demands removal of the sequestra. Ex- tensive caries requires excision. Acute Suppurative Arthritis. — This infection is usually due to the staphylococcus pyogenes aureus or to the strepto- coccus pyogenes which find entrance by means of a wound, by the spontaneous evacuation into a joint of the products of an osteomyeHtis, by extension of suppurative inflammation through contiguous structures, or by the blood-stream. In this disease all the joint-structures are involved and suppura- tion rapidly appears. It is very rarely due to gonorrhea, and sometimes to septicemia. Symptouis. — The symptoms of septic arthritis are — fever, high pulse, sometimes a chill, severe pain, which is aggra- vated by motion and is worse at night ; discoloration, heat, and edema of the skin; partial flexion of the joint; fluctua- tion; and marked constitutional symptoms of sepsis. The joint tends to rapid disorganization, and fatal septicemia is very apt to occur. In pyemic arthritis several joints become infected. Treatment. — The treatment in septic arthritis consists in prompt incision, evacuation, antiseptic irrigation, drainage, antiseptic dressing, and immobilization.. Cure is followed, as a rule, by ankylosis, but in cases treated early the joint may be preserved. Infective arthritis arises in the course of an acute infec- tious disease (such as erysipelas, typhoid fever, influenza, mumps, dysentery, diphtheria, measles, scarlatina, variola), and may be due to pyogenic cocci or to the specific micro- organism of the acute infectious disease. Joint-inflammation arising in the course, or as a sequel, of an acute infectious disease may or may not suppurate. Symptoms and Treatment. — If no suppuration takes place, the symptoms of the attack resemble those of rheumatism ; if suppuration occurs, the symptoms are identical with those of septic arthritis. Suppuration rarely occurs. Ashby has well described the arthritis which sometimes follows scarla- tina. It involves wrists, finger-joints, tendons of forearm, knees, ankles, or spine. The joints are painful, but are rarely much swollen or discolored (Howard Marsh). That the organism of typhoid may inflame the joints is proved (Klemm, Quincke, and others), but whether it does cause suppuration is not so certain. Some claim that mixed infection induces suppuration. The typhoid bacilli enter the bones in many typhoid cases and sometimes cause bone dis- DISEASES AND INJURIES OF BONES AND JOINTS. 423 ease. Joint disease is more common than bone disease. A typhoid joint begins when the fever is abating, and more than one joint may be involved. These joints may recover per- manently, may ankylose, may dislocate, or may lead to a fatal sepsis. We may tell this disease from rheumatism by the fact that it does not migrate, and is uninfluenced by anti- rheumatic remedies. In slight cases the synovial membrane only is involved ; in more severe cases capsule, cartilage, ligament, and even bones are involved. Some cases sup- purate. Keen tells us that septic typhoid arthritis results from a mixed infection with typhoid bacilli and pyogenic bacteria, and is identical in symptoms and progress with an ordinary septic arthritis. The same author points out that typhoid arthritis proper may be monarticular or polyarticular, the monarticular form being the most common, and the hip- joint being the articulation most liable to attack. In most cases typhoid arthritis causes but little pain. The swelling is marked, although in the hip it is concealed. Pus rarely forms. Keen calls attention to the fact that in the eighty- four cases he collected, spontaneous dislocation occurred in forty-three, nearly all in the hip.^ Treatment of a mild case, as for simple synovitis : if there is much fluid in the joint, aspirate and wash out with normal salt solution. If pus forms, open, irrigate, and drain. Gonorrheal Arthritis, or Gonorrheal Rheumatism. — During the progress of gonorrhea every rheumatic attack is not gonorrheal rheumatism, for ordinary rheumatism is just as likely to arise when a man has clap as when he has not this malady. Furthermore, the term is inaccurate, as gonorrheal rheumatism is not rheumatism at all, but is an infecti\-e disorder of the joints or of the synovial membranes, the infective material being contained primarily in the urethral discharge. Occasionally this form of arthritis arises from gonorrheal ophthalmia (Heiman's case). This infective ar- thritis sometimes, though rarely, arises during the height of a gonorrhea, but is more frequently met with in chronic cases or when the intensit}' of the inflammation is abating in acute cases. Men suffer from gonorrheal arthritis far more fre- quently than do women, and the seizure is very apt to recur again and again. In some cases many joints are involved, but in most cases only a few joints suffer. Osier states that the knees and ankles are most apt to be involved in a gonor- rheal rheumatism, and that this form of arthritis is peculiar in often attacking joints that are apt to be exempt in acute ' Keen on The Surgical Complications and Sequels of Typhoid Fever. 424 MODERN SURGERY. rheumatism (" the sternoclavicular, the intervertebral, the temporomaxillary, and the sacro-iliac "). Changes In and About the Joint. — The inflammation of gonorrheal arthritis may be located around rather than in the joint, and especially in the tendon-sheaths. Suppuration is unusual, but it may occur in joints and in tendon-sheaths. Cultivation of the exudate may or may not show the gono- cocci. Cover-glass preparations stained by Gram's method may show gonococci. Osier suggests that the non-suppura- tive cases are due to the action of toxins taken up from the area of primary infection, and that the suppurative cases are due to infection with pyogenic bacteria. Symptoms. — In gonorrheal arthritis there may be transi- tory, intermittent, and wandering pains in and about the joint, without any other symptom ; one or more joints may become swollen and painful, and moderate fever may develop. An acute inflammation with intense pain and great swelling may attack a single joint, in which case fever will be mod- erate unless suppuration follows. One joint, especially the knee, may swell to an enormous extent, pain, periarticular edema, redness, and fever being absent (hydrarthrosis, or drop.sy of a joint). Suppuration in this form is rare. The tendons, the tendon-sheaths, the bursae, and the periosteum may inflame. A case of gonorrheal arthritis is often very hard to check. It may last for a long period, and tends to recur again and again. Iritis, pleuritis, endocarditis, and pericarditis have been observed as complications. The diagnosis between gonorrheal arthritis and acute rheumatism rests chiefly on the great chronicity, the slight degree of fever, the excessive tendency to recurrence, and the absence of profuse acid sweats in gonorrheal rheuma- tism ; and on the shorter course, the higher fever, the pro- fuse acid sweats, the lesser tendency to rapid recurrence, the greater proneness to symmetrical involvement, and the great liability to cardiac and visceral complications in rheu- matic fever. Furthermore, in gonorrheal arthritis a gonor- rheal infection (urethral or ocular) certainly exists or recently existed ; in ordinary rheumatism a urethral discharge may, of course, happen to be present. Gonorrheal arthritis is apt to affect certain joints which acute rheumatism rarely attacks. Treatment. — Internally, in treating gonorrheal arthritis, the salicylates, the alkalies, salol, and iodid of potassium are use- less ; iron, arsenic, and strychnin are of some benefit. Quinin is distinctly helpful in some cases. In suppurative cases in- D/SEASES AND INJURIES OF BONES AND JOINTS. 425 cise and drain (sec Septic Arthritis, page 422). In non-sup- purativc cases treat as in simple synovitis (page 406). In lingering cases employ the hot-air bath, massage, passive motion, flying blisters, or the hot iron ; if these means fail, open the joint, wash it out with some antiseptic fluid, and dress antiseptically, or aspirate and irrigate with hot normal salt solution. Rheumatic Arthritis. — Acute rheumatism is a self-limited febrile malady whose characteristic features are polyarthritis, profuse acid sweats, and a tendency to heart-involvement. Symptoms of Acute Rheumatism. — In acute rheumatism the case begins with malaise and fever, and one or more joints become affected. The inflammation spreads from joint to joint, is apt to be symmetrical, and when it arises in fresh joints usually disappears quickly in those previously af- fected. The temperature is high, the skin sweats profusely, the joints are red, swollen, hot, and excruciatingly painful, and the structures about the joints are edematous. After a short time the inflammation subsides in one joint and passes into another, the joint first attacked regaining its functions. Suppuration does not take place. Anemia is pronounced, exhaustion is profound, the sweat is sour, the saliva is acid; the urine is acid, scanty, high-colored, often contains albu- min, and is deficient in chlorids. Cardiac disease is apt to be produced (endocarditis, pericarditis, or myocarditis). Nodules may form upon fibrous structures, hyperpyrexia is not un- usual, and cerebral or pulmonary complications may occur. Chronic rlieiimatism rarely follows repeated attacks of acute rheumatism, but rather arises insidiously in people who have been exposed to cold and damp, who have suffered from poverty, hardship, and priv^ation, or who have had much worry. The capsule and the tendon-sheaths thicken, and there is usually but little effusion in the joint, but the ar- ticulation becomes stiff and painful. The joint-cartilages are occasionally eroded. Muscular atrophy occurs. Symptoms of Clironic RJieiimatism. — In chronic rheuma- tism the affected joints are stiff and painful and are a little swollen, but not red. Dampness and cold aggravate the symptoms. One joint or many may be affected, but usually many are involved. Passive movements cause the joint to creak and develop crepitus in the tendon-sheaths. The muscles are wasted. The joints may ankylose. Anemia is usually pronounced. There is no fever and no tendency to suppuration, and the disease is incurable. The treatment in acute rheumatism comprises the use of 426 MODERN SURGERY. alkalies, salicylates, etc. (See a book upon medicine, as acute rheumatism is in the physician's province.) In chronic rheumatism maintain the general health of the patient, give courses of iron, arsenic, and strychnin, and an occasional course of iodid of potassium or a salt of lithium, and, if possible, send him every winter to a warm climate. Turkish baths give considerable temporary relief The waters and regimen of Carlsbad and Vichy are of positive though tem- porary benefit, and the sufferer may obtain relief at the hot springs of Virginia. The patient must avoid damp and must wear woollens. Frictions, the douche, massage, flying blisters, counter-irritation with the hot iron, ichthyol oint- ment, and mercurial ointment are of benefit. Subjecting the diseased joint to a very high temperature by placing it daily in a special apparatus often does great good. In partial anky- losis give ether and break up the adhesions. Gouty arthritis, which appears especially in the smaller joints (as the fingers and the metatarsophalangeal joint of the big toe), is due to a deposition of urate of sodium in the joint and in the periarticular structures. The irritant urate of sodium causes inflammation, inflammation forms embry- onic tissue, embryonic tissue is converted into fibrous tissue, and the fibrous tissue contracts and thus deforms the joint and limits its mobility. A great mass of urates in a joint constitutes a " chalk-stone." Symptoms. — The premonitory symptoms may be observed for a day or so, but the acute seizure occurs early in the morning, the patient, as a rule, being aroused by excruciat- ing pain in the metatarsophalangeal articulation of the great toe. The joint swells, and the skin over it feels hot to the hand and becomes red and shiny. There is often considerable fever. After a few hours the intensity of the seizure abates, only to recur again with renewed violence early the next morning, these remissions and recurrences taking place for six or eight days, when the attack subsides. In patients with chronic gout many joints are stiffened and deformed as a re- sult of repeated attacks. Chalk-stones form, and the skin above them may ulcerate. Such patients are chronic dys- peptics, have high-tension pulses, their hearts are hyper- trophied, and their urine contains albumin and casts. The treatment of gouty arthritis belongs to the physician, and not to the surgeon, although to the latter the symptoms of the disease should be known, so that it may be diagnosti- cated from other maladies. Arthritis Deformans (Rheumatoid Arthritis ; Osteo-ar- DISEASES AND INJURIES OF BONES AND JOINTS. 427 thritis ; Rheumatic Gout ; Paget's Disease). — In this disease, which is not a combination of gout and rheumatism, the synovial membrane and cartilages are affected, the peri- articular structures are involved, and masses of new bone are formed. Arthritis deformans has, as John K. Mitchell pointed out, a probable nervous origin. It arises especially in per- sons who have been worried, driven, and harassed. There is apt to be muscular atrophy ; trophic lesions of the hair and nails are likely to occur, and the symptoms are dis- posed to be symmetrical. The causative lesion has not been determined. Rheumatic gout is commoner in women than in men. The greatest liability exists between the ages of twenty and thirty, but children may acquire the disease, and it may also be developed in people beyond middle life. Apes in captivity ma\- develop it. Arthritis deformans may attack the rich or the poor ; it does not result from gout, nor does it often follow rheumatism ; it is not caused by damp and cold ; and it does not arise from traumatism. Arthritis deformans differs from gout in the entire absence of urate deposit, and it differs from chronic rheumatism in the extensive alterations in the joint-structures. The changes begin in the cartilage ; the cartilage-cells multiply, the inter- cellular substance degenerates, the pressure of the bone causes thinning, and at length the cartilage is entirely destroyed and the bone is exposed. The exposed bone is altered in shape, is hardened, and is worn away in the centre, the periphery increasing in thickness by ossific deposit ; thus the center becomes deepened by absorption and the periphery bulged and lengthened by deposit. The fringes of the syno- vial membrane hypertrophy and multiply, and some of them are apt to break off (loose cartilages). The capsule and the ligaments of the joint, as a rule, become fibrous and con- tract, but they may soften, relax, and permit of dislocation. The joint usually contains no effusion, but in some cases there is great effusion (hydrarthrosis). The tendons about the joint may become fibrous and contracted, they may ossify, they may be separated from the bone, or they may be destroyed entirely. Deformity is marked and motion is limited. The fingers, when involved, show nodules on the sides of the joints (Heberden's nodules). The vertebrae may be involved. Almost all the joints may suffer. Sup- puration does not occur. Symptoms. — Charcot classifies arthritis deformans into three forms, and giv^es their symptoms as follows : 428 MODERN SURGERY. (i) Heberden's nodosities, which condition is commoner in women than in men, comes on between the ages of thirty and forty, and is especially common in neurotic subjects. The interphalangeal joints become the victims of attacks of moderate swelling and of some tenderness, which attacks are not severe, but recur again and again. After a time small hard swellings (nodosities) appear upon the sides of the dorsal surfaces of the second and third phalanges, re- main permanently, and slowly increase in size. The joints become stiff and creak on movement, the cartilages are de- stroyed, and contractions and rigidity develop, but there is no fever and the larger joints are not involved. The malady is incurable. (2) Progressive rheumatic gout, which may be acute or chronic. The acute form begins as does rheumatic fever. There are moderate fever, and swelling, without redness, of a number of joints, of bursae, and of tendon-sheaths ; the joints are stiff and crepitate, and are apt to be symmetrically involved ; muscular atrophy begins early and rapidly be- comes decided ; pain is slight. This acute form is apt to arise in young women after pregnancy, but is not unusual at the climacteric and in children. Anemia always exists. The case is apt to advance progressively until a number of joints are firmly locked, when it may become stationary. Another pregnancy will develop anew the acute symptoms. In the chronic form swelling and pain on movement are noted in certain joints. The involvement is apt to be symmetrical. Attacks of swelling and pain alternate with periods of quies- cence, but the disease does not cease its advance. Articu- lation after articulation is attacked by the malady until almost all the joints are involved ; deformity and stiffness become pronounced, and pain may or may not be severe. There is no fever. Muscular atrophy is marked. (3) Partial rheumatic gout attacks one articulation, and it is most often met with in old men. It may fix itself on the vertebral column, on the knee, on the shoulder, on the elbow, or on the hip. The joint grates, and becomes stiff, swollen, and deformed ; the muscles atrophy ; there is usually pain, but fever is absent. Partial rheumatic gout of the hip-joint in an old person is known as "morbus coxae senilis," and partial rheumatic gout of the vertebral articu- lations causing fixation is called " spondylitis deformans." Treatment. — Rheumatic gout cannot be cured, but in some cases it remains stationary for many years. Treat the anemia by iron, arsenic, good food, and fresh air. Debihty is met by DISEASES AND INJURIES OF BONES AND JOINTS. 429 strychnin. Hot baths of mineral water do good. Massage retards the progress of the case, reheves the pain, aids in the absorption of effusion, and delays fixation. During an acute exacerbation the joint should be put at rest for a day or two, and there should be used lead-water and laudanum, cold water, or tincture of arnica. Douches and hot baths improv^e these cases, but electricity is entirely useless. Put- ting the affected joint in a special apparatus and subjecting it to a high degree of heat improves the condition. Counter- irritants do no good. The patient is unfortunately liable to develop the opium-habit. If dropsy of a joint arises, try compression with a Martin bandage, and, if this fails, aspi- rate and inject diluted carbolic acid. Patients with rheu- matic gout do best in a warm, dry climate. Cod-liver oil does good, as it improves nutrition and hence retards the progress of the disease. Do not be tempted to immobilize the joints beyond a day or two : fixation only hastens ankylosis. Charcot's Disease (Tabetic Arthropathy ; Charcot's Joint ; Neuropathic Arthritis). — This condition is an osteo-arthritis due to trophic disturbance, arising in a sufferer from loco- motor ataxia, and is anatomically identical with rheumatic gout. The knee is most apt to be attacked. The disease begins acutely, often as a sudden effusion, which after a time disappears. Pain is slight or is absent, there is no consti- tutional involvement, and the condition is unconnected with injury. The bones and cartilages are rapidly destroyed; fracture is apt to occur; the joint creaks and grates; the softening and relaxation of ligaments permit an extensive range of movement ; great deformity ensues ; dislocation is apt to occur ; muscular atrophy is decided ; and pus occa- sionally, though very rarely, forms. Treatment. — The treatment of Charcot's disease consists in the wearing of an apparatus to sustain the joint. Resec- tion is recommended by some, but most surgeons do not advise its performance. Osteo-arthropathie Hypertrophiante Pneumique (Marie's Disease). — A condition associated with and pos- sibly springing from pulmonary disease, and characterized by enlargement of joints, thickening of finger-ends, and the formation of a dorsolumbar kyphosis. The joints are pain- ful, the skin undergoes pigmentation, and profuse perspira- tion is often present. The head entirely escapes in this disease, which immunity marks a distinction from acromeg- aly. 430 MODERN SURGERY. Hysterical joint (Brodie's joint) is a condition mostly- encountered in young women. The disease occurs in the knee and the hip, and often follows a slight injury which acts as an autosuggestion, a latent hysteria being awakened into action and localized, though severity of the injury does not determine the severity of the symptoms. The disease may ensue upon an arthritis or may arise without apparent cause. The patient resists passive motion strenuously and claims that it causes much pain. There is occasionally some muscular atrophy from want of use, and the joint is a little swollen. The skin is hyperesthetic, and a light touch causes more pain than does deep pressure. The muscles may be rigid. The joint may be maintained either in flexion or in extension, but it is rarely in the exact degree of flexion assumed for ease in a true joint-inflammation, and the position is apt to be changed from day to day or from hour to hour. The skin is usually cool, but may be hot, and a periodically developed heat may be observed, espe- cially at night, accompanied apparently by much pain. The pain in some cases is a neuralgia, but in most cases is a pain- hallucination. In some rare cases organic disease arises in a hysterical joint. Hysterical phenomena are seldom isolated, but are asso- ciated with certain stigmata which may be latent. These stigmata are concentric contraction of the visual fields, pharyngeal anesthesia, convulsions, hysterogenic zones, globus hystericus, clavus hystericus, zones of anesthesia, especially hemianesthesia, and hyperesthetic areas. Such patients are predisposed by inheritance, and have previously, as a rule, had nervous troubles. Hysterical phenomena, be it remembered, lack regularity of evolution, and are pro- duced, altered, or abolished by mental influences and physi- cal sensations which are without effect in causing, modifying, or curing organic disease. The general health, as a rule, is good, but neurasthenia may coexist. In examining these patients the observer will note that the symptoms disappear when the attention is diverted ; that they are out of all proportion to the local evidences of the disease ; that there is no evidence of joint-destruction ; and that light touching causes more pain than does firm pressure. If the patient is anesthetized, perfect joint-mobility will be found. Treatmc7it. — The treatment in hysterical joints comprises attention to the general health, the employment of nourish- ing and easily digested food, the prevention of constipation, and the administration of tonics if they are needed. The DISEASES AND INJURIES OF BONES AND JOINTS. 43 1 surgeon must dominate his patient's mind and make her reahze that he is master of the case. He is to be an inex- orable but just ruler — never a brutal or a cruel one. If possible, send the patient away from the sympathies of her home and let her have the rest-treatment of Weir Mitchell. Local remedies applied to the joint do harm, as a rule, by concentrating afresh the patient's attention upon the articula- tion, although the hot iron sometimes does good. Sugges- tion in the hypnotic state may be tried. The use of morphin should be avoided as being the worst of enemies. Never immobilize the joint, and always use massage, passive motions, and frictions. Neuralgia of the joints as an independent, isolated affection is extremely rare, though as a complication of other diseases it is by no means uncommon. The neuralgia is more often outside of the joints than in them, and is espe- cially frequent in the knee and the ankle. Joint-neuralgia may arise in any person, but it is more commonly present in young neurotic females. The pain may be persistent, or it may occur in periodic storms, and it is often associated with neuralgia in other parts. The pain may be dull and aching, but it is more often sharp and shooting. Joint-neuralgia is associated with tenderness on pressure, soreness on motion, often with transitory swelling without redness, and some- times with numbness of the extremity. The diagnosis depends on the temperament of the patient, the sudden onset of the pain, the absence of constitutional symptoms, and the free mobility of the joint, especially under ether. Articular neuralgia may depend upon disease or injury of the central nervous system, upon malaria, syphilis, neuras- thenia, rheumatism, gout, hysteria, and neuritis, and may be due to reflected irritation, especially from the ovaries, the womb, and the rectum. Treatment. — The treatment to be observed in joint-neu- ralgia is to maintain the general health ; examine for a possible exciting cause, and, if found, remove it ; give a long course of iron, quinin, and strychnin or of arsenic. In rheu- matic or gouty subjects give suitable drugs and insist upon proper diet. During the attack use phenacetin. Morphin must occasionally be used in severe cases, but be careful of it, and never tell the patients they are taking it, as there is a possibility of their forming the opium-habit. Locally, employ frictions, ointment of aconite, heat, and keep upon the part a piece of flannel soaked in a mixture of soap-liniment, laudanum, and chloroform (Gross). Never let a joint stiffen ; 432 MODERN SURGERY. any tendency to do so should be met by daily massage^ frictions, passive motion, and hot and cold douches. In some rare cases nerve-stretching or neurectomy becomes necessary. Articular Wounds and Injuries. — A penetrating- wound is very serious, and it may be due to compound fracture, to compound dislocation, to gunshot-wounds, or to stabs. If a bursa near a joint be injured, secondary penetration may occur as a result of suppuration. In a penetrating wound, besides pain, hemorrhage, and swell- ing, there is a flow of synovial fluid. A small amount of synovia flows from an injured bursa, a large amount from an open joint. Treatment. — If a joint is opened aseptically (as when in- cised by the surgeon), it gets well nicely under rest and anti- sepsis. If a joint is opened by a septic body, suppurative arthritis is apt to arise, and the indications are to irrigate, drain, dress antiseptically, and secure rest. Normal salt solution is the best agent for irrigation, as it does not injure joint-endothelium. Active antiseptics are apt to lessen tissue- resistance and thus favor infection. In gunshot-wounds, if antisepsis is not employed, suppuration is inevitable ; hence military surgeons, as a rule, have advocated amputation or excision in gunshot-splinterings of large joints. In these injuries the wound is enlarged, the finger is introduced to discover and remove foreign bodies, through-and-through drainage is secured, a tube is inserted, the joint is irrigated, antiseptic dressings are applied, and the extremity is placed upon a splint. Very severe cases demand resection or even amputation. Ankylosis more or less complete follows a gunshot-wound of a joint. If the joint suppurates, the drainage must be made more free, sinuses must be slit up and packed, sloughs must be cut away, dead bone must be gouged out, and the patient must be placed upon a stimu- lant and tonic plan of treatment. Sprains. — A sprain is a joint-wrench due to a sudden twist or traction, the ligaments being pulled upon or lacerated and the surrounding parts being more or less damaged. A sprain is often a self-reduced dislocation (Douglas Graham). The joints most liable to sprains are the knee, the elbow, and the ankle. The smaller joints are also often sprained, but the ball-and-socket joints are infrequently sprained, their normal range of free movement saving them ; they do occasionally suffer severely, however, as a result of abduction. In a bad sprain the ligaments are torn ; the synovial membrane is con- DISEASES AND INJURIES OF RONES AND JOINTS. 433 tused or crushed ; cartilages are loosened or separated ; hem- orrhage takes place into and about the joint ; muscles and tendons are stretched, displaced, or lacerated ; vessels and nerves are damaged ; the skin is often contused ; and por- tions of bone or cartilage may be detached from their proper habitat, though still adhering to a ligament or tendon (sprain- fractures). Sprains are commonest in young persons and in adults with weak muscles. They happen from sudden twists and movements when the muscles are relaxed. A large part of the support of joints comes from muscles, and when they are suddenly caught unawares they do not support the joint and a sprain results. A joint once sprained is very liable to a repetition of the damage from slight force. Sprains are common in a limb wath weak muscles, in a deformed ex- tremity in which the muscles act in unnatural lines, and in a joint with relaxed ligaments. Symptoms. — The symptoms manifested in sprains are as follows : severe pain in the joint, accompanied by a weakness. Nausea, often vomiting, and sometimes syncope. Impair- ment or loss of motion is present. This condition is suc- ceeded by a season of relief from pain while at rest, numb- ness being complained of, and pain on motion being severe. Ver>' soon swelling begins if hemorrhage is severe. In any case swelling begins in a few hours. Movement of the joint becomes difficult or impossible ; the tear in the ligament may be distinctly felt ; pain and tenderness become intense ; joint- crepitus will be detected ; and in a day or two discoloration becomes marked. ]\Ioullin and others have pointed out that when a muscle is strained the skin above it becomes sensitive, especially at tendinous insertions over joints. As muscles are invariably strained when a joint is sprained, there is in- variably some cutaneous tenderness. There is always ten- derness over a sprained joint due to capsular injury, bands of adhesions, etc. Tenderness is apt to arise at certain reason- ably fixed points : in a hip-joint injur}' it is found behind the great trochanter, in a knee-joint injur}' by the side of the patella, in an ankle-joint injury to the inner side of the external malleolus (Culp). When the ligaments of the back are sprained the back muscles are rigid, the skin is often sensitive, pain may be awakened by pressure or by certain movements, but there is no sign of cord injur}-. Diagnosis and Prognosis. — Sprain-fractures can be diag- nosticated with certainty only by the x-rays. In the diag- nosis of a sprain fracture and dislocation must be consid- ered. In fracture, crepitus and mobilit}' exist ; in dislocation^ 2S 434 MODERN SURGERY. rigidity. The diagnosis should be made by a consideration ■of the joint involved, of the age, of the nature of the force, by the length of the limb, by the fact that the patient could use the joint for at least a short time after the accident, and by the local feel and movements of the part. In some cases examine under ether, in some apply the X-rays. The prog- nosis depends on the size of the joint, on the extent of lacer- ation, and on the amount of intra-articular hemorrhage. The danger is ankylosis. Treatment. — The first indication is to arrest hemorrhage and Hmit inflammation. For the first few hours apply press- ure and an ice-bag. Wrap the joint in absorbent cotton wet with iced water, apply a wet gauze bandage, and put on an ice-bag. In a mild sprain use lead-water and laudanum or apply at once a silicate dressing. In a severe sprain place the extremity upon a splint and to the joint apply flannel kept wet with lead-water and laudanum, iced water, tincture of arnica, alcohol and water, or a solution of chlorid of ammonium. The ice-bag should from time to time be laid upon the flannel for periods of twenty or thirty minutes. •Leeches around the joint do good. Constitutionally, em- ploy the remedies for inflammation (page 60). Morphin or "Dover's powder is given for the pain. Judicious bandaging limits the swelHng. After a day or two, if the symptoms continue or if they grow worse, use hot fomentations, hot lead-water and lauda- num, the hot-water bag, plunge the extremity frequently in very hot water, or apply heat by Leiter's tubes. When the acute symptoms begin to subside, rub stimulating liniments upon the joint once or twice a day and employ firm com- pression by means of a bandage of flannel or rubber. Fric- tions should be made from the periphery toward the body. Many cases do well at this stage under the local use of ichthyol and lanolin (50 per cent.), tincture of iodin, or blue ointment. Later in the case use hot and cold douches, massage, frictions, passive motion, and the bandage. Van Arsdale treats these cases by massage almost from the start. Gibney treats sprains by strapping with adhesive plaster. Passive motion is begun a day or so after swelling ceases. If massage causes the swelling to return, abandon it for sev- eral days and then try it again. Blisters are used when tender ■spots persist and stiffness is manifest. If stiffness becomes marked, move the joint forcibly. Give iodid of potassium, use tonics internally, and insist on open-air exercise. If the person is gouty or rheumatic, use appropriate remedies. DISEASES AND INJURIES OF BONES AND JOINTS. 435 Many sprains may be put up in an immoveable dressing the first day or two after the accident. If the joint contains much blood, aspiration should be practised before the dressing is applied. Ankylosis. — When a joint-inflammation eventuates in the formation of new tissue in and about the joint contraction of this tissue limits or destroys joint-mobility, producing the condition known as " ankylosis." Ankylosis may be com- plete (bony) or incomplete (fibrous) ; it may arise from con- tractures in the joint (true or intra-articular ankylosis) or from contractures in the structures external to the joint (false or extra-articular ankylosis). True or intra-articular ankylosis may arise from any cause which produces joint-inflammation with formation of new tissue, and may be due to wounds, contusions, sprains, dislocations, fractures in or near a joint, movable bodies in a joint, tubercle, gout, rheumatism, or syphilis. Want of use of the joints causes partial ankylosis, though this has been denied. Ankylosis is more apt to take place in a hinge- joint than in a ball-and-socket joint. In ankylosis from a general cause (as rheumatic gout) many joints are apt to suffer. Ankylosis may be due to fibrous tissue, and is then usually partial ; it may be due to chondrification of fibrous tissue, and is then incomplete ; it may be due to ossification of fibrous tissue, and is then complete, the joint being entirely immobile (osseous or bony ankylosis). The entire joint may be converted into bone. Only one small joint- surface may contain adhesions (limited adhesion), or the entire joint-surface may be bound up in them (diffused ad- hesion). Fibrous ankylosis follows aseptic inflammations ; bony ankylosis is apt to follow infections. Though slight motion is usually possible in fibrous ankylosis, in some cases it may be impossible. A joint immovable from fibrous ankylosis is distinguished from a joint immovable from bony ankylosis by the fact that in the former attempts at motion are pro- ductive of pain, and subsequently of inflammation. The incapacity resulting from ankylosis is due, first, to the im- pairment or destruction of joint-function, and, secondly, to the fixation at an inconvenient angle (a fixed flexed knee is worse than a fixed extended knee ; a fixed extended elbow is worse than a fixed partly flexed elbow). Treatment. — The effort should always be made to prevent an ankylosis by treating carefully any joint-inflammation and by beginning passive motion at the earliest safe period. To limit inflammation is to prevent ankylosis. Many cases of 436 MODERN SURGERY. fibrous ankylosis are improved by passive movements, mas- sage, frictions, stimulating liniments, inunctions of ichthyol or mercurial ointment, hot and cold douches, hot-air baths, and electricity. Some cases may be straightened out slowly by screw-splints or by weights and pulleys. Fibrous ankylosis of the elbow is best treated by using the joint. Fibrous ankylosis is often corrected by forcible straightening. If the tendons are much contracted, tenot- omy should be performed two or three days before forcible straightening is attempted. In order to straighten, always give ether. Suppose a case of ankylosis of the knee : put the patient upon his back, bring the leg over the end of the operating-table, grasp the ankle with one hand and the lower portion of the leg with the other hand, and make strong, steady movements of flexion and extension until the limb can be straightened. The adhesions will be felt to break, the snapping often being audible. At once apply a plaster-of- Paris dressing, and keep the limb immobile for two weeks. This procedure is not free from danger. Vessels may be ruptured, nerves may be torn, skin and fascia may be lacerated, suppuration may ensue from the admission into the joint of encapsuled cocci, or of organisms in the blood which find in this area a point of least resistance. Because of the danger of opening up depots of encapsuled bacilli and cocci, do not forcibly break up an ankylosis that results from a tubercular or a septic arthritis, but use gradual extension by weights or by screw-splints. Ankylosis of the knee follow- ing fracture of the patella is almost sure to recur after forcible breaking up. The best treatment for knee-ankylosis is use of the joint. In bony ankylosis of any joint other than the elbow-joint do nothing if the joint is in a useful position. If the joint is firmly fixed in an unfortunate position, resort to excision or an osteotomy. In the elbow excision should be performed, no matter what the position, in the hope of obtaining a movable joint. In ankylosis of the jaw surgeons are apt to try to remedy the condition by wedging the jaws apart with a mouth-gag, and afterward inserting boxwood plugs at frequent intervals. This method is invariably a fail- ure.^ Esmarch's operation is sometimes curative (removal of a wedge-shaped piece of bone). Some operators excise the condyle and a portion of the neck. Swain advocates sawing the bone at the angle. False or Extra-articular Ankylosis. — In this disease the joint is intact, but the contractures are in surrounding 1 Swain, in Lancet, 1894, vol. ii., p. 187. DISEASES AND INJURIES OF BONES AND JOINTS. 437 parts. The causes are muscular, fascial, and tendinous con- tractures, cicatrices (especially from burns), deposits of bone, muscular paralysis, tumors, and aneurysm. Contractions of muscles or tendons may be due to gout, rheumatism, injury, thecitis, fractures, and dislocations. False ankylosis is seen in club-foot and in Dupuytren's contraction. Treatment. — The treatment of false ankylosis depends upon the cause. Recently contracted muscles or tendons require motions, massage, frictions with stimulating lini- ments, and hot and cold douches. Old contractions require division. Whenever possible, excise a cicatrix that causes false ankylosis, and fill the gap with good tissue. Bony deposits are gouged away and tumors are removed. Con- tractures in cases of paralysis require electricity, passive motion, frictions with stimulating liniments, the hot-air bath, and general treatment. l/oose Bodies in Joints (Floating Cartilages). — The knee is the joint oftenest affected. These bodies may be free, may have a stalk or pedicle, may move about and occasion- ally block the joint, or may lie quietly in a joint-recess or diverticulum. They may be single or multiple, flat or ovoid, smooth or irregular, as small as peas or as large as plums, and may be composed of fibrous tissue, of bone, or of carti- lage. There are numerous different modes of origin of these bodies, many being " detached ecchondroses or pieces of hyaline cartilage hanging by narrow pedicles " (J. Bland Sutton), and they result from enlargement and chondrifica- tion of the villi of the synovial membrane. Some loose bodies are broken-off osteophytes ; some arise from blood- clots ; some by projection or herniation of the synovial membrane, which protrusion is broken ofl"; others are de- tached fringes of tubercular synovial membrane. Trauma- tism is usually an exciting cause. Loose cartilages are com- monest in adult men. Symptoms. — Many small bodies give rise to no symptoms other than those of synovitis. A large body produces pain and interferes with joint-function. The joint is weak and a little swollen, and the patient can feel the body and often can push it into a superficial area of the joint, where it may be felt by the surgeon. From time to time the body may get caught, thus suddenly locking the joint and producing intense and sickening pain, extension and fle.xion being im- possible until the body slips out. This accident is followed by inflammation and effusion. Treatment. — To relieve locking, employ forced flexion and 438 MODERN SURGERY. sudden extension. Cure can be obtained only by operation. Asepticize with the utmost care. Let the patient bring the foreign body to a point where it can be felt ; the surgeon then fixes it with a pin or holds it with the fingers, ether being given or cocain being used. The joint is now opened, the foreign body extracted, and an exploration made to see that no other bodies are present. The wound is now ■ stitched and the leg is placed upon a splint. Asepsis must be most rigid. The operation does not cure the causative lesion, and these bodies are apt to form again. 4. Luxations or Dislocations. A dislocation is the persistent separation from each other, partially or completely, of two articular surfaces. A self- reduced dislocation is called a sprain. There are three forms of dislocation: (i) traumatic; (2) spontaneous or pathologi- cal ; (3) congenital. I. Traumatic dislocations are due to injury. They are divided into — coinpletc dislocation, in which the two articular surfaces are entirely separated and the ligaments are torn ; incomplete or partial dislocation, in which the two articular surfaces are not completely separated and the liga- ments are rarely lacerated ; simple dislocation, in which the articular surfaces are not brought into contact with the ex- ternal air; compound dislocation, in which the external air has access to the articular surfaces ; complicated dislocation, in which, besides the dislocation, there is a fracture, exten- sive damage of the soft parts, an opening admitting air to the soft parts, or damage of a nerve or blood-vessel ; primitive dislocation, in which the bones remain as originally displaced ; secondary dislocation, in which the bone assumes a new position : for instance, a subglenoid luxation of the humerus is primary, and it may become secondarily a subcoracoid luxation because of muscular contraction or attempts at reduction ; recent dislocation, in which the displaced bone is not firmly fastened by tissue-changes in its new situation, and its old socket is not obliterated ; old dislocation, in which the displaced bone is firmly fastened by tissue-changes in its new habitat, and the old socket is to a great extent obliter- ated (whether a dislocation is old or new depends on the state of the parts rather than on the time which has elapsed since the accident) ; double dislocation, in which correspond- ing bones on each side are dislocated ; single dislocation, in which only one joint is dislocated ; unilateral dislocation, in DISEASES AND IXJURIES OF BONES AND JOINTS. 439 which one articulation of one bone is out of place ; bilateral dislocation, in which symmetrical articulations are dislocated ; and relapsing ox habitual dislocation, which recurs constantly from slight force because of relaxed ligaments or lack of complete repair after the ligamentous rupture of a first dis- location. 2. Spontaneous, Pathological, or Consecutive Dis- locations. — Spontaneous dislocation arises from such very slight force that it often cannot be identified, and it acts on a joint rendered lax by disease. It may arise in the course of chronic synovitis and during tubercular joint-disease. In typhoid fever spontaneous dislocation is not uncommon. The hip-joint is most often the one attacked. The dislo- cation follows a severe joint-inflammation, is usually upon the dorsum of the ilium, and is frequently not noticed until convalescence. If a typhoid dislocation is seen early, reduc- tion is easily effected, but if seen late is impossible. The treatment for irreducible typhoid dislocation is the same as for any other irreducible dislocation. In Charcot's joint {artJiropathie des ataxiqiies) this form of dislocation con- stantly appears. This condition comes on in a few hours, during the progress of locomotor ataxia, and is without ap- parent reason. The knee, the shoulder, or some other joint becomes greatly swollen, fluid gathers in large amount, the ligaments relax, the joint is destroyed and becomes exces- sively mobile, but there is no pain, no fever, and no sign of inflammation (p. 429). In Charcot's joint apply a support. 3. Congenital Dislocations. — The third form, or con- genital dislocation, is due to a congenital joint-malformation which renders it impossible for the bone to maintain a nor- mal position, or is due to external violence during the period of uterine gestation. Congenital dislocations should not be confounded with dislocations produced during delivery. The hip is the joint most often involved. The shoulder suffers occasionally. Lannelongue maintains that congenital dislocation of the hip is due to atrophy of the muscles and of the acetabulum following spinal-cord disease. Verneuil thinks the dislocation is paralytic. Broca truly says that in view of the fact that the head of the bone is larger than the cavity in which it belongs it is entirely useless to attempt reduction by manipulation or extension. Hoffa and Lorenz have each devised an operation for this condition (p. 503). Congenital dislocation of the shoulder requires incision, pos- sibly excision, or the paring dow^n of the head to fit the glenoid cavity (Phelps). 440 MODERN SURGERY. Traumatic Dislocations. — In the succeeding pages the traumatic form of dislocations will be particularly con- sidered. The causes of traumatic dislocations are divided into pre- disposing and exciting. Predisposing causes are (i) Age — dislocations are com- monest in middle life, the usual lesion of the young being green-stick fracture, and that of the old being fracture. Dislocations of the radius are not uncommon in youth. (2) Muscular development — dislocations being commonest in those with powerful muscles. (3) Sex — males being more predisposed than females, because of their occupations and muscular strength. (4) Occupation predisposes as a cause according as it demands the employment of muscular force, as in the carrying of burdens. (5) Nature of the joint — ball-and-socket joints being more liable to luxation than are ginglymoid joints, because of their wide range of motion. (6) Joint-disease predisposes by relaxing the ligaments. (7) Situation of the Joint — some joints being more exposed to injury than others. Exciting causes are classified into (i) external violence and (2) muscular action. External violence may be direct, as when a blow upon one of the bones forces it directly away from the other ; or it may be indirect, as when a blow at a distant part of a bone transmits force to its end and drives the bone out of its socket. Muscidar action is a cause when sudden and violent muscular contraction occurs during the maintenance of a position of the joint which gives the muscles full sway, and throws the head of the bone against the weakest part of its retaining ligaments. Patholog-ical Conditions. — In a recent complete trau- matic dislocation the ligaments are damaged, and may perhaps show extensive laceration, or may show only a button-hole laceration through which a bone projects. Ex- ternal force produces much laceration and little stretching of the ligaments ; muscular action produces little laceration and much stretching of the ligaments (Mears). In some cases of dislocation due to external violence the structures about the joint are bruised or otherwise damaged ; the old socket is filled with blood, and the bone in its new situa- tion lies in a bloody area. Large vessels and nerves are rarely torn, though they may be compressed. If a dislocation is not soon reduced, inflammation arises in the old joint and about the displaced bone, and the whole area is glued together, first by coagulated exudate, and DISEASES AND INJURIES OF BONES AND JOINTS. 44 1 finally by fibrous tissue. After a time, in ball-and-socket joints, the old socket fills with fibrous tissue, contracts, becomes irregular, and may even be obliterated ; the head of the dislocated bone alters its shape, its cartilage is de- stroyed or converted into fibrous tissue, and the pressure of the head of the bone forms a hollow in its new situation, which hollow becomes surrounded by fibrous tissue or even by bone. A new joint may form, the surrounding tissue becoming a compact capsule, and a bursa forming between the head of the bone and its new socket. In a dislocated hinge-joint the ends of the bone alter greatly in shape and their cartilage is converted into fibrous tissue. In an unre- duced dislocation the muscles shorten or lengthen or undergo atrophy or fatty degeneration, as the case may be. An unreduced dislocation of a ball-and-socket joint may give a fairly movable new joint, but an unreduced disloca- tion of a hinge-joint rarely allows of much motion. General Symptoms of Traumatic Dislocations. — In general, traumatic dislocations are indicated (i) by pain of a sickening, nauseating character ; (2) by rigidity voluntary motion is impossible except to a slight extent in the direc- tion of the deformity. (For instance, in dislocation of the inferior maxillar}^ the jaw can be opened a little more, but it cannot be closed. This rigidity brings about loss of function. When the surgeon attempts to move the joint he finds it very rigid) ; (3) by change in the shape of the Joint (as flattening of the shoulder after dislocation of the hume- rus) ; (4) by alteration in the nnitnal relations of bony promi- nences about a Joint (alteration of the relation between the olecranon and humeral condyles in dislocation of the elbow backward) ; (5) by feeling the displaced bone in its new situation ; (6) by missing the head of the bone from its proper situation ; (7) by alteration in the length of the limb' (in dislocation of the femur into the thyroid foramen the leg is lengthened, but in dislocation into the dorsum of the ilium it is shortened) ; and (8) by alteration in the axis of the bone (in dislocation upon the dorsum of the ilium the axis of the injured thigh would, if prolonged, pass through the lower third of the sound thigh) ; (9) by seeing the dislo- cation with a fluoroscope or looking at a skiagraph of it. Diagnosis of Traumatic Dislocation. — A dislocation may be mistaken for a fracture. In dislocation there is rigidity, in fracture there is preternatural mobility ; in dislo- cation there is no true crepitus (may get tendon- or joint- crepitus), in fracture there usually is crepitus ; in dislocation 442 MODERN SURGERY. the deformity does not tend to recur after reduction, in fracture it does recur after extension is relaxed. In a sprain the movements of the joint are only limited, not abolished, by an almost complete rigidity. The change which a sprain may cause in the shape of a joint is due to effusion or to bleeding ; there is no alteration in the relation of the bony prominences to one another ; there is no notable alteration in the length of the limb (a slight increase in length may arise from joint-effusion, or the head of the bone may sub- sequently be absorbed, and thus produce shortening after some weeks) ; there is no alteration in the axis of the bone ; the head is not felt in a new position, it being found in its normal place. Always remember that a fracture may exist with a dislocation. In any doubtful case — in fact, in most cases — give ether, for a dislocation should be reduced while the patient is anesthetized (except in dislocation of the jaw, of the fingers, of the carpus, etc.). In some cases swelling renders the diagnosis difficult or impossible. Always com- pare the injured joint with the corresponding joint of the sound side. The X-rays constitute a valuable aid to diag- nosis. Treatment of Traumatic Dislocations. — Recent Simple Dislocations. — Reduce simple dislocations under ether, as a rule. Try manipulation, a procedure in which it is sought to make the bone retrace its own pathway. If this proced- ure fails, employ extension and counter-extension. If con- siderable force is needed, an assistant makes counter-exten- sion, and the surgeon fastens to the extremity a clove-hitch which he ties about his waist, and thus secures powerful extension. Counter-extension may be obtained by bands, or, in some instances, by the foot of the surgeon. The clove-hitch is used because it will not tighten by traction, ■ as a tightening band would lacerate the soft parts (Fig. 112). If great power is needed, compound pulleys may be em- ployed, such as the Jarvis adjuster or some similar appli- ance, but at the present day pulleys are rarely used (see page 444). If these means fail, cut down upon the bone and restore it to position ; operation is much safer than is the application of great force. After reducing a dislocation, immobilize the joint for a time (time varies with different joints), and for the first few days combat swell- ing and inflammation with evaporating lotions. If there exists a fracture of the dislocated bone, apply splints and then try to reduce by manipulations, grasping the limb and the splint with one hand below and, if possible, with the DISEASES AND INJURIES OF BONES AND JOINTS. 443 Other hand above the seat of the fracture. In some cases with fracture reduction can be much aided by making a small incision, screwing a gimlet into the head of the bone, and using this tool as a handle. McBurney incises, drills a hole in each bone, inserts hooks into them, and pulls the dislocated bone into position (Figs. 68, 69). When the dislo- cation has been reduced the bone fragments are wired. Allis believes that a dislocation can be reduced even when a fract- ure exists. It is possible to pull the dislocated head down to the joint, because a portion of periosteum and possibly tendinous material and muscle still hold the two fragments as a strap might unite two sticks. The head can be forced into place by the fingers while traction is being made. If the fracture is near the joint and the fragments cannot be fixed, try to reduce the dislocation, first striving to press the bone into place. This attempt can be greatly aided by traction upon the lower fragment. Compound Traumatic Dislocations. — The opening in the soft parts may be due to external violence or to projection of a bone. Compound dislocations are very serious. Hinge- joints are more liable to these injuries than are ball-and- socket joints. Many cases require excision and amputation ; one that does not demand excision or amputation should be treated by counter-opening, by careful antisepsis, by drainage, and by immobilization, ankylosis generally ensuing, except sometimes in the small joints. It is scarcely ever necessary to cut away any portion of the protruding bone to effect reduction. If a joint is badly splintered, or if the soft parts are extensively damaged, excise or amputate ; if the main vessels or the nerves are seriously injured, or if the patient is so old or so feeble that it is perilous to force him to combat a long illness, amputate. Old Traumatic Dislocations. — The problem always pre- sented in old dislocation is. Shall reduction be tried, or shall the bones be left alone ? Sir Astley Cooper laid down this rule : " Do not attempt to reduce a shoulder-dislocation after three months, nor a hip-dislocation after two months ;" but this rule was laid down before the days of ether. Do not select any fixed period of time to determine what action is advisable. In dislocation of a ball-and-socket joint con- siderable motion may become possible and a new joint may form. If movement does not produce pain, a useful new joint may be obtained b\' the persistent employment of active and passive movements ; if movement of the limb does produce pain, enough motion will not be attempted by the y\/\/\ MODERN SURGERY. patient to produce a useful joint. In the former case try to obtain a useful new joint, and in the latter case try to reduce the old dislocation. In trying to reduce an old dislocation, give ether, make movement to break up adhesions, and persist in making these motions until the head of the bone is felt to move ; then try at once to reduce by manipulation, extension, or the pulleys, not waiting for two days, as some suggest. If the head of the bone cannot be made to move, the Dieffen- bach plan may be followed, which is to cut the tense restraining bands with a tenotome. Always remember that dislocations of a hinge-joint, if left unreduced, will never eventuate in a useful artificial joint. Sir Joseph Lister, being much impressed with the danger inevitably linked with for- cibly dragging old dislocations into place, prefers to cut down and restore the bone, employing, of course, the strict- est asepsis. Many surgeons adhere to this view. In some old dislocations excision of the head of the bone is the proper operation. Special Traumatic Dislocations. — Lower Jaw. — Without fracture the lower jaw can only be dislocated for- ward. There are two forms of dislocation — the unilateral, which is rare, and the bilateral, which is common. Disloca- tions of the jaw are commonest in women and during middle life. When the mouth is open contraction of the external pterygoid may pull the condyle over the articular eminence ; this contraction may be brought about by yawning, vomiting, scolding, etc. When the mouth is open dislocation of the lower jaw may be caused by a blow upon the chin ; it may also be caused by forcing the mouth more widely open by pushing a bulky body between the teeth. Syinptoms of Lower-jatv Dislocations. — In the bilateral form the mouth is open and fixed, and it cannot be closed, though it can be opened a little more. The condyles are in front of the articular eminences, and are fixed by the action of the masseters and internal pterygoids, the coronoid processes being wedged against the malar bones. The lower jaw is advanced in front of the upper and the face looks longer than natural. The lips cannot close, the saliva over- flows, swallowing and speech are difficult, there is a depres- sion in front of each ear, the condyles are recognizable in their new abodes, the coronoid processes are detected by a finger in the mouth, and the masseters and temporals stand out in a state of rigidity. Pain may be severe or be absent. In the unilateral form the chin goes toward the sound side, and the DISEASES AND INJURIES OF BONES AND JOINTS. 445 mouth is not so widely open as in the bilateral form, neither is the jaw so fixed. The symptoms are similar to those of a bilateral luxation, but are not so pronounced. The hollow in front of the ear and the condyle in an abnormal situation are only detected upon one side. In an unreduced disloca- tion the patient may after a time establish some movement of the jaw, but the power of mastication will always be im- paired seriously. Treatvicnt of Lo%vcr-jaw Dislocations. — In treating dislo- cations of the lower jaw the patient is placed with his head against the back of a chair or against the body of an assist- ant. The surgeon, after wrapping up his thumbs to protect them from being bitten, stands in front of the patient, puts his thumbs upon the last molar teeth, and grasps the chin with his free fingers. He now presses downward and back- ward on the jaw, and as soon as the condyle is loosened closes the jaw over the thumbs by pushing up the chin, using his thumbs as levers. If this procedure fails, wedges should be put between the molar teeth and the chin should be pushed up either by the hands or by a tourniquet whose band is round the head and chin. In a unilateral disloca- tion the wedge should only be used on the injured side. In difficult cases Sir Astley Cooper pushed a round wooden ruler between the molar teeth, used the upper teeth as a fulcrum, and raised the end of the ruler as the handle of a lever. The forceps used by an anesthetizer may depress the condyle from its point of fixation, whereupon the chin may be pushed up and back. Nelaton's plan was to put the thumbs in the mouth and push the coronoid pro- cesses backward. In an old dislocation always try reduc- tion, at least up to a period of six or seven months. After reduction apply a Barton bandage for over two weeks, taking it off once a day, and begin passive motion in the second week ; discard the bandage in the third week. Liquid diet is advisable for three weeks after the accident. An unre- ducible dislocation requires osteotomy of the neck of the bone, if the part cannot be restored after incision. Dislocation of the Clavicle. — Sternal End. — There are three forms of dislocation of the sternal end of the clavicle, namely: (i) forward; (2) backward; and (3) upward. For-ward Dislocation of the Sternal End of the Clavicle. — The causes of forward dislocation of the clavicle are blows, falls, or pulls which drive or draw the shoulder backward. Symptoms and Treatment of Forn'ard Dislocation of the Clavicle. — The symptoms manifest in dislocation of the clavi- 446 MODERN SURGERY. cle are — prominence in front of the sternum; the acromion is nearer to the sternum on the injured than on the sound side ; the clavicular origin of the sternocleidomastoid is rigid ; movement is difficult and painful. To treat a dislo- cation of the clavicle, pull the shoulders back against the knee of the surgeon, which is placed between the scapulae. Dress with a posterior figure-of-8 bandage (Fig. 271), or a Velpeau bandage (Fig. 273), the dressing to be worn for three weeks. After removal of the dressing apply a tru3s, the pad of which is put over the head of the clavicle, and which instrument is to be worn for a month. Dislocation of the clavicle is difficult to keep reduced, but even if it becomes fixed in deformity the motions of the arm will not be impaired permanently. It can be reduced and fixed by incision and wiring. Backward dislocation of the sternal end of the clavicle is very rare. The causes are direct violence and indirect force, such as falls or blows which drive the shoulder forward and inward. Symptoms and Treatment of Backzvard Dislocation of the Clavicle. — The symptoms are — pain ; loss of function in the arm ; incHnation of head toward the injured side ; stiffiiess of the neck ; the shoulder passes forward and inward, and often falls downward ; a depression exists over the sternoclavicular joint; the head of the clavicle cannot be felt, or is found back of the sternum. The displaced clavicle may press upon the trachea, the esophagus, or the great vessels, inducing dyspnea, dysphagia, obliteration of pulse in the arm of the injured side, or great venous congestion of the head (see Pick). To treat a backward dislocation, pull the shoulders backward and apply a posterior figure-of-8 bandage (Fig. 271), which must be worn for three weeks. If pressure- symptoms are urgent, resect the displaced head. Upward dislocation of a clavicle is very rare. The cause is indirect force which carries the shoulder downward, inward, and backward (Smith). Symptoms and Treatment of Upward Dislocation of the Sternal End of the Clavicle. — The chief symptom is impaired function of the arm ; the shoulder passes downward and inward, the clavicular axis is altered, and the displaced head is felt. Dyspnea may or may not exist. To treat this dis- location, put a pad in the axilla and press the elbow to the side in order to throw the bone outward, and tiy to push the head into place. Apply a Desault bandage (Fig. 276) and place a firm pad over the sternoclavicular joint. The DISEASES AXD IXJURIES OF BONES AND JOINTS. 447 deformity is apt to recur, but a useful limb will nevertheless be obtained. It may be desirable to wire the bones in place. Dislocation of the acromial end of the clavicle is almost alwa)'s upward, but it may be below the acromion. The cause is violent force, which, if so applied to the scapula as to drive the shoulder forward, may produce a dislocation upward. A dislocation downward is due to blows upon the upper surface of the outer end of the clavicle. Symptoms mid Treatment. — The symptoms of dislocation of the acromial end of the clavicle are — prominence of the clavicle upon the top of the acromion ; impaired function of the arm (it cannot be lifted over the head) ; the shoulder falls downward and passes inward ; there is apparent lengthening of the arm ; the head is bent toward the injured side, and the clavicular origin of the trapezius is strongly outlined (Pick). In dislocation downward both the acromion and the coracoid are very prominent, the clavicular axis is altered, and there is depression over the sternoclavicular joint. A dislocation upward is reduced by pulling the shoulder back and pushing the bone into place. The old method was to apply a Desault bandage, which was kept on for three weeks, and more or less deformity was looked for as inevitable. Stim- FiG. 109. — Rhoads's apparatus for treating dislocation upward of the acromial end of the clavicle. son dresses with adhesive plaster. The author has recently seen a case treated by the apparatus of Thomas Leidy Rhoads. The apparatus completely corrected the deformity, 448 MODERN SURGERY. and the patient made a most satisfactory recovery. The essential element of Rhoads's apparatus is a trunk strap applied as is shown in Fig. 109. Dislocation downward is reduced and treated in the same manner as dislocation upward. The so-called dislocation of the low^er angle of the scapula is not, as it was long thought to be, a disloca- tion at all. The lower angle and vertebral border deviate from the chest. This condition was thought to be due to the bone slipping from under the latissimus dorsi muscle, but it is now known to be due to paralysis of the serratus magnus muscle, the bone being acted upon by the trapezius, pector- alis minor, levator anguli scapulae, and rhomboid muscles. Examination shows that the scapula will not rotate normally forward. This is demonstrated by extending the arms in front to a right angle, the gliding forward of the scapula upon the sound side being marked and upon the diseased side being slight or absent. Treatment of dislocation of the lower angle of the scapula comprises massage, electricity, passive motion, and deep in- jections of strychnin. Simultaneous dislocation of both ends of the clavicle is a very rare injury. It is treated as is single dislocation. Dislocations of the Humerus (Shoulder-joint). — These injuries are quite frequent because of the free mobility of the shoulder-joint, its anatomical insecurity, and its exposed situ- ation ; they rarely occur in the very young and in the aged, and are oftenest encountered in muscular young adults. Four chief forms of shoulder-joint dislocation exist, namely: (i) forward, inward, and downward, under the coracoid pro- cess — subcoracoid ; (2) downward, forward, and inward, be- neath the glenoid cavity — subglenoid ; (3) backward, in- ward, and downward, under the spine of the scapula — subspinous ; and (4) forward, inward, and upward, under the clavicle — subclavicular. A very rare form of shoulder-joint dislocation has been described, which is known as the " supracoracoid." Another rare form is the luxatio erecta. Subcoracoid Luxation. — The subcoracoid variety of dis- location embraces three-fourths of all the shoulder-joint luxations. It may be caused by direct force driving the head of the humerus forward and inward, or by indirect force, such as falls upon the hand or the elbow. In this dislocation the anatomical neck of the humerus lies upon the anterior margin of the glenoid cavity, just beneath DISEASES AND INJURIES OF BONES AND JOINTS. 449 the coracoid process, and is above the tendon of the sub- scapularis muscle. Subglenoid or axillary fixation may be produced by con- traction of the great pectoral and latissimus dorsi muscles when the arm is at a right angle to the body, but it is usually due to falls upon the hand or the elbow when the arm is raised and the head of the bone is against the lower portion of the capsule. In this dislocation the head of the bone rests upon the border of the scapula, below the tendon of the sub- scapularis, in front of the long head of the triceps, and above the teres muscles. Some observers hold that most disloca- tions of the shoulder are primarily subglenoid, the position having been altered by muscular action. Subspinous luxation is a rare injury. Pick met with this accident in a man who, while having his hands in his pockets, fell upon the front of the point of the shoulder. The head of the bone reposes beneath the scapular spine, between the infraspinatus and teres minor muscles. Subclavicular luxation is very rare. It is caused by the same sort of violence which produces subcoracoid luxation. The head of the bone rests upon the thorax, below the clavicle and underneath the pectoralis major muscle. In the rare form known as the " supracoracoid " the head of the humerus rests upon the coraco-acromial ligament or upon the acromion process and the acromion or the coracoid is always fractured. Luxatio erccta is an unusual form of subglenoid dislocation. The arm is upright and the forearm rests behind the occiput or on the top of the head, and the patient holds it there to avoid pain. Judd, Hulke, and Cleland have related cases. Symptoms of Dislocation of the Shoulder-Joint. — Dislocation is diagnosticated by (i) pain of a sickening character ; (2) flat- tening of the shoulder, the head of the bone having ceased to bulge out the deltoid muscle ; (3) apparent projection of the acromion through sinking in of the deltoid ; (4) hollow beneath the acromion, over the empty glenoid cavity, and the bone missed from its normal habitat. This hollow may be easily appreciated by the finger, especially when the extrem- ity is somewhat abducted ; (5) rigidity (some movement is possible, in the direction especially of an existing deformity, but mobility is strictly limited and attempts at motion pro- duce great pain) ; (6) the elbow cannot touch the side when the hand is placed upon the sound shoulder, and the hand cannot be placed upon the sound shoulder if the elbow is to the side — Dugas's sign (this is due to the rotundity of the 29 450 MODERN SURGERY. chest. In a dislocation the head of the bone is already touch- ing the chest, and the bone, being approximately straight, cannot touch it in two places at the same time. If the elbow can be placed against the chest with the hand on the sound shoulder, there cannot be dislocation ; if it cannot be so placed, there must be dislocation) ; (7) finding the head of the bone in a new situation ; (8) examining by means of the A^'-rays. Symptoms i to 5 inclusive may be grouped as Erichsen's list of signs. The form of dislocation is made out by a study of the direction of the axis of the limb, the existence and extent of .lengthening or of shortening, and the situation of the head of the bone. The following table from T. Pickering Pick's work on Fractures and Dislocations makes the above points clear : Subcoracoid. Subglenoid. Subspinous. Subclavicular. Direction of the Axis of the Limb. The elbow is car- ried backward and slightly away from the side. The elbow is car- ried away from the trunk and slightly backward. The elbow is raised from the side and carried for- ward. The elbow is car- ried outward and backward. Alteration in the Length of the Limb. Very slight lengthening. Very consider- able lengthening. Lengthening in- termediate in de- gree between the subglenoid and the subcoracoid. Shortening. Presence of the Head of the Bone in New Situation. The head of the bone cannot easily be felt; if it can, it is found at the upper and inner part of the axilla. The head of the bone can easily be felt in the axilla. The head of the bone can be felt and be grasped beneath the spine of the scapula. The head of the bone can readily be seen and be felt be- neath the clavicle. In a shoulder-joint dislocation the head of the bone may press upon the brachial plexus and produce pain and numb- ness, and occasionally a traumatic neuritis or paralysis ; some- times pressure upon the axillary vein causes intense edema, and pressure upon the axillary artery diminishes or obHter- ates the pulse. The axillary vessels may be torn and the muscles may be lacerated badly. The capsule is torn and con.siderable blood is usually effused. Swelling is due first to hemorrhage, and secondly to inflammation. Partial dis- locations sometimes, though rarely, occur. What is usually spoken of as " partial dislocation " or " subluxation " is a condition in which the head of the humerus passes forward DISEASES AND INJURIES OF BONES AND JOINTS. 45 I under the coracoid because of rupture of the long head of the biceps or because this tendon slips out of its groove, the ligaments being intact. Diagnosis of Shojtldcr-joiiit Dislocation. — In fracture of the neck of the scapula there is prominence of the acromion and a hollow below it, a hard body being felt in the axilla ; but the coracoid process descends with the head of the bone, which it does not do in dislocation. Furthermore, in fract- ure there is mobility ; in dislocation rigidity. In fracture crepitus is present ; in dislocation it is absent. In fracture the deformity is easily reduced, but it at once recurs ; in dis- location the deformity is with difficulty reduced, but does not recur. In fracture the elbow can be made to touch the side when the hand is upon the sound shoulder ; in disloca- tion it cannot be so manipulated. In fracture of the anatomi- cal neck of the humerus deformity is slight ; the head of the humerus is found in place, and does not move when the shaft is rotated ; and the head is not in line with the axis of the bone. Crepitus exists in fracture if impaction is absent. In paralysis of the deltoid there is distinct flattening, but the bone is felt in place and there is no rigidity. The A-rays are a great aid to diagnosis. Treatinoit of SJiouldcr-joiiit Dislocation. — Reduction by manipulation is usually readily obtained in recent cases of shoulder-joint dislocation. It is usually well to give ether. Forward dislocations (subcoracoid, subclavicular, and axillar}-) are reduced by Kocher's method (Fig. no): Put the arm Fig. iio. — Kocher's method of reduction by manipulation : a, first movement, outward rotation ; h, second movement, elevation of elbow ; c, third movement, inward rotation and lowering of the elbow (Ceppi). against the side, flex the forearm to a right angle with the arm, perform external rotation of the arm until resistance be- comes decided, raise the elbow, make internal rotation, bring the arm across the front of the chest and lower the elbow. The formula is, flexion of the forearm, external rotation, lift- 452 MODERN SURGERY. ing elbow forward, internal rotation of the arm, and lowering the elbow. If in trying Kocher's plan external rotation of the humerus does not take place, abandon the method, as per- sistence will fracture the humerus. Another method of ma- nipulation is as follows : if the right shoulder is dislocated, the surgeon stands behind the patient (who is sitting erect) ; if the left shoulder is dislocated, he stands in front of the patient. The surgeon holds the forearm flexed upon the arm with his right hand and makes external traction and rotation, and with the fingers of his left hand he tries to force the bone into place. In Henry H. Smith's method for forward dislocations the surgeon stands in front of the patient. If the left shoulder is dislocated, the surgeon grasps it with his left hand ; if the right shoulder is dislocated, he grasps it with his right hand, the thumb resting on the head of the bone. With his disen- gaged hand the surgeon grasps the elbow, abducts it, makes traction and external rotation, and suddenly sweeps the elbow inward, aiming it at the sternum, and tries with his thumb to push the bone into place. In subspinous luxations reduction may be effected if the surgeon stands behind the patient, makes abduction, traction, and internal rotation, sweeps the elbow inward toward the spine, and with the thumb aids the bone in its return into position. Raising the elbow far above the head and sweeping it inward will reduce some disloca- tions. As the head of the bone slips back a distinct jar is felt and a snap is heard, the motions of the joint are again obtainable, and with the hand on the opposite shoulder the elbow may be made to touch the side. Reduction by Extension. — In reduction of shoulder-joint dislocation by extension the patient is anesthetized and placed upon a low bed or upon the floor. The surgeon then places his foot, covered only by a stocking, in the axilla. Place the sole of the foot, not the heel, against the chest high up, the instep being made to touch the humerus and the heel the border of the shoulder-blade, a towel being first put into the axilla to rest the foot against (Fig. in). If the left arm is dislocated, use the left foot, and vice versa. The elder Gross approved of making extension while sitting between the patient's limbs. Make steady extension, which will in many cases bring about the reduction. If it fails to cause reduction, bring the patient's arm across the chest and use the foot as the fulcrum of a lever. If the humerus is pretty firmly fixed in its abnormal position, make counter-extension with a foot in the axilla and make extension by fixing a clove- DISEASES AND INJURIES OF BOXES AND JOINTS. 453 hitch (Fig. 1 1 2) above the clbozv and fastening to it bands which go over one shoulder and under the other shoulder of the surgeon. The back may be used for extension, the hands being left free for manipulation (Allis's and Pick's plan). Fig. III. — Reduction of shoulder-joint disloca- tion by the foot in the axilla (Cooper). Fig. 112. — Clove-hitch knot applied above the wrist In dislocation of the shoulder this knot is put above the elbow (after Erichsen). Lateral extension is used by some surgeons. The patient lies down, a large piece of canvas is split, the arm is passed through the split and the body is thus fixed. The arm is pulled to a right angle with the body and traction is applied. The late Prof Joseph Pancoast favored Sir Astley Cooper's method of placing the unanesthetized patient in a chair and using the knee as a fulcrum, pushing the elbow to the side (Fig. 113). Brunus, in the thirteenth century, devised the method of upward ex- tcnsio)i. In appl}-ing this method Fig. 113.— Reduction of shoul- der-joint dislocation by the knee in the axilla (Cooper). Fig. 114. — Reduction of shoulder-joint disloca- tion by upward extension (Cooper). the surgeon takes his place behind the patient, steadies the scapula with his hand, and carries the patient's arm upward and backward above his head, making extension and external rotation (Fig. 114). La IVIothe's method is applied with the patient supine upon the floor. The surgeon places his foot 454 MODERN SURGERY. upon the shoulder to make counter-extension, and makes extension as in Brunus's method. It is a useful expedient, when either of these plans is applied, to have an assistant make the traction while the surgeon manipulates the head of the bone. Cock advises, when reduction fails, that an air-pad be placed in the axilla and the arm be bound to the side — a method by which reduction will often take place after two or three days. The pulleys should not be used, as they develop a dangerous force, antiseptic incision being a safer and a better expedient. After incision tr}' to restore the bone to place. In an old dislocation it may be necessary to resect the head of the bone. In reducing a dislocation the axillar}' artery or vein may be ruptured, fracture of the neck of the humerus may take place, injury to the brachial artery may occur, or the soft parts may be badly damaged. After reducing a dislocation apply a Velpeau bandage, keep the shoulder immobile for one week, then make passive motion daily, reapplying the dressing after each seance. The patient may wear a sling alone during the third week, after which period he may use the arm. (For old dislocations and compound dislocations see page 443.) Reduction of old dislocations may sometimes be effected by manipulation. Extension may have to be used, and ether may be required. In old dislocations tiy to reduce, after breaking up adhesions, by forced flexion and strong ex- tension. After reduction immobilize for three weeks, and begin passive motion after seven days. If a dislocation is complicated by a fracture of the humerus, try to pull the head of the bone opposite the joint. This may be possible if the two fragments are held partly together by a fair amount of periosteum, and muscle. Traction is made upon the arm, and an attempt is made to manipulate the head into the socket (Allis's plan in the hip). McBurney incises, fixes a hook in the scapula and a hook in the head of the humerus, pulls the head into place, and wires the fragments (Figs, ^y, 68, 69). In an emergency gimlets may be used instead of the hooks. In some cases it is necessary to excise the head of the bone. Dislocations of the Elbow-joint. — Injuries of the elbow- joint are not rare, and they are commonest in children. Both bones or only one bone may be dislocated, and the dislocation may be partial or complete. Dislocation of Both Bones Backward, — The causes of backward dislocation of both bones of the forearm are falls upon the extended hand or twists inward of the ulna DISEASES AND INJURIES OF BONES AND JOINTS. 455 (Malgaigne). The coronoid process lodges in the olecranon fossa of the humerus. Syuiptouis of Backzvard Dislocation. — In complete disloca- tion of both bones of the forearm the olecranon is very prominent ; the distance between the point of the olecranon and the apex of the inner condyle is notably greater than on the sound side ; the forearm is flexed, supinated, and short- ened ; the lower end of the humerus projects in front of the joint, below the skin-crease ; the head of the radius is found back of the outer condyle ; and there are the general symp- toms of dislocation. Fracture of the coronoid rarely occurs with backward dislocation, but if it does occur there will be crepitus and mobility. Fracture at the base of the con- dyles is distinguished from dislocation of both bones of the forearm backward by the following points : in fracture there are found the ordinary symptoms ; measurement from the condyles to the styloid processes does not show shortening ; there is no alteration of the normal relation between the olec- ranon process and the condyles ; and the projection in front of the joint is above the crease of the bend of the elbow. Treatment of Backiuard Dislocation. — Reduction must be effected early in dislocation of both bones of the forearm, or it will be found impos- sible, and an unreduced dislocation means a limb without the powers of flexion, pronation, and supination. The surgeon places his knee in front of the elbow-joint, grasps the patient's wTist, presses upon the radius and ulna with his knee, and bends the forearm with consid- erable force, the muscles pulling the bones into place (Sir Astley Cooper's plan). Forced flexion, traction, and extension may be tried (Fig. 115). Put the arm in Jones's position for two weeks, and make passive motion daily after the first few days. Dislocation of Both Bones Forward. — The cause of for- ward dislocation of both bones of the forearm is a blow on the olecranon when the arm is flexed. It is a rare accident. Symptoms and Treatment. — The symptoms of forward dislocation of both bones of the forearm are — forearm Fig. 115. — Reduction of elbow-joint dislocation. 456 MODERN SURGERY. is flexed and lengthened ; some slight motion is possible ; olecranon is on a level with the condyles if unfractured, hence its prominence is gone ; the humeral condyles are felt posteriorly, and the radius and ulna are felt anteriorly. The treatment of this injury consists in early reduction, which is accomplished by means of forced flexion and pressure, placing the part in Jones's position for two weeks, and making passive motion daily after the first few days. Lateral dislocations of both bones of the forearm are usually incomplete. Symptoms and Treatment of Outward Dislocatio)i.-^-Th& symptoms of outward dislocation of both bones of the forearm are — forearm is flexed, fixed, and pronated; joint is widened ; the head of the radius projects externally and has a depression above it; the inner condyle projects internally and has a depression below it ; the olecranon is nearer than normal to the external condyle and further than normal from the internal condyle. Reduction is ef- fected by extension of the forearm and pressure inward upon the head of the radius. Apply an ascending spiral reverse bandage of the forearm, a figure-of-8 bandage of the elbow- joint, and a sHng. Make passive motion after a few days. The bandages must be worn for two weeks. Symptoms and Treatment of Inward Dislocation. — In dis- location inward of both bones of the forearm the posi- tion of the forearm is the same as that in dislocation out- ward; the sigmoid cavity of the ulna projects internally, and the external condyle projects externally. Reduction is effected by extension of the forearm and pressure outward on the ulna, subsequent treatment being the same as that employed in the preceding form. Dislocation of the ulna alone is very rare, and can only take place backward. Symptoms and Treatment. — Dislocation of the ulna alone is indicated by the forearm being flexed and pronated. The head of the radius is found in place, and the olecranon pro- jects posteriorly. The treatment of this injury is the same as that for dislocation of both bones. Dislocation of the Radius Forward. — Dislocation of the radius forward is the commonest form of dislocation of the elbow. This injury is caused by a fall upon the hand with the forearm in pronation and extension, or is produced by blows on the back of the joint ; forced pronation alone will not cause it. Symptoms and Treatment. — The symptoms in dislocation DISEASES AXD IXJCRIES OF BONES AND JOINTS. 457 of the radius forward are — forearm midway between prona- tion and supination, and semiflexed ; attempts to increase flexion cause the radius to strike against the humerus with a distinct blow ; the head of the radius is felt in front of the outer condyle and is missed from its proper abode. Re- duction is effected by flexion over the knee, extension, and manipulation. Subsequent treatment is Jones's position and passive motion. Deformity is apt to recur after reduction, because of rupture of the orbicular ligament. Dislocation of the radius backward is caused by falls on the hand or by blows on the front of the joint. Syiiiptoj/ts and Treatment. — Backward dislocation of the radius is indicated by the forearm being slightly flexed and fixed in pronation, by some impairment of flexion and extension, and by the radius being felt behind the outer condyle. Reduction is effected by flexion over the knee, extension, and manipulation, and the subsequent treatment is the same as that given for the preceding dislocation. Dislocation of the radius outAvard is very rare. In this injur}^ the head of the radius is distinctly felt. Reduc- tion is effected by extension and pressure ; the subsequent treatment is the same as that for the above-mentioned dis- locations. Subluxation of the Head of the Radius. — This name is given to an injury which is ver>' frequent in children between two and four years of age. It results from traction upon the hand or the forearm, and often arises when the nurse or the mother pulls upon a child's arm to save it from a fall or to lift it over a gutter. Some writers hold that pronation is required, as well as extension, to produce the injury; many surgeons claim that extension and adduction are the causa- tive forces. Hutchinson maintains that supination may cause subluxation. Bardenheuer assigned falls as causes. The symptoms are very characteristic. The histor}' points to the injur)^ Pain, and often a click, may be felt in the wrist at the time of the accident. The arm hangs by the side, with the elbow-joint slightly flexed and the forearm midway between pronation and supination. Flexion to a less angle than 60° and complete extension are resisted and are very painful, but movements between 60° and 130° are free and painless.^ The movements of the wrist-joint are free and painless. The elbow-joint presents no deformity. Pressure over the head of the radius causes pain. Strong ' See the instructive article by \V. W. Van Arsdale, in the Amiah of Surgery, vol. ix., 1889. 458 MODERN SURGERY. pronation is painful ; strong supination is very painful, and there seems to be a mechanical obstacle to its performance. Forced supination develops a distinct click at the head of the radius, and causes pronation and supination to become natural and free from pain. The condition will be repro- duced if a splint is not used. The nature of the lesion is not understood, and various conditions have been thought to exist by different observers. Among them may be men- tioned the following : a slight anterior displacement of the head of the radius ; a slight posterior displacement ; locking of the tuberosity of the radius behind the inner edge of the ulna ; dislocation of the triangular cartilage of the wrist ; intracapsular fracture of the radial head ; painful paralysis from nerve-injury ; displacement by elongation, the return of the bone being prevented by collapse of the capsule ; and the slipping up of the margin of the orbicular ligament over the rim of the head of the radius. Ti'eatment. — Place the forearm at a right angle to the arm and make forcible supination ; apply an anterior angular splint, and have it worn for four or five days, or put the part in Jones's position for an equal period. Dislocations of the "wrist, which are very rare, are caused by falls upon the hand. Back-ward Dislocation of the "Wrist. — Symptoms. — The deformity in backward dislocation of the wrist (Fig. ii6, a) resembles that of Colles's fracture (Fig. 1 16, b). The fingers are flexed, the wrist is bent backward, the radius projects Fig. ii6. — Deformity in dislocation of the wrist backward (a) and in Colles's fracture (b) (Stimson). on the front of the wrist, the carpus projects on the dorsal surface of the forearm, the relation of the styloid process of the radius to the styloid process of the ulna is unaltered (it is altered in Colles's fracture), there is rigidity, and crepitus is absent (Fig. 1 16). Forward dislocation of the -wrist, which is very unusual, is caused by a fall upon the back of the hand. Symptoms and Treatment. — In forward dislocation of the wrist the radius and ulna project posteriorly and the carpus DISEASES AND INJURIES OF BONES AND JOINTS. 459 projects in front. The treatment in both of these dislocations is reduction by extension and manipulation, the use of a Bond splint for ten days, and the employment of passive motion after five or six days. Dislocation at the inferior radio-ulnar articulation, which is also very rare, is caused by twists. Symptoms and Treatment. — In forzuard dislocation at the inferior radio-ulnar articulation the forearm is pronated, the space between the styloid processes is diminished, and the ulna forms a projection posteriorly. In backivard disloca- tion the forearm is supinated, the space between the styloid processes is diminished, and the ulna projects in front. Re- duction is accomplished by extension and manipulation. Two straight splints (as in fracture of both bones) are to be ap- plied for four weeks, and passive motion is to be made in the third week. Dislocation of Individual Carpal Bones. — Pick says there is one weak spot, which is " between the head of the OS magnum and the scaphoid and semilunar bones," and the OS magnum may be forced up. The os magnum is the only bone dislocated with any frequency, and the injury is caused by forced flexion of the wrist. Symptoms and Treatment. — The symptom of dislocation of the carpal bones is a firm projection which becomes more prominent during flexion of the wrist. The treatment is ex- tension and manipulation, a Bond splint being worn for three weeks. Dislocations of metacarpal bones are rare. The first metacarpal bone is most liable to dislocation. Symptoms and Treatment. — Dislocations of the metacarpal bones are obvious because of projection. The dislocations are reduced by extension and manipulation, a straight splint and large pad for the palm are applied (as in fracture of the metacarpus), and the splint is to be worn for three weeks. Dislocations at the metacarpophalangeal articulations are rare, and backward dislocation is the most common. The cause is a fall upon the hand. Symptoms and Treatment. — Dislocated metacarpophalan- geal articulations are obvious. Reduction is easily effected by extension and manipulation, except in the case of the thumb. A splint must be worn for three weeks. Dislocation of the Metacarpophalangeal Joint of the Thumb. — In this dislocation the phalanx usually passes backward. Symptoms. — Symptoms of backzvard dislocation are — the 460 MODERN SURGERY. base of the first phalanx rests upon the metacarpal bone ; the head of the metacarpal bone projects forward and button- holes the muscles of the thumb ; the first phalanx of the thumb is strongly extended, and the terminal phalanx is semiflexed. The symptoms oi forward dislocation are — the base of the first phalanx is felt in the palm, and the head of the metacarpal bone is felt posteriorly. Treatment. — In treating backward dislocation of the meta- carpophalangeal joint of the thumb, reduction is difficult because of the head of the bone being caught in the perfora- tion of the flexor muscle. Always give ether. Keetley's directions are to adduct the metacarpal bone into the palm (to relax the muscles) and to have an assistant hold it ; bend the thumb strongly back, extend, pull the thumb toward the fingers, and suddenly flex. To get a firm enough grasp for these manipulations use the apparatus of Charriere or of Levis (Figs. 117, 118). If the above maneuvers fail, perform tenotomy or incise freely and Fig. 117. — Levis's splint for reducing dislocation of phalanges. Fig. 118. — Levis's splint applied. reduce. After reduction of this dislocation a splint must be worn for three weeks. In forward dislocation reduction is easily effected by strong extension and forced flexion. A splint is to be worn for three weeks. Dislocations of the phalanges may be complete or may be partial. They are commonest between the first and second phalanges. Symptoms and Treatment. — Dislocations of the phalanges are obvious. In treating such dislocations employ extension and manipulation, and use a splint for one week. DISEASES AND INJURIES OF BONES AND JOINTS. 46 1 Dislocations of the Ribs and Costal Cartilages. — The ribs may be dislocated from the vertebrae. This accident is rarely uncomplicated, and cannot be differentiated from fract- ure. The diagnosis is rarely made, and the injury is treated as a fracture. The ribs may be dislocated from their carti- lages, one or more ribs being displaced. The end of the rib forms an anterior projection, there is a depression over the cartilage, and crepitus is absent. Treatment is the same as that employed for fractured ribs. The costal cartilages may be displaced from the sternum, forming an anterior projec- tion upon this bone. Reduction is brought about by placing the patient upon a table, with a sand pillow between the scapuljE, pushing back the shoulders and chest, and forcing the cartilage into place. The dressings are the same as those used in fractured sternum. The cartilages of the lower ribs (sixth, seventh, eighth, ninth, and tenth) may be separated. The inferior cartilage goes forward and can be felt. Pick states that reduction is brought about by causing the patient to hold the chest full of air while efforts are made to push the cartilage into place. Dress as for fractured ribs. Dislocations of the Sternum. — In dislocations of the sternum the manubrium may be separated from the gladio- lus in young subjects. The symptoms and treatmettt are the same as those in fracture (page 353). Pelvic dislocations are almost always complicated with fracture. A pubic bone can be dislocated by falls from a height or by applying violent force to the acetabula. The dislocation may be up or down, front or back, and it may damage the urethra or the bladder. The patient cannot stand ; there are great pain and recognizable deformity. Treat by moulding the bones into place, by applying a pelvic belt, and by rest in bed for four weeks. Dislocations of the sacro-iliac joint are produced by falls. Movement on the part of the patient is difficult or impossible ; there is violent pain, and often paralysis (from pressure upon nerves). In dislocation backward there is an apparent shortening of the leg, eversion of the foot exists, and the ilium moves poste- riorly and upward. In dislocation forward the anterior supe- rior iliac spine projects and the pelvis is broadened. Sacro- iliac dislocations are reduced by holding the pelvis firm and making extension with a pulley. The patient stays in bed for four weeks and wears a pelvic belt as in fracture. Dislocations of the Femur (Hip-joint). — These injuries are rare, as the hip-joint is very strong. They occur in young adults. In forcible extension the head of the femur 462 MODERN SURGERY. presses against the capsule, but the capsule here is very- thick, and certain muscles, the rectus, psoas, and iliacus, are pulled tight and serve to strengthen the capsule. The head of the bone cannot go directly upward, because of the ace- tabulum (Edmund Owen). The weak point of the acetabular rim is below ; the weak part of the capsule is also below ; hence forced abduction is apt to take the head of the bone through the lower part of the capsule, a dislocation occur- ring primarily into the thyroid foramen. The signs of the dislocation depend upon the untorn portion of the capsule. The Y-ligament and more than the Y-ligament usually escapes laceration. Vessels are rarely injured. Muscles are often torn. In some cases the sciatic nerve is lacerated, bruised, or caught up on the neck of the bone. Four forms of hip-joint dislocation exist : (i) upward and backward, on the dorsum of the iHum; (2) backward, into the sciatic notch ; (3) downward, into the obturator foramen ; and (4) inward, on the pubes. All dislocations are primarily inward or outward. From these initial positions the head may be shifted to any region about the socket within reach of the remnant of untorn cap- sule (Oscar H. Allis). AlHs would reject the old classi- fication. He would suggest the following : Low thyroid, | All present abduction and -TT- 1 « r outward rotation. High j Reversed thyroid : IVTH^ " ' I ^^ present adduction and TT- i" „ i inward rotation. High ) Dislocation upon the dorsum of the ilium comprises one- half of all hip-dislocations. It is caused by a fall or a blow when the limb is flexed and abducted (as in carrying a weight upon the shoulder), by a fall upon the knees or feet, by a weight striking the back while bending, etc. Allis says rotation inward is the chief element in its production. In this dislocation the head of the femur goes upward and backward, rests upon the ilium, and is always above the tendon of the obturator internus muscle. This dislocation is secondary to a thyroid dislocation, because of muscular action shifting the bone from its initial seat of displacement. Signs. — Dislocation on to the dorsum of the ilium is indi- cated by the following symptoms : the buttock looks flat and broad; the great trochanter is above Nelaton's line and is DISEASES AND Ii\yUKIES OF BONES AND JOINTS. 463 Fig. 119. — Hip- joint dislocation : upward, or on the dorsum of the ilium (Cooper). deeply placed ; the head of the bone can be detected in its new situation ; deep pressure in front of the joints finds a hollow; the leg is shortened by about two or three inches, as a rule ; the fascia lata is relaxed ; in some thin people the socket can be outlined ; when the patient is recumbent the injured extremity can be brought to the perpendicular without flexing the leg (Allis) ; the knee is slightly flexed ; the thigh is slightly flexed, inwardly rotated, and adducted (Fig. 1 19), this is shown by the fact that the axis of the thigh of the injured side, if prolonged, would pass through the lower third of the sound thigh) ; when the capsule is extensively lacerated there may be no adduction and may be eversion (Allis) ; the heel is raised, and the great toe of the foot of the injured side rests upon the front of the instep or the ankle of the sound side ; rigidity exists ; voluntary movement is impossi- ble, though some passive motion is possible in the direction of the deformity (the deformity can be made more marked). If a patient is recumbent and the knees vertical, the foot of the sound extremity is free of the bed, but the foot of the injured extremity touches the bed (Allis's sign). Diagnosis. — Examine first without anesthesia, and then again while the patient is anesthetized. The A'-rays are valuable in diagnosis. Dislocation is separated from intra- capsular fracture by noting the inversion, the great shorten- ing, the absence of crepitus, the age of the subject, and the nature of the force. The nature of the force, the inversion, and the absence of crepitus mark the diagnosis from extra- capsular fracture. Treatment. — The chief obstacle to reduction in dislocation on to the dorsum of the ilium, Bigelow states, is the untorn portion of the capsule, especially the Y-ligament. The ilio- femoral, Y, or Bigelow's ligament resembles an inverted Y, arises from the anterior inferior spine of the ilium, is inserted into the anterior intertrochanteric line, and is incorporated into the front of the capsule. To reduce a dislocation this ligament must be relaxed by manipulation or be torn by extension. Manipulation makes the head of the bone re- trace its steps over the same route it took in emerging. Give ether ; place the patient supine upon a mattress on the floor ; flex the leg on the thigh (to relax the hamstrings), the thigh on the pelvis ; increase the adduction over the middle line ; 464 MODERN SURGERY. strongly abduct ; perform external rotation and extension. This treatment may be summed up as flexion, adduction, external circumduction, and extension ; or, as Pick puts it, " bend up, roll out, turn out, and extend." Allis's advice is to fix the pelvis to the floor, lift the head of the bone to the level of the socket, rotate outward by carrying the leg toward the pubis, and extend the femur. If extension and counter- extension are employed, make extension in the axis of the dislocated limb and obtain counter-extension by a perineal band. The extension band is fastened to the thigh by a clove-hitch. After reduction put the patient to bed and use sand-bags (as in fracture of the hip) for four weeks. We may tie the knees together instead of using the sand-bags.. Passive motion is made in the third week. The pulleys must not be used in reduction. They may inflict great or even fatal injury. If the surgeon fails to reduce the deformity, there are two courses open to him. He may leave it alone. He may operate. If he leaves it alone, the limb will become ankylosed, though probably useful. Allis thinks the dorsal region will be the best place to leave it. If he determines to operate, he must recognize that tenotomy is useless. It is necessary to make a free incision in order to restore the bone. Dislocation into the Sciatic Notch. — In this dislocation the head of the bone passes backward and a little upward, and rests upon the ischium at the margin of the sciatic notch (not in the notch), below the tendon of the obturator internus muscle. The causes are the same as those given for the previous dislocation. Signs. — The signs in dislocation into the sciatic notch are like those of dislocation upon the dorsum of the ilium, but they are not so marked. There are flattening and broaden- ing of the hip ; ascent of the trochanter above Nekton's line ; shortening to the ex- tent of an inch ; relaxation of the fascia lata. Allis's sign is present, that is, if the knee of the injured side is vertical, the sole of the foot touches the bed. Flexion, inward rotation, and adduction exist, but the axis of the femur of the injured side passes through the knee of the sound side, and the ball of the great toe of the injured side rests upon the great toe of the sound side (Fig. 120). Other symptoms Fig. 120. — Hip-joint dislocation: back- ward, or into the sci- atic notch (Cooper). DISEASES AND INJURIES OF BONES AND JOINTS. 465 are identical with those of dislocation upon the dorsum of the ilium, but are less pronounced. Allis's signs of this dislocation are of value : if, with the patient recumbent, the thighs are brought to a right angle with the body, shorten- ing on the affected side is materially increased ; if the dislo- cated thigh is extended, the back arches as in hip disease. Diagnosis and Treatment. — The signs of dislocation into the sciatic notch are similar to, but are less marked than, those of dorsal dislocation, and, being a backward disloca- tion, the reduction and treatment are the same as for dis- location backward upon the dorsum of the ilium. Dislocation Downward into the Obturator Foramen. — Downward dislocation is the primary position of most dislo- cations of the hip, the bone rarely remaining in the thyroid foramen, but usually mounting up as a result of muscular action or of the initial violence. The cause is violent abduc- tion by falls or by stepping from a moving car. Signs. — Dislocation downward into the obturator foramen is indicated by flattening of the hip ; the head of the bone is felt in its new position and is missed from the acetabulum ; rigidity exists ; passive motion is only possible in the direc- tion of deformity, and that to a slight extent ; a hollow is noted over the great trochanter, which process is well below Nelaton's line and nearer than normal to the middle line. There is a depression from relaxed muscles and fascia noted between the ilium and femur. The gluteal crease is lower than is the crease of the opposite side ; there is lengthening to the extent of one to two inches ; the body is bent forward by the traction upon the psoas and iliacus muscles, and is also deviated to the side, thus causing great apparent lengthening ; the limb is advanced partially flexed and abducted, and the foot is pointed straight ahead or is a little everted (Fig. 121); when the patient is recumbent extension is impossible, the knees cannot be pushed together without great pain, and the abductor muscles are hard and rigid. Allis's sign is absent. Unreduced dislocations do well, the patient obtaining a very useful hip-joint (Sedillot). Treatment. — In treating dislocation downward into the obturator foramen give ether and effect reduction if possible by manipulation, and, if this fails, by extension. To reduce by manipulation, flex the leg on the thigh and the thigh on the pelvis, and then perform, in the following order, abduction, internal circumduction, and extension. Allis's rule of reduction is as follows : flex the pelvis to the floor ; pull the head outward and above the socket ; fix the head ; 30 466 MODERN SURGERY. push knee toward sound knee ; extend femur. If extension is made, make traction in the axis of the hmb by means of muslin fastened around the thigh by a clove-hitch. Do not use the pulleys ; operate rather than use them. Dislocation upon the pubis is very rare. The head of the bone usually rests just internal to the anterior inferior Fig. 121. — Hip-joint dislocation : down- ward into the obtutator or thyroid fora- men (Cooper). Fig. 122. — Dislocation on the pubis (Cooper). spine of the ilium. The primary position of the bone is in the thyroid foramen ; the pubic dislocation, when it occurs, is always secondary, and is due to the initial force and to muscular action. Syinptoms. — In pubic dislocation the head of the bone can be felt and seen in its new position ; the hip is flattened ; there is a hollow over the great trochanter, this process being found below the anterior superior spine of the ilium ; there is shortening to the extent of an inch ; the Hmb is in abduction with eversion (Fig. 122), and the knees cannot be approximated without great pain. When the knee is per- pendicular the foot of the injured side touches the foot of the bed. Treatment. — In the treatment of pubic dislocation give ether and employ manipulation as for thyroid dislocation. If this fails, employ extension. The hmb is well abducted, extension is made downward and backward, and the head of the femur is pulled outward " by a towel around the thigh, just beneath the groin" (Keetley). The after-treatment is the same as that for the previous forms. Anomalous Dislocations of the Hip. — In supraspinous dislocation the dislocation of the hip is backward, the head DISEASES AND INJURIES OF BONES AND JOINTS. 467 of the femur resting upon the ilium above or even anterior to the anterior superior spine. In ischial dislocation the dis- location is downward and backward, the head of the femur resting on the ischial tuberosity or in the lesser sciatic notch. Monteggid s dislocation is a supraspinous dislocation with eversion of the limb. In perineal dislocation the head of the femur is in the perineum. In suprapubic dislocation the head of the femur passes above the pubes. In siibspinoiis disloca- tion the femoral head rests on the horizontal ramus of the pubes. Dislocation with Catching- Up of Sciatic Nerve upon Reduction. — This accident causes severe pain. The leg is flexed on the thigh and the thigh is flexed on the pelvis. Allis tells us that the task of reduction is very unpromising. We must strive to put the neck of the femur in such a position that the ner\'e will " drop off," and yet often the nerve cannot drop off because it is held by adhesion to the injured muscles. Allis attempts reduction by the following plan : 1. Place the patient upon his back and redislocate the femur. 2. Extend the thigh. 3. Flex the leg on the thigh. 4. Turn ankle out until the leg is horizontal (this causes the head to look downward). 5. " Shake, shock, jar, adduct and abduct," to disengage the nerve. 6. Rotate into socket without flexing the leg (without making the nerve tense). 7. If this fails, make an incision above the popliteal space, and draw the nerve out of the wound. Detach the head from its entanglement and rotate it into the socket. Dislocation of Head of Femur -with Fracture of Shaft. — We may incise and replace and wire the fragments. We may use AIcBurney's hooks as in the shoulder. We may be forced to do a resection of the head. Allis maintains that it is possible to reduce it by manipu- lation. He states that the upper fragment is the entire lever, and the lower fragment " is only the agent through w'hich we apply our force." The fragments are not completely separated, but are connected at one side by material which is " partly periosteal, partly tendinous, and partly muscular." This connecting material enables us to make traction upon the upper fragment, but does not allow " rotation, circum- duction, and leverage through the agency of the lower frag- 468 MODERN SURGERY. ment." Hence " the only agency at our command is trac- tion." If the dislocation is inward (forward), draw the head outward and have an assistant make direct pressure upon the head. If this fails, the assistant holds the head to pre- vent its slipping into the thyroid depression, and the surgeon makes traction inward or inward and downward. If the dislocation is outward (backward), make traction directly upward to lift the head to the level of the socket, and try to place the head over the socket by traction obliquely upward and inward. During all these manipulations an assistant presses upon the trochanter to prevent the head slipping back. Traction is now made downward and inward, and the tightened ligament drags the head into place. Dislocations of the Knee. — These dislocations are rare. There are four forms — forward, backward, inward, and out- ward. They may be complete or be incomplete ; the com- monest dislocations are lateral. The cause is violent force, such as a fall, or in jumping from a moving train, or in being caught by the foot and dragged. Dislocation Forward of the Knee-joint. — In the com- plete form of forward dislocation the deformity is obvious. The limb is usually extended, but it may be flexed. Much shortening exists ; the condyles are felt posterior and below ; the head of the tibia is felt anterior and above ; the patella is movable and the quadriceps is lax ; pressure of the condyles upon the contents of the popliteal space arrests the tibial pulse and causes edema and intense pain. In incomplete dislocation the symptoms are identical in kind, but are less pronounced. Treatment. — Compound dislocation of the knee-joint often demands excision. or amputation. In simple dislocation give ether, have one assistant extend the leg while another makes counter-extension on the thigh, and the surgeon pushes the bone into place. Reduction is easy because of hgamentous laceration. Place the limb on a double incKned plane, and combat inflammation by the usual methods (see Synovitis, page 406). Begin passive motion in the third week. The patient must wear a knee-support for months. If the pop- liteal vessels are much damaged, gangrene will supervene and amputation will be demanded. Dislocation Backward of the Knee-joint. — In the com- plete form of knee-joint dislocation backward displacement is not so great as in dislocation forward. The head of the tibia projects posteriorly and above, the femoral condyles anteriorly and below ; the leg is, as a rule, partly flexed, DISEASES AND INJURIES OF BONES AND JOINTS. aJo^ but it may be extended, and there is moderate shortening. In incomplete dislocation the symptoms are less marked. Treatment. — The treatment of backward dislocation of the knee-joint is the same as for forward dislocation. Dislocation Outward of the E^ee-joint. — Is usually in- complete. The inner tuberosity of the tibia in outward dis- location lies upon the outer condyle of the femur (Pick) ; the inner condyle of the femur projects internally ; the outer tibial tuberosity and fibular head project externally, the former having a depression below it, and the latter above it ; the leg is semiflexed, but shortening is absent. Dislocation Inward of the Knee-joint. — Is usually incom- plete. The outer tuberosity of the tibia in inward dislocation lies upon the inner condyle of the femur ; the outer condyle of the femur forms an external prominence, and the inner tuberosity of the tibia forms an internal prominence. Pick cautions us not to mistake a separation of the lower femoral epiphysis for lateral dislocation (the former is reduced easily, the deformity tends to recur, and there is soft crepitus). Treatment. — In treating lateral dislocation of the knee- joint, effect extension and counter-extension as in antero- posterior dislocations. The leg is moved from side to side and attempts are made at rotation. The after-treatment is the same as that for anteroposterior luxations. Dislocations of the Patella. — Are usually acquired. There are thirty-five congenital cases on record (Bajardi). There are three forms : outward, inward, and edgewise. The so-called dislocation upward is in reality rupture of the ligamentum patellae (page 508). Dislocation outward may be due to muscular action or to direct force, and occurs during extension of the leg. It occasionally happens in a person with knock-knees. If the dislocation is complete, the bone lies upon the external sur- face of the external condyle ; if incomplete, the patella rests upon the anterior surface of the external condyle. The leg is extended, flexion is impossible, and attempts at flexion produce great agony. The knee is wider than normal. There is a hollow in front of the joint. The bone is felt in its new position. Dislocation inward is extremely rare. The signs of this dislocation are like the signs of dislocation outward, except that the patella rests upon the inner condyle. Treatment. — Give ether. Raise the body upon a bed-rest, and flex the thigh. Grasp the patella, depress the margin of the patella which is farthest from the center of the joint 470 MODERN SURGERY. (Pick). The muscles pull the bone into place. Immobilize for three weeks, when passive motion is begun. Dislocation of the Patella Edgewise. — The patella rotates vertically, one edge resting between the condyles. As a rule, the outer border is in the intercondyloid notch (Pick). This condition is produced by direct force when the extremity is partly flexed. Twisting and muscular action have been assigned as causes. The condition is obviously manifest. Treatment. — Give ether. Pick recommends " sudden and forcible bending of the knee." In some cases the bone can be pushed into place, the limb being extended and flexed as in the reduction of a lateral dislocation. In some cases incision will be necessary. Dislocation of the Semilunar Cartilages of the Knee (the Internal Derangement of Hey; Subluxation of the Knee-joint). — These interarticular cartilages are attached in front of and behind the tibial spine, and their convexity is attached to the edge of the tibial tuberosities by the coro- nary ligament. The inner cartilage is connected with the internal lateral ligament, and it has a moderate freedom of movement; the outer cartilage is not connected with the external lateral ligament, and is not freely movable, yet the outer is more often dislocated than is the inner cartilage. People who kneel much are predisposed to this accident (Annandale). The cause is a twist when the knee is flexed, as in stubbing the toe. Symptoms. — The indications of interarticular-cartilage dis- location are a sudden, violent, sickening pain in the knee, that may cause the patient to fall; the position is one of fixed semiflexion, voluntary motion being impossible and passive motion causing fierce pain ; a displacement of either cartilage away from the tibial spine produces a prominence on one or the other side of the knee-joint, and a displace- ment toward the tibial spine makes a prominence on one side of the ligament of the patella. Subluxation is soon followed by inflammation of the cartilages and of the joint, and swell- ing rapidly masks the projection. This accident is usually mistaken for blocking of the joint by a floating cartilage. One point in diagnosis is that a loose cartilage changes its position, but a dislocated cartilage remains always in the same position (Turner). Treatment. — In treating dislocation of the semilunar carti- lages of the knee give ether and reduce by forced flexion and sudden extension with rotation, at the same time endeavor- ing to push the projecting cartilage into place. After reduc- DISEASES AND INJURIES OE BONES AND JOINTS. 47 1 tion combat inflammation, apply a splint, and use the proper remedies for one week (see Synovitis), then begin passive motion. As recurrence of the displacement is usual, the patient should wear a knee-cap for a year or more. If reduction is impossible, persistent passive motion will usu- ally secure a useful joint. In intractable cases incise and stitch the cartilages or remove the loosened portion (Annan- dale). Dislocations of the Fibula : Dislocation at the Supe- rior Tibiofibular Articulation. — This injury is rare. The head of the fibula may go forward or backward. The causes are direct force and violent adduction of the foot with abduc- tion of the knee (Bryant). Symptoms. — In dislocation of the fibula the position is one of semiflexion, voluntary extension and flexion being impaired or lost. A distinct movable projection is readily noticed in front or behind, which is found to be continuous with the fibula. There is a depression over the normal position of the head of the fibula. Treatment. — In treating dislocation of the fibula bend the knee to relax the biceps, and proceed to push the bone into place. Put a compress over the head of the fibula, apply a bandage, and put the limb on a double inclined plane for three weeks. At the end of this time put a lacing knee-support upon the knee and let the patient up. Displacement being liable to recur, a knee-cap must be worn for a year. Dislocations of the Ankle-joint. — These injuries are not unusual. Fracture is a frequent complication. There are five forms of ankle-joint dislocation — outward, inward, for- ward, backward, and upward. Lateral dislocations of the ankle-joint are either outward or inward, and may be complete or incomplete. In these dislocations the astragalus rotates. In incomplete dislocations " there is no great separation of the trochlear surface of the astragalus from the under surface of the tibia, but the outer or inner margin of this surface is brought into contact with the articular surface of the tibia, and the w^hole foot presents a lateral twist " (Pick). The causes of these dislocations are twists of the joint. Symptoms. — Incomplete outward dislocation of the ankle- joint is known as Pott's fracture (see page 402). Complete outward dislocation, in which the articular surface of the astragalus is completely displaced outward from the articular surface of the tibia, and which condition is associated with a fracture of the fibula and separation of the inferior tibiofibu- 472 MODERN SURGERY. lar articulation, is known as Dupuytr en' s fracture. In incom- plete dislocation the foot goes outward and upward, the fibula is fractured, and the tibiofibular ligaments are torn off In Dupuytren's fracture the ankle is broad, the inner malleolus projects and looks lower than natural, the outer malleolus ascends with the foot, the foot rotates outward, and crepitus can be found. In inward dislocation which is associated with fracture of the inner malleolus there is inversion, the outer malleolus projects, and crepitus can be found. In incom- plete separation the symptoms are similar, but are not so marked. Treatment. — In treating a case of dislocation of the ankle- joint the deformity is reduced by flexing the leg on the thigh and the thigh on the pelvis ; an assistant makes counter-ex- tension from the knee ; the surgeon makes extension from the foot, and at the same time rocks the astragalus into place. Dupuytren's fracture is treated in the same manner as Pott's fracture (page 402). Dislocation inward is treated in a fract- ure-box for the same period as Pott's fracture. Anteroposterior dislocations of the ankleTJoint are rare. The cause is the catching of the foot in jumping or falling — direct violence. In dislocation forward the foot is lengthened, the heel is not conspicuous, the tibia and fibula project against the tendo Achillis, and the relation of the malleoli to the tarsus is altered. In incomplete dislocation the symptoms are similar, but less pronounced. In dislocation backward the foot is shortened, the tibia and fibula project in front, the heel is prominent, and the relation between the malleoli and the tarsus is altered. In incomplete dislocation the symp- toms are similar, but less marked. Treatment. — In anteroposterior dislocation of the ankle- joint, reduce as in lateral dislocations. Sometimes the tendo Achillis must be cut. Apply a silicate-of-sodium dressing, and let it be worn for two weeks ; then begin passive motion, and let the patiept wear side-splints for a week longer. Dislocation upward of the ankle-joint, or Nekton's dislocation, is a very rare injury. The astragalus is wedged between the widely separated tibia and fibula. This dislo- cation is usually associated with fracture. The cause is a fall upon the feet from a great height. Symptoms. — UpAvard dislocation of the ankle-joint is indi- cated by the widening of the ankle and by the flattening of the foot. The malleoli are nearly on a level with the plantar surface of the foot, and there is absolute rigidity. Treatment. — In treating upward dislocation of the ankle- DISEASES AND INJURIES OF BONES AND JOINTS. 473 joint give ether, and try to reduce by powerful extension and counter-extension. Treat the injury afterward in the same manner as for an anteroposterior luxation. Dislocation of the Astragalus. — The astragalus may be displaced from the bones of the leg and at the same time be separated from the rest of the tarsus. The displacement may be forward, backward, outward, inward, or rotary. Dislocation of the astragalus forward or backward is caused by falls or twists. Symptoms. — In forward dislocation the astragalus projects strongly ; there is shortening of the foot, and the malleoli approach the plantar aspect of the foot ; the foot is deviated to one side or to the other, and there is absolute rigidity of the ankle-joint. In incomplete luxations the symptoms are similar, but less marked. This dislocation may be obliquely forward. In backward dislocation of the astragalus the foot is not deviated to either side ; the astragalus projects between the malleoli and above the os calcis, and the tendo Achillis is stretched over the projection. Rigidity is absolute. This dislocation may be obliquely backward. Lateral and Rotary Dislocations of the Astragalus. — Lateral dislocations of the astragalus are rare, are always compound, and are always associated with fracture. In rotary dislocation the astragalus remains in its normal habitat after rotating on its own axis, either horizontal or vertical. The causes of rotary dislocation are twists of the foot when it is at a right angle to the leg (Barwell). The symptoms of rotary dislocations are obscure. There is rigidity, but sometimes portions of the astragalus may be made out. Treatment of Dislocations of the Astragalus. — In treating astragalus dislocation reduce under ether by flexing the knee to relax the gastrocnemius, extending the foot, and pushing the bone into place. It may be necessary to cut the tendo Achillis. After reduction put up the foot and leg in silicate-of-sodium dressing for two weeks, and then begin passive motion and apply side-splints, which are to be worn for one week more. If reduction fails, support the limb on splints, combat inflammation, and endeavor to bring about union between the dislocated bone and the tissues. Often, in unreduced dislocation, the skin sloughs over the project- ing bone. Excision is demanded the moment sloughing is seen to be inevitable. Cases of compound dislocation of the astragalus require immediate excision. Subastragaloid Dislocation. — This condition is a sepa- ration of the astragalus from the os calcis and scaphoid. 474 MODERN SURGERY. without separation of the astragalus from the bones of the leg. Pick states that the usual classification for these dislocations is forward, backward, inward, and outward, but that the displacement is, as a rule, oblique, the foot pass- ing backward and outward or backward and inward. The causes are twists. Symptoms. — In subastragaloid dislocation the astragalus projects on the dorsum ; the foot is everted in outward dis- location and inverted in inward dislocation ; the relation of the malleoli to the astragalus is unaltered ; the ankle-joint is not absolutely rigid ; the foot " is shortened in front and is elongated behind " (Pick). Treatment. — To treat subastragaloid dislocation make extension in the direction opposite to that of the displace- ment. In dislocation of the tarsus backward fix a bandage around the foot, on a level with the heads of the metatarsal bones, which bandage the surgeon ties around his shoulders. The surgeon puts one knee in front of the angle and thus fixes the leg, raises himself up to make extension upon the tarsus, and moulds the bone into position. Tenotomy may be necessary. After reduction apply a silicate dressing for three weeks. The ankle-joint, fortunately, is not involved, and stiffness of this articulation need not be apprehended. If reduction is impossible, take the same course as in luxa- tions of the astragalus. Dislocations of the other tarsal bones are very rare. Single bones may be dislocated, or the luxation may occur at the mediotarsal articulation. Symptoms and Treatment. — Projection is an obvious symptom in dislocation of the other tarsal bones. The treatment is to reduce by extension and moulding, the part being put up in silicate-of-sodium dressing for two weeks. Dislocations of the metatarsal bones are rare. Symptoms and Treatment. — Shortening of the toes and projection of the dislocated bone are symptoms of disloca- tion of the metatarsal bones. To treat these dislocations reduce by extension under ether and put up in a silicate dressing for two weeks. If reduction fails, the functions of the foot will not be much impaired. Dislocations of the phalanges are very rare. The first phalanx of the big toe is the one most liable to dislo- cation. Symptoms and Treatment. — Dislocations of the phalanges are obvious. The treatmeiit is by reduction as in dislocations of the thumb. Immobilize for two weeks. DISEASES AND INJURIES OF BONES AND JOINTS. 475 5. Operations upon Bones. Osteotomy. — By the term osteotomy the modern surgeon means Hterally the sectioning of a bone for the purpose of straightening a Hmb ankylosed in a bad position, correcting a bony deformity, or amending a vicious union of a fracture. In a linear osteotomy the bone is transversely divided in one spot ; in a cuneiform osteotomy a wedge-shaped portion of bone is removed. The operation of osteotomy may be per- formed with a saw (Fig. 123) or with an osteotome. The saw creates dust, draws much air into the wound, and lacerates the tissues to a considerable degree. Most surgeons prefer the chisel or the osteotome. The osteotome slopes down to a point from each side (Fig. 124) ; the chisel is straight on one side and on the other is bevelled to a point. Osteotomy for Genu Valgum, or Knock-knee (Macewen's Operation, Fig. 126). — In this operation the instruments re- FiG. 124. — Osteotome. Fig. 125. — Rawhide mallet. quired are the scalpel, hemostatic forceps, osteotomes of sev- eral sizes, a mallet (Fig. 125), and a sand-bag wrapped in an aseptic towel. Operation. — The patient lies upon his back, being rolled a little toward the diseased side. The leg of the diseased side is partly flexed upon the thigh and the thigh upon the pelvis, and the extremity is laid upon its outer surface, the sand-bag being pushed between the extremity and the bed, opposite to the site of section. The flexion of the knee relaxes the popliteal vessels and saves them from injury. The surgeon, if operating on the right leg, stands outside of that ex- 476 MODERN SURGERY. tremity ; if operating on the left leg, he stands opposite the left hip (Barker). Enter the knife at the inner side of the knee, just in front of the adductor tubercle of the inner con- dyle and on a level with the upper border of " the patellar articular surface of the femur" (Barker) ; cut down to the bone, and make an incision upward one inch in length, in the direction of the axis of the femur. At the lower angle of this wound insert an osteo- tome and turn it to a right Fig. 126. — Osteotomj' of the right femur in a case of knock-knee : A B, epiphyseal line; c, section of Mac- ewen : d e, section of Ogston. Fig. 127. — Macewen's operation for genu val- gum : the chisel is held in the line for striking with a mallet ; the arrow shows the direction in which the chisel is levered up and down so as to make a wide gap in the bone (after Barker). angle with the shaft, half an inch above the epiphysis (Fig. 1 26) ; strike the osteotome several times with a mallet ; move the handle several times toward and from the body, so as to widen the cut in the bone (Fig. 127); strike the osteotome again several times, move it again, and continue this process until the bone is cut one-third through. If the osteotome becomes tightly fixed, withdraw it and introduce a smaller one. When the bone is cut two-thirds through withdraw the osteotome, hold a piece of wet antiseptic gauze over the opening, and fracture the femur by strong adduction. Do not suture nor drain the wound, but dress it antiseptically, wrap the entire extremity in cotton, and apply a plaster-of- Paris dressing up to the groin. This dressing may be re- moved in two weeks, and the patient may subsequently be treated with sand-bags, as for an ordinary fracture of the thigh, but without extension. This operation is scarcely ever fatal. Ogston' s Operation (Fig. 1 26). — In this operation the inter- nal condyle is sawed off obliquely with an Adams saw — a proceeding which permits the straigthening of the knee. The objection to this operation is that it opens the knee- DISEASES AND INJURIES OF BONES AND JOINTS. 477 joint, and that this cavity fills up more or less with a mixture of blood and bone-dust. Macewen's operation is decidedly the safer. Osteotomy for a Bent Tibia. — In this operation the in- struments required are the same as those indicated in the above operation. The tibia is divided transversely or obliquely (linear osteotomy), or a wedge-shaped piece is removed (cuneiform osteotomy). The oblique incision is the best. If the convexity of the tibial curve is inward, cut the bone from above downward and from in front backward ; if the curve is forward, section the bone from above down- ward and from within outward. The fibula need rarely be interfered with. After the osteotomy the limb is treated just as it would be for an ordinary fracture. Osteotomy for Faulty Ankylosis of the Hip-joint. — This operation is performed in order to allow straightening of a limb that has undergone bony ankylosis in a faulty or an inconvenient position. In some cases an attempt is made to obtain a movable joint, but in most cases the sur- geon must be satisfied with an ankylosis in extension. Oste- otomy may be performed through the neck of the femur or through the shaft of the femur below the trochanters. Osteotomy through the neck of the femur is performed (i) with a saw (Adams's operation) or (2) with an osteotome. I. Adams's Operation (Fig. 128). — In this operation the instruments required are a scalpel, hemostatic forceps, a long, blunt-pointed tenotome, and an Adams saw. Operation. — The patient lies upon his sound hip ; the sur- geon stands upon the side to be operated upon, and back of the patient. The knife is entered a finger's breadth above the great trochanter, ky\\ is pushed in until it strikes the neck of the /^'^^'^""'^'■•^XJ bone, is then carried across the front of and [ / at a right angle with the neck, and is with- / \ drawn, enlarging the wound in the soft \ / parts, as it emerges, to the extent of an inch. The saw is now introduced and the neck is entirely divided. After the osteot- omy dress the wound antiseptically and place the extremity straight. To straighten the limb it may be found necessary to cut fig. 128— Osteotomy contracted tendons and fascial bands. Ihe7et.r:^l. Adams°s Apply the weight-extension apparatus and operation' ^' ^^"''^ the sand-bags. Begin passive movements from the start if a movable joint is desired ; few patients can 478 MODERN SURGERY. tolerate the pain necessary to bring this about. If it is determined to aim for a stiff joint, treat the case as an intra- capsular fracture would be treated. 2. With an Osteotome. — The instruments required in this operation are the same as those used for genu valgum. No sand-bag is required. The position of the patient is the same as that in Adams's operation. An incision one inch long is made, starting just above the great trochanter, ascending in the axis of the femoral neck, and reaching to the bone. An osteotome is introduced, is turned to a right angle with the bone, and is struck with a mallet until the bone is completely divided. (It is not to be divided partially and then broken.) The after-treatment is the same as that for Adams's opera- tion. The operation with the osteotome is to be preferred to that by the saw. Osteotomy of the Shaft of the Femur below the Tro- chanters (Gant's Operation). — In this operation (Fig. 128) the saw may be used, but the osteotome is to be preferred. The instruments employed are the same as those used for Adams's operation, plus an osteotome. Operation. — The position in Gant's is like that in Adams's operation. A longitudinal incision one inch long is made upon the outer aspect of the femur and on a level with the lesser trochanter. The osteotome is inserted and the bone is completely divided below the lesser trochanter. The after-treatment is the same as that for Adams's operation. Gant's operation is the best method for correcting faulty position in bony ankylosis, and Adams's operation can only be employed in those cases where the femur still has a neck which practically is unchanged. Osteotomy for Faulty Ankylosis of the Knee-joint. — This operation is performed for bony ankylosis of a knee in a position of flexion. The instruments employed are the same as those used for genu valgum. Operation. — The patient lies upon his back with his thighs flat upon the bed, the legs hanging over the end of the bed. The surgeon stands on the patient's right side. Just above the patellar articular surface upon the femur a transverse incision is made, one inch in length and reaching to the bone. The osteotome is introduced and the bone is cut nearly through. The leg is then forcibly extended. Do not extend too violently, or the popliteal vessels may be injured. In cases where the structures of the popliteal space are tense, do not at once bring the leg into extension, but do so gradually by means of weights. The wound is dressed DISEASES AND INJURIES OF BONES AND JOINTS. 479 aseptically, and the extremity is placed upon a double inclined plane and is treated as for fracture near the knee-joint. Osteotomy for vicious union of a fracture is performed in case of angular deformity, and is carried out in the same man- ner as are the above procedures. It is best, when possible, to enter the osteotome upon the concavity of the bent bone, so that the periosteum will not rupture when extension is made, and the patient will in consequence gain a longer limb. Osteotomy for Hallux Valgus. — In this operation a linear osteotomy is made through the neck of the metatarsal bone of the great toe, the toe is forcibly adducted, and a splint is applied to the inside of the foot and the toe. Osteotomy for Talipes Bquinovarus. — The instruments required in this operation are a scalpel, hemostatic forceps, a narrow, blunt-pointed saw, special directors, bone-cutting forceps, sequestrum-forceps, and scissors. Operation (after Barker). — The patient lies upon his back, the thigh is semiflexed, the knee is bent, and the sole of the foot rests upon the table. The surgeon stands to the right side if it is the right limb to be operated upon, or to the left side if it is the left limb. Feel for the outer surface of the cu- boid bone, and cut away from over the latter a piece of skin corresponding in size with the bone-wedge intended to be removed (this piece of skin must include the bursa which forms in these cases). Turn the foot outward, find the astragaloscaphoid articulation, over which make an incision " from the lower to the upper dorsal border of the scaphoid bone " (Barker), reaching through the skin only ; place the foot again in the first position, raise all the soft parts from off the superior surface of the tarsus, and clear a triangular surface corresponding with the base of the wedge to be removed; pass a "kite-shaped" director (Fig. 129) into the external wound, and cause it to project from the internal wound ; push the saw through the groove of the director nearest the toes, and saw through the tarsus, from the dor- sum to the sole, at right angles to the metatarsal bones ; push the saw through the groove of the director nearest the ankle, and saw from the dorsum to the sole, at right angles to the long Fig. i29.-Davy's director (Pyer axis of the calcaneum ; grasp the wedge-shaped piece of bone with sequestrum-forceps, and cut it out with scissors, with bone-forceps, or with a blunt bistoury. The wound is well irrigated, the foot is straight- 48o MODERN SURGERY. ened, the internal wound is sewed up, the external wound is sutured except at its lowest portion, where a drainage-tube is to be retained for twenty-four hours, and the wound is dressed antiseptically. The foot is put up in plaster or is put upon a Davy spHnt. Osteotomy for Talipes Equinus. — This operation is de- scribed by Mr. Davy, who devised it, as follows : ^ " Taking the line of the transverse tarsal joint as a guide, on the outer and inner sides of the foot, and immediately over the joint, two wedge-shaped pieces of skin are removed, equal in extent to- the amount of bone demanded. The soft structures are freed on the dorsum of the foot in the way previously described ; but, as the base of the osseous wedge for equinus cases is at the dorsum and its apex at the sole, the parallel wire director, instead of the kite-shaped varus one, is used. The saw is successively inserted in its grooves, and by keeping in mind the idea of a keystone a clean wedge of bone is cut out from the dorsum to the sole of the foot." The wedge is extracted, and the foot is straight- ened and is put in plaster or in a Davy spHnt. Operative Treatment of Recent Fractures. — In recent fractures where reduction is impossible or where displace- ment recurs in spite of splints, it may be advisable to oper- ate. In such cases a skiagraph should always be taken, and it will often decide whether operation is or is not indi- cated. In most instances of irreducible fracture reduction of the fragments is impossible because of muscle or fascia caught between them or because of hardening and shorten- ing of periosteal soft parts, due to hemorrhage and inflam- FiG. 130. — Bone ferrules (Senn). mation. In such cases it may be necessary to make a tolerably long incision ; the ends of the fragments are loos- ened from their anchorage, the inflammatory ties are cut, tissue is removed from between the fragments, and if the ends are very irregular they are sawn off evenly. 1 Barker's Manual of Surgical Operations. DISEASES AND INJURIES OF BONES AND JOINTS. 48 1 The fragments are bored and brought together, and are held by silver wire or kangaroo-tendon, or both fragments are sur- rounded by Senn's bone ferrule, and fixation is thus secured (Figs. 130, 131). Drainage is unnecessary, the soft parts are Fig. 131. — Bone ring and ferrule applied (Senn). sutured and dressed with sterile gauze, and the extremity is put up in plaster. If the clavicle is operated upon, after sterile dressings are applied a Velpeau bandage is put on, and the turns of this bandage are overlaid with plaster-of- Paris, a trap-door being cut over the seat of operation. In such operations the author does not use an Esmarch band- age, as he believes it best to see what is cut and thoroughly arrest bleeding at the time, rather than run the danger of oozing and infection. The author has wired recent fractures of the humerus, tibia, femur, and clavicle. Arbuthnot Lane believes that every very oblique fracture of the tibia and fibula low down should be treated by incision and fixation.' It is necessary to bear in mind that if one of two parallel lines is broken (as the radius alone or tibia alone), and it is found necessary to resect a considerable portion, a like amount should be re- sected from the companion bone in order to prevent great deformity. Recent Transverse Fracture of the Patella (see page 397). 1 Brit. Med. Jour., April 20, 1895. »1 482 MODERN SURGERY. Bone -grafting, or Transplantation (see page 316). Operative Treatment of Ununited Fracture.^The instruments required in this operation are a scalpel, hemo- static forceps, dissecting-forceps, retractors, Allis's dissector, Fig. 132. — Hamilton's improved bone-drills. Fig. 133. — Brainard's drills with Wyeth's adjustable handles. an awl or special drill (Figs. 132, 133), chisels, a mallet, a iine saw, lion-jaw forceps, and silver wire. In operating, incise longitudinally down to the seat of fracture, retract the periosteum from the bone, drill the bones before cutting them, chisel away the material of imperfect union, saw through each end far enough from the seat of fracture to reach sound tissue, pass large silver wires through the holes (this wire should be one-tenth inch in diameter for the femur, one-sixteenth inch for the patella, etc.) (Fig. 1 34), Fig. 134. — Wiring of bones for ununited fracture : aa, sawn surfaces approximated after removal of old material which was interposed between the fragments; (53, (5<5, perforations drilled completely across the bone ; cc, wires ready for twisting. twist the wires a fixed number of times (two complete turns) in the direction that the hands of a watch move (this is Keen's direction in case removal of the wires should be DISEASES AND INJURIES OF BONES AND JOINTS. 483 demanded), sever the ends of the wires, and hammer their stems against the bone. The wires may never require re- moval. Dress the part as a recent fracture. Various plans besides wiring have been employed in ununited fracture. Gussenbauer's clamp is used by some. Menard and Lanne- longue inject a i : 10 solution of chlorid of zinc between the fragments and around their ends, and then immobilize the parts. Some surgeons unite the fragments with kangaroo- tendon instead of wire (suturing of bone) ; others use nails of bone or ivory ; others use screws. Senn asserts that the above methods will not hold fragments in contact if these fragments have a tendency to become displaced. Senn fastens the bones together by hollow cylinders of decalcified bone or ivory, the cylinders being perforated in many places (bone ferrules) (Fig. 1 30). The soft parts are sutured, no drain is used, and the limb is encased in plaster. Ununited Fracture of Patella. — An incision is made in the long axis of the limb, over the middle of the space between the fragments, from well above the upper fragment to well below the lower piece ; this in- cision divides all the soft parts. The soft parts are retracted, but the periosteum is undis- turbed ; each fragment is bored (Fig. 135, i) in one or two places ; the surfaces of the frag- ments are cut square through sound bone with a saw ; all old reparative material is cut away ; the wires are passed through the perforations, twisted, cut off, and hammered down as before (Fig. 135, 2). If the ends cannot be approximated, it may become nec- essary to incise the muscle around and above the patella or to partially separate the tuberosity of the tibia and bend this process upward. A small drain is inserted above the bone, the wound is sutured, aseptic dressings are applied, and the limb is put upon a Macewen splint. Treves' s Operation for Caries of the I/Umbar and I/ast Dorsal Vertebrae. — In this operation the right loin is chosen for incision, as a rule. The instruments required are a scalpel, hemostatic forceps, grooved director, an Allis Fig. 135. — Wiring of the patella : i, fragments cut and cleaned and the wires passed ; 2, wires twisted and hammered down upon the bone (after Barker). 484 MODERN SURGERY. dissector, sequestrum-forceps, curet spoons, and a sand bag. Operation. — The patient lies upon his left side, with the knees drawn up and a sand bag under him. The surgeon stands behind the patient (Barker). An incision is made at the outer border of the erector spinae mass, reaching from the last rib to the iliac crest and going down at once to the lumbar fascia. The lumbar aponeurosis is opened, the erector spinae is retracted inward, and the anterior portion of the erector spinae sheath is incised. The quadratus lumborum muscle is next cut, and then the anterior leaflet of the lumbar aponeurosis is slit. Loose pieces of bone are removed with forceps, and cavities are thoroughly curetted. The Avound is irrigated with corrosive sublimate and is dusted with iodo- form ; a large tube is inserted ; the wound is packed with iodoform gauze, is partly closed by sutures of silkworm gut, and is dressed antiseptically. Aspiration of Joints. — In certain cases of joint-effusion from inflammation, tubercular or otherwise, and sometimes in hemorrhage into a joint, it is desirable to remove the fluid by aspiration. The pneumatic aspirator is used (Fig. 136). Fig. 136. — Aspirator and injector. The trocar and cannula are thoroughly asepticized and the joint is prepared as for a set operation. The needle is entered at a surface free from vessels. The directions for using an aspirator are as follows : insert the stopper firmly into a strong bottle (a clear glass one preferred), then attach the short elastic hose to the stopcock B of the tube projecting from the stopper, and attach the other end of the same elastic DISEASES AND INJURIES OF BONES AND JOINTS. 485 hose to the exhausting or inward-flowing chamber of the pump. Next attach one end of the longer elastic hose to the stopcock A projecting from the stopper, and the other end to the needle. Care should be taken that all the fittings or attachments are placed firmly into their respective places. Now close the stopcock A and open stopcock B, and by giving from thirty-five to fifty strokes of the pump a suffi- cient vacuum can be produced to fill with the fluid from the joint a bottle holding from a pint to a quart. After having formed the vacuum, close the stopcock B, and the instru- ment is for use. The trocar may be used to inject antiseptic agents into the part. The part is dressed antiseptically and is put at rest upon splints. Bxcisions of Bones and Joints. — Excision or resec- tion of a joint is the removal of the articular portions of the bones of the joint, and also the cartilage and synovial mem- brane. In the hip-joint and shoulder-joint the head of the long bone only may be removed, and not the articular sur- faces of both bones. In excision enough bone is known to have been removed only when the remaining bone bleeds. Excision of a bone .is the removal of an entire bone or of a portion of it. Excision is a conservative operation which often averts amputation. Excision may be performed by the open method, in which the periosteum is not preserved, or it may be performed by the subperiosteal method, in which the periosteum is carefully separated by a rugine and the capsular ligament is preserved. Artlirectoiny, or evasion, is the excision of the diseased syno- vial membrane and ligament, and also small foci of disease of bone and cartilage. Excision may be employed for compound dislocation, and in compound dislocations of the elbow and the shoulder it is usually performed. Excisions for compound dislocations in other large joints are very dangerous ; they are rarely at- tempted in battle-field practice, and are to be avoided even in civil practice unless the patient is young and vigorous and every advantage can be given him during the operation and convalescence. Excision for deformity is rarely performed except upon the hip, the knee, and the shoulder, and these ex- cisions must not be employed if the patient's condition leads one to fear the result of a protracted convalescence. Ex- cision of the elbow, however, is usually a safe operation. In excising for deformity always consider the patient's trade and the demands of habitual position which it makes upon him.^ ^ Joseph Bell, in his Manual of Surgical Operations. 486 MODERN SURGERY. Excision is largely employed for joint-disease, especially for tubercular joints. Bell states that attempts to preserve the limb without excision are more largely justifiable in the lower than in the upper limbs, because operation in the lower extremity is more dangerous than in the upper, and because a cure without operation in the lower limbs, if this cure can be brought about, gives as good a result as a cure by excision. In the upper extremities the danger from operation is less than is the danger from waiting. In a young subject an ex- cision may remove the epiphysis, and thus lead to permanent shortening, which is productive of less inconvenience and de- formity in the arm than in the leg. The great danger of ex- cision operations is that the section may be made through cancellous bony tissue ; hence suppuration, phlebitis, myelitis, septicemia, or pyemia may follow ; further, in excision the cut is through diseased tissue, and a protracted convalescence is often inevitable. Amputation is effected through healthy tissue, and the convalescence is short. Excision, however, when successful, gives the patient a very useful limb. Brasion, or Arthrectomy. — Erasion is the complete re- moval of diseased synovial membrane, ligaments, etc. This operation seeks to remove a depot of infection in an early stage of tubercular synovitis, and it possesses the conspicu- ous merit of not interfering with the epiphysis. Erasion is oftenest practised upon the knee-joint. The instruments required are a scalpel, hemostatic forceps, dissecting-forceps, toothed forceps, volsellum, scissors, bone-gouges, curets, and an Esmarch apparatus. Erasion of the Kjiee-joint. — The patient lies upon his back ; the limb is flexed with the sole of the foot planted upon the table, and an Esmarch bandage is applied at a point well up on the thigh. The surgeon stands to the right of the patient. The incision starts in the mid-line of the thigh (on the side opposite to that occupied by the surgeon), about three inches above the patella ; it is carried down across the ligament of the patella and up to a corresponding point on the opposite side of the thigh. This incision is made down to the bone ; the flap is turned up and the joint exposed ; the knee-joint is strongly flexed, and the synovial membrane and diseased Hgaments are dissected away with scissors and forceps, great care being taken that the posterior ligaments (which, fortu- nately, are rarely implicated early in the case) are not divided and that the contents of the popliteal space remain intact. After removing the diseased ligaments and synovial mem- brane examine the cartilage and remove any diseased por- DISEASES AND INJURIES OF BONES AND JOINTS. 487 tion, and then examine the bone and gouge away any tuber- cular foci. Ligate any exposed vessels, irrigate the wound and dust with iodoform, straighten the extremity, suture to- gether the ends of the ligamentum patellae, suture the skin after inserting a drainage-tube in each angle, dust iodoform over the wound, and dress antiseptically. Put the limb upon a posterior splint for a few days, then take out the drainage- tubes, re-dress antiseptically, and put up in a plaster-of-Paris cast, cutting trap-doors upon each side and keeping the joint immobile for two or three weeks. This operation is Fig. 137. Fig. 138. Fig. 137.— i-io. Amputations (Joseph Bell): i, of lower third of forearm (Teale's); 2, at shoulder-joint by large postero-external flap (second method) ; 3, at shoulder-joint by triangular flap from deltoid (third method) ; 4, 5, through tarsus (Chopart's): 6, 7, at knee- joint ; 8, by single flap (Garden's) ; 9, 10, of thigh (Teale's). A, excision of hip ; B, of ankle- joint (Hancock's incision). Fig. 138.— 1-18, Amputations (Joseph Bell): i, amputation at wrist-joint (dorsal in- cision): 2, at wrist-joint (palmar incision); 3, at forearm (dorsal incision); 4, at forearm (palmar incision) ; 5, at elbow-joint (anterior flap) ; 6, at arm (Teale's) ; 7, at shoulder-joint (first method); 8, 9, of metatarsus (Hey's) ; 10, 11, at ankle (Syme's) ; 12, 13, of leg, pos- terior flap (Lee's); 14, at knee-joint (Garden's); 15. of thigh (B. Bell's); 16, of thigh (Spence',s) ; 17, of thigh in middle third; 18, at hip-joint. A, excision of wrist (radial in- cision); E, of wrist (ulnar incision). only suited to early cases in which the lesion involves chiefly or purely the synovial membrane and ligaments, and in these cases it frequently gives a good result, some capacity for motion being not unusually preserved. Excision of the Shoulder-joint. — In the shoulder-joint 488 MODERN SURGERY. partial excision is often performed, the head of the humerus being removed and the glenoid being undisturbed ; but some patients require complete excision, the entire glenoid depres- sion, as well as the head of the humerus, being removed by the surgeon. Excision of the shoulder-joint is made, if possible, an intracapsular operation, the capsule being Fig. 139. Fig. 140. Fig. 139. — 1-9, Amputations (Joseph Bell) : i, of arm by double flaps; 2, at shoulder- joint; 3, at ankle-joint by internal flap (Mackenzie's) ; 4, 5, of leg just above the ankle-joint (Syme's) ; 6, 7, below the knee (modified circular) ; 8, through condyles of femur (Byrne's); p, at lower third of thigh (Syme's). a, excision of head of humerus ; b, of knee-joint (semi- lunar incision). Fig. 140. — 1-8, Amputations (Joseph Bell) : i, at elbow-joint (posterior flap) ; 2, at shoul- der-joint, posterior incision (first method) ; 3, at ankle-joint (Mackenzie's) ; 4, through con- dyles of femur (Syme's) ; 5, at lower third of thigh (Syme's) ; 6, at knee (posterior incision) ; 7, of thigh (Spencer's); 8, at hip-joint, a-g, Excisions; A, excision of shoulder-joint (deltoid flap) ; B, of shoulder-joint (posterior incision) ; c, of elbow-joint (H-shaped incision); D, of elbow-joint (linear incision) ; E, of hip-joint (Gross's) ; F, of os calcis ; G, of scapula. opened, but the capsular attachment to the anatomical neck not being interfered with. In bad cases, however, the capsular attachment must be destroyed. This operation is rare in civil, but is common in military practice ; it is per- formed in gunshot-wounds, in compound dislocations, in tubercular disease, and in tumors of the head and upper por- tion of the humerus. The instruments required are a scalpel, an Adams saw, an osteotome or chisel, a mallet, an Allis dissector, a periosteum-elevator, hemostatic forceps, dissect- ing-forceps, toothed forceps, lion-jawed forceps, sequestrum- forceps, metal retractors, curets, and cutting bone-forceps. DISEASES AND INJURIES OF BONES AND JOINTS. 489 Operation by Anterior Incision. — The patient lies supine ; a pillow is placed beneath the shoulders, and a sand pillow is put beneath the shoulder to be operated upon. The arm is held to the side with the outer condyle forward and the bicipital groove inward (Barker's directions). The surgeon stands by the affected side. An incision three or four inches in length is made from just external to the cora- coid process, running straight down the humerus (Fig. 139, a). This incision divides the border of the deltoid muscle and brings into sight the long head of the biceps. The tendon of the biceps is retracted inward, unless it is dis- eased, in which case it is resected. The knife is carried up the groove and opens the capsule of the joint. The peri- osteum is lifted from the neck of the bone while an assistant rotates the elbow to make the muscles tense. In some places, if the periosteum tears, muscular insertions must be cut with a knife. The head of the bone is sawn off while the bone is in place, or the elbow is strongly pulled back, and the head of the bone is forced out of the wound, and is then sawn off at the point required. In ordinary cases remove only the articular head ; in other cases make the section just above the surgical neck ; in yet others remove a portion of the shaft. If the glenoid cavity is found slightly diseased, any dead bone must be removed by the chisel and mallet or b\' the cutting-forceps. If the cavity is seriously diseased, the entire glenoid should be removed. Scrape away all dam- aged tissue ; ligate bleeding points ; irrigate the wound with corrosive-sublimate solution ; swab it out with a solution of chlorid of zinc (gr. xx to oj) ; dust with iodoform ; close the upper portion of the wound and insert a drainage-tube in the lower angle ; dress the wound antiseptically ; place a small pad in the axilla ; apply the second roller of Desault; and put the patient in bed with a pillow under the affected shoulder. In seven days the hand-sling is substituted for the bandage, and with the elbow hanging free the patient is permitted to get up and is advised to move his arm frequently. Drainage is maintained until the wound is well healed from the bottom. Great limi- tation of mov^ement inevitably follows upon a shoulder-joint resection. Excision by the deltoid flap is performed when the head of the bone is much enlarged (as by a tumor) or when the tissues are thick and indurated. The deltoid flap is in the shape of a V or is semilunar (Fig. 140, a). Raising this flap exposes the head of the bone most satisfactorily. Bell 490 MODERN SURGERY. states that when the glenoid cavity is chiefly involved the incision should be posterior (Fig. 140, b). Senn's Method. — Senn has recently described^ an incision which does not damage any important vessels, muscles, ten- dons, or nerves, and which is followed by good functional results. A semilunar skin-flap is formed, the incision run- ning from the coracoid process to the posterior border of the axillary space. This flap is turned up, exposing the upper half of the deltoid muscle. The acromion is sawn off and turned down with the attached deltoid. The capsule is now freely exposed ; it is opened, and either arthrectomy or excis- ion is performed, according to conditions. In closing the wound it is not necessary to bore the acromion and pass silver wires to join the fragments ; it is enough to suture the periosteum with catgut. Excision of the Elbo-w-joint. — This operation is per- formed for wounds, faulty ankylosis, and chronic articular disease. Excision must be complete. Endeavor to make a subperiosteal resection ; this maintains the shape of the articulation and gives the best chance for a movable joint. The instruments used are the same as those for the shoulder,, plus a Butcher saw. Opej^ation. — The patient is " supine, but inclining to the sound side, the affected arm being held almost vertical, with the forearm flexed and nearly horizontal" (Barker). The incision is made on the posterior surface of the joint. A single posterior incision is usually employed (Fig. 140, d, f). An incision is made a little internal to the long axis of the olecranon, and reaching two inches above and two inches below the tip of the olecranon. This incision goes down to the bone, and throughout the entire operation the surgeon must guard and shield the ulnar nerve. The periosteum and soft parts are well separated ; the olecranon is sawn off ;^ forced flexion exposes the joint-cavity freely, and enables the surgeon to lift the periosteum and soft parts from the humerus ; the humerus is sawn through at the beginning of its condyloid processes ; the radius and ulna are cleared and are sawn at a level below that of the base of the coro- noid process of the ulna. Cut and spoon away diseased tissues, the wound being irrigated, closed, drained, and dressed. In some cases an H-shaped incision is employed (Fig. 140, c),. but the cicatrix of a transverse cut will limit flexion of the limb. After excision of the elbow the patient is put to bed and 1 Phila. Med. Jourti., Jan. i, 1898. DISEASES AND INJURIES OF BONES AND JOINTS. 49 1 the arm is laid upon a pillow, the elbow being placed mid- way between a right angle and complete extension, the fore- arm being placed midway between pronation and supination. No splint is used, as a rule. Esmarch used the splint shown in Figure 141. The aim in treatment is to obtain a freely movable joint. Passive motion is begun in one week, when the patient gets up. The hand is carried for a time in a sling. Fig. 141. — Esmarch's splint for the treatment of a limb after excision of the elbow-joint. Excision of the Wrist-joint. — Bell states that, whatever method of excision is chosen, three cardinal rules must be borne in mind: (i) remove all the diseased bone, including the portions of the radius, ulna, carpus, and metacarpus which are covered with cartilage ; (2) interfere with the tendons to the least possible degree ; and (3) begin passive motion of the fingers very early. Many surgeons prefer the simple gouging away of diseased foci and the scraping of sinuses instead of a formal resection of the wrist, amputation being employed in severe cases or when scraping fails after several trials. Formal excision is not very often done, and the results cannot often be considered as very favorable. Lister's Open Method of Excision. — The instruments re- quired in this operation are the same as those used for any resection. Break up adhesions as completely as possible by forcible movements. Apply a tourniquet or an Esmarch appa- ratus. The patient lies upon his back, the arm and the fore- arm being brought, from stage to stage, into the most desirable positions. Begin an incision over the middle of the dorsum of the radius, on a level with the styloid process ; carry it downward in the direction of the inner edge of the articula- tion of the thumb with its metacarpal bone, and when the knife reaches the radial side of the second metacarpal bone alter the direction of the incision and carry it downward in the long axis of the metacarpal bone to about its middle (Fig. 138, a). This is known as the radial incision, and the 492 MODERN SURGERY. only tendon divided is that of the extensor carpi radialis brevior muscle. The tissues upon the radial aspect of the incision are dissected up, the tendon of the extensor carpi radialis longior muscle is divided at its point of insertion (Bell), and all the soft structures are retracted outward, exposing the trapezium, which is cut off from the rest of the carpus, but which is left in place, as its removal at this stage endangers the radial artery (Barker). By extending the hand the tendons are loosened and the carpus is cleared in the direction of the ulnar border of the hand. Another incision is made, starting upon the inner surface of the wrist, two inches above the articular surface of the ulna, and midway between the ulna and the flexor carpi ulnaris tendon. This incision, which is known as the nlnar incision, is carried down until it is opposite the middle of the fifth metacarpal bone in the palm (Fig. 138, b). "The dorsal lip of this incision is raised " (Bell), and the extensor carpi ulnaris tendon is divided and dissected from its depres- sion, but is not separated from the integument. The extensor tendons are lifted ; the ligaments upon the dorsum and sides of the wrist-joint are cut; the flexor tendons are raised from the carpal bones ; the pisiform bone is cut from the carpus, but is not yet removed ; and the unciform process of the unciform bone is cut with forceps. The anterior radio- carpal ligament is divided, the carpometacarpal articulations are cut through, and the carpus is pulled out with bone- forceps. The ends of the radius and ulna are forced out of the ulnar incision. All that portion of the ulna which is crusted wdth cartilage is to be removed, the saw-cut is to be oblique, and the base of the styloid process is to be left behind. A thin section is to be sawn from the radius, and the tendon-grooves are not to be impinged upon. The artic- ular surface of the ulna is cut away with pliers (Bell). If foci of disease are discovered beyond these points, they are to be gouged out. The ends of the metacarpal bones are sawn off, and their articular facets are cut away by means of pHers. The trapezium is dissected out, the end of the first metacarpal bone is sawn off and its facet is cut away with pliers, and a portion of the pisiform bone is removed (the entire bone being removed if it be diseased). The wound is irrigated, vessels are tied, the radial incision is closed, the ulnar incision is partly closed, a drainage-tube is inserted by way of the ulnar incision, the wounds are dressed antiseptically, and the Esmarch apparatus is taken off. The forearm and hand are placed upon a splint which DISEASES AND INJURIES OF BONES AND JOINTS. 493 immobilizes the wrist and leaves the fingers semiflexed. The splint is worn for man\- months, until the wrist-joint is immo- bile and solid. Esmarch uses the splint shown in Fig. 142. Fig. 142. — Esmarch's interrupted splint applied. Passive motion of the fingers is begun after thirty-six hours. Excision of Metacarpal Bones and of Phalanges. — Excision of a metacarpal bone, except in cases of necro- sis with the formation of large quantities of new bone, usually leaves a useless finger ; hence amputation is pre- ferred usually to excision. This rule does not apply to the metacarpal bone of the thumb, which is occasionally resected. The incision for this operation is made upon the dorsum, and is straight. Excision of the proximal phalanx of the thumb is sometimes performed. Excision for disease is rarely performed upon the finger-joints, amputation being preferred, though the operation is sometimes undertaken for compound dislocation. In the metacarpophalangeal joint of the thumb excision, if it can be performed, is preferred to amputation. The incision for resection of this joint is placed upon the radial aspect. Excision of the Hip-joint. — Some surgeons advocate this operation ; others, notably Marsh, are emphatically opposed to it. Excision should be performed in the early stage of tubercular disease if less radical treatment has failed, and in this stage the usual position of the limb is one of flexion, abduction, and eversion. In cases of long duration, espec- ially where dislocation exists, excision is an easy and a com- paratively safe operation ; in recent cases it is difficult and carries with it decided dangers, but the peril of delay may be greater than the peril of an early resection. In cases of hip disease with involvement of the acetabulum the mor- tality is 50 per cent, whether operation is or is not at- tempted. Excision is performed especially for tubercular 494 MODERN SURGERY. disease and for gunshot-injuries. The instruments required are those used for other excisions. Operation by Antej'ior Incision (Fig. 143) (Parker's Operation). — In this operation the patient is supine, with the thighs extended as thoroughly as circumstances permit. The surgeon stands to the right of the patient. An incision is begun half an inch below and half an inch external to the anterior superior iliac spine, and it is carried down- ward and a little inward for about three inches (Fig. 143, d). If dislocation exists, the incision must not be so long. This in- cision is carried at once deeply between the muscles, and the capsule of the joint is opened. The neck of the bone is divided from its upper surface down- ward with a saw or an osteotome, and without dislocating the bone through the wound by forcible extension and eversion, the head of the bone is removed. All tubercular foci must be scraped away, and the flushing gouge is used upon tuber- cular areas of the acetabulum. All sinuses should be thor- oughly scraped. Bleeding is arrested, the wound is irrigated with corrosive-sublimate solution, mopped out with chlorid- of-zinc solution, and dusted with iodoform. A drainage-tube is inserted at the lower angle of the incision, and the upper portion of the cut is closed. The wound is dressed antisep- tically. Extension is made with the extension apparatus until healing has obtained a good headway, when a double Thomas's .splint is applied, so that the patient can be taken out daily in the air and sunlight. As a rule, rigid ankylosis results from resection of the hip, but occasionally a joint results with a small range of movement. Operation by Lateral Incision (Langenbeck's Operation). — In this operation a straight incision two inches long is made in the direction of the axis of the femur, and runs downward from the apex of the great trochanter. From the beginning of this incision a curved incision is carried toward the head of the bone, the convexity of the curve being backward Fig. 143. — Excision of the hip-joint : A, gluteus muscle ; B, tensor vaginae femoris muscle; c, sartorius muscle; D, anterior incision. DISEASES AND INJURIES OF BONES AND JOINTS. 495 (Fig. 137, a). Bell advises the use of the saw after bringing the head of the bone into the wound by abduction and ever- sion of the thigh. Barker applies the saw with the bone in situ, and strongly opposes wrenching the bone out of the incision, because of the danger of peeling off the periosteum, which peeling, if it takes place, favors necrosis. Incision of Gross. — In Gross's operation a semilunar flap is made with the convexity backward (Fig. 140, e). Excision of the Knee-joint. — In this operation a com- plete excision should be performed, and the patella ought to be removed. This operation is performed in tubercular dis- ease, in some compound fractures and compound disloca- tions, and in some cases of angular ankylosis, but it is rarely employed for gunshot-injuries, amputation being advisable (Ashhurst). The instruments required are the same as those for the shoulder, plus Butcher's saw. Operation by Anterior Semilunar Flap. — The patient lies upon his back, and the joint, if not ankylosed in extension, is semiflexed. The surgeon stands to the right side. An incision is made, at once opening the joint, starting from one condyle and reaching the other condyle by a downward curve which passes through the ligamentum patellae midway between the tuberosity of the tibia and the inferior margin of the patella (Fig. 139, b). The flap is dissected up, the knee is thrown into forced flexion, the lateral ligaments and crucial ligaments are cut, and the end of the femur is well cleared. The blade of Butcher's saw is passed beneath the bone, which is sawn from below upward (Ashhurst). The end of the tibia is cleared and a portion is sawn off. If, after sawing, diseased foci are discovered, another section can be sawn off or the foci can be gouged away. Ashhurst, who has had a vast experience with this operation, insists that in sawing through the femur the natural obliquity of the bone must be borne in mind and the section must be made in " a line parallel to that of the free surface of the condyles." If the section is made transverse to the axis of the femur, " the limb, after ad- justment, will be found to be markedly bowed outward." The same surgeon says that the epiphyseal line is somewhat higher on the front than it is on the back of the femur, and in con- sequence the following rule is formulated for section of the condyles : the section of the condyles should be " in a plane which, as regards the axis of the femur, is oblique from be- hind forward, from below upward, and from within outward." Ashhurst advocates section of the tibia " in a plane trans- verse to the long axis of the bone, w^ith a slight anteroposte- 496 MODERN SURGERY. rior obliquity, so as to correspond with that of the section of the cond}-les," and further says also that the patella must be removed, whether it is diseased or not, and he quotes Peniere's observations to the effect that excision of the patella dimin- ishes the risk of death one-third, and its retention doubles the probability of an amputation becoming necessary in the future. After removing the patella the diseased synovial membrane is clipped away with scissors and all sinuses and diseased territories are well curetted. The posterior ligament of the joint is not removed unless it is diseased ; its retention pre- vents displacement and guards the popliteal space. In chil- dren the fragments should be wired together ; in adults this need not be done. After hemostasia irrigate, dust with iodo- form, insert a drainage-tube, suture, dress antiseptically, and adjust the limb upon Price's splint or Ashhurst's bracketed wire splint. In some cases tenotomy is required to permit extension. Instead of the bracketed splint, a long fracture-box may be used. If the femur tends to project anteriorly, use an anterior splint. If there be a tendency to outward bowing, adopt Ashhurst's expedient of carrying a strip of adhesive plaster around the outside of the limb and fastening it to the inner side of the splint. The splint is kept on until bony union is complete, as in this operation a movable joint is never sought. Many surgeons use a plaster-of-Paris splint, which is employed until the parts have become firm and solid (Fig. 144). Fig. 144. — Watson's plaster-of-Paris swing-splint. Excision of the Ankle-joint. — This operation is per- formed chiefly in gunshot-wounds, in compound dislocations, and in early cases of chronic joint-disease. Complete resec- tion is employed for chronic joint-disease. Excision of the ankle is a rare operation. The instruments used are the same as those employed for any resection. DISEASES AND INJURIES OF BONES AND JOINTS. 497 Operation (Hancock's Method). — In this operation the pa- tient lies upon his back, the foot rests upon its inner side, and the surgeon stands to the outer side of the damaged limb. Begin an incision just behind and two inches above the ex- ternal malleolus, and carry it across the front of the joint to a corresponding point above and behind the internal malleolus (Fig. 137, b) ; this incision goes only through the skin, and the flap thus marked out is reflected. " Cut down upon the external malleolus, carrying the knife close to the edge of the bone both behind and below the process, dislodge the peronei tendons, and divide the external lateral ligaments " (Joseph Bell). Cut the fibula one inch above the malleolus by means of pliers; divide the tibiofibular ligament; turn the foot upon its outer side ; dissect from their habitat back of the inner malleolus the tendons of the posterior tibial and the com- mon flexor of the toes ; carry the knife around the inner malleolus, close to the bony edge ; separate the internal lat- eral ligament, and dislocate the lower end of the tibia through the wound by turning the sole of the foot downward ; saw off the lower end of the tibia and the articular process of the astragalus, sawing away from the tendo Achillis, and remove the fragments with bone-forceps. Cut away diseased syno- vial membrane, and curet all sinuses and tubercular areas. Arrest bleeding, irrigate, and drain. Sew up the wound, insert a tube at the outer angle, and cause it to emerge at the inner angle. Apply antiseptic dressings, and put up the foot in fixed dressing or in splints at a right angle to the leg (Fig. 145). In Langenbeck's operation the excision is subperios- 145— Volkmann's dorsal splint for excision of the ankle. teal. If, in an excision of the ankle-joint, the astragalus is found extensively diseased, remove the entire bone. Excision of the Os Calcis. — In caries limited to the os 32 498 MODERN SURGERY. calcis most surgeons prefer to gouge away the dead bone, leaving the periosteum and, if possible, a shell of healthy- bone, and draining thoroughly. Others advocate excision in some cases. Extensive disease Hmited purely to the os calcis is rare, and most surgeons advise gouging for limited caries, and Syme's amputation in the event of the disease ex- tending beyond the periosteum or reaching adjacent bones. Operation by Subperiosteal Method. — In this operation the position assumed by the patient is supine with the leg extended and the foot resting on its inner side. The incision, which cuts the tendo Achillis and reaches the bone at once, is begun at the upper border of the os calcis and the inner margin of the tendo Achillis, and is taken outward and horizontally forward to a point in front of* the calcaneocuboid articulation. A vertical incision is begun near the forward termination of the initial incision, is carried across the outer edge and plantar surface of the foot, and terminates at the external margin of the inner surface of the OS calcis. Some surgeons carry the vertical incision a little upward, toward the dorsum (Fig. 140, f). The periosteum is entirely stripped with an elevator, the os calcis is removed, the cavity is packed with iodoform gauze, the wound is stitched, a drain is inserted posteriorly, and the foot is dressed antiseptically and put up in plaster at a right angle to the leg, trap-doors being cut for drainage. Excision of the astragalus is a rare operation. Operation by the Subperiosteal Plan. — Barker advises an incision going at once to the bone, from the " tip of the ex- ternal malleolus forward and a little inward, curving toward the dorsum of the foot." The foot is extended and turned inward, the periosteum is lifted, the bone is removed, and the wound is treated and the foot is dressed as is done in excision of the os calcis. Excision of the Metatarsophalangeal Articulation of the G-reat Toe. — In this operation make a lateral incision and cut off or saw off the proximal end of the first phalanx and the distal third of the first metatarsal bone. Excision of the Metatarsal Bone of the Great Toe (Butcher's Method). — In this operation a lateral straight incision is made, the periosteum is elevated, and the shaft is sawn from each extremity and removed. Excision of the clavicle may be required in dislocation, in caries, in necrosis, for gunshot-wounds, in tumor of this bone, as a preliminary to ligation of the artery and vein in certain cases of amputation at the shoulder-joint, or in cases DISEASES AND INJURIES OF BOA^ES AND JOINTS. 499 of removal of the entire upper extremity. In excision of the clavicle the position of the patient is the same as that for ligation of the third part of the subclavian artery (page 288). An incision is made down to the bone, from the sternoclavicular joint to the acromioclavicular articulation. If the case is suitable, the periosteum is stripped and the bone is sawn and removed ; if not, the bone is sawn and each half is separately disarticulated. The wound is sutured and dressed, and the limb is put up in a Velpeau bandage. Excision of the Scapula, — Complete excision of the scap- ula is most usually performed for tumors. Partial excision requires no detailed description. In excision of the scap- ula the patient lies upon his sound side. Treves suggests the following incisions : one outside the vertebral border of the scapula, from its superior to its inferior angle ; another from over the acromioclavicular joint, along the acromion process and spine of the scapula, to meet the first incision, Syme used an incision carried transversely inward from the acromion process to the vertebral border of the scapula, and another cut directly downward from the center of the first incision (Fig. 140, g). In the method of Treves ^ the upper flap is reflected and the trapezius muscle is divided ; the lower flap is reflected and the deltoid muscle is divided. The patient's hand is placed on the sound shoulder ; the muscles of the vertebral border are divided, the posterior scapular artery is tied, and while the vertebral border of the scapula is pulled toward the surgeon the serratus magnus muscle is cut, the upper border of the shoulder-blade is cleared, and the suprascapular artery is tied. The hand is now brought down to the side ; the acromioclavicular joint is disarticulated ; the conoid and trapezoid ligaments are divided ; the muscles of the coracoid process are cut ; the capsule is incised, with the supraspinatus and infraspinatus, the subscapularis muscles, and the scapular origins of the biceps and triceps ; and finally the teres major and minor muscles are divided, the subscapular artery is tied, and the bone is removed. The wound is stitched, a drain is introduced, and antiseptic dressings are applied. The patient lies upon his back until healing is well under way, when the arm is placed in a sling. The drainage-tube may be removed in twenty-four hours. Excision of a Rib. — In caries the gouge and rongeur may remove the disease. In other cases excision is performed. In this operation the patient lies upon his sound side. The ^ Treves's Manual of Operative Surgery. 500 . MODERN SURGERY. surgeon faces the patient. Make an incision down to the bone, in the long axis of the rib. The periosteum, if not dis- eased, is hfted from the bone, and the intercostal artery is thus saved from being cut. After sawing the bone beyond the limits of disease, remove it. During the sawing a metal retractor is held beneath the rib, between the rib and the periosteum. If the periosteum is diseased, remove it after tying the intercostal artery. Curet sinuses. Pack with iodoform gauze for some days. Sew up the wound except at one end. Dress antiseptically and apply a binder. If a rib is resected in order to drain the pleural cavity, remove it by the subperiosteal section, ligate the artery after a portion of the rib" has been removed, cut away the periosteum to pre- vent re-formation of bone, and open the pleura. (See Opera- tions upon the Chest and Estlander's Operation.) Complete Excision of One-half of the Upper Ja'w. — The whole upper jaw has been removed, but in what fol- lows only resection of one-half the jaw will be described. This operation is performed for malignant tumors of the superior maxillary bone or its antrum. Up to 1826, at which time Lizars of Edinburgh suggested the operation, tumors of the antrum were treated by scraping them away with a sharp spoon. Gensoul of Lyons in 1827 performed the first operation for resection of the upper jaw. This operation is not justifiable, except as a palliative measure, if the orbit is invaded, if the skin and subcutaneous tissues are infiltrated, or if the disease extends beyond the superior maxillary and palate bones. The instruments required are a mouth-gag ; scalpels ; strong scissors ; dissecting, toothed, and hemo- static forceps ; bone-cutting forceps ; lion-jaw and seques- trum-forceps ; tooth-extracting forceps ; a volsella ; a narrow- bladed saw ; a chisel and mallet ; a periosteum-elevator ; a spatula or metal retractor ; Paquelin's cautery ; sponges which are tied to sticks ; needles, curved and straight ; silk and catgut ligatures ; silkworm-sutures ; large curved needles; and Horsley's antiseptic bone-wax. Operation by Median Incision. — The patient, whose face has been shaved, is placed in the Trendelenburg position, thus avoiding the possible need of instant tracheotomy. The surgeon stands to the right side of, and faces, the pa- tient. The incisor tooth on the diseased side is pulled out. The incision (Fig. 146, line A b) is begun half an inch below the inner canthus of the eye, and is carried along the side of the nose, around the ala of the nose, by the margin of the nostril, and through the middle of the lip. While DISEASES AND INJURIES OF BONES AND JOINTS. 50I Fig. 146. ^a b. excision of the upper jaw ; c D E, excision of the lower jaw. the lip is being incised the assistant arrests hemorrhage by grasping the corners of the mouth, and after the Hp is divided the coronary arteries are at once Hgated. Some operators approach the mucous membrane cautiously and ligate the vessels before opening the cavity of the mouth. The upper portion of the wound having been compressed by another assistant during these manipulations, pressure is now removed and bleeding points are ligated. Another incision is now carried outward from the begin- ning of the first incision, along the orbital margin to well over the malar bone. The flap is lifted from the periosteum, and the bleeding from the infraorbital artery and the small vessels is restrained by pressure. The nasal cartilage is separated from the bone, and the nasal process of the superior maxillary is sawn (line a b, Fig. 147). The orbital periosteum is lifted up, and the orbital plate is cut with forceps from the saw-cut in the supe- rior maxillary bone to the spheno- maxillary fissure (line b c, Fig. 147). The malar bone is sawn or is bitten through about its center, the cut running into the sphenomaxillary fissure and taking a downward and outward direction (line CD, Fig. 147). The soft parts covering the hard palate are incised in the median line, a corresponding incision is made along the floor of the nose near the septum, and the soft palate is sepa- rated from the hard palate by a trans- verse cut. The saw is introduced through the nose, and the palate is sawn (line e. Fig. 147). The upper jaw-bone is grasped with Fergusson's lion-jaw forceps and removed, the removal being aided by the use of the scissors and bone- cutters ; the latter are used to separate the upper jaw from the pterygoid process (Treves). Every vessel that can be Fig. 147. — I. Excision of the upper jaw : A B, section of the nasal process ; B c, section of the orbital plate ; D, section of the malar bone and orbital plate ; e, section of the alveolus, and hard palate. 2. Excision of the lower jaw; G, section of the inferior maxillary; H, section of the ramus in partial resection. 502 MODERN SURGERY. seen is tied, and severe bleeding from bone is arrested by antiseptic wax. Oozing is controlled by hot water and pressure or by Paquelin's cautery. Examine carefully to see if all the diseased area is removed ; if it is not, use the gouge, scissors, chisel, and saw until healthy tissue is reached. The wound is packed with iodoform gauze, and the end of the strip is so placed as to be accessible through the mouth. The wound is sutured (the mucous membrane of the lip must be stitched, as well as the skin) and is dressed antiseptically (the eye being protected by aseptic gauze), and a crossed bandage of the angle of the jaw is applied. Excision of One-half of the Lo^wer Ja^w. — In some rare instances the entire inferior maxillary bone is removed. The lesions necessitating removal of the lower jaw are of the same nature as cause us to remove the upper jaw. The instruments required for removal of the lower jaw are those used for excision of the upper jaw, plus a metacarpal saw (having a movable back). In this operation the patient is placed in the same posi- tion as for excision of the upper jaw, the chin having been previously shaved. A vertical cut is made through the chin-tissue, starting below the margin of the lip and reaching to below the border of the jaw (c d. Fig. 146). From the point d an incision is carried outward below the border of the jaw and then back of the ramus, as shown in the line d e (Fig. 146). Treves's advice is to carry this incision down to the bone, except at the line of the facial artery, at which point it must go through the skin only. The facial artery is now to be sought for, tied in two places, and divided. The periosteum is lifted from the external surface of the bone, from the symphysis outward. Hemorrhage is arrested. The buccal mucous membrane is cut from the alveolus. A lateral incisor tooth is pulled, and the bone is sawn in the line g (Fig. 147). The bone is grasped in a lion-jaw forceps and is drawn outward. The mylohyoid insertion is cut ; the internal pterygoid muscle is cut or the periosteum at this spot is lifted ; the inferior dental artery is cut and tied ; the jaw is pulled down ; the insertion of the temporal muscle upon the coronoid process is cut away ; and the external pterygoid muscle is divided. The capsule of the joint is opened, and the bone is separated from the ligaments which still hold it in place. Bleeding is arrested, the wound is sutured, a tube is introduced in the posterior portion of the wound and retained for twenty-four hours, and antiseptic dressings and DISEASES AND INJURIES OF BONES AND JOINTS. 503 a Gibson or a Barton bandage are applied. Partial excisions of the alveolus may be performed through the mouth by means of chisels and rongeur forceps, and Wyeth has re- moved half of the jaw by this method ; but if any consider- able part of the body of the jaw is to be removed, it is usually best to make an incision below the jaw. Operation for Congenital Dislocation of Hip. — Hoffa's Operation. — The instruments used are the same as for a resection. Make the external incision of Langenbeck to open the joint (page 494). The capsule is incised at its inser- tion into the neck, and the periosteum and muscles are lifted from the great trochanter. Hoffa claims that in children less than five years of age the head can be readily replaced into the acetabulum by flexing the thigh and making direct pressure upon the head of the bone. After replacing the head it is held in place while an assistant extends the leg in order to stretch the muscles. In children over five years of age cut the muscles which spring from the ischial tube- rosity and also the adductors with a tenotome ; cut the fascia lata and muscles which arise from the anterior superior iliac spine by incision; open the joint and hberate the head; remove the ligamentum teres ; scrape out the acetabulum, removing " cartilage, fat, and considerable spongy tissue " (Tubby) ; and replace the head in the acetabulum. The limb is maintained in inversion, abduction, and extension for several weeks, when it is straightened. Massage and passive motion are begun in the fifth week. The patient now gets about, wearing an apparatus for many weeks. This apparatus per- mits the head of the bone to move in the socket, but pre- vents redislocation. Lorcnz's Operation. — This is a modification of Hofifa's. The muscles inserted into the greater trochanter and the lesser trochanter are not cut ; the sartorius, the hamstrings, and the external portion of the fascia lata are cut (Tubby). The incision of Lorenz is longitudinally from the anterior superior spine. Another incision is carried inward from this at the level of the lesser trochanter. The capsule is opened by a crucial cut ; the acetabulum is enlarged ; the head of the bone, if it remains, is inserted into the acetabulum ; if there is no true head, a new one is formed and inserted into the cavity. The Hmb is immobilized in a position of mod- erate abduction. Massage and passive motion are begun in the fifth week, and are continued for months.^ ^ I have drawn from the very lucid description of these operations in A. H. Tubby's treatise upon " Deformities." 504 MODERN SURGERY. XX. DISEASES AND INJURIES OF MUSCLES, TEN= DONS, AND BURS>E. Myalgia, or muscular rheumatism, is a painful dis- order of the voluntary muscles and of the fibrous and peri- osteal areas where they are attached. The term " muscular rheumatism " is not strictly correct. It is possible that in some cases the muscular structure is inflamed, but it is cer- tain that in many cases the pain is distinctly neuralgic. Muscular rheumatism may be due to cold and wet, to over- exertion and strain, to acute infectious disorders, to syphilis, to chronic intoxications (lead, mercury, and alcohol), and to disturbances of the circulation. Gouty and rheumatic per- sons are especially predisposed, men being more liable to the disease than women. The disease is usually acute, but it may be chronic. Symptoms. — Muscular rheumatism is apt to come on suddenly. The pain, which may be very acute and lanci- nating or may be dull and aching, is in some cases con- stantly present; in other cases it is awakened only by muscular contraction. The pain is frequently reheved by pressure, though there is often some soreness. The skin above the muscle is sometimes tender to light pressure. The disease usually lasts for a few days, but it tends to recur. There is little, if any, fever. Lumbago is myalgia of the muscles of the loins. Rheu- matic torticollis is myalgia of the muscles of the neck. Usually one side of the neck is attacked. The chin is turned from the affected side and the neck is stiff. Pleurodynia is myalgia of the intercostal muscles. The pain is very severe, is aggravated by deep respiration, by coughing, and by yawning, there may be tenderness, and the patient tries to limit chest-movement. In intercostal neuralgia the pain is limited, is not constant, but occurs in distinct paroxysms, and is linked with the presence of the tender spots of Val- leix. Pleurodynia lacks the physical signs of pleurisy. Myalgia must not be confused with the pains of locomotor ataxia. Cephalodynia is myalgia of the muscles of the scalp. The muscles of the shoulder, upper dorsal region, abdomen, and extremities may also be attacked by myalgia. Treatment. — Remove any obvious cause. Treat any ex- isting diathesis, such as gout or rheumatism. Rest is of the first importance. For lumbago, put the person to bed. For pleurodynia, strap the side of the chest. A hypodermatic injection of morphin and atropin into the affected muscles at DISEASES AND INJURIES OF MUSCLES, ETC. 505 once allays the pain, and a deep injection of water is often curative. The introduction of four or five aseptic needles into the muscles, and their retention for a few minutes, some- times act most favorably. Ironing the skin above the pain- ful muscles is a useful domestic remedy. Vigorous rubbing of the area with a piece of ice allays the pain. Hot poultices do good. If the pain is widely diffused, alters its seat, or is very obstinate, order hot baths or Turkish baths and admin- ister diuretics. In chronic cases employ blisters or counter- irritation by the cautery, give iodid of potassium and nux vomica, and have the patient take a Turkish bath every week. The constant electric current finds advocates. In an ordinary severe case order a hot bath, put the patient to bed with a hot-water bag over the part, and administer 10 grains of Dover's powder ; the next morning order to be taken four times daily a capsule containing 5 grains of salol and 3 grains of phenacetin, until the pain disappears. Citrate of potassium, citrate of lithium, chlorid of ammonium, or the salicylate of colchicin may be ordered. Infective myositis is a widespread inflammation of the voluntary muscles, due to an unknown infective cause. It is a disorder accompanied by pain and stiffness, by cutaneous edema, and by various paresthesiae. Myositis resembles trichinosis, and is distinguished from it only by spearing out a bit of muscle and examining it microscopically. Occasion- ally diffuse suppuration occurs. Ordinary myositis arises from injuries, from syphilis, or from rheumatism, and it pre- sents the usual inflammatory symptoms. Contraction and adhesions may follow. Treatment. — Infective myositis is treated by anodynes, stimulants, nutritious food, hot applications, and rest. If pus forms, it should be evacuated. Rheumatic myositis calls for the administration of the salicylates, the alkalies, or salol. Syphilitic myositis is treated with mercury and iodid of potassium. The remedies employed for myalgia are used in traumatic myositis. Hypertrophy of the muscles may arise from their in- creased use. In pseudohypertrophic paralysis the bulk of the muscle is greatly augmented, but it contains less muscle- structure and more fat or connective tissue. Atrophy of the muscles arises from want of use, from injury, from continuous pressure, from interference with the blood-supply, from disease of the nerves or their centers, or from lead-poisoning. Degeneration of Muscles. — The muscles may undergo 506 MODERN SURGERY. granular degeneration, waxy degeneration, fatty degenera- tion, and calcareous degeneration, and may become pig- mented. I/Ocal Ossification and Myositis Ossificans. — It is not unusual for a small portion of bone to form in the peri- osteal insertion of a muscle which is subjected to frequent strain. In persons who ride many hours a day there not infrequently develops the "rider's bone," which is an area of ossification in the adductor muscles of the thigh. Myositis ossificans, a widespread ossification of the muscles, is a rare disorder the cause of which is unknown, and which if not congenital begins at least in early life. IHiniors of the Muscles. — Primary tumors of the mus- cles are rare. Among those which may occur are sarcoma, fibroma, lipoma, osteoma, angioma, myxoma, and enchon- droma. Most cases of supposed primary sarcoma of mus- cle are in reality cases of syphiloma (Esmarch). Syphilis may cause inflammation. Gummata may form, or gummatous infiltration may take place. Trichinosis or trichiniasis is a disease due to the embryos of the trichina spiralis. The disease originates from eating insufficiently cooked meat which contains the trichinae. These nematodes are carried into the intestine, there to develop and multiply. In from seven to nine days a horde of embryos develop in the bowel, and leave the aHmentary canal by passing through the peritoneum or by means of the blood, and finally reach the connective tissue of the muscles. From the connective tissue the em- bryos migrate into the primitive muscle-fibers, where they dwell and enlarge. Myositis develops, and in the course of five or six weeks the parasites become encapsuled and develop no further. The cyst-walls may calcify and the worms may become calcified, or may live for years. Because in- fected meat is eaten the disease does not inevitably develop, and a few embryos lodged in muscle may cause no symp- toms. Symptoms. — The symptoms of trichinosis often appear in a day or two after eating infected meat. The symptoms of acute gastro-intestinal catarrh or of cholera morbus are com- mon, but in some cases no gastro-intestinal manifestations usher in the disease. In from seven to fourteen days after the infected meat is eaten the migration of the parasites develops obvious symptoms. A chill may be noted ; there is usually fever ; muscular pain, tenderness, swelling, and stiffness are complained of This condition may be widespread. Involve- DISEASES AND INJURIES OF MUSCLES, ETC. 507 ment of the muscles of mastication interferes with chewing; of the lary-nx, with audition and respiration ; of the inter- costals and diaphragm, with respiration. Skin-edema and itching are marked. In some cases dehrium exists. The writer saw in the Philadelphia Hospital one fatal case which was mistaken for erysipelas because of the high fever, the delirium, and the edematous redness of the face and neck, D}-spnea is frequent. Mild cases get well in a week or two ; severe cases may last many weeks. The mortality varies in different epidemics from i to 30 per cent. (Osier). The diagnosis is made by spearing out a piece of muscle, which is then examined for trichinae under a microscope ; or the worm may be detected in the feces by means of a pocket- lens. Treatment. — To treat trichinosis employ purgatives (senna and calomel) early in the case, and give glycerin, and also santonin or filix mas. When muscular invasion has taken place, sedatives, hypnotics, nourishing diet, and stimulants are indicated. Wounds and Contusions of the Muscles. — Wounds of muscles may be either open or siibciitancoiis. In a longi- tudinal wound the edges lie close together, and hence drain- age must be provided for by the surgeon. In a transverse wound the edges separate widely, and catgut stitches must be inserted. Contusions of muscles, like contusions of other tissues, \-Axy in extent and in severity. There are pain (which is increased by attempts to use the muscle), loss of function, swelling beneath the deep fascia, and discoloration, which may appear at once because of superficial damage from the initial injury, or which may appear in dependent parts after many days by gravitation of the blood and the blood-stained serum. As a result of contusion, suppuration, inflammation, or atrophy may arise. Treatment. — The indications in wounds and contusions of muscles are to obtain rest by means of splints and to secure relaxation. Limitation of swelling is secured by bandaging. Inflammation is combated first by cold and lead- water and laudanum ; later by iodin, blue ointment, ichthyol, and intermittent heat. To prevent loss of function employ, as soon as the acute symptoms subside, massage, passive motion, and stimulating liniments, and, later in the case, elec- tricity (galvanism if the reactions of degeneration exist, faradism if they are absent). Strains and Ruptures. — A strain is a stretching of a muscle with a small amount of rupture. The muscle is 508 MODERN SURGERY. swollen, tender, stiff, weak, and sore, and attempts at motion produce sharp pain. Strains are common in the deltoid, the hamstring muscles, the back, the calf, the biceps, and the great pectoral. Strain of the psoas muscle causes pain on flexing the thigh, and is associated with tenderness in the iliac fossa. Strain of the right psoas may be mistaken for appendicitis, but it lacks the intense local tenderness, the abdominal rigidity, and the constitutional symptoms. "Lawn-tennis arm " is a strain of the pronator radii teres muscle, " Rider's leg " is a strain of the adductor muscles of the thigh. A strain may be the only injury, or may be associated with some other condition (fracture of bone, dis- location, sprain, contusion, etc.). The muscle is often rigid, is tender, and pains greatly when an attempt is made to use it. The skin over it, especially over its point of insertion, is usually tender. A strain of the back is a very common accident which is often associated with sprains of the vertebral hga- ments. There is great pain when the patient voluntarily straightens up. If the vertebral ligaments are not sprained, the patient can be straightened by passive motion with- out pain. The skin is tender in certain areas. The mus- cles are often rigid. There may be unilateral rigidity. In a back injury make a careful examination to be sure there is no damage to vertebrae or cord. Treatment. — Relaxation by suitable position ; rest by the use of splints or by putting the patient to bed ; bandages for compression ; hot fomentations or hot lead-water and lauda- num ; ichthyol. As soon as acute symptoms subside employ frictions and massage. If there is much pain after a strain, administer Dover's powder, or even morphin. Rupture of a muscle is announced by a sudden and vio- lent pain and by loss of function arising during powerful mus- cular contraction or strong traction on a muscle. The rupt- ure may be announced by a clearly audible snap (A. Pearce Gould). A distinct gap is felt between the ends ; great pain develops on movement ; there are tenderness, loss of power, and swelling. Strains and rupture may be followed by atrophy, as are contusions. Among the muscles which occasionally rupture we may mention the quadriceps, biceps, triceps, deltoid, etc. Treatment. — In limited rupture treat as a severe strain. In treating extensive rupture of an important muscle, when the ends are widely separated, incise with every aseptic care, unite the divided ends by sutures of chromic catgut, and DISEASES AND INJURIES OF MUSCLES, ETC. 509 sew up the skin with silkworm-gut. Treat the part in any case by rest and relaxation, and combat inflammation by appropriate means. Passive motion and massage are em- ployed as soon as union is firm. In rupture of the quad- riceps extensor femoris operation should be undertaken, be- cause mechanical treatment gives frequently a bad result and confines the patient to bed for many weeks. Hernia of Muscles. — When a tear takes place in a mus- cular sheath a portion of the muscle protrudes. The treatment is incision and the stitching of the fascia. Contractions of muscles may result from injury, from joint-disease, from malposition of parts (as in old dislocation or torticollis), or from diseases of the nervous system. The treatment in some cases is sudden extension, in other cases gradual extension, tenotomy, or myotomy. Macewen recom- mends the making of a number of V-shaped incisions in the muscle. In some cases of spasmodic contraction nerve- stretching is of value. Dislocation of Muscles and Tendons. — The long head of the biceps is oftenest displaced. The flexor carpi ulnaris, the peroneus brevis, the peroneus longus, the tibialis posticus, the sartorius, the plantaris, the quadriceps extensor femoris, and the extensors back of the wrist, may be dislo- cated. What is known as dislocation of the latissimus dorsi, a condition in which that muscle no longer lies upon the angle of the scapula, is not a dislocation, but a paralysis. Most of these accidents are associated with chronic joint- disease or with fracture, but displacement may exist as a solitary injury. Dislocation of the long head of the biceps may occur tolerably early in the progress of rheumatoid arthritis of the shoulder-joint, and the displaced tendon may be absorbed. Symptoms. — After dislocations of a tendon the muscle of the tendon can still contract, but it acts at a disadvan- tage ; thus the corresponding joint exhibits partial loss of function. The displaced tendon can be felt, and a hollow exists where it normally resides.- When the muscle contracts the tendon is felt to slip from its groove. When the tendon of the biceps is dislocated the head of the bone passes forward (so-called subluxation of the humerus). Treatment. — In tendon-dislocation reduction is easy, but the displacement is apt to recur because of laceration of the sheath. The treatment usually advised is to reduce the ten- don by relaxation of the limb and manipulation of the tendon. 5IO MODERN SURGERY. Place upon a splint, so that the muscle belonging to the ten- don is relaxed, and apply pressure over the point of injury. This treatment usually fails, and if the tendon does not be- come anchored firmly in four weeks we should operate. In some tendons it is enough to incise, freshen the edges of the torn sheath, and sew up with kangaroo-tendon or chromic catgut. In a tendon lying in a long groove, make a halter for the tendon by incising the periosteum and suturing it over the tendon.^ Passive movements are begun at the end of the first week. Even if the tendon will not remain re- duced, a useful joint will be obtained. Wood of New York advised in obstinate cases tenotomy and immobilization. Wounds of Tendons. — Subcutaneous wounds of ten- dons are usually inflicted by the surgeon, and they heal well. Open wounds require rigid antisepsis and the suturing of the tendon. In wounds of the wrist especially always suture the tendons (Fig. 149), and be sure to bring the proper ends into apposition. Rupture of Tendons. — A violent muscular effort may rupture a tendon, and a snap may often be heard. The symp- toms are sudden pain and loss of power, fulness of the asso- ciated muscle from retraction, and absolute inability to bring the tendon into action. A gap may often be felt in the tendon. Treatment. — The best procedure in treating rupture of a tendon is incision and tendon-suture. Some surgeons relax the parts and apply splints. Thecitis or tenosynovitis is inflammation of the sheath of a tendon. Acute thecitis may arise from a contusion, from a wound, from repeated over-action in working, from rheu- matism, from gonorrhea, from influenza, from the continued fevers, or from syphilis. In early syphilis certain tendon sheaths may rapidly develop effusion because of hyperemia of the sheaths (Taylor). Symptoms. — In nonsuppurative cases of thecitis the symptoms are pain, swelling, tenderness, and moist crep- itus along the tendon-sheath, due to inflammatory rough- ening. The crepitus disappears as the swelling increases, but it reappears as the swelling diminishes. In suppurative cases the symptoms are great swelling, pulsatile pain, dusky discoloration, inflammation spreading up the tendon-sheaths, and the constitutional symptoms of sepsis. Treatment. — In treating non-suppurative thecitis, employ ^ Walsham's case of dislocation of peroneus longus, Brit. Med. Joiir., Nov. 2, 1895- DISEASES AND INJURIES OF MUSCLES, ETC. 511 splints and apply locally iodin, blue ointment, or ichthyol. Treat any causative constitutional state. In the suppurative form make free incisions, irrigate, and drain. Palmar Abscess. — A thecal abscess about the flexor tendons of the fingers travels rapidly upward and is apt to produce a palmar abscess. A thecal abscess of either the in- dex ring or middle finger is usually arrested at the lower end of the palm, but suppurative thecitis of the thumb or the little finger diffuses pus over a large surface of the palm and also up the arm. Palmar abscess is a most serious affection. The pus may dissect up all the structures of the palm, may reach the dorsum, or may pass beneath the anterior annular ligament into the connective-tissue planes of the forearm. Treatment. — A palmar abscess demands free incision and drainage at the earliest possible moment. The incision is made in the line of the metacarpal bone and, if possible, below the palmar arches. A line transverse with the web of the thumb is below the palmar arches. In an incision above this line, try not to cut either arch ; but if one be cut, at once take means to arrest the hemorrhage (page 263). Chronic thecitis may follow an acute thecitis, but may be due to injury, to rheumatism, to gummatous infiltration, to rheumatoid arthritis, or to a tubercular inflammation of a tendon-sheath. In tubercular thecitis the swelling is firm or doughy when due to granulation-tissue, but is fluctuating when due to fluid. Grating is marked. The tendon-sheath may contain numerous small bodies which are either free or are attached (rice, riziform, or melon-seed bodies). Tubercle bacilli are present in the fluid or in the granulation-tissue. Chronic thecitis is commonest in the tendons of the fingers, the ankle, and the knee ; it may spread to a joint, or it may arise from a tubercular joint. This condition causes very little pain. In ordinary non-tubercular thecitis the part is weak, tender, painful, and stiff, crepitates on motion, and is swollen. Treatment. — Tubercular cases are treated as follows : in cases in which there is fluid effusion make a small incision, wash out with iodoform emulsion, and close the wound. In cases in which there are rice-bodies, open the sheath, evacuate the contents, scrape the walls thoroughly, inject with iodo- form emulsion, and close the wound. (If the annular liga- ment is divided, stitch it together; Fig. 152). In cases with extensive formation of embryonic tissue apply an Esmarch bandage, make a large incision, and remove all infected tis- sue from the sheath, around the sheath, and from the ten- 512 MODERN SURGERY. don. In an ordinary traumatic case employ hot and cold douches, massage, and passive movements, strapping of the part, inunctions of ichthyol, and the hot-air bath. If effusion is persistent or rice-bodies exist, make an incision and scrape out the tendon-sheath. In rheumatic cases give anti-rheumatic remedies and employ the hot-air bath. In syphilitic cases administer mercury and iodid of potassium. Ganglia. — In connection with tendon-sheaths simple gangha may develop. They are small, tense, round swell- ings, which are firm, grow progressively though slowly, are painless when uninflamed, and contain a fluid of the appear- ance and consistence of glycerin jelly (Bowlby). These gan- glia are commonest upon the dorsum of the wrist, and they occur especially in those who constantly use the wrist-mus- cles. Paget states that a simple ganglion is due to cystic degeneration of a synovial fringe inside a tendon-sheath, and that the fluid of the ganglion does not communicate with the fluid of the tendon-sheath. Other pathologists believe a sim- ple ganglion to be a hernia of synovial membrane through a rent in a tendon-sheath, all communication between the her- niated part and the tendon-sheath being soon obliterated. Compound ganglion is an old name for tubercular thecitis. Treatment. — Ganglia are treated by aseptic puncture with a tenotome, evacuation, scarification of the walls, antiseptic dressing, and pressure. An old-time method of treatment was subcutaneous rupture brought about by striking with a heavy book. Duplay treats a ganglion by injecting a few drops of iodin through a hypodermatic needle. The cyst is not evacuated before injection. The parts are dressed anti- septically, and cure is obtained in one week. Recurrent ganglia, very large ganglia, and ganglia with very thick contents should be dissected out. Felon, or whitlow, is a violent inflammation of a finger or a toe which leads to rapid suppuration and sometimes to gangrene. As a rule, an injury precedes the whitlow, an abrasion of the surface which admits pus organisms or a contusion which creates a point of least resistance. The commonest seat of a felon is the last digit of the finger or thumb. An abrasion of the surface at this point absorbs pus organisms and the superficial lymphatics carry them directly inward, lodging them, it may be, in the subcutaneous tissues, or it may be beneath the periosteum. Felons are very rare in infants, but may occur in children. Women are more liable to them than are men. Several fingers may be attacked at once or successively in persons DISEASES AND INJURIES OF MUSCLES, ETC. 513 of dilapidated constitution. In certain cases of neuritis painless suppuration may arise. There are two forms of felons, the superficial and the deep. Superficial felon, or paronychia, is a cellulitis starting at the end or side of the digit, and involving the parts around and below the nail. The pus organisms obtain entrance by means of an abrasion, a puncture, or an ulcerated " step- mother," The pain is throbbing and violent ; is increased by motion, pressure, or a dependent position ; the skin is dusky red, but the swelling is slight. In about forty-eight hours pus forms in the superficial parts, the epidermis being lifted into pustules or blebs, and pus may also form under the nail. A portion of the nail, or the entire nail, may be lost. Deep felon, or bone-felon, involves most of the structures of the finger (periosteum, bone, tendon, tendon-sheath, and cellular tissue), and may destroy the digit or the finger. It arises in the same manner as paronychia, but the organisms are lodged in the deeper parts. The pain is agonizing, en- tirely preventing sleep, pulsatile in character, associated with excruciating tenderness, greatly aggravated by motion or a dependent position, and often extending up the hand and forearm. The skin is red and edematous, and the part is enormously swollen. Pus forms quickly ; diffuse cellulitis may arise; thecal suppuration may occur; sloughing of the tendon and subcutaneous tissue may take place ; necrosis of one or more bones may ensue, and in some cases gangrene of the finger follows. In deep whitlow lymphangitis of the forearm and arm is not unusual, adenitis of the axillary glands is common, and almost always there is fever. In superficial felon constitutional symptoms are slight or absent, and lymphangitis and adenitis arise in a minority of cases. Treatment. — A superficial felon demands instant incision in all cases, and the parts are irrigated and dressed with hot antiseptic fomentations. A bone-felon should be incised at once to the bone alongside the tendon. Do not wait for pus to form, but allay tension and prevent pus-formation by early incision. Do not waste time with poultices : to wait means agonizing pain, sleepless nights, constitutional involvement, and perhaps sloughing of tendons or death of the bone. Incision and drainage constitute the treatment, followed by irrigation, antiseptic fomentations, and splinting of the extremity. If the patient cannot sleep, give morphin. See that the bowels are moved once a day. Give quinin, iron, and milk punch. Opening a felon is exquisitely pain- 33 5 1 4 MODERN SURGER K ful ; hence ether should be given to the first stage, nitrous oxid should be administered, or the superficial parts should be firozen by a spray of chlorid of ethyl. Bursitis is inflammation of a bursa. Acute bursitis arises from strain or from traumatism. The symptoms of acute bursitis are pain, limited swelling, moist crepitus, fluct- uation, and discoloration in the anatomical position of a bursa. Bursitis of the retrocalcaneal bursa (Albert's disease) is a painful affection which is often overlooked. Walking causes great pain in the heel. Raising up on the toes is excessively painful. It is usually associated with flat foot. In these cases osteophytes often form within the bursa. Bursitis of the gluteal bursae produces symptoms resem- bling those of incipient coxalgia. But in bursitis the symp- toms do not remit as in hip disease. There is moderate pain back of the leg and knee which disappears when the patient is at rest ; there is marked limp, limitation of motion, and an area of deep fluctuation in the buttock (Brackett). It is difficult to separate bursitis of any deep bursa from synovitis ; indeed, the joint is apt to become sec- ondarily affected. This difficulty is especially vexatious in distinguishing between joint-injury and injury of the bursa beneath the deltoid. Suppuration may take place. Direct force may rupture a bursa. When this accident happens there are pain, marked swelling, a large area of moist crepitus, and later extensive discoloration from blood. Chronic bur- sitis may follow acute bursitis, or the disease may be chronic from the start. Its symptom is swelling with little or no pain unless acute inflammation arises. Chronic bursitis of the sub- hyoid bursa is known as Boyer's cyst. Treatment. — Acute bursitis is treated at first by rest and pressure and with lead-water and laudanum ; later with iodin, blue ointment, or ichthyol. If the swelling persists, aspirate. If pus forms, incise, swab out the sac with pure carbolic acid, and pack it with iodoform gauze. A chronic bursitis may get well from the use of pressure, as the appli- cation of blue ointment, with treatment of any causative diathesis ; but most cases require incision and packing. A ruptured bursa is treated as an acute bursitis. Some cases of retrocalcaneal bursitis get well from rest, but others demand incision and drainage. If osteophytic formation takes place in Albert's Disease remove the bony stalactites with a rongeur forceps or a gouge. Housemaid's knee is thickening and enlargement of the prepatellar bursa, due to intermittent pressure. In effusion DISEASES AND INJURIES OF MUSCLES, ETC. 515 into the knee-joint the fluid is behind the patella and the bone floats up ; in housemaid's knee the fluid is above the bone and the osseous surface can be felt beneath it. " Miners' elbow," which is a condition similar to housemaid's knee, affects the olecranon bursa. " Weavers' bottom " is enlargement of the bursa over the tuberosity of the ischium. A bursa which is simply thickened and enlarged rarely gives rise to annoyance ; but when it inflames, as it is apt to do, it causes the ordinary symptoms of bursitis. Treatment. — Housemaid's knee is treated by incision and packing with iodoform gauze. In enlargement of the bursa beneath the ligamentum patellae, if rest and blistering fail to cure, aspirate or incise. In enlargement of the bursa below the tendon of the semimembranosus and also in " weavers' bottom " incise and pack. Bunion. — A bunion is a bursa due to pressure, and it is most commonly found above the metatarsophalangeal articu- lation of the great toe, but is occasionally seen over the joint of another toe. When the big toe is pushed inward by ill- fitting- boots a bunion forms. When a bunion is not in- flamed it may cause but little trouble, but when it is mflamed the bursa enlarges and the parts become hot, tender, and excessively painful. Suppuration may occur and pus may invade the joint, and the bone not unusually becomes dis- eased. Treatment. — In treating a bunion the patient must wear shoes that are not pointed, that have the inner borders straight, and that have rounded toes (Jacobson). For a mild case a bunion-plaster gives comfort. Sayre advises the use of a linen glove over the phalanges, which are to be drawn inward by a piece of elastic webbing one end of which is fastened to the glove and the other end to a piece of strapping from the heel, A special apparatus may be worn (Fig. 148). In many cases osteotomy of the first phalanx or of the first metatarsal bone is required ; in some cases excision of the joint is necessary ; in others amputation must be performed. When the bursa is not inflamed, but only thickened, blisters should be employed over it, or there ., op-. . i^ •' . ' tlG. 148. — Biggs should be applied tincture of iodin, ichthyol, apparatus for bun- or mercurial ointment. When the bursa in- flames, lead-water and laudanum is applied, and intermittent heat by foot-baths gives relief Suppuration demands im- mediate incision and antiseptic dressing. If an ulcerated 5 1 6 MODERN SUR GER Y. bunion does not heal by antiseptic dressing, stimulate it with silver and dress it with unguent, hydrarg. nitrat. (i part to 7 of cosmolin). Jacobson recommends skin-grafting for some cases. Operations upon Muscles and Tendons. Tenotomy is the cutting of a tendon. It may be open or subcutaneous, the open operation being preferred in dan- gerous regions. Division of the Sterno-cleido-mastoid Muscle for Wry-neck. — Subcutaneous tenotomy has been abandoned. It is not only more unsafe than the open operation, but it never completely divides all of the thickness of the con- tracted band. The instruments required consist of a scalpel, dissecting- forceps, hemostatic forceps, scissors, needles, ligatures, etc. The patient is placed recumbent, the chin being drawn more toward the opposite side. A transverse incision is made over the muscle about one- fourth of an inch above the clavicle. The superficial parts are divided, the muscle is exposed and sectioned, bleeding is arrested, and the skin is sutured. Avoid the anterior jugular vein, which is underneath the muscle, and also the external jugular, which is close to the outer edge of the muscle. Mikulicz advocates the removal of almost the entire muscle, leaving, however, the upper and posterior portion where the spinal accessory nerve passes. After operation for wry-neck support the head with sand bags until healing occurs, and then inaugurate motions active and passive. Subcutaneous Tenotomy of the Tendo Achillis. — This operation is performed for club-foot, in which the heel is raised. The tendon is cut about one inch above its point of insertion. The instrument used for the first puncture is a sharp tenotome. The patient lies upon his back " with his body rolled a little toward the affected side " (Treves), the foot being placed upon its outer side on a sand pillow. The surgeon stands to the outside. The tendon is rendered moderately rigid, and the sharp tenotome, with its blade turned upward, is inserted along the anterior border of the tendon until the surgeon's finger feels the knife approaching the outer side. A blunt-pointed tenotome is inserted in place of the sharp instrument. The tendon is drawn into rigid- ity, and the surgeon turns the blade of his knife toward the DISEASES AND INJURIES OF MUSCLES, ETC. 517 tendon, places his finger over the skin, and saws toward his finger. The tendon gives way with a snap. Treves states that a beginner is apt not to push the knife far enough toward the outside, or he may in the first puncture push the knife through the tendon ; in either case the tendon is not completely cut. The little wound, which is covered with a bit of gauze, will be entirely closed in forty-eight hours. In club-foot cases after tenotomy some surgeons at once correct the deformity and immobilize the limb in plaster ; some partially correct the deformity and apply plaster for one week, at which time they remove the plaster, correct the deformity further, reapply the plaster, and so on ; other surgeons do not attempt correction of the deformit}' until the cut tendon has begun to unite, when they gradually stretch the new material. Subcutaneous Tenotomy of the Tendon of the Tibialis Anticus. — The tendon is divided about one and a half inches above its point of insertion. It can be made tense by extending and abducting the foot. The sharp- pointed tenotome is entered upon the outside of the tendon, and is passed well around it. The blunt-pointed tenotome is used to cut the tense tendon. Subcutaneous Tenotomy of the Tendons of the Peroneus I/OngUS and Brevis. — These two tendons are cut together back of the external malleolus, and one and a half inches above the tip of the malleolus, so as to avoid the synovial sheath (Treves). The patient lies upon the sound side, the outer aspect of the deformed foot being upward and the inner aspect of the ankle of the deformed side resting upon a sand pillow^ The instrument is introduced close to the fibula, and is carried around the loose tendons. A blunt- pointed tenotome is now introduced, its edge is turned toward the tendons, and these structures are cut as they are made tense. Subcutaneous Tenotomy of the Tendon of the Tibialis Posticus. — This tendon is sectioned above the point where its synovial sheath begins ; that is, above the internal annular ligament (Treves). The tendon is made tense and the knife is entered above the base of the inner malleolus. The knife is entered just back of the inner edge of the tibia, and is carried around the muscle while it is kept close to the bone. The tendon is sectioned with a blunt knife. Subcutaneous Fasciotomy of Plantar Fascia. — The contracted bands are discovered by motions which 5i8 MODERN SURGERY. render them tense, and they are divided just in front of the attachment to the os calcis. The sharp knife passes between the skin and fascia at the inner side of the sole of the foot. The fascia is cut from without inward by the blunt-pointed tenotome. It is usually necessary to section the fascia at more than one point. Tendon-suture and Tendon-lengthening. — The in- struments required in these operations are an Esmarch appa- ratus ; curved needles and needle-holder ; chromicized gut, kangaroo-tendon, or silk for an ordinary case, silver wire for a suppurating wound. In performing tendon-suture make the part aseptic and bloodless. It is wise to apply a rubber bandage on the proximal side, the bandage being applied centrifugally, forcing the proximal end of the tendon into view (Haegler). If searching for the proximal end of a flexor of the finger, flex the injured finger, and hyper- extend the adjoining fingers (Filiget). If this expedient fails, enlarge the incision, or, what is better, make a large flap in the skin. After finding the ends approximate them, being sure the proper ends are brought into contact ; stitch them together with a continuous suture or with one of the sutures shown in Fig. 149, a, b, and c. In a suppurating wound B-i L 1 Fig. 149. — Tendon-sutures : a. of Le Fort ; B, of Le Dentu ; c, of Lejars. Fig. 150. — Anderson's method of tendon- lengthening. suture by silver wire should be tried, though it usually fails. After suturing, remove the Esmarch apparatus, arrest bleed- ing, close the wound and dress it antiseptically, relax the parts, and place the Hmb on a splint. If, after suturing, there is much tension, stitch the cut tendon above the sutures to an adjacent tendon, and apply a splint, the finger which was injured being flexed, the others being extended. If only the distal end of the tendon can be found, graft it upon the nearest tendon with a like anatomical course and function. When a tendon has been sutured begin gentle ORTHOPEDIC SURGERY. 519 massage in two weeks. Positive passive motion is begun in three or four weeks. In old inju- ries, when the ends cannot be brought into apposition, lengthen one end or both ends, either by the method of Anderson (Fig. 1 50) or by the method of Czerny (Fig. 151). Poncet makes F:g. 152. — Method of suturing the annular ligament of the Fig. 151. — Czerny 's method of tendon-lengthening. wrist. several zigzag incisions on each side of the tendon, and when the tendon is pulled upon it elongates decidedly. These methods of lengthening may be used in cases of de- formity from a contracted tendon. If the tendon cannot be lengthened sufficiently, make a bridge of catgut from one end of it to the other, or graft in another tendon from the same person or from one of the lower animals. The annular ligament is sutured as shown in Fig. 152. In some cases in which a muscle has been paralyzed, Nicoladoni and others have divided the tendon of the para- lyzed muscle and have united its distal end with the tendon of a normal muscle, the normal tendon being split to re- ceive it. XXI. ORTHOPEDIC SURGERY. This branch of surgery formerly dealt only with the treat- ment of deformities by means of mechanical appliances, but of recent years its domain has been enlarged to include the treatment, surgical and mechanical, of deformities, contract- ures, and many joint-diseases. Torticollis (wry-neck) is a condition in which contrac- tion of certain of the neck-muscles causes an alteration in the position of the head. The disease is one-sided ; the sterno-cleido-mastoid is the muscle chiefly involved, though the trapezius, splenius, and other muscles sometimes suffer. Acute torticollis, which is rare, results from cold or from injury (see Myalgia). Chronic torticollis may be congenital, it may be due to nerve-irritation, or it may be due to an assumed attitude because of eye-defect. Chronic torticollis may be intermittent, but is usually persistent. The muscle stands out in bold outline, the head is turned to the oppo- site side, the ear of the disordered side is turned toward the shoulder, and the chin is thrown forward. There is no pain. Spinal curvature may arise. The head may often be restored 520 MODERN SURGERY. to its normal position by passive movement or by voluntary effort, but it at once returns to its habitual position. The corresponding- side of the face atrophies. MikuHcz asserts that torticollis is a chronic fibrous myositis, due often to compression during labor. He further says that the lesion known as hematoma of the sternomastoid, which occasionally follows labor, is not hematoma, but thickening due to myositis. Symptoms. — Congenital wry-neck is due to central ner- vous disease, to spinal deformity, or to injury during birth, and in this form the sternomastoid is shortened, hardened, and atrophied. It may not be noticed for some years be- cause of the short neck of infancy, and it is associated with asymmetrical development of the face. It is almost inva- riably upon the right side. Spasmodic wry-neck may present tonic spasm only, intermittent spasm alone, or both may appear alternately. It is a disease especially of adults ; in women it is often linked with hysteria. The exciting cause may be a cold, a blow, or a mental storm ; the predisposing cause is the neurotic temperament. In some rare cases bilateral spasm occurs, the head being pulled backward and the face being turned upward. Clonic spasms may come on unannounced, or they may be preceded by pain and stiffness ; the head can be held still for a moment only ; there is sometimes pain, always fatigue, but during sleep the contractions cease. The attack will probably pass away, but will almost certainly recur. Treatment. — Congenital wry-neck is treated by myo- tenotomy (through an open wound) and the use of proper braces and supports. The old subcutaneous myotenotomy should be abandoned, as aseptic incision enables the surgeon to see and to feel all the contracted bands of fascia, muscle, and tendon, and to avoid vital structures (page 516). In spasmodic wry-neck treat the neurotic temperament ; in per- sistent cases stretch, or divide and exsect a part of the spinal accessory nerve. To reach this nerve make an in- cision along the posterior edge of the sternocleidomastoid, find the nerve as it emerges from under the middle of the muscle, and retract the muscle at this point (Keen). For the treatment of rheumatic wry-neck see Myalgia (page 504). Dupuytren's contraction is a contraction of the palmar fascia, of its digital prolongations, and of the fibers joining the fascia and skin. Fixed contraction of one or more fingers occurs. The ring-finger and the little finger most often suffer. The condition may be symmetrical. The dis- ease arises oftenest in men beyond middle age. The cause ORTHOPEDIC SURGERY. 521 of this disease is unknown : some refer it to gout or rheu- matism, others to traumatism, reflex irritation, or neuritis. Symptoms. — Dupuytren's contraction is indicated by a small hard lump or crease which appears over the palmar surface of the metacarpophalangeal joint. This nodule grows and the corresponding finger is pulled down. In some cases the tip of the finger is forced against the palm. The skin becomes dimpled or puckered. Treatment. — In treating Dupuytren's contraction subcu- taneous multiple incisions may be made, the tense fascia and the fasciocutaneous fibers being cut. The finger is straight- ened and is placed upon a straight splint, which is worn continuously for a week or ten days and is worn at night for at least a month. Keen divides the skin by a V-shaped cut, the base oi the V being downward, lifts up the flap, and dissects out the contracted tissue. Syndactylism (webbed fingers) is always congenital, and may persist through several generations. Simple incision of the web is useless ; the operation to be performed is that of Agnew or of Diday (Figs. 153, 154). In Agnew's operation a flap of skin from the dorsum is inserted between the fingers. In Diday's operation a flap is taken from the dorsal sur- face and another flap is raised from the palmar surface, and each flap is sutured to the finger from which it springs. Fig. 153. — Agnew's operation for webbed fingers (Pye). Fig. 154. — Diday's operation for webbed fingers (Pye). Polydactylism (supernumerary digits) is always con- genital, is often hereditary, and is usually symmetrical. There may be an incomplete digit, or there may be an entire and well-developed finger or toe with a metacarpal or meta- tarsal bone. The connection to the metatarsus or metacar- pus may be by a fibrous pedicle only. If the digit is com- plete, with a metacarpal bone, no operation is required ; if it is incomplete or is ill-developed, it should be remov^ed. Trigger-finger or Jerk-finger. — The patient can close the fingers, but on trying to open them one finger remains 522 MODERN SURGERY. closed. It can be opened by grasping it with the other hand, but flies open with a snap hke an opening knife (Abbe). The condition is due to enlargement of the flexor tendon, or to contraction of the groove in the transverse ligament in the palm (Tubby). This condition may be due to ganglion, enchondroma, or tenosynovitis. Treatment. — If a trauma, a ganglion, or inflammation exists, treat by ordinary means. If there is no obvious cause, put a compress over the tunnel in the ligament and apply a splint. Mallet-finger. — This is called also drop-finger and rupt- ure of the extensor tendon. It is due to a blow in the direc- tion of flexion when the finger is extended. It is supposed to be due partly to stretching and partly to rupture of the ex- tensor tendon at the point at which it is the posterior liga- ment of the distal interphalangeal joint. Abbe has shown that baseball players are Hable to a condition which is the reverse of this, in which the last phalanx is dislocated back- ward. Drop-finger is treated by incision and suture of the tendon to the periosteum (Abbe). Genu valgum (knock-knee) results from an unnatural growth of the internal condyle, causing the shaft of the femur to curve inward and the internal lateral ligament of the knee-joint to stretch, the knees coming close together and the feet being widely separated. This deformity is usu- ally noted when the child begins to walk, but it may not appear until puberty or even long after. Knock-knee may arise from rickets, from an occupation demanding prolonged standing, or from flat-foot. It may be noted in one knee or in both knees. Treatment. — Mild rachitic cases of knock-knee may re- main in slight deformity, or may get well from improvement of the general health. In ordinary cases simply treat the rickety condition. The patient is forbidden to stand or to walk, and the limb, after being put as straight as it can be, is fixed on an external splint and a pad is put over the inner condyle. Later in the case plaster-of-Paris is used. Some surgeons prefer to immobilize while the leg is flexed to a right angle Avith the thigh. In a severe case the sur- geon can immobilize after forcibly straightening (causing an epiphyseal separation) or after the performance of osteotomy (Fig. 127). Osteotomy is preferable to fracture by a mechan- ical appliance (osteoclasis). Genu varum (bow-legs) is the opposite of knock-knee. Usually both legs are bowed 07it, the knees being widely separated, the tibise and femurs, as a rule, being curved, and ORTHOPEDIC SURGERY. 523 Fig. 155. — Talipes equiiius (Albert). Fig. 156. — Talipes calcaneus (Albert). the feet being turned in. This disease is due to rickets, the weight of the body producing the deformity in early life. In older people incurable bow-legs may arise from ar- thritis deformans. Treatment. — Some mild cases of genu varum recover as a result of improvement of the health. Ordinary cases are treated by braces, by plas- ter-of-Paris bandages, and by attention to the general health. When the bones have hardened osteotomy is indicated. Club-hand. — A congenital deformity in which the hand deviates from the normal relation to the forearm. It is usu- ally associated with other deformities. In some cases the radius and possibly some of the carpal bones are absent. Treatment. — By massage and passive motion, by immob- ilization, by tenotomy or osteotomy. Talipes (club-foot) is a permanent deviation of the foot. There are several forms. Talipes cqtdmis (Fig. 155) is a con- firmed extension; talipes calcaneus (Fig. 156) is a confirmed flexion ; talipes variis is a confirmed adduction and inversion ; and talipes valgus is a confirmed abduction and eversion. Two of these forms may be combined, as in talipes equino-varus (Fig. 157), talipes equino-valgus, talipes calcaneo-varus, and talipes calcaneo-valgus. The causes of talipes are con- genital or acquired. The congenital form is due to persist- ence of the fetal form of the foot. Acquired cases may arise from infantile paralysis, from spastic contrac- tions, from cicatrices, from traumatisms, from arrest of bony growth following upon bone inflammation, or from hysterical contractures. Talipes egjtinus is rarely congenital, this condition the tient walks upon In pa- the Fig. 157. — Double equino-varus (Am. Text-book oy Surgery). toes and cannot bring the heel to the ground. Talipes Calcaneus. — The patient walks upon the heel and 524 MODERN SURGERY. cannot bring the toes to the ground. The true form is seen in congenital cases, the flexors of the foot being short- ened, and the tendo AchilHs being lengthened. Talipes varus is rarely met with without equinus. In this condition the patient walks on the outer edge of the foot. Talipes valgus is met with in flat-foot. The patient walks on the inner edge of the foot. Talipes eqiiino-varus. — The heel is raised and the patient walks upon the outer edge of the foot. This is the usual congenital form. Talipes equino-valgus is very rarely congenital. The heel is raised and the patient walks upon the inner side of the foot. Talipes calcaneo-variis is a combination of calcaneus and varus. Talipes calcaneo-valgus is a combination of calcaneus and valgus. Treatment. — In congenital cases the condition is usually manifest on both sides, and is nearly always talipes equino- varus. Congenital club-foot should be treated in infancy, and when a restoration to position can be effected by the hands of the surgeon, is treated by plaster-of-Paris bandages. If a child has begun to walk, it may still be possible to correct the deformity eventually by manipulations, by plaster-of-Paris bandages, or by club-foot shoes, but most cases require tenot- omy of the tendo Achillis before the application of the shoe or the plaster. The club-foot shoe may do good service, but in many instances it is painful and is not so efficient as plaster. In severe cases, before applying the plaster, the patient is given ether ; the surgeon cuts the tendo Achillis, the ten- dons of the anterior and posterior tibial muscles, and the plantar fascia, and forcibly corrects the deformity. In old cases with alteration in the shape of the bones, cuneiform osteotomy, or the removal of the cuboid or other tarsal bones, is indicated. In these cases Phelps advises a trans- verse incision through all the plantar soft parts. In talipes due to infantile paralysis the operative treatment is the same, but we should not immobilize in plaster, but rather in some apparatus which can easily be removed to permit the use of massage and electricity. In some cases of talipes calcaneus the surgeon may be forced to shorten the tendo Achillis. In paralytic cases Nicoladoni's operation is occasionally employed. This consists in dividing the tendon of the paralyzed muscle and attaching its distal end to the adjacent tendon of a healthy muscle. (For full consideration, see a work on Orthopedic Surgery.) ORTHOPEDIC SURGERY. 525 Pes planus (flat-foot) is the loss of the arch of the foot due to muscular paralysis or ligamentous weakness, to pro- longed standing, or to trauma. Many cases are due to rickets. Spurious flat-foot or inflammatory flat-foot occurs in Pott's fracture, and in inflammation of the ankle-joint or the tendon of the peroneus longus. Static flat-foot is due to " lack of balance between the weight of the body and the strength of the foot" (Moore). All children are born with flat-feet, but the arch usually begins to form soon after birth, but in some cases it never forms. This condition is pro- ductive of much pain on standing. Flat-foot can at once be recognized by wetting the sole of the patient's foot with a colored fluid and causing him to step firmly upon a piece of paper (Fig. 158, A, b). It can also be detected by measurement to find the mid- dle of the foot. In flat-foot the extremity is lengthened. Flat-foot causes much pain upon walking ; in fact, the individual may = « , f ^ , , . , , Ti • • • 1 1 v\G. 158. — Print of a be completely crippled. rain is quickly normal ' foot-soie (a) ,. , • , ,- \ iirn- „ and of a flat foot-sole relieved upon sitting down. Walking upon (b) (Albert). the toes is not painful. Treatment. — In static flat-foot exercise is practised sev- eral hours a day to increase the arch. Rising upon the toes again and again is valuable. After exercise the patient rests for a time, sitting tailor-fashion with legs crossed under him. Massage is valuable. A shoe should be made containing a piece of steel so arranged as to raise the arch of the foot. The patient's general health must also be looked to. In very severe cases operation may be required. Gleich shortens the foot and raises the arch by saw^ing through the OS calcis and fastening the posterior part at a lower level. Trendelenburg advises supramalleolar osteotomy. This operation permits us to adduct the foot and put it in this position in plaster. In paralytic flat-foot, which arises from infantile paralysis, employ exercise, electricity, and massage. Pes cavUS (hollow-foot) is an increase in the arch of the foot, due to contraction of the peroneus longus muscle or to paralysis of the muscles of the calf It is the opposite of flat-foot. Treatment. — A shoe is worn containing a plate of steel in the sole, and pressure is applied over the instep. Tenotomy, cutting of the plantar fascia, or excision of bone may be required. Hallux valgus, or varus, a displacement of the great 526 MODERN SURGERY. toe outward or inward, may occur in the young, but it is most frequent in old men. It arises oftener from wearing narrow shoes, but may be due to gout, or to rheumatic gout. In hallux valgus a bunion is apt to form over the metatarso- phalangeal joint. Treatment. — An arrangement may be worn to straighten the toe and to protect the bunion (Fig. 148), osteotomy may be performed upon the metatarsal bone, the joint may be excised, or amputation may be required. Hammer-toe (Fig. 159) is the flexion of one or more toes at the first interphalangeal ^''"merll^?^"'' joint. Shattuck shows that this condition is due to contraction of " the plantar fibers of the lateral ligaments of the joint." ^ This disease usually begins in youth. A bunion is apt to form, and the joint may be dislocated. The treatment is excision of the joint or amputation. Terrier's plan consists in making a dorsal flap, removing a bursa if one is found, dividing the extensor tendon, opening the articulation, removing each articular surface with cutting- forceps, suturing the soft parts, and applying a plantar spHnt for two weeks.^ Metatarsalgia (Morton's Disease). — A painful con- dition of the foot, due to jamming of a nerve between the heads of the fourth and fifth metatarsal bones. It is usually associated with flat-foot. Treatment. — Mild cases may be cured occasionally by wearing well-fitting shoes and employing massage. Some cases require a brace. Severe cases demand resection of the fourth metatarsophalangeal joint, or amputation of the fourth toe, and with it the head of the fourth metatarsal bone. Coxa vara is bending of the neck of the femur, the hip- joint being perfectly healthy, and the condition, as a rule, being unilateral. This condition was described by Miiller in 1889. The disease arises, as a rule, between the thirteenth and twentieth years, and the commonly accepted view has been that the deformity is rachitic, but Kredel has recently reported two congenital cases.^ The patient develops a limp, and grows tired after slight exertion, but there is no swelling or tenderness, and little or no pain. Shortening after a time becomes apparent, and the trochanter can be detected above Nelaton's line. The extremity is adducted. 1 American Text-book of Surgery. " Revue de Chirurgie, July, 1S95. 3 Centralbl.f. Chir., Oct. 17, 1896. DISEASES AND INJURIES OF NERVES. 527 Treatment. — As long as bending is progressing employ- rest. When the bone hardens perform osteotomy below the trochanters. Flail-joints. — After an attack of infantile paralysis in which the entire lower extremity of each side was involved, the limbs are limp and swing flail-like when the extremity is made to move, and the joints are much relaxed. In such cases the psoas and iliacus muscles are never completely paralyzed, and the aim of the surgeon is to utilize these muscles in enabling the patient to walk. In many cases the application of apparatus is sufficient. In others ankylosis is established by operation in the ankles and knees, so as to give the psoas and iliacus control of the legs. XXII. DISEASES AND INJURIES OF NERVES. I. Diseases of Nerves. Neuritis, or inflammation of a nerve, may be limited or be widely distributed (multiple neuritis). The first-men- tioned form will here be considered. The causes of neuritis are traumatism, wounds, over-action of muscles, gout, rheu- matism, syphilis, fevers, and alcohoHsm. Syraptoms. — The symptoms of neuritis are as follows: excessive pain, usually intermittent, in the area of nerve- distribution. The pain is worse at night, is aggravated by motion and pressure, and occasionally diffuses to adjacent nerve-areas or awakens sympathetic pains in the opposite side of the body. The nerve is very tender. The area of nerve-distribution feels numb and is often swollen. Early in the case the skin is hyperesthetic ; later it may become anesthetic. The muscles atrophy and present the reactions of degeneration ; that is, the muscles first cease to respond to rapidly-interrupted, and next to s/ozu/j'-'mterrupted, faradic currents ; faradic excitability diminishes, but galvanic excita- bility increases. When, in neuritis, faradism produces no contraction, a slowly-interrupted galvanic current which is so weak that it would produce no movement in the healthy muscles causes marked response in the degenerated muscles. In health the most vigorous contraction is obtained by clos- ing with the — pole ; in degenerated muscles the most vigorous contraction is obtained by closmg with the -f pole. When voluntary power returns galvanic excitability declines, but power is often nearly restored before faradic excitability becomes manifest (Buzzard). Treatment. — The treatment of neuritis consists of rest 528 MODERN SURGERY. upon splints, ice-bags early in the case, and hot-water bags later. Blisters are of value in traumatic neuritis. Massage and electricity must be used to antagonize degeneration. Deep injections of chloroform may allay pain. Treat the patient's general health, especially any constitutional disease or causative diathesis. The salicylate of ammonium or phenacetin may be given internally. In some cases nerve- stretching is advisable. Neuralgia is manifested by violent paroxysmal pain in the trajectory of a nerve. This disease belongs chiefly to the physician, except in very bad cases. Neuralgia of stumps and scars belongs to the surgeon, and is due to neuromata, or entanglement of nerve-filaments in a cicatrix. Tic douloureux and other intractable neuralgias require careful removal of any cause of reflex irritation (stomach, eyes, uterus, nose, throat, etc.). Tic douloureux has been treated by removal of the Gasserian ganglion (page 533); removal of Meckel's ganglion ; ligation of the common carotid artery ; neurectomy of terminal branches (page 532); division of motor nerves ; massive doses of strychnin (Dana) and purgatives (Esmarch). Treatment of Neuralg-ia of Stumps. — Excise the scar; find the bulbous end of the nerve and cut it off. Senn tells us to section the nerve by V-shaped cuts, the apex of the V being toward the body, and to suture the flaps together. Senn's method will prevent recurrence. In some cases re- amputation is performed. In entanglement of a nerve in a scar remove a portion of a nerve above the scar. 2. Wounds and Injuries of Nerves. Section of Nerves (as from an incised wound). — In nerve-section the entire peripheral portion of the nerve de- generates and ceases structurally to be a nerve in a few weeks, but after many months, or even after years, the nerve again regenerates — with difficulty, if union of the ends has not taken place, with much greater ease if the ends have united. The proximal end only suffers in the portion im- mediately adjacent to the section ; it degenerates, but rapidly regenerates, and a bulb or enlargement composed of fibrous tissue and small nerve-fibers forms just above the line of section ; this bulb adheres to the perineural tissues. Union of a divided nerve is brought about by the projection of an axis-cylinder from the proximal end or from each end and the fusion of these cylinders. The nearer the two ends are to each other the better is the chance of union. DISEASES AND INJURIES OF NERVES. 529 Symptoms. — Pronounced changes occur in the trajectory of a divided nerve. The muscles degenerate, atrophy and shorten, and show the reactions of degeneration. When union of the nerve occurs the muscles are restored to a normal condition. If the nerve contains sensory fibers, com- plete anesthesia (to touch, pain, and temperature) usually follows its division ; but if a part is supplied by another nerve as well as by the divided one, anesthesia will not be com- plete. Trophic changes arise in the paralyzed parts. Among these changes are muscular atrophy ; glossy skin ; cutaneous eruptions; ulcers; dry gangrene; painless felons; falling of the hair; brittleness, furrowing, or casting off of the nails; joint- inflammations ; and ankylosis. Immediately after nerve-sec- tion vasomotor paralysis comes on, and for a few days the paralyzed part presents a temperature higher than normal. The diagnosis as to which nerve is cut depends upon a study of the distribution of paralysis and anesthesia.^ Treatment. — In all recent cases of nerve-section, suture the ends. In 123 cases of primary suture, 119 were cured in from one day to one year (Willard). In 130 cases of secondary suture, 80 per cent, were more or less improved (Willard). If the patient is not seen until long after the accident, incise and apply sutures (secondary sutures) ; if the nerve cannot be found, extend the incision, find the trunk above and trace it down, and find the trunk below and follow it up. Even after primary suture loss of function is bound to occur for a time. After secondary suture sensation may return in a few days, but it may not return until after a much longer period ; in any case muscular function is not restored for months. In partial section of a nerve the ends should be sutured. In secondary suture it may be necessary to perform " lengthening " in order to approximate the ends. Pressure upon nerves may arise from callus, scars, pressure of a dislocated bone or a tumor, or pressure from an external body. The symptoms may be anesthetic, para- lytic, and trophic. The treatment is as follows : remove the cause (reduce a dislocated bone, chisel away callus, excise a scar, etc.) ; then employ massage, douches, and electricity. Dislocation of the Ulnar Nerve at the Blbow. — This condition is very rare. It may occur as a complication of a fracture or a dislocation, or as an uncomplicated condi- tion. It may be produced by violence or by muscular effort, which ruptures the fascia whose function is to retain the nerve back of the inner condyle of the humerus. In some ^ See Bowlby on Injuries of N'erves. 34 530 MODERN SURGERY. cases the symptoms are slight and transitory, the nerve func- tionating well in its new situation. As a rule, there are pain, numbness, or anesthesia of the ulnar trajectory, some stiff- ness of the elbow and stiffness of the little finger or ring finger. The nerve can be felt in front of the inner condyle of the hu- merus. In some cases neuritis follows, with trophic changes. Treatment. — McCorniick's Operation. — Expose the nerve by an incision, incise the fibrous tissue back of the inner condyle, and press the nerve into the bed prepared for it and hold it in place by sutures of kangaroo-tendon passing through the triceps tendon. Wharton advises suturing also "the margin of the fascial expansion of the triceps tendon superficial to the nerve." ^ Contusion of Nerves. — The symptoms of contusion of nerves may be identical with those of section. Sensation or motion, or both, may be lost. The case may get well in a short time, or the nerve may degenerate as after section. The treatment at first is rest, and later electricity, massage, frictions, and douches. Punctured Wounds of Nerves. — The symptoms of punctured wounds of nerves may be partly irritative (hyper- esthesia, acute pain, and muscular spasm) and partly paralytic (anesthesia, muscular wasting, and paralysis). The treatment is the same as that for contusion. 3. Operations upon Nerves. Neurorrhaphy, or Nerve-suture. — When a nerve is completely or partially divided by accident it should be sutured. The instruments required are an Esmarch ap- paratus, a scalpel, blunt hooks, dissecting-forceps, hemo- static forceps, curved needles or sewing-needles, a needle- holder, and catgut or kangaroo-tendon. In primary suture render the part bloodless and aseptic. Enlarge the incision if necessary. If the ends can readily be approximated, pass two or three sutures through both the nerve and its sheath and tie them (Fig. 160). If the ends can- _ not be approximated, stretch each end and then suture. Remove the Esmarch band, arrest bleeding, suture the wound, Fig. 160.— Nefve-suture. drcss antiseptically, and put the part in a relaxed position on a splint. After union of the wound remove the splint and use massage, ^ A report of fourteen cases of dislocation of the ulnar nerve at the elbow, by H. R. y- dissector, dissecting- and hemostatic forceps, 534 MODERN SURGERY. and an electric forehead-light are required. Long strips of gauze must be ready for packing in case of hemorrhage. The pa- tient is placed recumbent, with head turned to the opposite side. A large osteoplastic flap is formed in front of the ear (Fig. 162), and is broken down. Hemorrhage is arrested. It may be found that the meningeal artery has been ruptured. If this accident has happened, and the vessel lies in a bony canal, plug with Horsley's wax. If the vessel is bleeding upon the dura, ligate by passing suture ligatures around it. If it is torn off at the foramen spinosum, pack with iodoform gauze, and postpone the rest of the opera- tion for forty-eight hours. It may be necessary at any stage Fig. 162. — Hartley's osteoplastic flap in removal of Gasserian ganglion (Tiffany). Fig. 163. — Removal of Gasserian ganglion (Krause) A, middle meningeal artery; II, ophthalmic division : iii, submaxillary division ; o, ganglion. of this formidable operation to pack the wound and postpone completion for two days. The next step is to lift up the dura and with it the brain (Fig. 163). Find the inferior maxillary DISEASES AND INJURIES OF THE HEAD. 535 nerve and clamp it with hemostatic forceps. Find the supe- rior maxillary nerve and clamp it. Loosen the nerves from their beds with a dry dissector. Twist the clamp-forceps so as to reel up the nerves. This pulls out the ganglion intact with the motor root and the root of origin, as far back as the pons (Krause's method). Arrest bleeding ; close the flap ; sew the lids of the affected side together ; and cover the eye with a watch-crystal. XXIII. DISEASES AND INJURIES OF THE HEAD. I. Diseases of the Head. In approaching cases of brain disorder, first endeavor to locate the seat of the trouble ; next, ascertain the nature of the lesion ; and finally, determine the best plan of treatment, operative or otherwise. In all operations upon the brain the surgeon must be able to determine accurately the situations of certain fissures and convolutions, the find- ing of the situations of these convolutions and fissures com- prising the science of craniocerebral topography. TJic regional terms used in craniocerebral topography are derived from Broca (Fig. 165). The middle meningeal artery Fig. 164. — The meningeal artery exposed by trephining (after Esmarch). is found at the pterion, one and one-quarter inches posterior to the external angular process, on a level with the roof of the orbit (Fig. 164). The fissures and convolutions of the brain are shown in Figs. 166, 167, and 168. The fissure of Bichat is marked by a line on each side drawn from the inion to the external auditory process. A line from the glabella to the inion overlies the median fissure and the superior longi- tudinal sinus. The fissure of Rolando is very important, as 536 MODERN SURGERY. marking the motor region of the brain. It begins in the median Hne, half an inch posterior to the middle of the dis- tance between the inion and gla- bella (Keen). This fissure runs downward and forward at an angle of 67.5° for a distance of three and three-eighths inches. Chiene finds the fissure of Rolando by the follow- ing method : he takes a square piece Fig. 165. — Skull showing the points named by Broca: As, asterion (junction of the occipital, parietal, and temporal bones); basion, middle of anterior wall of foramen magnum ; B, bregma (junction of the sagittal and coronal sutures); G, ophryon (on a level with the superior border of the eyebrows, and corresponding nearly to the glabella, the smooth swelling between the eyebrows) ; g, gonion (angle of the lower jaw) ; /, inion (external occipital protuber- ance) ; L, lambda (junction of sagit- tal and lambdoidal sutures) ; N, na- sion (junction of the nasal and front- al) ; Ob, obelion (the sagittal suture between the parietal foramina) ; P, pterion (point of junction of great wing of sphenoid and the frontal, parietal, and squamous bones. This may be H-shaped or K-shaped, or " retourne," in which the frontal and temporal just touch) ; S, stephanion (or, better, the superior stephanion, intersection of ridge for temporal fas- cia and coronal suture) ; S' , inferior stephanion (intersection of ridge for temporal muscle and coronal suture). Fig. 166. — View of the brain from above (Ecker). of paper and folds it into a triangle (Fig. 1 70, i) ; the angle bag of this triangle is 45 ° ; the edge d a is folded back on the dotted line ae; the angle dae equals half of 45°, or 22.5°, and the angle cae equals the same (Fig. 170, 2); unfold the paper in the line ca; in the figure thus formed b a = 45° and eac = 22.5°; e a b = 67.5°, which is the angle desired. Place the point a in the mid-line of the head, over the point of ori- gin of the Rolandic fissure ; the side a b is laid along the middle line of the head, and the line A e corresponds to the fissure of Rolando.^ Fig. 169 shows Chiene's scheme for locating various points upon the brain. Horsley de- termines the situation of the Rolandic fissure by the use ^ At?ierican Text-book of Surgery, DISEASES AND INJURIES OF THE HEAD. 537 of his metal cyrtometer (Fig. 171). He places the point marked zero over the inioglabellar line and midway be- tween the inion and the glabella. To find the fissure of Fig. 167.— Outer surface of the left hemisphere of the brain (Ecker). Sylvius (Fig. 167, 5, s' , s"^, draw a line from the exter- nal angular process to the occipital protuberance. The fissure of Sylvius begins on this line one and one-eighth Fig. 16S.— Inner surface of the right hemisphere of the brain (Ecker). inches behind the external angular process ; the main branch of the fissure runs toward the parietal eminence; the ascending branch of the fissure corresponds to the squamoso-sphenoidal suture, and continues upward in the 538 MODERN SURGERY. same line half an inch above the suture. The precentral sulcus (Fig. 167, f) Hmits anteriorly the ascending frontal convolution; it runs parallel with and just behind the Fig. 169.— Chiene's lines for localizing brain-areas: M D c A, Rolandic or motor area; A, anterior branch of middle meningeal and bifurcation of fissure of Sylvius ; A c, horizontal part of Sylvian fissure; the highest part of the lateral sinus touches Ps at r; ma, precentral sulcus ; I, beginning of inferior frontal sulcus ; K, beginning of superior frontal sulcus ; M B c contains the supramarginal convolution ; B, angular gyrus. coronal suture, and a finger's breadth in front of the fissure of Rolando. The intraparietal fissure (Figs. 166, 167, ip) limits the motor region posteriorly. It begins opposite the junction of the lower and middle thirds of the fissure of Fig. 170. — Chiene's method of fixing position of the Rolandic fissure {Am. Text-book of Siirgery). Rolando, passes upward in a line parallel with the longi- tudinal fissure and midway between the Rolandic fissure and the parietal eminence, passes by the parieto-occipital fis- DISEASES AND IXJURIES OF THE HEAD. 539 sure, and downward and backward into the occipital lobe. The motor areas, which on the outer surface are adjacent to the fissure of Rolando, are shown in Figs. i66 and 167. ^. ..■'l.,.6|.,.S|.,.'H.,.»|.,.»|.,.<|.,°| .l'^,.|3. l.l»,.l^,.l'. ,.K.T^ Fig. 171. — Horsley's cyrtometer. The superior longitudinal sinus is overlaid by a line from the inion to the glabella. The lateral sinus is indicated by a line running from the occipital protuberance horizontally out- ward to a point one inch pos- teriorly to the external auditory meatus, and from this point by a second line dropped to the mas- toid process. The suprameatal triangle of Macewen is bounded by the posterior root of the zy- goma, the posterior bony wall of the auditory meatus, and a line joining the two. The mas- toid process is opened through Macewen's triangle to avoid in- jury to the lateral sinus. Bark- er's point, the proper spot to apply the trephine in abscess of the temporosphenoidal lobe, is one and one-fourth inches above and one and one-fourth inches behind the middle of the external auditory meatus. Fig. 172 shows clearly the main points of craniocerebral topography, obtained by methods approved by many scientists. Diseases of the Scalp. — The scalp is composed of skin, subcutaneous fat, and the occipitofrontalis muscle and apo- neurosis. The scalp is liable to inflammation from various Fig. 172. — Head, skull, and cere- bral fissures : B corresponds to Broca's convolution ; EAP, external angular process ; FR, fissure of Rolando ; IF, inferior frontal sulcus ; IPF, intrapari- etal sulcus : MMA, middle meningeal artery; OPr, occipital protuberance; PE, parietal eminence : POF, parieto- occipital fissure ; SF, Sylvian fissure; A, its ascending limb ; TS, tip of tem- porosphenoidal 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 tem- poral bones (adapted from Marshall by Hare). 540 MODERN SURGERY. causes, and also to other diseases — namely, tumors, cysts, warts, moles (local cutaneous hypertrophies), cirsoid aneur- ysm (page 256), nevi, and lupus. Abscesses of the scalp are common. If an abscess forms beneath the pericranium, the pus diffuses over the area of one bone, being limited by the attachment of the pericranium in the sutures. If an abscess forms in the tissue between the occipitofrontaHs and the pericranium, it is widely diffused. Treves calls this subaponeurotic connective tissue " the dangerous area." Abscess of the subcutaneous tissue is apt to be limited because of the great amount of fibrous tissue. Abscess is treated by instant incision at the most dependent part, anti- septic irrigation, and drainage. ■ Diseases and Malformations of the Bones of the Skull. — The bones of the skull are liable to caries, necrosis, osteitis, periostitis, atrophy, hypertrophy, tumors, etc. (see Diseases of Bones). MicrocephaltlS. — By microcephalus is meant unnatural smallness of the head due to imperfect development. Marked microcephalus is not a common condition, but it is an occa- sional cause or associate of idiocy. A child may be born with a skull completely ossified even at the fontanelles, or the ossification may become complete soon after birth, but in many cases of microcephalus ossification takes place late or not at all. In microcephalus the face is apt to be fairly well developed ; the jaws are prominent ; the forehead is flat ; the cranium and brain are small ; the convolutions of the brain are simpler than is natural ; there is apt to be marked asymmetry of the two sides of the brain ; internal hydro- cephalus may exist ; areas of sclerosis and atrophy are common ; porencephaly is not unusual. Some patients have perfect motor power ; others are slow and inco-ordinate. Epilepsy, chorea, and athetosis frequently complicate the case. Idiots of this type often present deformities such as cleft-palate, strabismus, distorted ears, hypertrophied tongue, deformed genitals or extremities, ill-shaped and irregularly developed teeth. They exhibit irregular muscular move- ments, are frequently paralyzed in childhood (infantile para- plegia or hemiplegia), and suffer from subsequent contract- ures. These idiots are active, destructive, excitable, and are liable to be violent and almost demoniacal. Clouston says they look impish and unearthly. Treatment. — Skilled training in a school for the feeble- minded or in an institution for idiots is necessary in treating microcephalus. Idiots have but little power of attention, DISEASES AND INJURIES OF THE HEAD. 54 1 and sensory impressions give rise to but few concepts, and these are feeble and fleeting. In order to educate the idiot it is highly desirable that speech be acquired, and " the more strongly the attention can be aroused the more perfect does speech become " (Kirchhoff ). The principle of the educa- tion of idiots is to stimulate, co-ordinate, and guide sight, hearing, and feeling. Lannelongue of Paris has suggested an operation in cases of idiocy with premature ossification (see Linear Craniotomy, page 577). In this procedure the author has no confidence. Idiocy is a general disorder and not a local brain disease. Soft parts mould bone, and bone does not mould soft parts. There is no evidence that the brain is being compressed ; in fact, the simplicity of the convolutions suggests the contrary. In many typical cases of microcephalic idiocy there is no synostosis even years after birth. The operation has been much abused. It is sometimes fatal, and, although a fatality may gratify the family, a surgeon is not a legal executioner. The remarkable improvement which has been reported in some cases results probably from misconception ; the new surroundings, the strange faces, the firm discipline, the effect of the anesthetic, and the shock of the operation attract the feeble attention and rouse the sluggish senses. Many cases are brought for operation because they are for the time being unusually intractable and excitable, and the return to the usual level of conduct after operation is regarded as a permanent gain when it is often but a temporary alle- viation. We believe that scientific training is the proper treatment, and that the efficiency of training is not in- creased by the previous performance of craniotomy, and we follow the precept of Agnew, that a surgeon might as well cut a piece out of a turtle's back to make a turtle grow^ as to cut a piece out of the skull to make the brain grow. Diseases and Malformations Involving the Brain. — Meningocele is a congenital protrusion of the cerebral membranes through a bony aperture, the sac containing some extracerebral fluid. Meningocele feels and looks like a cyst (is translucent and fluctuates) ; it does not usually pulsate, it has a small base, it becomes tense on forcible expiration, and it may be reduced. Encephalocele is a congenital protrusion not only of membranes, but also of a portion of the brain as well, the sac containing some extracerebral fluid. Encephalocele is small, opaque, does not fluctuate, has a broad base, does 542 MODERN SURGERY. pulsate, becomes tense on forced expiration, and attempts at reduction cause pressure-symptoms. Hydrencephalocele is a congenital protrusion of mem- branes and brain-substance, the interior of the mass com- municating with the ventricles and containing ventricular fluid. This is the most frequent and the most dangerous form. Hydrencephalocele is larger than a meningocele, is translucent, fluctuates, rarely pulsates, is pedunculated, is rendered a little tense on forced expiration, and cannot be reduced.^ Treatment. — For hydrencephalocele nothing can be done, and early death is inevitable. In rare instances an enceph- alocele is converted into a meningocele, and the bony aperture closes, thus bringing about a cure. Among the expedients for treating meningocele and encephalocele are electrolysis, injection of Morton's fluid (gr. x of iodin, gr. XXX of iodid of potassium, ,?j of glycerin), pressure and excision. In cases of meningocele, when portions of the nerve- centers are not contained in the sac, Mayo Robson advises the performance of a plastic operation. He ligates the neck of the sac, cuts away the sac, sutures the skin-flaps separately, and leaves the stump outside the line of superficial sutures. It is usually possible to tell by palpation if nerve-centers are in the sac, but if in doubt, make an exploratory incision, and sweep the finger around inside of the sac.^ Hydrocephalus. — In external hydrocephalus the fluid is between the membranes and the brain ; in internal hydro- cephalus the fluid is in the ventricles. Hydrocephalus may be acute or chronic, congenital or acquired. Acute hydrocephalus, which results from meningitis (particularly tubercular meningitis), is usually internal, but may be external. The symptoms are headache, elevated temperature, delirium, stupor, convulsions, paralysis, and choked disk. Treatment of acute hydrocephalus is of no avail. Tapping of the ventricles may be tried. Chronic hydrocephalus is usually congenital. The cra- nium enlarges enormously and the bones of the skull are widely separated. The broad forehead overhangs the eyes. The child is an idiot, and very often does not learn to walk or to talk. Convulsions and palsies are common, and blind- ness is frequent. Such children usually die young. The treatme7it of chronic hydrocephalus is rarely of much 1 Ai?ierican Text-book of Surgery. ^ Atn.Jour. Aled. Sciences, Sept., 1895. DISEASES AND INJURIES OF THE HEAD. 543 avail. Pressure by strapping with adhesive plaster has been tried. Tappings through a fontanelle may be performed by means of a trocar (only sij or 5iij of fluid being drawn at a time). If much fluid is drawn, the head must be strapped afterward. If the skull ossifies, the lateral ventricles may be tapped. It has been proposed to drain by tapping the theca of the spinal cord (Quincke). This last operation is called lumbar puncture (page 595). 2. Injuries of the Head. Cephalhematoma (caput succedaneum), which is a col- lection of bloody serum under the scalp of a new-born child, results from the pressure of labor. No treatment is required. Scalp-wounds are treated as are other wounds. Even a large piece of scalp with only a narrow pedicle may not slough ; hence try to save any piece that has an attachment. Always shave a wide area and disinfect the wound thor- oughly. Stitch the wound with silkworm-gut. The hem- orrhage can, in most instances, be controlled by the sutures which are used to close the wound. If drainage is required, use a few strands of silkworm-gut. Contusions of the Head. — Scalp-swelling from hemor- rhage is usually considerable. The patient may be stunned or dazed. The swelling of hematoma must not be mistaken for fracture with depression. In hematoma there is a cen- tral depression, hard pressure on the centre finds bone on a level with the general contour of the bone, and the margin of a hematoma is circular, is not quite hard, and is elevated above the general contour. In depressed fracture the edge is on a level with or below the level of the general bony con- tour, and the margin is sharp and irregular. The treatment is by means of pressure and the use of lead-water and laud- anum. If suppuration arises, at once incise. Concussion or I/aceration of the Brain. — For many years it has been customary to regard concussion as a con- dition produced by molecular vibrations in the nervous sub- stance of the brain. Buret's classical observations have pro- foundly modified surgical thought, and have led to the opinion that in concussion of the brain there is injury to the brain itself, a rupture of cerebral vessels brought about by the advance and recession of a wave of cerebrospinal fluid. This wave first flows in the direction of the force. Keen says that there may be slight brain-injuries which can 544 MODERN SURGERY. properly be called " concussions," but it is better to consider concussion as synonymous with laceration of the brain. It seems, however, highly improbable that slight cases of con- cussion are accompanied by vascular rupture or organic mischief, the symptoms are too transitory, and reaction too rapid and complete to permit of any such view. These slight cases are identical with and at least can not be dis- tinguished from shock. The cause of concussion is violent force, either direct (as a blow upon the head) or indirect (as a fall upon the buttocks). This force shakes, oscillates, or jars the brain, giving rise to waves of cerebrospinal fluid, which sometimes rupture vascular twigs, large vessels, or even the membranes. In the slighter ruptures concussion only exists ; in the severe ruptures compression soon arises. Symptoras. — In a slight case of brain-concussion the patient may or may not fall ; his face is pale ; he feels weak, giddy, nauseated, and confused ; he often vomits, but soon reacts. In a severe case he lies with complete muscular relax- ation, cold extremities, pale and cold skin, shallow and quiet respiration, frequent, small, soft, and irregular pulse (pulse may not be detectable), and fluttering heart. He seems unconscious, but can usually be roused to monosyllabic response by shouting, pinching, or holding a bright light near his face. Occasionally, however, there is complete un- consciousness. The urine and feces are often passed in- voluntarily. The pupils may be unaltered, may be dilated or contracted, or may be equal or unequal, but in any case they will react to light. Paralysis rarely exists, but if there is paralysis it is temporary. The temperature at first is sub- normal. In a severe cortical laceration there will be twitch- ings or even general convulsions, or the patient will lie curled up with limbs flexed and eyelids shut, and will resist all attempts to open his eyes or mouth or to move his limbs (A. Pearce Gould). Erichsen called this condition " cerebral irritability." As the patient reacts he will most probably vomit. Within twenty-four hours he usually improves, but is feverish and complains of headache and lassitude, sometimes becomes delirious, and in rare cases develops mania. After concussion recovery may be complete, but, on the contrary, a person's whole nature may change : he may develop hysteria, insanity, or epilepsy, and in many cases there is complaint for a long time of headache, insom- nia, low spirits, and lassitude. If the patient in concussion recedes from, instead of advancing toward, recovery, coma will set in or inflammation will develop. Keen states that DISEASES AND INJURIES OF THE HEAD. 545 the prognosis is always uncertain. Any concussion pro- ducing unconsciousness is a serious injury, because consider- able laceration has probably occurred. Treatment. — In treating brain-concussion, bring about reaction by the administration of aromatic spirits of ammo- nia (no alcohol, as this agent excites the brain), by pouring a few drops of ammonia on a handkerchief and holding it near the nose, by surrounding the patient (who lies in bed with a pillow) with hot bottles, by hot irrigation of the head, by the application of mustard over the heart, and by the administration of hot coffee or hot saline enemata. Do not pour fluid into the patient's mouth until he becomes able to swallow. If he cannot swallow, rely on hot enemata and hypodermatic injections of strychnin. Place the patient in bed in a quiet room, and watch him. If reaction is inordinate, apply cold to the head, give arterial sedatives and diuretics, and purge. For some days or for some weeks, according to the case, insist on an easy life. Give a plain diet containing a minimum of meat, administer an occasional purgative, and secure sleep. Sleep can often be obtained by some simple expedient, such as the administration of warm milk, placing a hot-water bag to the abdomen or feet, or applying a mus- tard plaster for a short time to the back of the neck. Irk cases where obstinate wakefulness exists, it becomes neces- sary to give bromid, chloral, sulphonal, trional, or some other hypnotic. Morphin is avoided because it is thought to increase venous congestion of the brain, but the elder Gross often used it, especially in cerebral irritation. If signs of compression arise, it is best to trephine, as the compressing agent may be a clot (see page 548). If inflammation arises, some surgeons will not trephine ; but it is wise and proper, especially if the damage seems to be localized, to incise the scalp and inspect the bone. If a fracture is discovered and the symptoms are serious, perform an exploratory tre- phining, open the dura, and secure drainage for inflammatory products. In any severe contusion the surgeon should at once incise the scalp and inspect the bone. For many weeks after a grave concussion a patient must be kept away from business and be watched because of the possibility of an abscess of the brain arising, and because of the lia- bility of such patients to develop hysteria, neurasthenia, or insanity. Compression of the Brain.— The causes of brain- compression are hemorrhage, depressed fracture, tumor, in- 35 546 MODERN SURGERY. flammatory exudate, pus, and foreign bodies. Death tends to happen from respiratory failure, not from heart-failure (Horsley). Symptoms. — In great or sudden brain-compression com- plete coma exists without voluntary movement. The skin is hot and perspiring ; the respirations are slow and sterto- rous, and the cheeks flap during expiration ; the pulse is slow and full, and may be irregular; the pupils are somewhat dilated, and do not respond readily to light. In a unilateral compression the pupil on the side of the compressing-cause is apt to be much dilated if the compression is affecting the base of the brain. In cerebral compression there are usually retention of urine, and often incontinence of feces ; paraly.sis exists, which may be very limited (monoplegia), may be of one side (hemiplegia), or may be general. In hemorrhage into the interior of the brain the unconsciousness is imme- diate or nearly so. In bleeding from the middle meningeal artery a period of consciousness intervenes between the in- jury and the coma, in which period blood collects and the coma comes on gradually. In compression from depressed fracture or from a foreign body the symptoms usually come on at once, but they may be deferred for some hours. Com- pression from inflammation or pus begins gradually after a considerable time has elapsed. A diagnosis must be made between coma due to brain- injury and the comatose conditions of apoplexy, uremia, epilepsy, hysteria, diabetes, opium-poisoning, and alcohohc intoxication. In hospital practice cases of unconsciousness without a known hi.story are frequent. In attempting this diagnosis examine carefully for any evidence of traumatism, and inquire as to how and where the patient was found, if any fit occurred, and if a bottle or a pill-box was found near by or in the pockets. The surgeon should himself exam- ine the pockets. Smell the breath to notice alcohol or opium, but always remember that a man may be stricken with apoplexy while he is drunk, and may fracture his skull by falling when under the influence of opium or of alcohol. Draw the urine with the catheter if any water is in the bladder; examine the urine for albumin and alcohol, and take the specific gravity. In doubtful cases of coma use the ophthalmoscope. In post-epileptic coma the tempera- ture is never below normal, there are no unilateral symptoms, the condition resembles sleep, and the patient can be aroused. Hysterical coma occurs in boys and women ; there are no ob- jective symptoms, and the patient, though swallowing what is DISEASES AND INJURIES OF THE HEAD. 547 put into his mouth, cannot be roused (Gowers). In uremia, besides the condition of the urine (and always remember that a person with albuminuria is apt to develop apoplexy), there is a persistent subnormal temperature, and convulsions are prone to occur. There is edema of the legs, and paralysis and stertor are absent. In apoplexy hemiplegia exists, and the initial temperature is for a short time sub- normal. A single convulsion may have ushered in the case. Alcoholic iDiconsciousncss is often diagnosticated when apo- plexy really exists. A man will smell of alcohol who has had one drink, but one drink will not produce coma ; hence the smell of alcohol is not conclusive. In any case of doubt some hours of watching will clear up the diagnosis. Regard a doubtful case as serious until the truth is clear. In opiiim-poisoiiing the pupils are contracted to a pin-point, the respirations are usually slow, shallow, and quiet, but may be stertorous, but there is no paralysis. Always remember that hemorrhage into the pons will produce pin-point pupils, but it also causes paralysis (crossed paralysis if in the lower half of the pons) and high temperature with sweating. In opium-poisoning the temperature is subnormal. In diabetic coma the pupils will react to a very bright light, the tempera- ture is subnormal, and the breath and the urine smell like chloroform. Treatment. — The treatment of brain-compression depends on the cause. Hemorrhage (extradural or subdural) requires trephining and arrest of bleeding ; coma from depressed fract- ure demands trephining and elevation ; foreign bodies must be removed ; abscesses must be evacuated ; some tumors are to be removed. In cerebral compression, if death is threat- ened by respiratoiy failure, make artificial respiration, and at once trephine over the supposed region of compression (Victor Horsley). Horsley has shown that irrigation of the head with hot water is of great value in bringing about reac- tion from shock in cases of brain-injury. Intracranial hemorrhage may be either spontaneous or traumatic. In the vast majority of instances spontaneous hemorrhage comes from the lenticulo-striate artery (Char- cot's artery of cerebral hemorrhage), and produces apoplexy, a disease belonging to the physician except in some ingra- vescent cases, for which ligation of the common carotid on the same side as the rupture is indicated. Traumatism during delivery is a not unusual cause of hemorrhage from the mid- dle meningeal artery (Richardiere). A traumatic hemorrhage may take place (i) between the bone and the dura {extra- 548 MODERN SURGERY. dural) ; (2) between the dura and the brain {subdural) ; and (3) in the brain-substance {cerebral). (i) Extradural heraorrhage arises from the middle meningeal or, more often, from one of its branches. A spicule of bone may penetrate a venous sinus and pro- duce extradural hemorrhage, or a sinus may rupture. Rupt- ure of the meningeal artery or one of its branches is usu- ally, but not always, accompanied by fracture ; in fact, in some cases not even a bruise can be found. The ruptured vessel may be upon the opposite side, hence the evidence of scalp-injury is not a certain sign of the side of the skull involved. The accident may or may not cause temporary unconsciousness ; but even if it does, from this unconscious- ness the patient almost always reacts, and there is a distinct period of consciousness between the accident and the lasting coma, the coma being due to pressure from a continually in- creasing mass of extravasated blood. If the main trunk or a large branch is ruptured, the period of consciousness is short ; if a small branch is ruptured, the period of conscious- ness is prolonged for hours or perhaps for days. As the clot forms and enlarges the patient becomes heavy, dull, stupid, and sleepy, he sleeps so soundly he can scarcely be aroused and snores loudly, and finally passes into stupor and then into coma. The other signs of this condition are paralysis of the side opposite the blood-clot (not necessarily of the side op- posite the injury, for the artery may rupture from contre-coup on the uninjured side) ; this paralysis is apt at first to be localized, but it gradually and progressively widens its do- main. If the clot extends toward the base, the pupil on the same side as the clot ceases to react to light, becomes immob- ile and dilates widely, and, if the clot be on the left side, aphasia is noted. As the clot enlarges adjacent centers become involved. The face becomes paralyzed, then the arm, and finally the leg. Not unusually epileptiform attacks occur, starting in discharges from the centers which are irritated by the advancing clot before their function is abolished by press- ure. The pulse becomes full, strong, usually slow, but occasionally frequent ; the breathing becomes stertorous ; the temperature rises, that of the paralyzed side exceeding that of the sound side. In a compound fracture the pressure of escaping blood may force brain-matter out of the wound (Keen). In extradural hemorrhage from a sinus the symp- toms cannot be differentiated from those produced by arterial rupture. Treatment. — In treating extradural hemorrhage localize DISEASES AND INJURIES OF THE HEAD. 549 the clot, not by the seat of the wound or contusion, but entirely by the symptoms. To reach the middle meningeal artery or its anterior branch, trephine one and one-fourth inches back of the external angular process, at the level of the upper border of the orbit (Kronlein) (Fig. 164). If this incision does not expose the clot, trephine again at the level of the upper border of the orbit and just below the parietal eminence. The first incision gives access to the trunk and to the anterior branch ; the second incision exposes the poste- rior branch. If signs indicate that the clot is travelling to the base, the trephine should be used half an inch lower than the point first indicated. Arrest bleeding by a suture ligature or by packing (page 266), and always open the dura and inspect the brain. By this procedure a subdural hem- orrhage may be discovered which, without it, would have been missed. Drainage must be employed. (2) Subdural hemorrhage is usually due to depressed fracture and rupture of the middle cerebral artery or of a number of small vessels. The symptoms are identical with those of extradural bleeding, but are usually very rapid in onset. The treatment is trephining at the first point, enlarging the opening upward and backward with a rongeur, opening the dura, turning out the clot, Hgating the bleeding point or packing, elevating any depression of bone, draining, and stitching the dura with catgut. Hemorrhage from internal pachymeningitis requires the same treatment. (3) Cerebral Hemorrhage. — The symptoms of cerebral hemorrhage are identical with those of apoplexy. The trcat- fnent is the same as that for apoplexy, except in ingravescent cases, when the common carotid on the same side as the clot may be ligated. Rupture of a sinus usually arises from compound fract- ure or during a brain-operation. The treatment, if the rupture happens from fracture, is trephining. Enlarge the opening by the rongeur, pack with 07ie large piece of iodo- form gauze, or catch the rent with hemostatic forceps, leav- ing them in place for three or four days, or apply a lateral ligature or a suture ligature. Elevate depressed bone. In rupture during an operation control hemorrhage by packing. Fractures of the skull may be simple, compound, de- pressed, non-depressed, or punctured. They are divided into fractures of the vault, usually due to direct force, and fract- ures of the base, due to extension of fractures of the vault, to indirect violence (a fall upon the feet, the buttocks, or the 550 MODERN SURGERY. vault), to forcing of the condyles of the lower jaw against or through the base, or to foreign bodies breaking through the orbit, vault of the pharynx, the ear, or the roof of the nos- trils. Fracture by contre-coup, which occurs on the side opposite the application of the violence, is very rare. Fract- ures of the skull are uncommon in early youth, but they are much more frequent in the aged. Usually the entire thickness of the bone is fractured, but either the outer or the inner table may be broken alone. In complete fractures the inner table is broken more extensively than is the outer table, because the inner table is the more brittle, because the force diffuses, and also, as Agnew taught, because the inner table is part of a smaller curve than is the outer table, and violence forces bone-elements together at the outer table, but tears them asunder at the inner table (Figs. 173, 174). Fig. 173.— Section of outer and inner Fig. 174. — Greater yielding of the inner tables, with two parallel lines (after Ag- table than of the outer after the applica- nev/). tion of violence (after Agnew). Fractures of the Vault. — A fracture of the vault of the skull may be simple and undepressed, or it may be depressed, compound, or comminuted. A mere crack may exist in a bone, and if a rent exists in the soft parts, a bit of dirt or a hair may be caught in the crack. Fractures of the vault arise from direct force. A fissure may escape recognition, although in some cases percussion gives a "cracked-pot" sound. Any considerable depression can be detected. Tn a simple fracture occasionally the cerebrospinal fluid collects under the scalp and forms a tumor which pulsates and be- comes tense on forcible expiration (puffy tumor of Pott), Compound fractures can be readily recognized, but do not mistake a suture, a Wormian bone, or a tear in the pericra- nium for a fracture. A fissured fracture is marked by a dark line of blood which sponging will not remove. Fracture of the inner table alone can only be suspected (Keen). The prognosis of fractures of the vault depends upon the extent of brain-injury rather than upon the extent of bone-injury. Simple fractures unite by bone; compound fractures with loss of bone unite only by fibrous tissue. The dangers may DISEASES AND INJURIES OF THE HEAD. 55 1 be immediate (hemorrhage, brain-injury, and septic inflamma- tion) or be distant (epilepsy, insanity, and persistent headache). Treatment. — A simple fracture without depression and without brain-symptoms is treated expectantly (by rest, quiet, low diet, purgation, moderate elevation of and cold to the head, and arterial sedatives). A simple fracture with moderate depression and without cerebral symptoms is treated expectantly, and so also is a simple fracture in which symptoms existed but are abating. Simple fracture with marked depression requires immediate trephining, even when brain-symptoms are absent. Some surgeons make an excep- tion in young children, and wait awhile before trephining, in the expectation that the expansile brain will lift the de- pressed but elastic bone up to the level. Trephining in cases where no symptoms exist, although there is marked depression, often prevents disastrous consequences arising in the future, and is known as " preventive trephining " (Agnew, Keen, Horsley, Macewen, v. Bergmann, and others). In all compound fractures, shave and asepticize the entire scalp, enlarge the incision, and explore the bone. If a fissure exists it must be asepticized, and if a hair or other foreign body is found in it, in order to effect removal and se- cure asepsis the outer table of the skull must be cut away with a chisel, the fissure being thus converted into a broad groove. In a compound fracture with much depression, trephine, elevate, and irrigate. In any fracture, trephine if distinct symptoms exist. In punctured wounds of the brain (punctured fractures), ahvays trephine, open the dura, and disinfect (Keen). In any case of fracture of the vault where trephining has been performed, it is wise to open the dura and examine the brain. Fractures of the Base. — A fracture of the base of the skull may exist in only one of the three fossje, in two of them, or it may involve all. The middle fossa is oftenest involved. Fracture of the posterior fossa is the most fatal. These fractures may be due to direct violence, to indirect force, and to extension of a fracture of the vault. Extension from the vault is always by the shortest route. Fracture by direct violence may arise from the penetration of the nasal roof, the orbital roof, or the pharyngeal roof by a foreign body. The posterior fossa may suffer from a fracture by direct violence applied to the neck. Fractures by indirect force may arise from blows upon the frontal bone (the orbital portion of the frontal or the cribriform process of the eth- moid breaking), from falls upon the chin (the condyle of the 552 MODERN SURGERY. jaw breaking the middle fossa), or from falls upon the but- tocks, the knees, or the feet (fracture occurring in the poste- rior fossa). The base is very rarely broken by contre-coup (Treves). Symptoms. — Fractures of the base of the skull are apt to be compound. A solution of continuity in the pharynx, roof of the nares, orbit, or ear, permits access of air to the seat of fracture and allows blood and cerebrospinal fluid to flow externally. In fracture of the anterior fossa the fracture may be compound, because of laceration of the mucous mem- brane of the nares or of the conjunctiva. Blood may run from the nose, its source being the vessels of the mucous membrane or the dura, the fracture being compound. Epis- taxis does not prove the fracture to be compound, but only suggests it ; but if the epistaxis is prolonged, the probability is greatly increased; and if the flow of blood is succeeded by a flow of cerebrospinal fluid the diagnosis of compound fracture is positive. Cerebrospinal fluid only appears when the mu- cous membrane, the dura, and the arachnoid are each lacer- ated (Treves). In fractures of the anterior fossa blood is apt to flow into the orbit, producing subconjunctival ecchymosis, and some blood is often swallowed and vomited. In fractures of the middle fossa blood may flow from the ear through a tear in the tympanum, its source being the vessels of the tympanum, the meningeal vessels, or a sinus. Blood may flow through the Eustachian tube and come from the nose, may be spit up, or may be swallowed and vomited. In many cases a quantity of cerebrospinal fluid flows from the ear, the discharge being increased by expiratory effort and a position which favors gravity. The cerebrospinal fluid must not be confused with either blood-serum or liquor Cotunnii. The cerebrospinal fluid is always present in large amount ; the liquor Cotunnii can only be present in minute amount. Blood-serum is highly albuminous ; cerebrospinal fluid is a serous fluid of very low specific gravity, never shows more than a trace of albumin, and contains considerable chlorid of sodium and in some instances sugar, which, when present, reacts to Trommer's and to Moore's tests, but does not reflect polarized light nor ferment with yeast (Keetley, from Collins). Treves states ^ that cerebrospinal fluid cannot flow from the ear in fractures of the middle fossa unless (i) the line of fracture crosses the internal meatus, (2) unless the prolonga- tion of the membranes into the meatus is torn, (3) unless a communication exists between the internal ear and tympa- ^ Applied Anatomy. DISEASES AND INJURIES OF THE HEAD. 553 num, and (4) unless the drum-membrane is torn. Miles of Edinburgh ' claims that bleeding from the ear followed by a flow of cerebrospinal fluid is not pathognomonic of fracture of the middle fossa of the base. He maintains that when the drum is ruptured we may have these signs, when bone is not broken, the chief source of the blood being the vessels of the pia and temporosphenoidal lobe, the blood and cere- brospinal fluid flowing inside the sheath of the auditory nerve, passing into the vestibule, through the lamina crib- rosa, and from the vestibule into the middle ear, finding exits from this space by way of the Eustachian tube, and also through the rent in the drum-membrane. Profuse serous discharge may flow from the ear after an injury without fract- ure when the drum is ruptured, the fluid coming from the cells of the mastoid. It must be understood that fracture of the base may exist when there is no flow of blood or of serous fluid. A fracture of the middle fossa is usually com- pound, made so, even when the drum is not ruptured, by the Eustachian tube. In fracture of the posterior fossa blood accumulates beneath the deep fascia and produces discolora- tion in the line of the posterior auricular artery (Battle's sign), the discoloration first appearing near the tip of the mastoid. The discoloration appears in the line of nerves and vessels which emerge from the deep fascia, the vessels passing through openings and the extravasated blood emerg- ing from the same openings. Fractures of the posterior fossa are apt to be compound through the pharynx, and in such cases the patient spits or vomits blood. Compound fract- ures of the posterior fossa are more fatal than fractures in either of the other fossae. Fractures of the base are apt to be associated with paralysis of cranial nerves. Optic neuritis often arises after the first week. Keen says that in fractures of the base the temperature is subnormal during the shock, rises to 100° to 101°, falls again to a little below normal, and remains normal or subnormal unless there be inflammation or sepsis. Treatment. — In treating a compound fracture of the base of the skull, collect any serous discharge and analyze it, and disinfect any cavity involved. In fractures of the middle fossa with ruptured drum clean the ear mechanically, wash it out with hydrogen peroxid and with a stream of warm corrosive- sublimate solution of a strength of i : 2000 (turn the head toward the affected side while washing, so that the mercurial solution will not run down the Eustachian tube), pack with ' Edinburgh Med. Jour., Nov., 1895. 554 MODERN SURGERY. iodoform gauze, and apply an antiseptic dressing. Several times daily the ear is to be irrigated, and insufflated with iodo- form. The nasopharynx must be frequently irrigated with normal salt solution or boric-acid solution, and insufflated with iodoform. The conjunctival sac is frequently irrigated with boric-acid solution. If after a head-injury blood accu- mulates back of the drum, this membrane should be incised to permit of drainage and disinfection. In fractures of both the middle and anterior fossae the nasopharynx must always be cleaned. The exact method depends on the choice of the surgeon. We may wash out these cavities frequently with hot water, next with peroxid of hydrogen, and finally with boric-acid solution, or can use normal salt solution. Insuf- flate the nasopharynx with iodoform, and pack the nose with iodoform gauze (Keen, Dennis) ; also cleanse the con- junctival sac frequently. In some cases drainage has been obtained from the anterior fossa by breaking down the crib- riform plate and introducing a tube through the nostril (Allis), and from the middle fossa by trephining above and behind the external auditory meatus. In a compound fract- ure of the orbit disinfect and drain. It may be necessary to trephine the roof of the orbit for drainage. In fracture of the posterior fossa examine to see if the fracture is com- pound, into the pharynx, and if it is cleanse with great care the nasopharynx, and mouth, as previously directed. In a very extensive fracture of the base, besides use of the methods set forth above, the entire head should be shaved and a plaster cap be applied. Cases of fracture of the base must be put into a quiet and darkened room and be kept upon a low diet, sleep being secured, and the bowels and bladder being attended to. If we are not sure whether a fracture exists or not, keep the man quiet and in a darkened room, and on a low diet. Attend to the bladder, keep the bowels loose, examine the nasopharynx with mirrors and the drum through a speculum. Wounds of the brain are produced by violence and by foreign bodies (knives, bullets, etc.). Except when due to penetration of a fontanelle in a child or of a parietal foramen in adults, wounds of the brain are accompanied by fracture of the skull. These wounds are very dangerous : foreign bodies (bone, hair, clothing, etc.) are often lodged in the brain, hemorrhage is usually severe, and sepsis is almost inevitable without proper treatment. These cases are very fatal, though some astonishing recoveries are on record. The syraptoms of brain-wounds may be slight and long- DISEASES AND INJURIES OF THE HEAD. 555 deferred or may be immediate and overwhelming ; they depend upon the site and extent of the injury. Localizing symptoms may exist, and encephaHtis with coma is apt to arise. Abscess not unusually follows. In treating wounds of the brain always shave the entire scalp and examine the weapon, if possible, to see if a piece were broken off. Asepticize, enlarge the wound, trephine, arrest bleeding, elevate any depression, remove foreign bodies, irrigate the wound, suture the dura, drain, and dress. Gunshot- wounds of the Head. — A penetrating wound is one in which the bullet enters the head, but does not emerge ; a perforating wound is one in which the bullet passes through the head and emerges. The bullet of the modern rifle will rarely lodge, but a pistol-bullet will often lodge. The wound of entrance is small ; the wound of exit is large. At the wound of entrance the inner table is more extensively fractured than the outer table ; at the wound of exit, the outer table is more widely broken than the inner table. In these cases there is always great concussion, and concussion-symptoms exist even when the bullet has not entered the brain. In moderate concussion the action of the heart is retarded ; in severe concussion it is accelerated.^ A bullet may be lodged within the cranium when merely a fracture without a bullet-hole can be detected. In these cases the bullet produces a fracture and enters the cranium, and then the depressed bone flies back into place (v. Berg- mann). In such cases if complete perforation occurs, the one existing opening is the opening of exit. A bullet may lodge in the bone, between the dura and the bone, in the brain, between the dura and bone of the opposite side, or in the bone of the opposite side, in the nasal fossa, maxillary antrum, or orbit. Always examine the side of the head opposite to the wound of entrance to determine if there is any bulging or fracture. A bullet may pass or cross the brain and be deflected from the inner surface of the skull (Fluhrer). Ruth does not believe the bullet can re- bound from the opposite wall.^ The secondary symptoms of gunshot-wounds of the head are varied and uncertain, and may not be observed at all before death. Fowler wisely points out that a patient with a gunshot-wound of the head may have also received other injuries, and the other injuries may be in part, at least, responsible for cerebral symptoms. ^ Fowler, in Annals of Surgery, Nov., 1895. '^ See the instructive article by Fowler, in Annals of Surgery, Nov., 1895. 556 MODERN SURGERY. Treatment. — Bring about reaction (see Concussion). In severe cases apply heat to the head, and make artificial respi- ration. It will sometimes be necessary to operate while arti- ficial respiration is being made. In treating gunshot-wounds of the head shave and asepticize the whole scalp, disinfect the entire track of the ball, and arrest hemorrhage at the wounds of entrance and exit, using the rongeur to expose the bleed- ing points if the bullet be large, employing the trephine if it be small. If the bullet has emerged and has been picked up, examine it to see if it is entire. The bullet, if retained, is to be sought for. Place the head in such a position that the track of the ball will be vertical, then introduce Fluhrer's aluminum probe and let it find its way by gravity. The probe may find the ball near the wound of entrance, in which case extract the ball with forceps ; or the probe may find the ball near the opposite side of the head, in which case make a counter- opening through the bone at a point the probe would touch if it were pushed entirely across. Take a new and clean rubber catheter (No. 9, French), insert a stylet, and carry the catheter through the wound (Keen). Knowing the depth of the ball, search for it around the catheter-tube as an axis, and when found extract it. After extraction drain the wound by means of a tube. When a counter-opening exists drain through and through. If the ball cannot be detected, drain by a tube carried to the depths of the wound. After dressing always place the head in a position favor- able for drainage. Fluhrer tells us that when a counter- opening fails to disclose the bullet, use the new opening as a doorway through which to search for the ball. He believes the bullet is not unusually deflected. The angle of reflection is somewhat greater than the angle of in- cidence, and the bullet is apt to fall a little toward the base. Splinters of bone are often driven into the brain by a bullet, and these are removed whether the ball is found or not. Several varieties of probes have been com- mended. Fluhrer uses a large-sized aluminum probe. Senn uses an instrument shaped like the Nelaton probe, but of the same diameter as the bullet. (Of course, the porcelain probe will not show a black mark from contact with a modern bullet.) Fowler uses a graduated pressure-probe ; so long as the pressure is within the limits of the spring, as shown by the scale, the probe is in the bullet-track. Girdner's telephonic probe is a valuable aid to diagnosis. Recently bullets have been located by the Rontgen rays. There can be no doubt that many gunshot- wounds have DISEASES AND INJURIES OF THE HEAD. 557 been recovered from without operation, and there can be no doubt that many deaths follow operation (about 33^ per cent., according to Hahn). Von Bergmann is so impressed with these facts that he does not operate when symptoms are absent. Fungus cerebri (hernia of the brain) rarely contains true brain-substance. It is in most instances a growth from the neuroglia. Hernia cerebri cannot occur if the dura is not opened ; it is rare in any case unless the brain is damaged, and is most frequent after septic wounds. In any brain- operation where the dura is opened suture it ; or, if there be a great gap in the dura, turn in a flap of pericranium, its bone-forming surface being upward, and stitch this mem- brane to the dura (Keen). The evidence of brain-hernia is a protruding mass which is soft, lobulated, of a dirty-white color, pulsating, painless to the touch, often bleeding, and sometimes discharging cerebrospinal fluid. In treating brain-hernia employ antiseptic dressings. Skin-grafting benefits some cases. Pressure is dangerous. Excision by the knife or cautery does no good. After healing, a depres- sion marks the site of the hernia. Traumatic inflammation of the brain and its mem- branes is divided into encepJialitis or cerebritis, inflammation of the cerebrum ; cerebellitis, inflammation of the cerebellum ; meningitis, inflammation of the meninges ; ai-achiitis, inflam- mation of the arachnoid ; pachynieningitis, inflammation of the dura; and leptomeningitis, inflammation of the arachnoid and pia. Pachymeningitis. — Inflammation of the external layer of the dura is called pachymeningitis externa. It may arise from tumor, caries, necrosis, middle-ear disease, sunstroke, or traumatism. Syphilis is a not unusual cause. The other membranes may become involved. Suppuration may arise, having extended by contiguity from neighboring parts. The symptoms of pachymeningitis externa are uncertain. They resemble often those of leptomeningitis (page 558). Pressure- symptoms may arise. Headache is always present. Paralysis may or may not exist. If pus forms, the ordinary constitu- tional symptoms of suppuration arise (high temperature and sweats), not the symptoms of abscess in the brain. In a severe case the other membranes become involved. The treatment consists in removing the cause (carious bone, pus, middle-ear disease). In pachymeningitis from traumatism it is sometimes advisable to trephine in order to drain inflammatory products ; in a case with localizing 558 MODERN SURGERY. symptoms always trephine ; in an ordinary case, without pus and with no evidences of traumatism, use wet cups back of the mastoid processes, apply an ice-bag to the head, and purge by means of calomel. Use iodid of potassium in most cases. If sunstroke is the cause, treat accordingly. Pachymening-itis interna may extend from the pia, or may extend from the outer layer of the dura. The form known as hematoma of the dura mater, or pachymeningitis interna haemorrhagica, may arise during infectious diseases (typhoid fever and rheumatism), in persons of the hemor- rhagic diathesis, in diseases causing atrophy of the brain, in chronic diseases of the heart and kidneys, and in syph- ilitics. Among the exciting causes are traumatism, in- flammation in adjacent parts, and, especially, the abuse of alcohol. In this disease blood is extravasated on the inner surface of the dura. Many observers do not class hemor- rhagic pachymeningitis as inflammation, but regard the hemorrhage as primary. The symptoms of internal pachymeningitis are very chronic, are not characteristic, and tnay be absent. They consist usually of persistent headache and apoplectiform attacks, with contraction of the pupil, slow pulse, and vom- iting. ■ Choked disk is not infrequent, localizing symptoms may be made out, and coma is apt to arise. The treatment is the same as that for external pachy- meningitis. Acute leptomeningitis is a purulent inflammation of the soft membranes of the brain. The pathological changes can be noted in the pia and in the brain-substance. The brain is edematous, the pia purulent, the convolutions are flattened, the ventricles are distended with fluid, and hemorrhages occur into the brain-substance. Pus may be localized upon the pia, but it is usually diffused over one hemisphere or over both. Various organisms may be found, especially streptococci, staphylococci, and diplococci. In some cases we find the bacillus pyocyaneus or the bacillus pyocyaneus foetidus, which is identical with the colon bacillus and with the bacillus meningitis purulenta (Park). Saprophytic or- ganisms are occasionally present. This disease may be acute or chronic, and a severe case is spoken of as encephalitis. Secondary leptomeningitis is apt to affect the convexity ; primary leptomeningitis is apt to aflect the base (Hirt). The causes of leptomeningitis are epidemic cerebro- spinal fever, tuberculosis, acute general diseases (pneu- monia, typhoid, erysipelas, and rheumatism), bone-diseases, DISEASES AND INJURIES OF THE HEAD. 559 traumatisms, middle-ear disease, syphilis, and sunstroke. The tissues of the pia and the cerebrospinal fluid con- tain diplococci identical with pneumococci. Infection may take place by various avenues. It may pass from the nose by way of the Eustachian tube to the ear, or from the nose to the frontal sinus or ethmoid sinuses (Hirt), and from these situations to the brain. It may pass from the middle ear or mastoid to the membranes of the brain. In fractures at the base the organisms enter by way of the pharynx and the Eustachian tube, or the ear. The symptoms of acute leptomeningitis are violent headache persisting during delir- ium, flushing of the face, rigidity of the neck, cerebral vom- iting, a slow pulse, elevated temperature, photophobia, con- traction of the pupils, intolerance of sound, hyperesthesia of the skin and muscles, and delirium passing into stupor and coma. A chill or a succession of chills may occur. Choked disk, strabismus, and nystagmus are not unusual. Convulsions or paralyses may occur. Death is the rule within one week. The treatment usually consists of purga- tion with calomel ; bleeding behind the mastoid processes ; cold to the head ; warm baths with cold affusions to the head ; iodid of potassium, bromid of potassium, or morphin for vomiting and headache. Some surgeons trephine in order to relieve pressure and to give exit to inflammatory products, and this procedure should be employed. It gives some hope of recovery, and the usually adopted medical treatment is practically useless ; should the patient recover, he is guarded for a long time from physical exertion, mental excitement, worry, irritation, constipation, and insomnia. Chronic Iveptomeningitis (or Encephalitis). — The causes of chronic leptomeningitis are the same as those of the acute form. If traumatism is the cause, the inflamma- tion arises at a later period than it would in acute encepha- litis. The symptoms of concussion follow a head-injur>'. Days, or even weeks, after the accident, a series of symp- toms occur — namely : localized pain at the seat of injury, often accentuated by tapping ; listlessness ; irritability ; apathy regarding business affairs and home obligations, or profound depression and hypochondria with inability to attend to business. Choked disk may exist. In any case acute en- cephalitis may arise, with or without a chill. The treatment of this disease is symptomatic unless local symptoms exist. Always operate if localizing .symptoms are found. Intense local pain justifies trephining. Tubercular Meningitis (Acute Hydrocephalus ; Water 560 MODERN SURGERY. on the Brain). — This inflammatory condition is due to the bacilH of tuberculosis. In a child affected with meningitis there is often a record of a fall, the injury acting as an exciting cause by establishing an area of least resistance. Prodromal symp- toms are common (restlessness, irritability, anorexia, change of character). The disease begins with a convulsion or with headache, fever, and vomiting (Osier), the child cries out from pain (the hydrencephahc cry), and the bowels are con- stipated. The pulse is rapid in the beginning, but later be- comes slow and irregular. The pupils are contracted, there is muscular twitching, and the sleep is impaired. The tem- perature is about 103°. In the second period of the disease the vomiting ceases, constipation becomes more marked, the belly retracts, headache is not so violent, and the patient lies in a soporose condition interspersed with episodes of delirium. In this stage the pupils dilate and are often un- equal, the head is retracted, convulsions occur or limited rigidity is noted, the respirations are sighing, and if a finger- nail is drawn along the skin, a red hne develops (the tdche ch'ebrale, due to vasomotor paresis). Squint and conse- quent double vision are usual. In the last stage coma be- comes absolute and general convulsions or Hmited spasms are apt to occur. Optic neuritis exists, and the child passes to death along a road identical with that of typhoid collapse. In some cases the examination of cerebrospinal fluid with- drawn by lumbar puncture throws light upon the diagnosis. In children the base is usually involved, and the disease is apt to last from two to four weeks ; in adults the convexity of the brain is usually involved, and death is apt to occur in a few days. The treatment is like that for traumatic meningitis. Abscess of the brain is a localized collection of pus. The organisms found are noted upon page 558 (Acute Leptomeningitis). The causes are suppurative otitis media (in half of all the cases), fracture of the skull, concussion of the brain, and general septic diseases. A tubercular mass may caseate (tubercular abscess). The abscess may be between the dura and skull (extradural), adhesions forming and preventing a general leptomeningitis, between the dura and brain (subdural), or in the brain-substance (cerebral or cerebellar). Leptomeningitis may arise be- cause no adhesions form, because septic clot forms in veins or sinuses, or because infected blood regurgitates in sinuses (Park). A traumatic abscess is generally beneath the area to which the traumatism was applied, but it may be on the DISEASES AND INJURIES OF THE HEAD. 56 1 opposite side. The infection may begin in the nose (page 553), the orbit, or the middle ear. Roswell Park says in- fection may pass along blood-vessels, lymph-vessels, nerve- sheaths, or the prolongations of the membranes which extend outside of the skull. An acute inflammation of the middle ear rarely causes abscess, because an acute inflammation in sound tissues causes the formation of granulation-tissue, which acts as a barrier to infection. Chronic inflammation of the middle ear is the most frequent cause of abscess. Park tells us if the roof of the tympanum is involved, it is per- forated and abscess of the middle fossa ensues ; if the roof of the tympanum is perforated toward the mastoid antrum, the abscess arises in the temporosphenoidal lobe ; if the perfora- tion is toward the sigmoid groove, the abscess forms in the cerebellum.^ Symptoms of Abscess of the Cerebral Substance. — The symptoms due to pus-formation are as follows : there may be an initial rise of temperature, but (except in extra- dural abscess) the temperature quickly becomes normal or subnormal. Toward the end of the case the temperature may rise and the fever become linked with delirium. Surface elevation of temperature over the seat of the ab- scess is occasionally observed. A chill may or may not occur. Anorexia and vomiting are present. Urinary chlorids are diininished and the phosphates are increased (Somerville). Symptoms due to pressure are — headache (which at first is general, then local, and grows worse later in the case, and exists even in delirium : this fact dis- tinguishes it from the headache of fever, which ceases in delirium) ; pulse is very slow ; respiration tends to the Cheyne-Stokes type ; drowsiness lapses into stupor and stupor passes into coma ; paralysis of the sphincters takes place; convulsions are common; sensation is rarely impaired; and paralysis of the basal nerves may occur (third and sixth especially). The pupil on the same side as the abscess is dilated and fixed. Choked disk is not invariably found ; if it is unilateral, it is on the same side as the abscess ; if it is bilateral, it is more marked on the same side as the abscess. Localizing symptoms, spasmodic and paralytic, depend upon the center which is irritated or destroyed. In cerebellar abscess there are vertigo, vomiting, occipital headache, rigidity of the post-cervical muscles, and inco- ordination. Choked disk is often absent. Meningitis arises soon after an accident ; an abscess, more 1 Park, in Chicago Med. Record, Feb., 1895. 562 MODERN SURGERY. than a week, often many weeks, after an accident. Menin- gitis presents high temperature and the general symptoms before outhned. Mastoid disease may occasion cerebral symptoms without abscess, or it may cause abscess. In sinus-tlirombosis there is septic temperature, the veins of the face and neck are enlarged, and a clot can usually be felt in the jugular. A tumor grows slowly, usually presents almost from the start distant locaHzing symptoms, and double choked disk is frequently present. In tumor the temperature is apt to be normal. Treatment. — If abscess is due to ear disease with implica- tion of the mastoid cells, at once open the mastoid, and after this proceed to trephine the skull in order to reach the ab- scess. In any case, if symptoms of abscess exist, trephine the skull at once. If localizing symptoms are present, open over the suspected region. If localizing symptoms are not present and the cause is ear disease, trephine at Barker's point (Fig. 179). If no pus is found between the bone and dura, open the membrane. When the dura is opened, if the abscess is subdural pus will be evacuated ; if the abscess is in the brain-substance, the brain will bulge very much and will not be seen to pulsate. A grooved director is plunged into the brain, in the direction of the abscess, for two or two and a half inches (Keen). If pus is not found, withdraw the director and introduce it at another point. When pus is discovered incise the brain with a knife, enlarge the open- ing by inserting a closed pair of forceps and withdrawing the instrument with the blades open. Scrape away the granulation-tissue lining the abscess-cavity, irrigate with hot salt solution, and introduce a rubber drainage-tube ; stitch the dura, but leave an ample opening for the tube ; bring the tube out through a button-hole in the scalp, and after the first two days pull the tube out a little every day and cut off a piece. If the first trephining does not find pus, trephine again at another point. In cerebellar abscess make a flap with the base up, and trephine or gouge away the bone just below the line of the lateral sinus. Puncture the brain as for cerebral abscess. Brain Disease from Suppurative Bar Disease. — Chronic disease of the middle ear is apt to destroy the bone between the tympanum and the middle fossa of the skull, and thus produce meningitis, thrombosis of the petrosal or lateral sinuses, abscess of the temporosphenoidal lobe or of the cerebellum, or extradural abscess. Chronic otitis media also induces inflammation or suppuration of the mastoid DISEASES AND INJURIES OF THE HEAD. 563 cells (empyema of mastoid). Pus in the mastoid may dis- charge itself into the middle ear, and from this point into the external auditory canal, through a perforation in the drum-membrane (especially in acute cases). In some cases the pus becomes blocked up within the mastoid process. Pus in the mastoid may after a time break into the cavity of the cranium or into the lateral sinus, or may find its way externally and open into the sheaths of muscles aris- ing from the mastoid. It not unusually opens into the sheath of the digastric muscle (Bezold's abscess). These facts teach the surgeon that chronic ear disease should never be neglected, but should, if possible, receive the closest atten- tion of the specialist. If no perforation exists in the drum, the surgeon must make one. In ordinary cases cleanliness and antisepsis are sufficient, the ear being syringed every day with a warm 2 per cent, solution of common salt. If only a small drum-perforation exists, 10 drops of pure alco- hol or of corrosive-sublimate solution (i : 5000) are dropped into the ear daily; but if a large drum-perforation exists, boric acid and iodoform (7 to i) are insufflated. Never inject alum. A strong silver solution is not safe ; if it is used, wash the ear out afterward with warm salt water. If granulations or polypi exist, they must be removed (Burnett). Some cases require the removal of the drum-membrane and the ossicles of the ear. Many cases of mastoid necrosis are due to tuber- culosis. If headache, vomiting, and mastoid tenderness exist, open the mastoid (see Operations), in order to prevent ab- scess of the brain. In acute otitis media it is very rarely necessary to open the mastoid. The middle ear is on a lower level than the antrum of the mastoid, and in most acute cases both the middle ear and mastoid cells drain safely through a drum-perforation. Because a man has chronic otitis media it is by no means always necessary to trephine the mastoid. In many cases removal of the ossicles and drum-membrane effects a cure. In chronic otitis media, even if the mastoid is trephined, the ossicles and membrane ought to be removed. Cerebral abscess from ear disease is almost always in the temporospiienoidal lobe, but may arise in the cere- bellum. The symptoms are a transient rise of temperature followed by a subnormal temperature ; vomiting ; mastoid, frontal, and temporal pain. The mind is dull, and stupor arises which passes into coma ; the bowels are constipated ; choked disk may be present ; and convulsions or spasms or paralyses may exist. Trephine and clean out the mastoid, 564 MODERN SURGERY. and asepticize (see Operations upon the Skull and Brain). Trephine at Barker's point, one and one-fourth inches be- hind, and the same distance above, the middle of the exter- nal auditory meatus. If pus is not found, open the cerebel- lum. !^xtradural Abscess. — The eye-symptoms and pain are the same in this as in cerebral or subdural abscess, but the temperature is different, rising to 103° or 104°. There is often con.siderable tenderness above and behind the mastoid. Trephine and clean out the mastoid; follow up a bone sinus to the abscess, rongeur away the bone, avoiding the lateral sinus, curet, irrigate, and drain. Infective Sinus-thrombosis (a form of Pyemia). — The symptoins of this disease present a history of chronic ear disease ; general headache and pain over the sinus arise ; violent rigors occur ; and the temperature rises and fluctu- ates greatly. The patient is nauseated, labors under vertigo, is very restless, is dull and stupid, sometimes delirious, and the muscles of the neck are stiff. Tenderness and marked edema are detected over the mastoid. When the clot extends into the jugular vein there is pain on moving the head and on swallowing, glands are swollen, and a clot may be felt in the neck. Exophthalmos and swelling of the eyelids point to involvement of the cavernous sinus (Jansen). Choked disk exists in about half of all cases. There is usually a profuse discharge of pus from the ear. In early cases there is throm- bosis of the lateral sinus alone, or of the lateral sinus and jugular vein. In advanced cases other sinuses become in- volved (superior petrosal, inferior petrosal, both cavernous, the lateral sinus of the opposite side, the ophthalmic veins, and the torcular Herophili). A patient with sinus-throm- bosis is in great danger from pulmonary metastasis and septic meningitis (Jansen). Septic meningitis is accompanied by abscess about the sinus. The prognosis largely depends upon early recognition. The surgeon should open a mastoid before sinus-thrombosis arises, and should evacuate a perisinous abscess before a clot forms in the sinus, or at least before that clot is septic (Jan- sen). Treatment. — Infective sinus-thrombosis is treated as fol- lows : open and clean out the mastoid, and expose the sinus by the use of the chisel or rongeur (Fig. 179). Open the sinus as far as the clot is soft, and cut away the wall of the sinus. In- troduce a small spoon in the sinus and carry it toward the torcular Herophili, and scrape away the clot until blood DISEASES AND INJURIES OF THE HEAD. 565 flows. Stop hemorrhage by plugging a piece of iodoform gauze into the wound and toward the torcular. Jansen op- poses removing the entire clot toward the jugular, and does not tie the jugular, believing that to do so increases the dan- ger of thrombosis of the inferior petrosal and cavernous sinuses. Influenced by these views, Jansen removes the soft clot, but does not disturb the solid clot toward the heart. Most surgeons differ with him, and after opening the sinus, turning out the clot and packing, proceed to ligate the jugu- lar vein at the level of the cricoid cartilage. If, after this operation, the clot in the jugular becomes septic, incise the vein up to the base of the skull and pack. It is obviously futile to do any operation if pulmonary metastasis has taken place. Intracranial tumors may be true neoplasms, may be of parasitic origin, may result from injury, may be tubercular or syphilitic. Among these tumors are papillomata, gliomata, sarcomata, cholesteatomata, fibromata, psammomata, myxo- mata, osteomata, etc. (see Tumors). Cysts sometimes occur. The symptoms are diffuse and local, and are similar in many particulars to the symptoms of some other lesions. Among the symptoms of tumor are headache, slow speech, stupor or coma, slow pulse, pain on percussion of the cra- nium, vertigo, vomiting, epileptic convulsions, double choked disk, partial or complete blindness, extensive or limited paralyses, paralysis of face, of eye-muscles, or of limbs, zones of anesthesia and aphasia, word-deafness, word-blind- ness, agraphia, inco-ordination, and mental disturbances. The situation of a tumor is determined from localizing' symptoms, their mode of onset and manner of combina- tion. In some cases the symptoms are not character- istic, and in some cases there are no localizing symp- toms. The nature of the tumor, its depth, and whether it is single or other tumors exist, is, if possible, determined. Localizing symptoms may be due to irritation or destruction of functionating power. Irritation causes spasm and destruc- tion induces paralysis. Convulsions which are local or which begin locally are known as Jacksonian epilepsy. A local convulsion points to an irritative lesion of, or immediately adjacent to, the center which presides over the muscular movements of the part convulsed. Local paralysis points to a destructive lesion of the center which presides over the movements of the paralyzed part. In some cases a center is damaged and the muscular movements it controls are para- lyzed, but the adjacent brain-areas are irritated and the mus- 566 MODERN SURGERY. cles they represent are attacked with spasms. In some cases an apparently paralyzed part becomes convulsed, the center not being completely destroyed and sudden hyperemia serv- ing to awaken spasm. Always note the order of invasion of different regions and observe if spasm is followed by mus- cular weakness or anesthesia. 1. Lesions in the Cortical Motor Area. — An irritative le- sion of the lower third of this area causes spasm of the oppo- site side of the face, angle of mouth, or tongue ; and this con- dition is often associated with tingling (Osier). The spasm may remain limited or may extend widely, and may even become general. Tumors of the third frontal convolution of the left side cause motor aphasia. An irritative lesion of the middle third of the cortical area causes spasm, which is lim- ited to or begins in the fingers, thumb, wrist, or shoulder (Osier). An irritative lesion of the upper third of the cor- tical motor area causes spasm, which is limited to or be- gins in the toes, ankle, leg, or hip. In these lesions an aura is occasionally felt in the affected region before the spasm begins, and there is often numbness after the spasm. De- structive lesions of this region cause local paralysis, which is often preceded by local spasm of the same parts^ and is often associated with local spasm of other parts. 2. Tumors of the prefrontal region give no localizing symptoms, but produce the general symptoms. Mental dis- orders are apt to occur. The tumor may grow and subse- quently involve the motor region. 3. Tumors of the parieto-occipital lobe may occupy a silent region of this lobe. There may be blindness or para- phasia when the angular gyrus is affected. 4. Tumors of the occipital lobe produce homonymous hemianopsia. 5. Tumors of the temporosphenoidal lobe frequently produce no symptoms. Tumors in the left lobe may cause deafness. 6. Tumors of any size in or about the corpus striatum cause hemiplegia by pressure upon the internal capsule. Pressure upon the optic thalamus produces hemianopsia and hemianes- thesia. Growths near the basal ganglion produce intense optic neuritis, and early pressure because of distention of the ven- tricles. Osier tells us that tumors of the corpora quadri- gemina are apt to involve the crura, and later the third nerve. Ocular symptoms are always present (loss of pupillary reflex and nystagmus). If the third nerve is involved, there are paralysis of the motor oculi area on the side of the lesion DISEASES AND INJURIES OF THE HEAD. 567 (external strabismus, dilated pupil, and drop lid), and hemi- plegia of the opposite side of the body from pressure upon the crus. This condition is known as a crossed paralysis. 7. Turaors of the Pons. — Pontine lesions produce symp- toms by pressure upon the particular nerves which come from this region, with or without the evidences of pressure upon the motor path. Forms of crossed paralysis may exist. Lesions in the low^er half of the pons may affect the fifth, sixth, and seventh nerves on the side of the lesion, and the limbs on the opposite side. The auditory nerve may be involved in the lesion. In crossed paralysis the face on the side of the limb paralysis is usually not affected, but in extensive tumors it may be paralyzed. Conjugate deviation may occur atvay from \}:iQ facial paralysis. In tumors of the upper part of the pons the pupils may be first contracted from irritation of the third nerve nuclei, and later dilated from destruction of these nuclei. Anesthesia as a result of pontine tumors is not nearly so common as is motor paralysis, and convulsions are rare. 8. Tumors of the Medulla.- — An extensive lesion inev- itably causes death. Cranial nerves only may be involved, but crossed paralysis may take place. Vomiting is com- mon, retraction of head is not unusual, respiratory and cir- culatory disturbances and dysphagia are frequently noted; sometimes there is numbness, and occasionally there are convulsions ; usually there is inco-ordination, because of pressure upon the cerebellum. 9. Tumors of the Cerebellum. — Tiiinors of the middle pe- djuiclc cause sudden uncontrollable movements of the trunk, either toward the side of the tumor or away from it. Vertigo and nystagmus are common. Symptoms are frequently com- plicated by evidences of pontine disease proper. Tuviors of the middle lobe of the ccrebelhnn cause a sense of lost equilibrium and obvious unsteadiness in attempting to walk, or even to stand (Gowers). The patient has a ten- dency to fall ; there are giddiness and vomiting. Tumors of the cerebellar hemispheres produce no localizing symptoms. The usual unsteadiness of gait is due to press- ure upon the middle lobe (Nothnagel).^ Treatment. — In brain tumors, where any doubt exists as to their nature, giv^e a course of iodid of potassium, and as doubt is the rule, we almost invariably administer it. Give at first in small amounts, but rapidly increase it until heroic 1 For full consideration of localizing symptoms, see Gowers and Osier, from which the above has been condensed. 568 MODERN SURGERY. doses are taken (loo or more grains a day). Mercury should also be given hypodermatically. If iodid of potassium and mercury relieve the symptoms, operation is unnecessary, although it may be demanded later in order to remove an irritant scar. If antisyphilitic treatment fails, the question of operation must be considered. In many cases of un- doubted tumor excision for cure is not attempted because of the absence of localizing symptoms or because of the inaccessible situation of the growth. Tumors at the base, tumors of the pons and medulla, of the corpus callosum, of the basal ganglia, of the deeper parts of the centrum ovale, are irremovable (Byrom Bramwell). Most tumors of the cerebellum should not be attacked. In tumors which are very extensive complete removal is usually out of the question. There is no use in removing secondary malignant tumors. It often happens that the brain itself (as in syphilis) is so extensively diseased, or that other organs (as in tuber- culosis) are so involved, as to render attempts at removal futile. Bramwell tells us ^ that he has studied eighty -two cases of intracranial tumors, and he considers that in only five of them could the tumor have been entirely removed. Our conclusion is that though some tumors of the brain may be successfully removed, extirpation is only to be decided on after careful study of all the indications and contraindications offered by the case. The fibromata constitute the best cases for operation. In cases not operated upon it may be neces- sary to use the bromids for convulsions and morphin for headache. The headache is often benefited by purgatives, courses of potassium iodid, the ice-bag to the head, and the application of a hot iron to the nape of the neck. Though thorough extirpation is feasible in but few cases, operation should often be performed for palliative purposes. Grainger Stewart, Annandale, Horsley, Macewen, and Keen have ad- vocated palliative trephining in certain cases. This procedure is of value in diminishing excessive intra- cranial pressure, and thus relieving headache and decreasing the tendency to sudden death from inhibition of the heart (Hughlings Jackson and Byrom Bramwell) or respiratory failure. Palliative trephining will relieve optic neuritis and thus tend to prevent atrophy and blindness. Bramwell asserts this positively, and he still believes that high pressure is an important element, though not the only element in neuritis. Most cases of tumor should be trephined for exploration ; 1 Edin. Med. Jour., June, 1894. - DISEASES AND INJURIES OF THE HEAD. 569 in some cases extirpation may be performed ; in most cases ex- tirpation is impossible, and the surgeon must be content with the palliative influence of trephining. A tumor of the brain is of necessity fatal if unoperated upon, and trephining is not a very dangerous operation. After palliative trephining, make an attempt to obtain prolonged drainage of cerebrospinal fluid. Operative Treatment of Epilepsy. — The shock of an accident or a general concussion may establish epilepsy, especially in those predisposed by heredity or other causes. Traumatic epilepsy, Le Dentu tells us,' may be due to : (i) bone-fragments from skull-fracture; (2) outgrowths of bone due to tumor; (3) cicatrices of meninges resulting from- laceration of membranes by bone-fragments ; (4) chronic meningitis which ends in sclerosis of membranes ; (5) cysts resulting from intracranial hemorrhage at the point of fracture ; (6) arteriovenous aneurysm. We refer here, in speaking of traumatic epilepsy, purely to the condition when it follows a head-injury, and this is the common meaning of the term. When epilepsy has followed trau- matism and a scar exists upon the scalp, excise the scar, especially if it is tender or is the seat of an aura. If, on hfting the scalp, a depression of bone or a disease of the bone is manifest, trephine for exploration, even over a silent area. Remember that epilepsy, as shown by Sachs, may follow a long-forgotten injury. Where the injury is over a known center, trephine. This operation is especially indi- cated when the convulsions begin in the muscles of this center, in which case remove the center after trephining. Remove all sources of peripheral irritation (Briggs reported a case of epilepsy in which there was distinct skull-depres- sion and necrosis of the tibia, but the cure of the necrosis of the tibia stopped the fits). Trephining in epilepsy may disclose a cyst, a dural scar, a brain-scar, a depressed portion of bone, or eburnation of bone from osteitis (Keen). In ex- ploratory operations for epilepsy always open the dura. If epilepsy arises notwithstanding a primary trephining, open the flap, round the bony edges with a rongeur, and cut out the scar.^ These operations sometimes seem to cure, but so, occasion- ally, does any operation. White records ^ ninety trephin- ^ La Presse Midi rale, June 9, 1894. ^ The author, in Hare's System of Practical Therapeutics. ^ " The Supposed Curative Effects of Operations per se," Annals of Surgery, August and September, 1891. 570 MODERN SURGERY. ings in which, though nothing was found, great relief fol- lowed, and two cases were apparently cured ; he mentions benefit or apparent cure following tracheotomy, ligation of the carotid, incision of the scalp, etc. The same effect may be obtained by a great shock, high fever, the administration of an anesthetic, or an accident. The fact seems to be that any- operation, by means of nervous shock, may interrupt the epileptic habit ; but in ordinary operations the fits tend to recur, and soon reach their old standard of frequency. In the special brain-operations with excision of obvious lesions or discharging centers the fits usually recur, but they will rarely reach the old standard of frequency, and will be more amenable to medical treatment. Bramwell says that when traumatism is followed by epilepsy and the epileptic discharge starts from a cortical center which is not beneath the scar, trephine first at the seat of injury, and if no lesion is met with, trephine over the discharging center. In epilepsy the fits are to be studied by a competent observer (Keen), and, if focal epilepsy or Jacksonian epilepsy exist, and treatment by drugs has failed, trephining is to be performed over the diseased center and the explosive focus is to be located by an electric current and removed. Keen, Horsley, Nancrede, Macewen, and others practise this, but hope for improve- ment rather than expect cure. This operation causes paraly- sis, but the paralysis is rarely permanent, except, perhaps, of the finer movements. In non-traumatic chronic epilepsy without localizing symp- toms trephining is not justifiable unless persistent headache calls for it as a means of relief from intracranial pressure. Annandale has recently advised us to consider experimental operation in such cases when the drug-treatment has failed and when the patient's condition seems hopeless. He says there is no chance of improvement without operation, and operation may possibly disclose a removable lesion.^ After trephining for epilepsy five years should elapse without a convulsion before cure is reasonably assured; and if con- vulsions arise, they must at once be met by medical treat- ment. A man having once had a convulsion may at any time have others ; hence he should always be watched. It is not unusual for a few convulsions to occur soon after an operation, and then to cease for a considerable time. These early fits result from habit. Among the operative procedures suggested for the treatment of epilepsy may be mentioned circumcision, clitoridectomy, ocular tenotomy, ligation of the ^ Edin. Med. Jour., April, 1894. DISEASES AND INJURIES OF THE HEAD. 571 vertebral arteries, removal of the cervical ganglia of the sympathetic (Alexander), and the actual cautery to the head (Fere). Operations on the Skull and Brain. — Trephining (in a fracture of the skull). — Shave the scalp, wash it with ethereal soap, then with ether, scrub with a brush wet with corrosive-sublimate solution (i : 1000), and wrap up the scalp in wet corrosive-sublimate gauze (i : 2000). The instruments required are a scalpel, an Allis dissector, hemo- static, dissecting-, and toothed-forceps, trephines of several sizes (Figs. 175, 176), a periosteum-elevator, a Hey saw, Fig. 175. — Gait's conical trephine. Fig. 176. — Crown trephine. rongeur forceps, a bone-elevator, a dural separator, a tenac- ulum, small curved and large curved Hagedorn needles, and a needle-holder, catgut, fine silk, silkworm-gut, and Horsley's wax. Provide a sand pillow. The patient is anesthetized unless he is unconscious. The patient lies upon his back, the shoulders are a little raised, the sand pillow is placed under the neck, and his head is turned away from the side to be operated upon. The position of the surgeon is such that the patient's head is a little to his left. A large semilunar incision is made with the base down, which incision goes through the periosteum, and the flap is lifted. The bleeding vessels of the flap are caught with forceps. The fracture is sought for and found. The pin of the trephine is projected beyond the crown and is set upon sound bone, the crown overhanging the line or edge of the fracture. The surgeon tries to avoid the region of a sinus or large artery. A gutter is cut in the bone, the pin is withdrawn, and the trephining is completed. In going through the diploe bleeding is copious. The inner table feels very dense. Stop from time to time, clean out the gutter with the dissector, and try the bone with an elevator 572 . MODERN SURGERY. to see if it is loose. When the fragment is loose enough, pry it out and hand it to an assistant, who places it at once in a bowl of solution of corrosive sublimate (i : 2000), kept warm by standing in a basin of water at 105°, or who puts it in warm carbolized towels or in warm normal salt solution. The edges of the opening are rounded with a rongeur and the bone is elevated. Sometimes it may be necessary to re- move splinters and fragments of bone. The dura should be ex- amined to see if injury exists, and hemorrhage must be stopped. Bleeding from the dura is arrested by passing a hgature of silk or catgut under the vessel on each side of the wound. This is effected by means of a curved needle. Bleeding from the pia is arrested by direct ligation, or in the same way as is bleeding from the dura. Bleeding from the diploe is arrested by the use of Horsley's wax. The wound is cleansed, the button of bone is re-introduced, or some chips are cut from the bone and scattered upon the dura. The scalp is sutured with silkworm-gut and horse-hair or gauze drainage is em- ployed for a day or two. Sterilized gauze dressings are put on, a rubber-dam is laid over them, and a gauze bandage wet with bichlorid of mercury is applied. Instead of the trephine some surgeons use the chisel, or gouge, and hammer to remove a portion of the bone. Other operators maintain that this procedure may cause concussion, and employ the surgical engine. After removing the frag- ments the edges of the opening should be smoothed by the use of the rongeur forceps. Osteoplastic Resection of the Skull. — Wagner devised the osteoplastic method of resection. It is employed for the re- moval of tumors and the Gasserian ganglion, and for explora- tion. A horseshoe incision is made through the scalp and periosteum, a groove corresponding to this incision is chiselled in the bone, the bone is chiselled through, but is left attached to the scalp. The bone is then broken outward, the fracture taking place at the base of the bone-flap. After the opera- tion the bone which is still adherent to the pericranium is restored to its proper place. Some surgeons use the surgical engine instead of the chisel, and others make trephine-open- ings and cut from within outward by means of the Gigli wire saw (Obalinski). The osteoplastic method of opening the skull is employed when a large opening is necessary, as when the operation is first of all for diagnosis. Krause, Keen, and others employ this plan in operating to remove the Gasserian ganglion. Doyen of Rheims has advocated the most extraordinary DISEASES AND INJURIES OF THE HEAD. 573 exploratory operation. He sections the vault of the skull from before backward near the median line and forces one entire side outward, thus exposing half of the brain. Besides restoring a flap of bone into position, or replacing a button of bone, or strewing the dura with bone-fragments, other methods of closing the opening have been practised. For instance, heteroplasty with decalcified bone-plates and heteroplasty with celluloid plates or other foreign material.^ Trephining the Frontal Sinus. — This operation may be employed for inflammation of the lining membrane of the sinus or for empyema. Make a vertical incision in the mid- dle of the forehead, starting one and one-half inches above the nasion and terminating at the root of the nose. The button of bone is removed and the opening is enlarged if necessary. The mucous membrane is incised, the opening into the nose is found and is dilated, and a drainage-tube is passed into the nose from the sinus, the upper end being left in the sinus. In some severe cases Jacobson advises us to first curet the sinus, to disinfect it by the use of silver nitrate or chlorid of zinc, and to insufflate an " aseptic powder." In some cases resect the mucous membrane. Some surgeons prefer an osteoplastic resection to trephining. Trephining the Mastoid (page 575). Technique of Brain-operations (after Horsley and Keen). — Instruments as for fractured skull. In focal epilepsy a fara- dic battery is required. Always shave the scalp, and always antisepticize it. In localizations, mark out the fissure upon the scalp with an anilin pencil or with iodin. Have the patient semi-recumbent. Mark three points upon the bone with the center-pin of the trephine before incising the scalp (both ends of the Rolandic fissure and the point at w^hich the trephine will be applied). Make a semilunar flap three inches in diameter, with the base below. Control bleeding in the flap by forceps pressure. The one and a half inch trephine should be employed, but if a smaller trephine is used, the opening must be enlarged with a rongeur. Before enlarging the opening, separate the dura from the bone by a dural separator. As a rule, open the dura and examine the brain. The dura is lifted by rat-toothed forceps and is opened with scissors along a line a quarter of an inch from the bone-edge, a broad pedicle of dura being left uncut. Hemorrhage is arrested by pressure and hot water, or by passing a curved needle threaded with catgut around any bleeding vessel. In some cases packing must be left in or 1 See Bretans, in Detiische med. Woch., May 17, 1894. 5 74 MODERN SUR GER V. forceps must be kept on. In packing, never use more than one piece of gauze, so as to avoid leaving in a forgotten piece. Upon opening the dura cerebrospinal fluid flows out, the stream being increased with each expiration. Absence of pulsation of the brain points to tumor, and a livid color indicates subcortical growth. An old laceration is brownish. If the brain bulges through the opening, it means increased pressure (tumor, abscess, effusion into the ventricles, etc.). After opening the dura employ no antiseptics except normal salt solution, especially when the surgeon intends using elec- tricity to locate a center. Remove any abnormal brain-tissue which is found. In operating for tumor the dura is opened and in some cases the brain is incised. The tumor is turned out by the finger, or, if this is impossible, by the dry dissector, the scissors, or the sharp spoon. If the entire tumor cannot be removed, take away as much as possible. The removal of a portion retards the growth of the remainder (Horsley), and the trephining, by lessening cerebral pressure, relieves the symptoms and prolongs life. After removing a tumor arrest distinct points of bleeding with the ligature alone or the ligature passed around the vessel by means of a needle. Pack the tumor-cavity with gauze and bring the end of the plug out of the wound. Stitch the dura with silk and suture the scalp with silkworm-gut. In electrifying the brain faradism is employed of a strength about sufficient to rnove the thenar muscles when applied to them. The current is applied to the motor area by the double electrode. A careful observer watches the muscular movements. If, for instance, the surgeon wishes to remove the thumb-center, he moves the electrode from point to point until he obtains thumb- movements. The region is sHced away bit by bit until the current applied to this zone no longer causes thumb-move- ments. It will be found impossible to remove only the thumb- center. Adjacent centers are sure to be more or less dam- aged, and a certain amount of paralysis follows the operation. If we wish to tap the ventricles. Keen directs that the tre- phine-opening be one and one-fourth inches behind the exter- nal auditory meatus and the same distance above the base-line of Reid (Fig. 179, a). A grooved director or metal tube is passed into the brain in the direction of a point " two and one-half to three inches above the opposite meatus." The normal ventricle will be entered at a depth of two to two and one-fourth inches, but the dilated ventricle will be entered sooner (Keen). The moment of entry is marked by lessened resistance and a flow of cerebrospinal fluid. Drainage can DISEASES AND INJURIES OF THE HEAD. 575 be maintained by introducing a rubber tube. This operation has been employed in hydrocephalus. After an aseptic cere- bral operation, as a rule, do not drain unless hemorrhage has been considerable. In many cases replace the bone, but not when the bone is diseased, is infected, or is very compact, or if it is desired to alter pressure. The dura is sutured by a continuous silk suture (Fig. 177); the scalp is sutured by interrupted silkworm-gut sutures (Fig. 178). (I Fig. 177.— Continuous suture. FiG. 178.— Interrupted suture. Operation for Mastoid Suppuration. — The instruments required in this operation are a scalpel, a gouge, a chisel, a mallet, curets, a probe, a dissector, dissecting- and hemo- static forceps, and needles. Provide a sand bag to place under the neck. An incision is made one-quarter of an inch posterior to the auricle and down to the bone, and in the direction of the long axis of the mastoid. The bone is bared and examined, especially at a point in the line of the incision which is on a level with the roof of the meatus (Fig. 179, c). The bone will usually be found softened. Gouge it away and thus open the mastoid antrum. This bone-opening is within the limits of Macewen's suprameatal triangle, a space bounded by the posterior root of the zygoma, the posterior bony wall of the meatus, and a line joining the two. If the mastoid is opened in this triangle, the antrum is entered directly and there is no chance of wounding the lateral sinus. If, in the adult, pus is not found on opening the mas- toid antrum, gouge downward and backward, but with great care, so as to avoid the lateral sinus. After evacuating the pus, scrape out the cavities with the curet, enlarge the opening between the mastoid and the middle ear with the gouge, turn the head toward the side operated upon, and irrigate the mastoid with corrosive-sublimate solution (i : 2000) ; dust in iodoform, pack with iodoform gauze for a few days, and then introduce a silver drainage-tube. Treat the causative ear disease. A. Marmaduke Sheild and Macewen operate on inveterate cases of mastoid disease as follows : a thick flap is raised behind the auricle, the flap including* the orifice of any sinus and being " left attached by 576 MODERN SURGERY. its stalk." The auricle is " detached forward and the soft parts over the mastoid are turned backward by horizontal in- cision." The " lining membrane of the canal is separated from the bone." The mastoid is opened and dead bone and caseous matter are removed, overhanging edges are chiselled down, and the posterior bony wall is gouged away. Fig. 179. — Opening the mastoid antrum and the lateral sinus ; exposure of the temporo- sphenoidal lobe and puncture of the descending horn of the lateral ventricle : a, temporo- sphenoidal lobe (descending cornu of lateral ventricle is i cm. deeper) ; b, inner surface of periosteum ; c, mastoid antrum ; d, lateral sinus (Kocher). The skin-flap is pushed into the cavity and is held in place with pads of gauze. The margins of the flap may be sutured, but this is not necessary. Macewen calls this procedure " papering " the cavity with skin.^ If mastoid suppuration has established abscess in the temporosplienoidal lobe, trephine one and a quarter inches behind and one and a quarter inches above the middle of the external meatus (Barker's point, Fig. 179, a), and search 1 Lancet, Feb. 8, 1896. SURGERY OF THE SPINE. 577 for pus as directed on page 562. If abscess of the cerebellum exists, trephine below the Hne of the lateral sinus — that is, belovv^ a line running from the inion to a point on a hori- zontal line from the roof of the meatus, one inch posterior to the middle of the meatus. If hifcctive simis-tJirovibosis exists, break into the lateral sinus (Fig. 179, d^ through the mastoid opening and proceed as directed on page 564. Linear Craniotomy. — Instruments as for any brain opera- tion, plus, however, several kinds of rongeur forceps. Make a large flap. Trephine the skull a finger's breadth from the sagittal suture, and the same distance back of the coronal suture. Rongeur the bone away in a line parallel with the sagittal suture up to a point in front of the lambdoidal suture. Remove the pericranium which covered the bone excised. Insert the dural separator, or pass it along the margins. In some cases an additional portion of the bone is removed over the fissure of Rolando. Various sugges- tions have been made as to the direction and situation of bone-sections. Bleeding is arrested and the flap is closed without drainage. Removal of Gasserian Ganglion (page 533). Operation for Infective Sinus-thrombosis (page 564). XXIV. SURGERY OF THE SPINE. Congenital Deformities. — Spina bifida, or hydrorrha- chitis, is a congenital cystic tumor due to vertebral deficiency, permitting protrusion of the contents of the spinal canal in the median line. The laminae or spines of one vertebra or of several vertebrae may be deficient, most frequently in the lumbosacral region. Meningocele is a protrusion of dura mater and arachnoid, the sac containing cerebrospinal fluid, but no nerv^es and no cord-substance. Alcningoviyelocele (the commonest form) is a protrusion of dura mater and arachnoid, the sac containing cerebrospinal fluid, nerves, and cord-substance. The cord may spread upon the sac- wall or it may pass through the sac and re-enter the canal. Syringomyelocele is great distention of the central canal, the sac-w^all being formed of the thinned cord. A spina bifida varies in size from that of a walnut to that of a child's head ; it grows rapidly during the early weeks of life ; it is usually sessile, but may present where it joins the body a definite constriction, or even a pedicle ; the base of the sac is covered with healthy skin, and the fundus is covered only by thin epidermis or by the spinal membranes 37 5/8 MODERN SURGERY. themselves. Pressure upon the tumor is found to diminish its size and to increase the tension of the anterior fontanelle, and possibly to cause convulsions or stupor. The cyst is translucent, and the margins of the bony aperture are dis- tinct. Crying, coughing, or pressure upon the anterior fontanelle makes the tumor more tense. Spina bifida is apt to be associated with club-foot, with hydrocephalus, and with rectal or vesical paralysis. Spina bifida usually causes death. A few meningoceles and a very few meningomyelo- celes undergo spontaneous cure by the shrinking of the sac. Syringomyelocele is invariably fatal. The cause of death may be rupture of the sac or marasmus. Treatment. — Very small protrusions which grow slowly and are covered with sound skin may be treated by the use of a compress and bandage, by an elastic bandage, or by applications of contractile collodion. Some surgeons tap and drain the sac. Injection is used by many. The sac being cleaned, the child is placed on its side and a little chloroform is given. A fine trocar is plunged obliquely in at the side through sound skin, little or no fluid being drawn off, and 3j of Morton's fluid is injected (iodin, gr. x ; iodid of potassium, gr. xxx ; glycerin, .Ij). The trocar is with- drawn and the puncture is sealed with a bit of gauze and iodoform collodion. The child is put to bed. If the injec- tion proves successful, the sac shrinks ; if the injection fails, it may be repeated at intervals of from seven to ten days (Jacobson, White). Many surgeons prefer excision of the sac. Bayer treats it as he would a hernia. Robson, in some cases, excises the entire sac (page 594)- Tumors of the Spine. — Among congenital tumors are lipomata and cysts (dermoid, congenital, sacral, and fetal). Tubercle, gumma, psammoma, and fibroma may arise from the cord or its membranes. Glioma is the most usual growth. Primary sarcoma is rare. Angeioma may occur. Carcinoma is never primary. A tumor rarely produces obvi- ous symptoms until it is as large as a hazel-nut. Symptoms and Treatment. — Pain, stiffness of the back, areas of anesthesia, and progressively advancing motor paralysis are symptoms of spinal tumors. A tumor may produce the symptoms of compression-myelitis, locomotor ataxia, or myelitis. In glioma there are apt to be loss of ability to recognize variations of temperature (or even to distinguish between heat and cold), loss of the sense of pain, and paresis and atrophy of muscles. Contractures or para- plegia may arise. The location of the tumor can be inferred SURGERY OF THE SPINE. $79 by a study of the territory of paralysis and the zone of sensory disturbance. The tumor is always somewhat above the upper limit of anesthesia. In many cases the diagnosis is impossible. Gradually increasing painful paraplegia, with pain in the back, or with sensory paralysis after a time ap- pearing and ascending from the feet toward the trunk, points to tumor as a cause. The reflexes are at first increased, but are finally lost from below upward. Spasms may de- velop, and lateral spinal curvature may arise. If curvature arises, the concavity of the curve will be on the side of the tumor. Growths outside the membranes produce partic- ularly pain and spasm ; growths within the membranes pro- duce especially motor paralysis and anesthesia. If syphilis is suspected, give the patient a course of heroic doses of iodid of potassium. In a focal lesion not due to dissemination of a known malignant growth perform the operation of lamin- ectomy to permit of exploration and possibly of removal. Acute osteomyelitis of the vertebrae is a rare dis- ease ; it may be associated with osteomyeHtis of other bones, but may occur alone. Infections of the viscera not unusually accompany it. Any part of a vertebra may suffer from it. This condition arises from cold, over-exertion, or traumatism, and is more common in the young than in the old. The process may be superficial, or it may involve the bone deeply and widely. Suppuration always occurs; sequestra generally form; and phlebitis is a dangerous complication. Any region of the spine may be attacked, but the lumbar region is par- ticularly liable to invasion. The situation of the abscess varies with the situation of the disease. If the bodies are diseased the pus passes forward (retropharyngeal, mediasti- nal, psoas, or pelvic abscess). If the vertebral arches suffer, the pus passes backward (lumbar or dorsal abscess). The membranes of the cord, the cord itself, the nerves, and the vertebral articulations are frequently involved in the process. Staphylococci or streptococci may be grown from the pus. Symptoms. — General symptoms are those of osteomyel- itis. Local symptoms depend on the seat of disease. If the posterior portion of the column is diseased, there is a hard swelling, which, in the neck, is in the middle line ; in the dor- sal and lumbar regions, in the middle or to the side ; and in the sacral region, invariably to one side. Rigidity always exists. If the vertebral bodies are affected, rigidity is noted, the spine is tender, and special symptoms arise dependent on the region affected (retropharyngeal ab- scess, etc.). Occasionally symptoms of meningomyelitis are 58o MODERN SURGERY. noted. The constitutional symptoms of sepsis are marked, the condition is sudden in onset, and purulent collections diffuse widely and rapidly. These points enable the surgeon to make a diagnosis between osteomyelitis and Pott's disease. In osteomyelitis angular deformity very rarely arises, be- cause the patient is recumbent and because hyperostosis is taking place. Treatment. — The patient is kept recumbent. His consti- tutional treatment is such as will combat sepsis (food, stimu- lants, etc.). A puriform area must be incised and disinfected. If bone denuded of periosteum is found, it is touched with a solution of chlorid of zinc or the actual cautery. If a seques- trum exists, it is removed. A drainage-tube is inserted and dressings are applied (Miiller, Makins, Abbot, and Chi- pault). Spinal Curvatures. — There are four chief forms of spinal curvature : (i) lateral curvature (the scoliosis of the older sur- geons) ; (2) posterior curvature (the excurvation, gibbosity, or kyphosis of the older surgeons) ; (3) anterior curvature (the lordosis of the older surgeons) ; and (4) angular curva- ture (from spinal caries). The normal spine has four curves : the cervical curve, the convexity of which is forward ; the dor- sal curve, the concavity of which is backward ; the lumbar curve, which is convex anteriorly ; and the pelvic curve, which is concave anteriorly. The dorsal and the pelvic curves, which are primary, are due to the formation of the cavities of the chest and pelvis, and depend upon the shape of the bones (Treves). The cervical and lumbar curves, which are com- pensatory, depend upon the shape of the intervertebral disks, and only appear after birth when the erect position is assumed. Lateral curvature (scoliosis) is a lateral deviation of the spinal column, often accompanied with rotation of the ver- tebrae and associated with increase or with diminution of the normal curves. Lateral curvature is predisposed to by weak muscles and ligaments, by the habitual assumption of strained and unnatural attitudes, by unequal length of the legs, and by paralysis of one leg. This distortion, which is commonest in girls, is apt to arise at the age of puberty (it is usually cor- rected in boys by outdoor exercise). The bones are soft and the muscles are weak, and this condition is often hereditary. Rickets is very commonly associated with lateral curvature. Any condition of ill-health weakens the muscles ; hence lat- eral curvature may arise after an acute sickness or in a per- son who outgrows his strength. An empyema with adhe- SUJiGERY OF THE SPINE. 58 1 sions, by pulling on the chest-wall, may produce a curvature the concavity of which is toward the diseased side. The weak muscles cease to sustain the spinal column, and the ligaments stretch, relax, or lengthen. The commonest curve is toward the right in the dorsal region (be- cause most people use the right hand more than the left). As soon as a dorsal curve to the right arises a compensatory lumbar curve (Fig. 180) takes place to the left, thus enabling the patient still to sit or to stand erect. In almost all cases the vertebrse soon rotate, the bodies turning to the convexity and the spines turning to the concavity of the curve ; hence the transverse processes to- ward the convexity project. The ribs follow the spinal rotation ; the shoulder is elevated on the side of the convexity, and the hip on the same side l JjJ;, ^l^;~x is raised (Bowlby). The intervertebral disks are curvature to n 1 • r 1 T '"^ fight, and apt to flatten out on the concavity ot the curve. In compensatory very rare instances lateral curvature results from [""thrief"'^^'^ caries of a half of one or of several vertebrje. In a spinal tumor lateral curvature may occur, the concavity of the bend being on the side of the growth. Symptoms. — An ordinary case of spinal curvature from weak muscles arises gradually. Stooping is noticed, and after a time pain is complained of in the dorsal and lumbar regions, and weakness in the back is detected by the sufferer. The pain is made more severe by sitting long in one attitude. Anemia is manifest, and walking is awkward and ungraceful. When the shoes and clothing are removed, and the child stands with its back toward the surgeon and the feet sym- metrically together, the lower angle of the right scapula (in a dorsal curvature to the right) is unduly prominent and is elevated above the left ; the normal prominence of the left iliac crest is lost ; the right iliac crest is unduly distinct ; on marking the spinous processes with an anilin pencil the curve becomes manifest ; tenderness is often developed on pressing the spines; the normal dorsal anteroposterior curve is exag- gerated ; the abdomen is protuberant ; the chest is flattened ; the neck juts forward ; and the breast on the same side as the concavity of the curve is more prominent and on a lower level than the other breast. Always observe if the anterior iliac spines are on a level or not, and always measure the length of the legs. The patient, with the knees extended, bends forward with the arms hanging loosely : the erector spinae muscle between the iliac crest and the last rib is seen to be 582 MODERN SURGERY. more prominent on the convexity of the lumbar curve than on its concavity (Bernard Roth), and the angles of the ribs on the side of the convexity of the dorsal curve are on a higher level than are those on its concavity. Have the child assume what it supposes to be an erect attitude, and let the surgeon correct this into the best possible position (Roth), and see how long the new position can voluntarily be main- tained. A large percentage of these patients labor under pes planus. When there is no osseous deformity (that is, when the surgeon may, by manipulation and traction, correct the deformity), and when the spinal muscles are not paralyzed, the prognosis is good for complete cure. Roth states that cases without osseous deformity can practically be cured in one month, but the treatment must be continued for one year to prevent relapse.^ In cases of moderate osseous deformity the patient can be improved vastly by three months' daily treatment (Roth). Even in severe cases of bony deformity the pain may be relieved and the deformity be modified. Treatment. — If one leg is too short, let the patient wear a thick-soled shoe. No treatment for weak muscles has ever been devised so utterly irrational and absurd as the prevention of all movement ; and neglect of all treatment for lateral curvature does less harm than immobilizing the spinal muscles by braces and supports. The muscular nutrition in these cases is to be restored, as is muscular nutrition in any other region, by scientific gymnastics, electricity, the douche, salt baths, frictions, and massage. Bicycles with specially constructed seats are used with advantage in some cases. The mode of exercise to be used should be directed by some one skilled in orthopedics, and the instruction in the details must be thorough and persistent. Roth's advice is to so re-educate the muscular sense that a patient can again know whether she is or is not standing straight ; to maintain an improved position in sitting and standing; to use such clothing as will not interfere with the assumption of a normal attitude ; to enforce systematic training of the muscles of the spine and thorax ; and to give attention to the general health. In some cases where, in spite of all attempts at correction, deformity increases, it may be neces- sary to immobilize in hope of obtaining ankylosis and pre- venting further deformity. In those rare lateral curvatures due to caries a supporting apparatus must, of course, be applied. Anteroposterior curvature (not from spinal caries or 1 Heath's Dictionary of Practical Surgery. Si'RGERY OF THE SPINE. 583 from hip-joint disease) is an increase of the normal antero- posterior curves. Increase of the dorsal curve is posterior curvature, kyphosis, or excurvation (Fig. 181, a) ; increase of the lumbar curve is anterior curvature, lordosis, or saddle-back (Fig. 181, b). Both lordosis and kyphosis are apt to be present. Scoliosis has nearly always some anteroposterior curvature asso- ciated with it. Lordosis is apt to be compensatory, to prevent the center of gravity going too far forward. Lordosis is found in pregnant women and in very fat men. In an old man kyphosis arises from flattening out of the vertebral disks from pressure. Rheumatic gout may ^10.^:8^.. -Kyphosis (a) cause it. Anteroposterior curvature is often due to paralysis of the erector spinse mass (from infantile paralysis). Pseudo-hypertrophic paralysis causes lordosis. Symptoms ami Treatment— T\\& symptoms of anteropos- terior curvature are as follows : the thorax is flattened or pigeon-breasted; the shoulder-blades are widely separated and the scapular angles project ; the abdomen is protuberant ; the patient complains of backache and soon tires. A recent kyphosis disappears when the patient lies upon his stomach. The facts that the erector spinae muscles are soft, and that pain is absent on concussion transmitted from the heels, separate kyphosis from caries. Lordosis is unmistakable. When the spine is movable employ the same plan of trcat- mait as that in lateral curvature, suiting the gymnastics to the deformity (Roth). In painful kyphosis with partial ankylosis endeavor to make the ankylosis complete to pre- vent pain, obtaining this result by applying a plaster jacket which laces up and letting the patient wear it for several years. . . ^ ■, Angular curvature (Spinal Caries ; Spond>4itis ; Pott s Disease) is usually due to tubercular caries of the vertebral bodies, and occurs particularly in children who are predis- posed to tuberculosis, but it may arise at any age. Any por- tion of the spinal column may be attacked. The dorso- lumbar region is most prone to suffer. The chief cause is tuberculosis, but syphilis, secondary cancer, and acute myelitis of the vertebrae are occasional causes. Blows or strains are often exciting causes. Angular curvature may develop after an exanthematous fever. The cancellous tissue of the anterior portion of a verte- 584 MODERN SURGERY. bral body becomes primarily carious, or the inflamma- tion begins in an intervertebral disk. (The changes of tubercular osteitis have previously been set forth.) The body of the vertebra and the vertebral disk are destroyed, and the process extends to adjacent vertebrae. The weight which rests upon the spinal column causes softened bone to crumble, compresses the diseased vertebrae and disks, and produces angular deformity (the anterior part of the spine formed by the vertebral bodies is shortened, the pos- terior part is not, and hence the spines project). In some cases the disease is spontaneously arrested by organization of inflammatory products, and ankylosis (fibrous or bony) in deformity is Nature's cure. In most cases, however, the dis- ease spreads and caseous pus is formed, which, according to the route it takes, causes lumbar abscess, dorsal abscess, psoas abscess, or postpharyngeal abscess (page 106). In some cases the spinal cord is compressed, but in most cases it is not, and even when it is compressed paraplegia is rare and is usually temporary. Compression of the cord may be caused by the displaced vertebrae or by in- flammatory material or caseous matter between the bone and dura mater, but is most often due to pachymeningitis. Caries of the cervical region constitutes a more danger- ous disease than caries of either the dorsal or the lumbar region (dangerous pressure occurs more easily). Death may be caused by exhaustion, sepsis, hemorrhage, amyloid disease, pneumonia, peritonitis, pleuritis, tubercular dissemi- nation, pressure upon the cord, or inflammation of the cord or its membranes. Symptoms. — The first symptom of angular curvature is pain in the back, which is increased by motion, by pressure, and by vertebral jars. Neuralgic pains pass into distant parts (sciatica, intercostal neuralgia) and are often linked with muscular spasm. Pain may not appear until late in the progress of the case. A chronic bilateral pain in the trunk or extremities is suggestive of Pott's disease. " Chronic bilat- eral belly-aches in children are almost diagnostic " (Jordan Lloyd). The pain of dorsal caries can be relieved by lifting the shoulders ; the pain of cervical caries by traction on the head. Cramp in the legs occurs in dorsal and in lumbar caries. The sufferer from Pott's disease, if a child, grows tired easily, shows alteration of disposition, becomes moody and irritable, complains of vague pains in many places, constantly leans, rests, or lies down, and walks with the back rigid, which produces a peculiar gait. A painful spot is found by press- SURGERY OF THE SPINE. 5^5 ing upon the spines, and the same spot is painful on pressing the head downward or upon jarring the entire spine. Fara- dism to the back causes pain. Spasm of the erector spinae mass is detected (Hilton, Golding-Eird). The presence of the knuckle due to bending the spine at an acute angle is a very important sign of the disease. In many cases angular deformity appears late, in some cases it does not appear at all. An angular deformity is detected sooner in those regions where the normal curves are posterior than where normal curves are anterior (Jordan Lloyd). The deformity appears early in the dorsal region, but late in the cervical and lumbar regions. In some rare cases lateral deformity occurs. Rigidity is an early sign of great impor- tance. It is always present. Rigidity is manifest very early in cervical caries, tolerably early in lumbar caries, late in dorsal caries. Lloyd gives the following practical rules to enable us to detect rigidity.^ In the cervical region : sit the patient in a chair and tell him to nod the head. Sdffness in nodding points to occipito-aUoid disease. Tell him to look far to the right and then far to the left. Stiffness of these motions suggests atlo-axoid disease. Tell him to place his shoulders against the back of the chair and carry his eyes back along the ceiling. Stiffness in this movement indicates disease below the second cervical vertebra. It is practically useless to examine the dorsal region of an adult for rigidity, but such an examination can be made in a child. Place the patient prone on an adult's lap, mark the tip of each spinous process with an anilin pencil, make the child stand up straight, and observe if any of the marks have come nearer together. If it is seen that two or more marks do not approach each other, there is rigidity which prevents approximation. To test for rigidity in the lumbar region lay the naked patient prone upon a couch. Grasp the patient's ankles and raise the pelvis from the couch. If the lumbar spine is flexible, the pelvis can be lifted without raising the chest from the bed, and the maneuver deepens the hollow of the loin. If the lumbar spine is stiff, the maneuver lifts the trunk and produces no alteration in vertical outline of the lumbar spines. If a child with Pott's disease is asked to pick up something from the ground, because of rigidity or pain on movement he will not bend the back, but will bend the knees or get upon the knees. Paralysis may exist, and it is due to pachymeningitis more often than to pressure from bone. Cervical caries causes dyspnea and torticollis, the 1 Birmingham Med. Review, April, 1897. 586 MODERN SURGERY. head requiring support with the hand. Dysphagia indicates abscess. In adults the first signs of Pott's disease to attract attention are backache, neuralgia, girdle-pain, cramp, or even paralysis. In sacral caries there is no deformity and fre- quently no pain. The diagnosis becomes apparent when bilateral abscess is detected in the buttocks or groins (Jordan Lloyd). Treatment of Caries of the Spine. — When recent caries of the spine is active and affects a child, when it is accompa- nied with pain and fever, and when paralysis threatens, insist upon perfect rest. Place the child supine on a hard mattress^ and, if possible, take it, while still in bed, out of doors daily. Leeches, blisters, or the hot iron over the area of pain may do good. When the activity of the process abates apply a fixation apparatus. In diseases at or near the vertebro- occipital articulation, as long as dyspnea persists, keep the patient supine with a small hard pillow under the nape of the neck (Hilton) and a sand-bag on each side of the head Fig. 182. — Plaster-of- Paris jacket (Sayre). Fig. 183. — Plaster-of- Paris jacket and jury-mast applied (Sayre). and neck. After several months mechanical support can be given by Furneaux Jordan's method. Jordan applies his support as follows : the patient lies on a flat hard table, his arms are raised above his head, and traction is made upon the head by means of a pulley and a weight. Cotton pads are placed over the ears, the back of the neck, and the clav- icles, and are held in place by a flannel bandage applied as a figure-of-8 of the head, neck, and chest. The flannel SURGERY OF THE SPEXE. 587 bandage is overlaid with plaster-of- Paris bandages.^ In disease of the cer\^ical region below the axis use Sayre's jury-mast (Fig. 183). This appliance relieves the spine from the weight of the head and acts admirabh'. In many cases of Pott's disease some fixation apparatus is employed. The best of all fixation apparatus is Sayre's plaster-of- Paris jacket applied while the patient is suspended (Fig. 182). The Sayre appa- ratus applied in this manner is used for the treatment of caries of the lumbar region and the lower half of the dorsal region. When all subjective signs cease substitute for Sayre's jacket a felt jacket which laces (Golding Bird). Caries of the upper half of the dorsal region is often treated by a Sayre's jury-mast (Fig. 183), but in many cases the jury-mast will fail, and it is necessary to place the patient horizontally in " an open cuirass, fitted to the back from occiput to sacrum, and combined with pulley extension to the head and pelvis." ^ Spinal abscesses are treated as indicated on page 483. Treves operates to remove the carious bone, making his incision in the back, but many surgeons do not approve of the operation. Chipault and Calot have advocated forci- ble correction of the deformity. The patient is anesthe- tized, and is placed face down ; one assistant holds the feet, another the head, another supports the abdomen, and another the pelvis. While strong traction is made on the head and feet, the surgeon makes very forcible pressure on the projection. After the correction of the deformity a plaster-of-Paris support is applied so as to include the neck, trunk, and pelvis. Plaster-of-Paris support is used for at least six months. In some cases Calot resects the spines and laminae of the diseased vertebrae, and performs osteotomy of the ankylosed vertebral bodies.^ Some surgeons have warmly advocated laminectomy in spinal caries paraplegia. This operation is rarely necessary, but in some few cases is imperatively demanded. Many cases recover from paraplegia without operation — operation has a ver>' heav>^ mortality ; many are not benefited at all by it, but in some cases it has certainly saved life (page 595). Laminectomy should not be undertaken until treatment by rest and fixation has been applied for at least one year (Willard). Laminectomy may be necessary in cervical caries to pre- vent asphyxia. The operation enables the surgeon to re- 1 See Children's Deformities, by Walter Pye. ^ Jordan Lloyd, in Birmingham Afedical Reznnv, April, 1897. ^ F. Calot, in Archiv. Prov. de Chirurgie, Feb., 1S97. 588 MODERN SURGERY. , move masses of inflammatory material which make pressure on the cord. The dura should not be opened unless there is evidently trouble beneath it, in which case it is incised and any tubercular area removed, the dura being subsequently sutured. Menards removes the transverse processes of the diseased vertebrae and the heads and necks of the associated ribs in order to give the surgeon access to the diseased ver- tebral bodies. During the course of caries of the spine give fats, tonics, and nutritious food, and try to get the patient out often into the fresh air. Sea-air is very beneficial. When all active disease ceases, and only angular curvature remains, use an apparatus to combine extension with mechanical support, the plaster jacket being generally employed. Injuries of spinal ligaments and muscles, which may complicate more serious injuries or may exist alone, are caused by wrenches, twists, and violent muscular efforts (as in lifting). Railway accidents may be responsible for these sprains and strains. Symptoms. — Injuries of the back, even without cord- injury, are frequently Hnked with very deceptive nervous symptoms. Symptoms are often severe, but are usually temporary. In some few cases the symptoms are per- sistent. Secondary disease of the cord is extremely rare. Any region may be affected, but the lumbar is most usu- ally injured, and the entire spine may suffer. The three marked symptoms are pain, tenderness, and stiffness of the back. At the time of injury, and for a time after, there is often marked shock, and hysterical excitement is occa- .sionally observed. The cardinal symptoms may arise very soon, but may not become severe for a day or two. The pain is not acute when at rest, but becomes acute on move- ment.^ This pain is felt in the back, and sometimes darts into the extremities. The muscles are rigid, the spasm being due to pain. The patient is very careful not to twist or bend the spine, because to do so increases pain. In a one-sided injury the rigidity is unilateral, and this symptom cannot be simulated. Often, but by no means always, the region of the back is swollen and the skin is discolored. The tenderness is not of the skin, but of the muscles. Firm pressure on a real spot of tenderness causes rapid pulse (Mannkapf). The vertebral spines are regular and are not mobile. There is no distant paralysis or hyperesthesia unless the cord is damaged (though in some ^ Moullin on Sprains. SURGERY OF THE SPINE. 589 rare cases the bladder and the rectum are paralyzed when no cord-lesion can be detected), and hyperesthesia may exist over the spines. Moullin tells us that the extremities feel weak because they are deprived of proper support on account of the immobility of the muscles of the back. For the same reason the action of the abdominal muscles is inter- fered with, and the power of micturition and of defecation is impaired (there are constipation and difficulty in emptying the bladder). The treatment of recent injuries comprises rest; the ice-bag and leeching over the painful area ; in a day or two hot fomentations, tincture of iodin, and inunctions of ichthyol and lanolin ; and, later, massage, douches, and frictions with a stimulating ointment. Phenacetin relieves pain, though in some cases opium is necessary. The injury is called " railway spine " when it is caused by a railway acci- dent. After the ivnncdiatc effects of the accident subside trau- matic neurasthenia is apt to arise. In this condition the patient grows tired easily and complains of pains and aches in the back and loins, interfering with or preventing work ; paresthesia and numbness exist in the extremities ; in many cases sexual intercourse is impossible because of premature ejaculation or of incapacity for erection ; there are dyspepsia, eye-strain, insomnia, loss of memor^^', rapid and irregular pulse, cardiac palpitation, and mental depression or con- fusion. The reflexes are usually exaggerated, but they can be exhausted more easily than can the exaggerated reflexes of organic cord disease (because of irritable weakness). Some rigidity and tenderness exist in the back, and the skin over this region is often hyperesthetic. Attacks of retention of urine may occur. Hypochondria is not unusual. Treatment of Tratiniatic Neurasthe?iia. — Employ rest, tonics, massage, douches, and frictions to the back. Secure sleep, and endeavor to bring about a gain in weight. If sexual incapacity or seminal emissions worry the patient, dilate the urethra with steel bougies. Traumatic hysteria develops only in those predisposed by a neuropathic hereditar\^ tendency ; traumatic neurasthenia may arise in anybody. In the first disease the accident is only the exciting cause ; in the second disorder it is tlie cause. Many cases of so-called " railway spine" are really examples of traumatic hysteria. Traumatic hysteria and neurasthenia may be associated. Neurasthenia is a con- dition of exhaustion associated with a number of chronic 590 MODERN SURGERY. disorders ; it forms a foundation on which hysteria loves to build its structure. This structure of hysteria is made up of morbid impressionability, hyperesthesia of centers, low- ered self-control, and sensitiveness of the peripheral nervous system. The accident plays a double part in producing trau- matic hysteria : first, by its effect on the mind (psychical trau- matism) ; second, by its effect on the body, which anchors the attention at one point, and this area of pain or stiffness often serves as an autosuggestion which undergoes morbid magnif- ication when viewed through the distorting medium of hysteria. Erichsen taught that the symptoms of what he named " rail- way spine" arose from inflammation of the cord and its mem- branes, a view now abandoned. A blow given to a hysterical person causes a feeling of numbness, and this negative sen- sation from local shock may estabhsh the idea of paralysis, or the traumatism, acting as a suggestion, may inhibit motor representations and destroy the normal ideas of motion and feeling (Charcot and Pitre). Terror always causes a feeling of loss of power in the legs, and the terror of the accident may thus develop the idea of paraplegia. The site of a trau- matism may localize symptoms ; for instance, a blow upon the eye may cause amaurosis or blepharospasm. It is im- portant to remember Charcot's saying that a hysteria, long latent and unrecognized, may be awakened into obvious activity by a blow or an accident. Pitre shows the same to be true of epilepsy. A not unusual lesion is hysterical trau- matic monoplegia, not coming on at once after the accident, but usually some days afterward, and presenting flaccid mus- cles, the electrical reactions and reflexes remaining normal, but the muscular sense being lost (Pitre). The muscles usually waste. The skin of the paralyzed limb is anesthetic or analgesic. There may be anesthesia limited to a limb, hemianesthesia, or general anesthesia.^ Hysterical paraly- sis is usually associated with the permanent stigmata of hysteria — concentric contraction of the visual field, pharyn- geal anesthesia, convulsive seizure, and hysterogenic zones (Clarke and Pitre). The permanent stigmata may be latent. Hysterical phenomena lack regularity of evolution, and they may be produced, altered, or abolished by mental influences or by physical forces which produce no effect on organic disease. In most hysterical conditions the general health is not profoundly impaired.^ Treatment. — By moral means chiefly. Gain the confidence of the patient. In many cases separation from family and ^ J. Michell Clark, in Brain. ^ Read the works of Thorburn and Pitre. SURGERY OF THE SPINE. 59 1 friends is necessary- and isolation is desirable. The Weir Mitchell rest-cure is the best plan of treatment, and all its details should be carried out faithfully. Malingering-. — Persons injured in accidents often pretend to suffer from maladies which do not exist in them. Some get well upon the rendering of a favorable verdict by a jury. In any case always examine carefully, so as to be able to exclude malingering. Note the patient's behavior and motions when his attention is diverted from his disease. Meningomyelitis can be excluded if there be no spasm nor paralysis, hyperesthesia, paresthesia, or anesthesia at a dis- tance (A. Pearce Gould). If pain has lasted for months, if pressure downward upon the head or shoulders does not increase pain, if the vertebrae are movable and there is no angular displacement, exclude caries. Gould states that when there are wasted muscles, when moderate spine-move- ment is painless, but effort in bringing the body erect causes pain in the erector spinae region, the trouble is a strain of the erector spinae muscle. If the muscle is not wasted, and the pain is in bending forward rather than in straightening up, the vertebral ligaments are the seat of trouble. Unilateral spasm cannot be simulated. The administration of ether may dispose of a pretended paralysis. Concussion of the Spinal Cord. — This term has no definite pathological meaning. It is probable that the condi- tion is one of laceration of capillaries and of cord-substance. The symptom is shock, with intense pallor, nausea, often vomiting, and sometimes .syncope. To this condition special symptoms may be linked — as temporary^ paralysis, a girdle- sensation, numbness and loss of power in the Hmbs, hiccough, torticollis, coarse tremors, pains in the back and limbs, areas of anesthesia and analgesia — depending on the portion of cord lacerated. Treatment. — The treatment in concussion of the spinal cord is the same as that for sprains. Traumatic neurasthenia and hysteria or organic cord-disease may follow this injury. Contusion of the spinal cord may arise from a sprain, but it is usually due to extreme flexion of the spine. It causes hemorrhage into the gray matter of the cord (hema- tomyelia). The symptoms are motor and sensor}- palsy and diminished reflexes. Some cases recover, but others end in myelitis. Wounds of the spinal cord, which are rare, are usually fatal. Wounds above the origin of the phrenic nerves cause almost instant death. Gunshot-wounds are the most usual 592 MODERN SURGERY. form, the cord being damaged by the bullet and by bone- fragments. A knife is sometimes thrust in between the occiput and atlas. Compression of the spinal cord may be due to blood or to lymph. Compression from blood may be due to extra- medidlmy hemorrhage or to intramedidlary hemorrhage, Extramedidlary hemorrhage causes sudden pain in the back, the pain radiating from compressed nerve-roots ; hyperes- thesia and paresthesia in the area of the radiated pain, spasm of vertebral muscles supplied by the compressed nerves, sometimes of muscles whose nervous supply is below the lesion ; tremors ; convulsions ; retention of urine ; paralytic symptoms following the signs of irritation, but no absolute paralysis (Mills). A girdle-sensation is usual. Intramedul- lary hemorrhage causes pain, a girdle-sensation, abolition of reflexes, and paralysis. Spasms, rigidity, and paralysis come on early. Bed-sores, retention of urine, and incontinence of feces may occur. Paralysis from hemorrhage is gradually progressive from below upward (crawling paralysis). Treatment, — If paralysis from spinal-cord bleeding .ex- tends rapidly, and life is endangered through the probable involvement of a vital center, perform a laminectomy, arrest the hemorrhage, and remove the clot. It is wise to always open the dura and inspect the cord. Extramedullary hem- orrhage may be arrested by packing. Intramedullary hem- orrhage may be arrested by a suture, ligature, or packing. If an extramedullary clot is extensive, it is necessary to make a second laminectomy opening in order to thoroughly wash it out. The dura must be sutured and drainage is to be employed. If there is paraplegia, complete anesthesia of the paralyzed parts, and entire abolition of the deep reflexes, operation is useless because the cord is destroyed (White). In some cases with persistent paraplegia the operation should be undertaken. If operation is not undertaken, cause the patient to lie upon his side and give morphin hypodermat- ically. If hemorrhage continues in the cord and if the patient be plethoric, perform venesection. Some surgeons advise hypodermatic injections of ergotin. To promote absorption of the clot and exudate give a combination of carbonate and acetate of ammonium, order pilocarpin, and employ spinal galvanism and hot douches (Bartholow). Fractures and dislocations of the spine are very rare. The spinal regions most liable to injury are the atlo-axial, the cervicodorsal, and the dorsolumbar (Treves). A verte- bra may be fractured alone, but dislocation without fracture,. SURGERY OF THE SPINE. 593 except in the upper cervical region, very rarely occurs. These two lesions, dislocation and fracture, are so often associated that the term fracture-dislocation is used by many surgeons to include them both. The causes of fracture and dislocation are direct force (rarely) and indirect violence (commonly). Fracture-dislocation from direct force may occur at any part of the column, and in this accident the posterior vertebral segments are driven together, and the cord, as a rule, escapes injury. Fracture-dislocations from indirect force most commonly happen in the cervical and dorsal regions. In the cervical region reduction can usually be secured, but in the lumbar region reduction is impossible. In fractures from indirect force the cord generally suffers. Symptoms, — In fracture-dislocations much displacement is rare, but some is almost always recognizable (irregularity of spines or angular deformity). In fractures there are pain (which is increased on motion), tenderness, ecchymosis, and motor and sensory paralyses. Priapism, cystitis, and reten- tion of urine often occur. Horsley has pointed out that in many cases a paralysis passes away only to subsequently recur, the recurrence being due to edema of the cord. In some cases of spinal injury there is temporary paralysis due to shock. Persistent paralysis may be due to laceration of cord or compression of the cord by bone, blood-clot, or products of inflammation. In total division of the cord the deep re- flexes are abolished, anesthesia exists, and there is vasomotor paralysis. The extent of paralysis depends on the seat of the cord-injury. The prognosis depends on the amount of damage done to the cord. Fracture-dislocations in the cer- vical region produce obvious deformity, stiffness of the neck, and irregularity of the spines, and a displaced vertebra may occasionally be detected by a finger in the pharynx. Crepitus can rarely be detected unless a spinous process is fractured. The Rontgen rays aid diagnosis. Treatment of Fracture-dislocations. — When dislocation of the body of a vertebra obviously exists attempt reduc- tion by extension and rotation (White). The maneuver is very dangerous in the cervical region, and, as deaths have happened, some eminent surgeons advise against re- duction when the injury affects that region. In fracture- dislocation the traditional plan is to straighten the spine, gently if possible, and to put the patient upon his back upon a water-bed or upon air-cushions. In fractures in the cervical region support the head and neck with sand- bags. Empty the bladder four times every twenty-four 38 594 MODERN SURGERY. liours with a soft catheter, which is kept strictly aseptic. Take every precaution to prevent bed-sores. Some sur- geons advocate reduction of the deformity by extension and counter-extension, and by the appHcation of a firmly-fitting but removable jacket with the suspension collar (as used in Pott's disease). The head of the bed is raised and the collar is fastened to it. Every day extend gently from the shoul- ders in dorsolumbar fracture, and from the chin and occi- put in cervical fractures. Extension may be maintained permanently until cure. White says laminectomy should be performed for fracture or for dislocation when there is obvious depression of the vertebral arches ; in all cases of pressure upon the cauda equina ; when there are character- istic symptoms of spinal hemorrhage ; and in some cases where rapid degeneration becomes manifest. Surgeons, as a rule, agree that operation will be useless when there are com- plete persistent anesthesia and entire loss of reflexes, because these symptoms indicate that total division of the cord has taken place. It is useless to operate for fracture-dislocation of the atlas or axis. In ordinary cases treat by extension for six or eight weeks, and then operate if the case is not improving. In hemorrhagic cases, or cases with marked depression of the arches, operate early. If signs of degen- eration begin within six or eight weeks, operate at once. *' In compound fractures, in injuries of the laminae and spinous processes without a complete crush of the cord, when symp- toms are due to hemorrhage, when pachymeningitis arises, if the Cauda equina is compressed, operate" (Thorburn). Operations on the Spine. — Operations for Spina Bifida. — Mayo Robson maintains^ that operation is not de- manded when the sac is of small size and is well protected by sound integument ; that operation is improper when a large portion of the column is fissured, or when paraplegia or hydrocephalus exists ; that operation is only advisable in meningocele, in cases where integument is thin and trans- lucent, in cases where the cord is flattened out, or the nerves are fused. Robson has closed the osseous defect by trans- planting periosteum. Instruments Required. — Scalpels, dissecting- and hemo- static forceps, scissors, rongeur forceps, dural separator, Hagedorn needles and needle-holder, silk, silkworm-gut or -catgut. Operation. — Surround the sac by elliptical incisions. Find the neck of the sac, and if it contains no visible nerves ligate ^ Annals of Surgery, vol. xxii., No. i. SURGERY OF THE SPINE. 595 it and cut off the protrusion. Push the stump into the canal. Freshen the bone-margins and spring a piece of celluloid beneath them to close the gap (Park). Suture over the stump with small sutures of catgut.' Treves's Operation for Vertebral Caries (page 483). Laminectomy. — The instruments required in laminectomy are dissecting-, rat-toothed, and hemostatic forceps; scalpels; bone-cutting forceps ; rongeur forceps ; a dry dissector ; a periosteum - elevator ; sequestrum - forceps ; small scissors, straight and curved on the flat; a chisel and mallet; re- tractors ; blunt hooks ; a probe ; tenaculum-forceps ; a spoon-curet ; a sand -pillow; fine needles, curved and straight, large needles, and a needle-holder. In the operation of laminectomy the patient lies prone and a sand-pillow is placed under the lower ribs. Make an incision down the vertebral spines, the middle of the incision corresponding to the seat of fracture. The sides of the spinous process and the laminae are cleared. The perios- teum is incised in the angle between the laminae and spines, and it is lifted away from the arch. The spinous processes are cut off with forceps close to their bases, the laminae are removed on each side with the rongeur, and the dura is exposed. In some cases the fragments will be found on exposing the vertebra, or the blood-clot will be seen between the dura and the bone ; in other cases the dura must be opened with scissors vertically in the middle line while it is grasped with rat-toothed forceps. After reaching and re- moving the compressing cause, or after failing to find or remove it, close the dura with catgut, drain the length of the wound with a tube, stitch the superficial parts with silkworm- gut, and dress antiseptically.^ Puncture of the spinal meninges, or lumbar puncture, was devised by Quincke, and has been carefully tried by many surgeons (Furbringer, Naunyn, and others). It is employed as a means of diminishing cerebral pressure in hydrocephalus, cerebral tumor, uremia, and tubercular men- ingitis. It has proved of little therapeutic value. In some cases the examination of the fluid has been of diagnostic value. Stadelmann has reported 37 cases in which tubercle bacilli were found in the fluid.^ Turbidity of the fluid indi- cates the existence of meningitis. The back is sterilized ; the ^ A full consideration of the various plans of operating will be found in an article by Marcy. in Annals of Surgery, March. 1895. 2 See J. W. White's description in the Annals of Surgery, July, 1889. ^Berliner klinische IVochenschrift, July 8, 1895. 596 MODERN SURGERY. patient may lie prone, with a pillow under the belly, or may sit in a chair, with the body bent forward ; no anesthetic is required. A Pravaz syringe is employed, and the point is in- serted at the under surface of a spinous process. In some cases but £1 few drops of fluid will be obtained, in other cases many ounces can be removed. XXV. SURGERY OF THE RESPIRATORY ORGANS. I. Diseases and Injuries of the Nose and Antrum. Foreign bodies in the nose are usually introduced through the anterior nares, but in rare instances they enter by way of the posterior nares. Small particles are often expelled spontaneously ; larger pieces gather mucus and become fixed. Some materials swell after lodgement. Treatment. — Illuminate the nostril, and, if the foreign body can be seen, insert a hook back of it and effect its removal by means of forceps. In many cases anesthesia is required. Some foreign bodies require to be pushed back into the nasopharynx. Occasionally expulsion may be effected by inserting a rubber tube into the unblocked nostril and telUng the patient to blow forcibly through the tube. In serious cases a specialist should be summoned to remove a portion of the turbinated bone or to perform whatever operation he thinks best. Inflammation and Abscess of the Antrum of Highmore (Maxillary Antrum). — The source of this disease may be inflammation of the nose or periostitis around the roots of the teeth. In some cases the opening into the nose is patent ; in other cases it is partly or completely blocked. Caries and necrosis may arise. The symptoms are pain, edematous swelhng of the face, and thinning of the bone so that it may crepitate under pressure. When pus has formed certain positions of the head will cause a purulent flow from the nose, and if a speculum is inserted pus may be seen as it flows into the nose. The opening of the maxillary antrum into the nose is at the summit of the cavity ; hence the an- trum drains when the head is inverted. The ethmoidal cells and frontal sinus drain best when the patient is upright. Wipe the interior of the nose and place the patient with his head between his knees. If the nostril fills with pus, it comes from the antrum (Cobb). In severe cases the jaw expands, the eye protrudes, and great tenderness of the alveolus exists. Per- cussion exhibits a dull note. In making a diagnosis it is well to take the patient into a dark room, insert an electric Hght into SURGERY OF THE RESPIRATORY ORGANS. S97 the mouth and note the diminution of light-transmission on the diseased side as contrasted with the sound side Trans- illumination may be easily practised by the use of a cautery electrode, protected by a small glass vial. Any cautery bat- tery may be employed (plan suggested by Ohls). Explora- tory puncture will settle a doubtful diagnosis. This may be by way of the lower meatus, the canine fossa, or the alveolar process.^ Treatment. — Before pus forms, order the use of hot fomen- tations, and remove any diseased teeth. When pus has formed evacuate it at once. Before performing a severe operation try the effect of opening into the antrum from the nose, by means of Krause's trocar, followed by insufflation of iodoform. If this procedure fails, other means may be employed. If the disease arises from a carious tooth, pull the tooth and push a trocar through its socket into the antrum. If the teeth are sound, bore a hole with a large gimlet or with a bone- drill above the root of the second bicuspid tooth and one inch above the edge of the gum. A counter-opening should be made into the inferior nasal meatus. A drainage-tube is pulled from the first opening into the nose and is allowed to protrude from the nostril. Irrigate daily with peroxid of hydrogen. In three or four days discontinue through-and- through drainage, but prevent the first opening from closing until the discharge ceases to be purulent. In severe cases make a free incision through the canine fossa by means of a chisel. Distention and Abscess of the Frontal Sinus.— The usual cause is an injury which may long antedate the symptoms. This injury causes or leads to blocking of the infundibulum ; secretion accumulates and distends the sinus ; and in some cases pus forms. In many cases the fluid slowly accumulates, and it requires )-ears to produce marked symp- toms. In other cases infection takes place, and the symptoms are positive and violent. If the outlet into the nose is not permanently blocked, the fluid may discharge itself from time to time. In the chronic cases there is rarely much pain. The chief sign is a swelling of the inner or upper part of the orbit, which swelling progressively increases in size and displaces the eye. If at any time acute symptoms supervene, there will be pulsatile pain, discoloration, and tenderness. Treatment. — In some cases it is possible to pass a trocar upward from the nose into the sinus, and so drain and irri- gate. In most cases an incision should be made through the 1 Cobb, in Boston Med. and Surg. Jour., May 7, 1896. 598 MODERN SURGERY. soft parts, and the sinus opened by a trephine or chisel. After the sinus has been opened it must be curetted, the opening into the meatus should be restored and enlarged, and a drainage-tube is to be passed from the forehead incision into the nostril. Some surgeons open the sinus by making an osteoplastic flap. 2. Diseases and Injuries of the Larynx and Trachea. Bdema of the lyarynx (Edema of the Glottis). — The causes of edema of the larynx are — acute laryngitis ; chronic diseases, such as tuberculosis, malignant disease, or syphilis ; inflammatory disorders, such as diphtheria and erysipelas ; acute infectious diseases; Bright's disease ; aneurysm; whoop- ing-cough ; pneumonia ; quinsy ; wounds of the larynx ; wounds of the neck ; scalds and burns of the larynx, and the inhalation of irritating vapors, such as those of ammonia and sulphur. The symptoms are sudden and rapidly increas- ing dyspnea, respiratory stridor, huskiness of the voice, and finally aphonia. The swollen epiglottis may be felt with the finger and may be seen with a mirror. Treatment. — In cases in which edema of the larynx is not excessively acute make multiple punctures into the epi- glottis and favor bleeding by the inhalation of steam. In severe cases perform intubation or tracheotomy. Wounds and Injuries of the I^arynx. — The larynx may be injured internally by foreign bodies, and externally by blows and cuts. A condition often met with is cut throat, the result usually of a suicidal attempt on the part of the patient or a homicidal effort on the part of an assailant. The cut of the suicide is usually in front ; it misses the great vessels, but divides the cricothyroid or thyrohyoid membrane. The epiglottis may be incised, or even be cut off. If a large vessel is cut, death rapidly occurs. The immediate dangers of cut throat are hemorrhage, suffocation by blood, entrance of air into veins, and suffocation by displacement of parts. The secondary dangers are pneumonia, infection and sepsis, exhaustion, and secondary hemorrhage. The remote dangers are stricture and fistula (Keetley). Treatment. — In wounds of the throat arrest hemorrhage, remove clots from the larynx and trachea, bring about reac- tion, asepticize the parts as well as possible, suture the deeper structures with silver wire, cato-ut, or kangaroo-tendon, and the superficial parts with silkworm-gut, dress antiseptically, and place a bandage around the head and chest so as to SURGERY OF THE RESPIRATORY ORGANS. 599 pull the chin toward the sternum. If laryngeal breathing is much interfered with, perform tracheotomy. Feed the patient through a tube until union has well advanced. The old method of leaving the wound open is to be condemned. When sutures are used primary union may be obtained. This fact was proved by Henry Morris. Foreign Bodies in the Air-passages. — The lodge- ment of foreign bodies in the air-passages is a frequent acci- dent. Small solid bodies are usually expelled by coughing. Liquids and solids rarely pass beyond the larynx (except in laryngeal disease or palsy, wounds of the floor of the mouth, cut throat, and in people unconscious or very drunk). In vomitinsT during or after the administration of an anesthetic, or in the vomiting of drunkards, the vomited matter may find its way into the larynx or lungs. There is great danger of this accident in an operation upon a patient with intestinal ob- struction who has stercoraceous vomiting. In most instances of foreign bodies lodged in the air-passages it will be found that the object was being held in the mouth when a sudden deep inspiration was taken (often from laughter). The symp- toms are immediate, due to obstruction by the body and to spasm, and secondary, due to the situation of the body and the changes it undergoes or induces. Lodgement in the pharynx causes violent dyspnea. The body can be seen or felt. Lodgement in the Larynx. — In a severe case the patient fights madly for air ; his face becomes livid and cyanotic ; his veins stand out prominently ; speech is impossible, though he may make noises and utter harsh cries ; violent coughing be- gins, and then vomiting ; he tries to force a finger down his throat and clutches at his neck ; sweat pours from him ; he feels a sense of impending dissolution, and he falls down un- conscious, with incontinence of feces and urine.^ In a less severe case violent dyspnea gradually departs and the patient lies exhausted ; but dyspnea and cough are liable to recur suddenly at any time because of spasm, and they may be induced by a change of position. These attacks of fierce spasmodic cough are not at first linked with expectoration, but after inflammation begins there is a profuse and often bloody expectoration. Inflammation follows more rapidly the lodgement of a sharp or irregular body than it does that of a round or smooth body. Inflammation is apt to produce edema of the glottis, bronchopneumonia, or ulceration and necrosis of the larynx. Any foreign body in the larynx ^ See MouUin's graphic description in his Treatise on Surgery. 600 MODERN SURGERY. may at any moment produce spasmodic dyspnea, and it is always very liable to cause edema of the glottis. The body if bony or metallic can be detected by the X-rays. Lodgement in the Trachea. — The immediate symptoms of a foreign body in the trachea depend on the shape and weight of the body, and whether it becomes fixed in the mucous membrane or moves to and fro with the air-current. A smooth, heavy body falls to the tracheal bifurcation, and, if it does not enter a bronchus, moves with every breath, and by its movement causes violent laryngeal spasm, cough, and whooping inspiration without aphonia. The patient is often conscious of the movements of the foreign body, and the surgeon may detect them with the stethoscope. The for- eign body may be found with the Rontgen rays. A foreign body in the trachea is liable to cause death by dyspnea, or it may ascend so as to be caught in the larynx, or may even be expelled. Irregular or sharp bodies lodge in the mucous membrane, produce inflammation, frequent cough, and ex- pectoration, and finally lead to ulceration. Bodies which swell up from heat and moisture tend to lodge and to become fixed (seeds may sprout). Lodgement in a Bronchus. — Foreign bodies in the bronchi usually lodge in the right bronchus. When a small lung- area is obstructed the obstructed side shows diminished respiratory movement and murmur with occasional whistling sounds and large moist rales ; the percussion-note is normal. When an entire lobe is obstructed all respiratory sounds are absent over it, and over the unobstructed lung respira- tion is exaggerated ; the percussion-note over the obstructed area is at first resonant, but becomes dull. The X-rays will enable the surgeon to detect some foreign bodies in a bron- chus. Lodgement in a bronchus may cause bronchopneu- monia, abscess, hemorrhage, and even gangrene. Treatment. — If a foreign body lodges in the pharynx, try to pull it forward ; if this fails, push it back into the esoph- agus. In lodgement in the larynx or below, if the symptoms are very urgent, at once perform a quick laryngotomy. If the symptoms are not so urgent, get a complete history of the accident and find out the nature of the foreign body. Be sure a foreign body is retained in the respiratory tract, and de- termine what its situation may be. Often a laryngologist can remove a foreign body from the larynx by means of forceps, a mirror and lamp being used for illumination. The fauces and upper portion of the larynx should have cocain applied to them to lessen pain and spasm. If the surgeon fails in SURGERY OF THE RESPIRATORY ORGANS. 6oi extraction by forceps, and laryngotomy has been performed, continue the search through the opening in the cricothyroid membrane ; if laryngotomy has not been performed, let it be done in the form known as tJiyrotomy (a vertical incision between the alae of the thyroid cartilage, and the separation of these alae to permit of exploration). After a thyrotomy suture the perichondrium with catgut. If the foreign body is in the trachea or in a bronchus, perform tracheotomy : this prevents suffocation from laryngeal spasm or edema. The foreign body may be expelled ; if it is not expelled, search the trachea and bronchi with Gross's forceps, with probes, with hooks, or with the finger. If the foreign body cannot be found, put the patient to bed, and maintain a moist atmosphere in the room. As a rule, when the foreign body is not found insert a tube. If the foreign body be extracted do not insert a tube (unless edema of the glottis exists or is likely to come on), do not suture the wound, but cover it with moist gauze and let it heal by granulation. Morphin and sedative cough-mixtures are given. Gross says that even when a foreign body has long been retained an operation should be performed so long as the air-passages are not seriously diseased. What shall be done when a foreign body is lodged in a bronchus and we are unable to extract it through a tracheotomy w^ound ? True said if " the patient is in danger of death " go through the chest-wall and at- tempt to remove the body. He said this with a full knowl- edge of the difficulty of locating the body. This difficulty has been partly overcome by the X-rays, and it seems more certainly our duty now^ to pursue this plan than it was a short time ago. Some surgeons advocate incision from behind.^ It is possible to reach the bronchus, but many surgeons believe that advances in technique will be necessary before we can hope to save a patient by opening a bronchus and removing a foreign body. Paget disbelieves in any direct incision. 3. Operations on the Larynx and Trachea. Tracheotomy. — The instruments required in this oper- ation are the scalpel, dissecting-forceps, a dry dissector, hemostatic forceps, scissors, a tenaculum, aneurysm-needle, tubes, tapes, Paquelin cautery, needles, needle-holder, a mouth-gag, tongue-forceps, foreign-body forceps, retractors, and, if membrane is present, feathers and a solution of bicar- ^ See Stephen Paget's Surgery of the Air-passages. 6o2 MODERN SURGERY. bonate of sodium. In a formal operation give chloroform, but in an emergency case this cannot be done. The patient may be placed supine with a sand-pillow under the neck and with the head thrown over the end of the table. If a child, Liston used to wrap it up to the neck in a sheet to prevent movements of the limbs, would seat himself on a chair, place the child upon the nurse's lap, and take its head between his knees. If bleeding is profuse when the surgeon is ready to open the trachea, place the patient in the Trendel- enburg position with the neck extended. The head must be exactly in the middle line, and extended (in an adult this gives two and three-quarters inches of trachea above the manubrium ; in a child of ten, two and a quarter inches ; in a child of six, about two inches). The operator stands tO' the right side when the patient is supine. The trachea may be opened above or below the isthmus of the thyroid gland. The isthmus in an adult usually lies over the second and third rings (Fig. 184). The isthmus in a child usually lies. Fig. 184. — Blood-supply of the larynx and trachea (Esmarch and Kowalzig). Fig. 185. — Parts exposed in tracheotomy (Esmarch and Kowalzig). over the first ring or even over the space between the cri- coid cartilage and the first ring. The high operation is always performed except in cases where it is desired to search for a foreign body in a bronchus. High Tracheotomy. — This operation is preferred be- cause in this region the muscles are distinctly separated (Fig. 185), the main vessels of the neck and the inferior thyroid vessels are not encountered, the anterior jugular veins are small and have very few transverse branches, and the trachea SUKGERV OF THE RESPIRATORY ORGANS. 603 is near the surface (Treves). Accurately locate the cricoid and th)Toid cartilages. An incision is begun at the upper border of the cricoid cartilage, and is carried down precisely in the middle line for about one and a half inches. Treves advises the operator to steady the skin of the neck with the fingers of the left hand and to cut with the unsupported right hand (if the hand be supported, the respirations will interfere with the operation). Incise the skin, the superficial fascia, and the anterior layer of the cervical fascia, separate the sterno- hyoid and sternothyroid muscles, and divide the fascia over the trachea. This fascia is attached above to the cricoid cartilage, and it divides below into two layers to invest the thyroid body and its isthmus. If veins are in the line of the incision, push them aside, but do not stop to apply a double ligature. Even if bleeding is profuse, as soon as the trachea is opened and air enters freely into the lungs venous conges- tion is relieved and bleeding is apt to cease. If hemorrhage be violent and the veins are not at once caught by forceps, it may be well to place the patient in the Trendelenburg position. Before opening the trachea push the isthmus of the th}'roid gland down ; if it cannot be pushed down suf- ficiently, make a transverse incision through the fascia at the upper border of the cricoid cartilage, and lift the fascia, and the isthmus with it, off the trachea (Bose's method). In- sert a tenaculum into the cricoid cartilage in order to steady the tube. Turn the back of the knife toward the sternum, hold a finger on the blade to prevent too deep a cut being made, plunge the knife, like a trocar, into the mid-line of the trachea above the isthmus, and divide two or three rings from below upward. Do not remove the hook until the operation is completed. If a foreign body is present, try to remove it ; if success attends the effort, no tube need be worn, but if the body is not found, use a tube. In croup or in diphtheria remove membrane (b}- means of a feather and a solution of bicarbonate of sodium 5ij, ghxerin 5J, water sx — Parker) and insert a tube. Grasp an edge of the cut with the dissecting-forceps, include the mucous membrane in the bite, bring the head erect, intro- duce the tube, and remove the tenaculum. Secure the tube by tapes, and suture the wound below the tube. Remove the tube at the first moment consistent with safet}'. In croup or diphtheria put a screen around the bed ; have the air moist by steam ; remove the inner tube and clean every two or three hours at first ; clean the outer tube, and the larj-nx and trachea whenever required, by means 604 MODERN SURGERY. of a feather and Parker's solution. A steam spray atomizer may very often be used with advantage. Quick laryngotomy must never be attempted upon a child under thirteen years of age, because of the small size of the cricothyroid space before this age (Treves.) In view of the difficulty of introducing a tube and of wearing it so near the vocal cords, laryngotomy should not be per- formed for croup, diphtheria, or for any condition in which a tube must be long worn. An incision an inch and a quarter long is made in the middle line, from above the lower edge of the thyroid cartilage to below the lower border of the cricoid. Divide the skin, superficial fascia, and deep fascia, separate the cricothyroid and sternothy- roid muscles, divide the deep layer of fascia, and cut the cricothyroid membrane horizontally just above the cricoid cartilage. The tube must be shorter than is the tracheotomy- tube. An operation which opens vertically the cricothyroid membrane, the cricoid cartilage, and the upper rings of the trachea is called " laryngotracheotomy." Intubation of the I/arynx (O'Dwyer's Operation). — The instruments required in this operation are a mouth-gag, an instrument to hold the tube and introduce it, an instru- ment for extracting the tube, and a graduated scale. The collar of the tube has a perforation through which a piece of silk is fastened to draw out the tube. The child is wrapped in a sheet to secure the limbs, is seated in a nurse's lap, and its head is held by an assistant. The jaws are to be opened and held apart by the self-retaining mouth-gag. The sur- geon sits in front of the patient, wraps the index finger of his left hand with a piece of rubber plaster, and passes it into the child's mouth until his finger touches the epiglottis. He introduces the holder and tube (observing if the silk is free) along the surface of the tongue until the obturator touches the epiglottis ; raises the epiglottis with the left index finger, and passes the tube into the larynx ; places the left index finger against the tube, and withdraws the holder with the right hand. The silken thread is tied to the ear, and the nurse is directed to employ the thread to remove the obtu- rator if it becomes obstructed or is coughed up. The tube is removed in two or three days ; if breathing is easy, it is not reintroduced, but if dyspnea recurs, it is replaced for two or three days more. If, in introducing the tube, a mass of false membrane is pushed before it into the trachea, breathing ceases, and, if the mass is not at once coughed up, tracheotomy must be performed. Wharton feeds these SURGERY OF THE RESPIRATORY ORGANS. 605 patients on semi-solids rather than upon hquids (mush, soft eggs, and corn-starch), and if trouble occurs in swal- lowing these articles, he feeds by the rectum or by means of a tube. 4. Diseases and Injuries of the Chest, Pleura, and Lungs. Pleuritic effusion may arise from foreign bodies, from injury by fragments of a broken rib, from tumors, and from inflammation of the lung, but most usually from pleuritis. Inflammatory effusion is nearly always unilateral (except in tubercular pleurisy, but even this form is one-sided at the start). The signs of pleuritic effusion are — dulness on percussion over the effusion, this dulness, when the patient is erect, being at the lower part of the chest and ascending higher posteriorly than anteriorly (alteration of position alters the situation of the dulness) ; the intercostal spaces are widened and the intercostal depressions are obliterated ; no breath- sounds can be detected in the area of flatness when the col- lection of fluid is large, but in small effusions deeply situated the breath-sounds are often audible ; the percussion-note above the liquid is hyper-resonant or tympanitic, and is often associated, at the edge of the liquid, with a friction-sound ; posteriorly, high up and near the spine, there are bronchial respiration and bronchophony (DaCosta). In these cases pain disappears with the advent of effusion, dyspnea comes on, and the patient lies upon the diseased side. Cough and fever always exist. In serous effusions the diagnosis may be confirmed by the introduction of an asepticized aspirating- needle. The treatment in this stage is to discontinue arterial seda- tives and to stimulate if the circulation calls for it. The exudation is removed by salines, by compound jalap powder, or by elaterium. If these means fail, if the effusion is exces- sive, or if it is producing dyspnea, at once aspirate. If pus forms, drain by operation. Kmpyetna is a collection of pus in the pleural cavity. It may begin suddenly, but rarely does so. Among the causes of empyema are those of serous effusion. Empyema is due to infection of the pleura. The pneumococcus is the causa- tive organism in many of the cases which follow pneumonia. This organism lives but a short time, and an empyema due to pneumococci may possibly be absorbed (Stephen Paget). 6o6" MODERN SURGERY. Most cases of empyema are due to streptococci and staphylo- cocci. These organisms may appear in an empyema induced originally by pneumococci (Stephen Paget). In empyema de- veloping during or after typhoid fever the typhoid bacillus may be discovered. In putrid empyema various bacteria are found. Bouchard thinks acute empyema has a special organism. The bacilli of tuberculosis are present in tuber- cular empyema. Empyema may be due to a wound' or contusion, an attack of pneumonia, tubercular pleurisy, phthisis, typhoid fever, infection of a serous effusion, caries of a rib, specific fevers, peritonitis, malignant disease of the pleura, or gangrene of the lung. The signs are in reality those of pleurisy with effusion, viz., dulness on percussion, absent breath-sounds, bulging of the intercostal spaces, and sometimes edema of the skin of the chest. The symptoms are irregular fever, sweats, chills, dyspnea, pallor, and some- times cough. There is marked leukocytosis. The fingers may become clubbed. An empyema of the left side may pulsate. A neglected empyema may break into the lungs, esophagus, or pericardium, or may point in the lumbar region. Empyema may cause death by compression of the heart and lung, pulmonary embolism, pericarditis, peritonitis, cerebral embolism, cerebral abscess, septicemia (Stephen Paget), or exhaustion. The treatment is aspiration, incision and drainage, or thoracoplasty (see pages 608-610). Contusions and Wounds of the Chest. — The symp- toms of contusions of the chest are pain and soreness, and, as a consequence, abdominal respiration and decubitus upon the back inclining to the injured side. In severe contusions the viscera may be injured. The treatment is by strapping the chest as for fractured ribs (PI. 5, Fig. 13). Non-penetrat- ing wounds of the chest are not especially grave, and are treated according to general rules, the chest being immob- ilized. Penetrating wounds are very grave injuries. Visceral injury may be inflicted. Emphysema is apt to occur. Pro- fuse hemoptysis suggests a wound of the lung. In ex- amining chest-wounds feel with a finger, not with a probe. In wounds of the pleura cleanse, stitch the pleura with cat- gut or fine silk, suture the skin, dress with gauze, and immob- ilize the chest. Wounds of the lung demand absolute rest. If the bleeding is slight, do not operate ; but if bleeding threatens life, resect a rib to reach the lung, and arrest hem- orrhage. Hemorrhage of the lung may in some cases be arrested by the ligature, in some cases by packing a small SURGERY OF THE RESPIRATORY ORGANS. 607 wound with gauze, in some cases by the suture ligature. In a violent secondary hemorrhage following a gunshot-wound of the lung the author packed the entire pleural cavity with sterile gauze to obtain a base of support, and arrested the bleeding by carrying iodoform gauze directly against the oozing surface/ After arresting hemorrhage in hemothorax, turn out the clots and employ drainage. If emphysema of the chest-walls is moderate, strapping or a bandage will con- trol it ; if it is great, make multiple punctures and then apply pressure. In hernia of the lung try to restore the protru- sion, but if restoration is impossible or if gangrene seems highly probable, ligate the base of the protrusion with silk and cut away the mass. If foreign bodies in the thorax can be felt, remove them ; if they cannot be felt, do not conduct a prolonged search, but leave them to Nature. Abscess of the lung may follow ordinary pneumonia. It is apt to follow aspiration pneumonia. Osier tells us that it may arise by the aspiration of septic particles after " wounds of the neck, operations upon the throat," and suppurative lesions of the nose, larynx, or ear. Cancer of the esophagus may be a cause, so may perforation of the lung by an abscess, wound of the lung, impaction of a foreign body in the lung, suppuration about a focus of tubercle or metastatic abscess.^ Symptoms. — The physical signs of a large cavity are found, and there is profuse and offensive expectoration, the expectorated matter containing portions of lung-tissue. Pyemic abscesses are hard to diagnosticate. The treatment is purely surgical (Pneumotomy). Make an incision over the cavity. Resect a portion of one or more ribs. Expose the pleura. If the two layers of the pleura are not adherent, suture them together and wait two days. If they are adherent, proceed at once. Search for the ab- scess with an aspirator. When the cavity is found, open into it with the cautery and insert a drainage-tube. Gangrene of the I/Ung. — This term means the putre- faction of a devitalized portion of pulmonary tissue. It may follow pneumonia, or may be due to diabetes, to embolism of the pulmonary artery, bronchiectasis, tuberculosis, or malig- nant disease. Symptoms. — The symptoms of a cavity exist plus the expectoration of horribly offensive sputum, which contains fragments of lung-tissue and often altered blood ; there is some fever, and great exhaustion. The great fetor of the 1 Annals of Surgery, Jan., 1898. '^ See Osier's Practice of Medicine. 6o8 MODERN SURGERY. discharge is characteristic, and is much more intense than the fetor of abscess. The treatment is to operate as for pulmonary abscess. Tubercular Cavity in tlie I/Ung. — Surgical Treat- ment. — For the past decade surgical thought has been actively directed toward placing on a scientific footing op- erations for pulmonary phthisis. The matter is still in a transition stage, and operations at present have but a very limited field of application, although Sonnenberg and others have reported cures. Hosier, a number of years ago, at- tempted to treat cavities by introducing a trocar into the cavity and injecting permanganate of potassium solution through the cannula. Patients were not benefited by this procedure. Hillier tried injection of corrosive sublimate into the lung-parenchyma, but the effect of the injections was disastrous. When the strength of the patient is well preserved and the pulmonary lesion is circumscribed and slowly pro- gressive it may be justifiable to perform an operation, open the cavity, and treat it directly (pneumotomy). Fowler says it is not justifiable to operate if the disease has come " to a standstill." The same surgeon states that the only accessible region is bounded above by the clavicle, to the inner side by the manubrium, to the outer side by the lesser pectoral mus- cle, and below by the second rib.^ Manclaise says that pneumotomy is only justifiable in cir- cumscribed tubercular cavities without peripheral infiltra- tion and in pulmonary abscesses.^ Bronchiectatic cavities are usually multiple; they are excessively difficult to locate, and treatment by pneumotomy should not be attempted. In the treatment of pulmonary tuberculosis resection of the diseased area has been proposed (pneumectomy). Tufifier successfully performed this operation. Surgeons, as a, rule, do not believe in pneumectomy. Reclus voices the general opinion when he says the operation is not required if the area of disease is very limited, as such a condition is frequently curable by medical means, and it does no good if the area of disease is extensive.^ Paracentesis Thoracis. — Aspiration will very rarely cure empyema. It will occasionally cure a small encysted empyema or a pneumococcus empyema in a child. Its chief use is in diagnosis, or as a temporary measure when dyspnea is severe ^ See the very full and thoughtful article of George Ryerson Fowler on "The Surgery of Intrathoracic Tuberculosis," ^««a/5 of Surg., Nov., 1896. ' La Tribune inedicale, Sept. 21, 1893. ^ Revue de Chiru7-gie, Nov. Ii, 1895. SURGERY OF THE RESPIRATORY ORGANS. 609 or when operation is not indicated. In very large effusions it is wise to aspirate and withdraw part of the effusion several days before doing a radical operation. After the aspiration the patient takes an anesthetic with more safety, and the danger is obviated of suddenly evacuating a large effusion. The trocar must not be used except in an emergency ; the aspirator is greatly to be preferred. The aspirator evacu- ates the fluid, and, as bacteria do not enter, the lung ex- pands and infection does not occur. The skin, the instru- ments, and the surgeon's hands must be asepticized. Give the patient a little whiskey, and, unless he is very weak, make him sit up in bed. The arm hangs by the side, and the sur- geon introduces the needle in the fifth interspace, just in front of the angle of the scapula. The surgeon marks the upper border of the sixth rib with the index finger, and plunges in the needle just above the finger, thus avoiding the intercostal artery, which lies along the lower border of the rib above. Always guard the needle with a finger to prevent its going in too far. After withdrawing the needle, place iodoform collodion over the opening into the chest. In pleuritic effu- sion, if the lungs will not expand after tappings, perform thoracotomy. Thoracotomy is an incision into the cavity of an em- pyema. It may be merely an intercostal incision, or may be an opening into the chest after resecting a portion of a rib. The instruments required are a scalpel, a grooved director, forceps (hemostatic and dissecting-), scissors, a dry dissector, retractors, bone-instruments (in case rib-excision is required), drainage-tubes, and needles. Chloroform is given the patient, who lies supine at the edge of the table, with the arm elex^ated to a right angle with the body. Make an incision about three inches in length along the upper border of the lower rib bounding the space it is proposed to penetrate. This space is either the sixth or the seventh, and the desired site is in front of the posterior axillary fold. Incise the superficial structures, divide the inter- costal muscles near the rib, push a grooved director through the pleura, and enlarge the opening by means of forceps and the finger. The finger removes all masses of tubercular mate- rial or aplastic lymph within reach. Some surgeons advo- cate immediate irrigation, but this procedure is unsafe, as it 39 Fig. i85. — Resection of rib (Esmarch and Kowal- zig). 6 10 MODERN SURGERY. may produce dyspnea or pleuritic epilepsy, and has caused death. In some cases a counter-opening is made by cutting down upon the long probe which is pushed against the chest- wall after being introduced through the incision ; in other cases it is necessary to resect a rib (page 609 ; Fig. 1 86). A short drainage-tube is introduced and stitched in place. If a counter-opening has been made introduce another short tube, but do not pull one tube through both openings. Arrest bleeding, suture the skin, dust with iodoform, dress with gauze, wood-wool, and a binder, and have the dressings changed as .soon as they become soaked at one point. This operation is rarely curative, and in most cases the intercostal spaces are too narrow to permit of satisfactory drainage. It is far better to remove a piece of rib as directed on page 609 (see Fig. 186). Remove the periosteum and open the pleura. After opening the pleura insert a finger into the pleural cavity. Note if the lung can expand. If it is evident that it can ex- pand, insert a short drainage-tube, close the soft parts, and dress. Several times a day change the patient's position. At each change have him on the diseased side for half an hour, and with the foot of the bed raised for half an hour. Favor expansion by causing the patient to blow into a wash- bottle filled with water. Remove the tube when the dis- charge becomes thin and scanty (about the eighth or tenth day, as a rule). If the lung is bound down with adhesions and cannot expand to fill the space vacated by the pus, per- form the operation of Schede or Estlander. Thoracoplasty (Estlander's operation) is employed in old cases of empyema in which drainage has failed, and in cases with retracted chest-walls, collapsed lungs, thickened pleura, and cavities whose rigid walls will not collapse. The procedure recognises the fact that after pus is evacuated, if the lung is adherent, it cannot expand to fill the space once occupied by fluid, and that the rigid chest cannot fall in as a substitute for the lung, and seeks to destroy the rigidity of the chest and permit it to collapse and thus obliterate the cavity of the empyema. When the surgeon resects a rib and finds a cavity with uncollapsable walls, or a lung bound down with firm adhesions, he should perform thoracoplasty. This operation causes the obliteration of the cavity by collapsing that portion of the chest-wall overlying it. The cavity is in the upper or central part of the pleural space (Treves). The instruments required are the same as those for resection of a rib. The position is the same as that for rib-resec- tion. The length of the incision depends on the size of SURGERY OF THE RESPIRATORY ORGANS. 6ii the cavity. The surgeon usually removes portions of the second, third, fourth, fifth, sixth, and seventh ribs. Make a transverse incision along the center of an intercostal space, and through this incision remove the ribs above and below by the method set forth on page 609 (the removal of six ribs will require three incisions). Instead of this incision, we can make a vertical incision or a U shaped flap. Always take away the periosteum. Treves recommends that the cavity be at once washed out with corrosive sublimate (i : 1000); that if small it be packed with iodoform gauze and allowed to granulate ; that if large it be drained by a large tube, the skin being sutured by silkworm-gut. Irri- gation is thought by many to be dangerous and to possess no special power for good. Schede's Operation. — Schede showed that when the pleura is much thickened even Estlander's operation will not permit the chest-wall to collapse and fill the cavity once occupied by the fluid. Instruments, same as for Est- lander's operation, plus bone- shears. A U-shaped flap is made from the level of the axilla in front to the level of the second rib and between the scapula and spine behind. The lowest level of this incis- ion corresponds to the lowest limit of the pleura (Fig. 187). The flap is loosened and raised, and the scapula is lifted with it. The ribs from the second rib down and from the costal cartilages to the tubercles are removed, along with the chest-muscles and the pleura. This is accomplished by cutting with bone-shears and scissors. Hemorrhage is arrested. The pleura is curetted. A drainage-tube or a piece of iodo- form gauze is introduced, and the raw flap is laid against the visceral layer of the pleura. The superficial incision is sutured. Pneumotomy for Abscess of the I/Ung. — The instru- ments required are scalpels, hemostatic forceps, dissecting- forceps, dry dissector, retractors, periosteum elevator, meta- FiG. 187. — Incision for Schede's operation of thoracoplasty (Esmarch and Kowalzig.) 6l2 MODERN SURGERY. carpal saw, scissors, needles, curved and straight, Paquelin's cautery. Operation, — Place the patient recumbent with the shoul- ders a little raised. Make a U-shaped flap over the suspected trouble. If the intercostal spaces are wide, cut down in a space to the pleura. If they are not wide, resect a rib. If it is found that adhesions do not exist between the pulmonary and costal layers of the pleura, stitch these layers together with catgut and postpone further operation for forty-eight hours. If adhesions exist, proceed at once. Incise the aggluti- nated layers of the pleura, and pass an aspirating-needle into the lung in various directions. When the abscess is located open it by the cautery. Carry the Paquelin cautery slowly into the lung in the direction of the abscess-cavity. The cautery-knife should be at a dull-red heat. Fowler calls attention to the fact that lung-tissue is so insensitive that the administration of ether can be suspended as soon as the pleura has been opened. When the cautery opens the cavity withdraw the instrument and insert a drain- age-tube or a bit of iodoform gauze, and suture the flap of superficial tissue. If the abscess is not found after one or two punctures with the aspirating-needle, abandon the attempt. Tuffier explores for an abscess by what he calls decolle- ment of the parietal pleura. He exposes the parietal layer, passes his hand between this layer and the chest-wall, strips the pleura off over a considerable area, and is able to feel the lung below, and thus determine its condition. XXVI. DISEASES AND INJURIES OF THE UPPER DIGESTIVE TRACT. Diseases of the Mouth, Tongue, and Bsophagus. — Harelip and Cleft Palate. — Harelip is a congenital cleft in the upper lip due to defective development. Cleft palate is a congenital fissure in the soft palate or in both the hard and soft palates. In harelip the cleft is usually complete, through the entire lip into the nostril, but in rare cases it may only show as a furrow in the mucous edge or as a split from the nostril partly into the lip. It is most common on the left side. In double harelip the central portion of the lip is often adherent to the tip of the nose (Bowlby). Double harelip may be free from complication, but is often associated with a malformation of the alveolus and palate (Heath). Median harelip is exceedingly rare. In cleft palate the DISEASES AND INJURIES OF THE DIGESTIVE TRACT. 613 septum of the nose is usually adherent to the palatine proc- ess opposite the side upon which the fissure exists. In those rare cases of cleft palate double in front the nasal sep- tum is attached only to the premaxillary bone, and the pre- maxillary bone is not attached at all to the superior maxillae. In harelip there is often a cleft in the alveolus, and almost always flattening of the corresponding side of the nose. Harelip is often associated with cleft palate, talipes, and other deformities. It is a great deformity, and interferes with sucking, swallowing, and articulation. Operation for harelip should be performed between the third and sixth months of life in a child in good health, free from stomach trouble, cough, or coryza, but operation is not advisable in the early weeks of life. Always, if possible, operate before dentition begins (seventh month). If the child is in poor health, postpone the operation until restora- tion has so far advanced as to render operation safe. While waiting for operation be sure the child is getting enough food. If it cannot suck, feed it with a spoon. If a cleft exists in the palate, operate first upon the lip, because the pressure of the parts after the edges of the gap are approxi- mated aids in the closure of the bony cleft. Cleft palate interferes with sucking, deglutition, mastication, and articu- lation. In severe cases the food passes into the nose and excites inflammation. Loss of control of the palate-muscles always exists, and liquids and solids are liable to pass into the windpipe. Clefts in the hard palate should not be oper- ated on until the second year, but should be operated upon then, otherwise speech will be permanently affected. Some surgeons refuse to operate until the tenth or twelfth year, but operation done this late will not correct speech-defect. In many cases the passage of food and drink into the nose can largely be prevented by the use of a diaphragm. The patient at the period of operation should be well and free from cough. Operation for Harelip. — The instru- ments required are a tenotome, harelip- clamps, toothed forceps, hemostatic for- ceps, scissors curved on the flat and • ,1 i'ii.Li J. • L ^ • Fig. 188. — Malgaigne's opera- pomted, straight blunt-pomted scissors, uon for harelip, needles (straight and curved), silver wire or silkworm-gut and silk sutures, a mouth-gag and tongue- forceps, a needle-holder, and sequestrum-forceps, each blade protected by a rubber tube. Wrap the child in a 6 14 MODERN SURGERY. sheet; place it supine; raise the head and rest it upon a sand-pillow. The surgeon stands to the right side of the patient. Ether or chloroform is given. For single harelip, separate with the scissors the upper lip from the bone on each side of the cleft until approximation of the cleft can be effected without tension. If the maxillary bone of one side projects more than its fellow, grasp it with sequestrum- forceps and bend it back (Jacobson and Treves). Clamp the upper lip at each angle of the mouth to prevent hemor- rhage. If the edges are of equal or nearly equal length, and if the gap is not very wide, perform Malgaigne's opera- tion. This is performed as follows : a flap is detached on each side, the detachment beginning at the upper angle of the gap ; each flap is detached above but remains attached below. The flaps are drawn downward so as to form a prominence at the vermilion border (Fig. i88). If the edges are pared so that in closure the vermilion border is even, when the parts are healed a gutter will be visible at the line of union. The edges are approximated by an assistant, and silkworm-gut sutures or silver wires are passed by means of a straight needle. Each suture goes down to the mucous membrane. The first suture is passed through the middle of the lip, one- third of an inch from the cleft. Three or four main sutures are passed through the thickness of the lip, and are tied and cut off Two or three fine silk or catgut sutures are passed by a curved needle through the vermihon border of the lip and the mucous membrane of the mouth, and are tied and cut off. A small piece of gauze is placed over the lip and is held in place by straps of rubber plaster. After operation prevent the child crying by feeding it often and giving it small doses of laudanum. Heath orders two drops of laudanum in one ounce of distilled water, a teaspoonful to be given every two or three hours. About the sixth day one-half the sutures are taken out, and on the eighth or ninth day the remaining ones are removed. In many cases no further procedure is necessary, but if after some weeks the prominence at the lip- border does not shrink, it can be readily clipped away. Harelip-pins are not used at the present time, and are not needed if the lip is well separated from the bone. If the edges of the cleft are of unequal length, Edmund Owen's operation can be performed (see below under Double Harelip), or we can perform Mirault's operation, as shown in Fig. 190. In double harelip the operation is similar to that for single harelip. If the intervening piece is vertical and is covered with healthy skin, complete each operation as for single harelip, DISEASES AA'D INJURIES OF THE DIGESTIVE TRACT. 615 closing both fissures at once with silver wire in a strong, healthy child, closing them at intervals of three weeks in one not so lusty (Fig. 189). Excise the septum if it is deformed. The premaxillary bone should in most instances be removed, Fig. 180. — Incisions for double harelip (Esmarch and Kowalzig). Fig. 190. — JNIirault's operation for single harelip (Esmarch). the skin over it being preserved. Sir Wm. Fergusson was accustomed to incise the mucous membrane and shell out this bone. The premaxillary bone can be forced back into line, being held, if necessary, by catgut suture of the peri- osteum ; but if saved it is liable to necrose and its teeth soon decay. Heath removes this bone two weeks before operating on the lip. If there is much hemorrhage after removal, stop it with a hot wire or with Horsley's wax. Fig. 189 shows incisions for double harelip. Edmund Owen's operation is very useful (Figs. 191, 192). In this operation very thick flaps are cut. The prolabium and incisive bone are removed. The flaps are cut as shown, Fig. 191, Fig. 191. — Double harelip, the prolabium and incisive bone having been removed (Owen). Fig. 192. — The.two sides of the lip drawn together and secured by sutures (Owen). on one side by line ab, and on the other side by line cde. a is brought to e, b is brought to d, f is brought to c, and sutures are applied (Fig. 192). Operation for Cleft Palate. — It is true that during the early years of growth the clefts diminish in size ; but to wait too long before we operate means permanent speech-impairment. Bony clefts should be operated upon during the second year (Owen). Clefts of the soft palate only may be operated upon in the first six months (Edmund Owen). If both the hard and soft palates are cleft, close both at one operation. Edmund Owen has recently put forth a convincing plea for 6 1 6 MODERN SUR GER Y. early operation.^ He says he is operating earlier and earlier, and quotes Chilton as the gentleman who led him to do so. Owen maintains that if speech is to be improved operation must be done early, and he formulates some very valuable rules of preparation and cafe : have the child in the best condition, free from cough and stomach disorder. Operate in the summer. Place the child under the charge of a nurse several days before the operation. For suture of the soft palate istapliylorrhaph)') Treves says the following instru- ments are essential : two sharp-pointed tenotomes, a blunt- pointed tenotome, a rectanglar knife, two pairs of long forceps (one with tenaculum points, one serrated), a fine hook, a pair of sharp-pointed curved scissors, scissors curved on the flat, periosteum-elevators, two long-handled needles with eyes at their points, a suture-catcher, a tubular needle for wire su- tures, hemostatic forceps. Whitehead's gag and retractors, silver wire, silkworm-gut, and sponge-holders ; also an elec- tric forehead light. The patient's body is raised, and his head is elevated and rested upon a sand-bag. A better position would be that of Trendelenburg, thus avoiding the trickling of blood into the windpipe. Chloroform is given. The gag is introduced; the edges of the mucous membrane are pared with a tenotome ; the sutures are introduced from below up- ward, silkworm-gut being used for the uvula and lower part of the velum, silver wire for the remainder of the cleft ; each suture, as it is passed, is tied or twisted, but is not cut until the next suture is inserted, thus serving as a handle. If there is too much tension to allow of the sutures being tied as they are inserted, all the sutures are passed and loosely twdsted. A longitudinal incision is made upon each side, in- ternal to the hamular process, the mucous membrane being cut with a sharp tenotome, the deeper structures being di- vided with a blunt tenotome ; the sutures are tied or twisted and cut (Fig. 193). In Fergusson' s operation for clefts in the hard palate {iiranoplastyi) the mucous edges are pared and the sutures inserted but not tied. Make an incision upon each side down to the bone, the incision being midway be- tween the cleft and the alveolus. Divide the bone on each side, by means of a chisel, to the full length of the incision, and, using the chisel as a lever, force each half of the bone toward the gap. Tie the sutures, and plug each lateral in- cision with a piece of iodoform gauze (Fig. 194). After the operation for cleft palate put the patient to bed for one week ; forbid talking ; give fluid or semisolid food at intervals of two 1 Lancet, Jan. 4, 1896. DISEASES AND INJURIES OF THE DIGESTIVE TRACT. 617 or three hours for three weeks ; wash out the mouth very often (always after eating) with a carbohc solution (i : 100) or a solution of boric acid and listerine. Sutures are re- moved in from two to three weeks. Edmund Owen ' operates as follows : pare a strip of Fig. 193. -Staphylorrhaphy (Esmarch and Kowalzigj. Fig. 194 — Uranoplasty (Esmarch and Kowalzig). mucous membrane from each side of the fissure from the lip of the uvula to the top of the gap. Make a free incision " along the alveolar aspect of the palate " close to the teeth. Lift up the strips of muco-periosteum and shift them toward the cleft. Sever the attachments of the soft palate to the posterior border of the hard palate and extend the alveolar incision well backward. This incision relieves tension. Sew up with wire ; twist each wire and cut each wire, leaving an end one-eighth of an inch long. This procedure causes the child to keep his tongue from the suture-line. For the first twenty- four hours give only water, and after this feed with beef jelly and liquids. When feeding is begun attempt irrigation or spraying if it does not alarm the child. In a day or two the patient can Fig. 195. — Removal of lower lip and cheilo- Fig. 196. — Suturing in cheiloplasty (Es- plasty (Esmarch and Kowalzig). march and Kowalzig). take sweetened orange-juice, custard-pudding, finely sieved ' Lancet, Jan. 4, 1896. 6l8 MODERN SURGERY. meat or chicken. The best fluid for irrigation is Condy's fluid or mild carboHc acid. Get the child out in the air a day or two after the opera- tion and keep it out all day. (The entire article of Mr. Owen's will well repay a careful reading.) Cancer of the Lip. — Epithelioma is common in the lower lips of males (page 233). In most instances it may be re- moved by a V-shaped incision, the wound being closed as in harelip. The glands from beneath the jaw, whether enlarged or not, should always be removed. If the growth is exten- sive, the entire lower lip is removed and cheiloplasty is per- formed to replace the lip (Figs. 195, 196). Tongue-tie is a congenital shortness of the frenum. The tongue cannot be protruded beyond the incisor teeth. Swal- lowing is interfered with, and later in life articulation is impeded. To treat tongue-tie, tear up the frenum with the thumb-nail. If this fails, catch the frenum in the slit in the handle of a grooved director, push the director toward the base of the tongue, and divide the frenum with scissors curved on the flat and pointed toward the director. Ranula is a dilatation of one of the ducts of the mucous glands of Nuhn and Blandin. These glands lie on each side of the frenum of the tongue. It was long thought that a ranula arose from obstruction in the duct of the sublingual gland, A ranula appears upon the floor of the mouth on one side and pushes the tongue toward the opposite side. The contents of a ranula resemble mucus or saliva. The treatment of ranula is by excision of a portion of the cyst- wall and cauterization of the interior with pure carbolic acid or with 15 minims of a solution consisting of 10 parts of tincture of iodin, 10 parts of water, and i part of iodid of potassium ; or by cutting a flap from the cyst-wall and stitch- ing it aside so as to keep a permanent opening.. Partial Removal of the Tongue. — This has been practised many times for cancer of the anterior portion of this organ. In malignant disease, if one side of the tongue alone is in- volved, remove one-half of the organ ; if both sides of the tongue are involved, remove the organ entirely. Even in partial excision for malignant disease remove all of the glands from the submaxillary triangle of the diseased side, even when they are not apparently involved. This is the only chance for the patient's cure, as these glands are in- volved long before the involvement is obvious to touch. In performing the operation of partial excision introduce a mouth gag, place a silk ligature on each half of the tip of DISEASES AND INJURIES OF THE DIGESTIVE TRACT. 619 the tongue, and draw the tongue out of the mouth (Barker). Split the tongue back in the middle line with the scissors, and loosen the cancerous side from the floor of the mouth and side of the mouth. Pass a stout silk ligature through the base of the tongue posterior to the cancer. Draw the organ out and cut off the diseased side in front of the liga- ture but back of the disease. Tie the vessels, remove the constricting and traction threads, and treat subsequently as in cases of complete removal. Complete Removal of the Tongue (Kocher's Method). — Kocher used to employ a preliminary tracheotomy in tongue- excision, but the Trendelenburg position renders this proced- ure unnecessary so far as hemorrhage is concerned. Always clean the mouth well. The instruments required are a scalpel, retractors, a dry dissector, hemostatic and dissecting- forceps, a tenaculum, aneurysm-needle, tenaculum-forceps, needles, sutures, and scissors. In this operation the patient is placed in the Trendelenburg position, the surgeon standing by the affected side. Chloroform is given. An incision is made from behind the lobe of the ear, along the anterior edge of the sternocleidomastoid to about the middle of the margin of this muscle. From this point the incision is carried to the hyoid bone and then to the symphysis menti, along the anterior belly of the digastric muscle (Fig. 197). The flap is dissected and turned up ; the facial and lingual arteries are ligated ; " the submaxillary fossa is evacuated " (Treves) ; the sublingual and submaxillar}' glands are re- moved ; the mylohyoid muscle is divided ; the mucous mem- brane is incised close to the jaw, and the tongue, caught with tenaculum-forceps, is drawn through the opening. The tongue is split in the middle with scissors, and the near half is re- moved. Arrest bleeding. If the whole tongue requires re- moval, perform a set ligation of the lingual artery of the oppo- site side. Some surgeons stitch the mucous membrane of the stump to the mucous membrane of the floor of the mouth ; others employ no sutures. Kocher does not suture his skin-wound ; many surgeons do, and employ drainage- tubes. Keen advises closing the floor of the mouth, if pos- FiG. 197. — Kocher's excision of tongue (Esmarch and Kowalzig). 620 MODERN SURGERY. sible. Some hours after the operation, when oozing has ceased, dust the mouth-wound with iodoform. The patient, as soon as possible, is propped up in bed, and he must not swallow the discharges if it can be avoided. The mouth, every half hour, is sprayed out with peroxid of hydrogen and washed with a carbolic solution ( i : 60). Every three hours after washing the floor of the mouth and the stump, dry with absorbent cotton and dust with iodoform. For twenty-four hours after the operation nothing is given by the mouth except a little cracked ice, the patient being fed per rectum. At the end of twenty-four or forty-eight hours some liquid food is given from a feeding-cup. The patient will soon learn to swallow; but if he cannot swallow easily, feed from a tube. Treves, in his clear and positive directions for after-treatment, states that nutrient enemata are to be con- tinued until sufficient nourishment is taken by the mouth ; that the mouth should be flushed out by irrigation, and must be washed immediately after taking food ; that morphin is to be avoided ; and that the patient can usually leave the hos- pital in from seven to ten days. Whitehead removes the entire tongue from within the mouth by the use of scissors. He passes a ligature through the tip, cuts the frenum, draws the tongue strongly forward and separates by a series of clips with the scissors. The lingual arteries are tied as cut. " The stump should be kept under control, as regards hemorrhage, by a stout silk ligature passed through the remains of the glosso-epiglottidean fold and retained for twenty -four hours." ^ Heath has shown that if the forefinger be passed to the epi- glottis and used to " hook forward " the hyoid bone, the lin- gual arteries are stretched and portions of the tongue can be removed almost without bleeding. After Whitehead's opera- tion always remove the glands from the submaxillary triangles. Stricture of the Esophag-us. — Fibrous or cicatricial strict- ure is due to traumatism, chronic inflammation, syphilis, tuberculosis, ulcer, prolonged vomiting, variola, gout, or to swallowing a corrosive substance or a boiling liquid. It is commonest in the young, and is apt to be situated opposite the cricoid cartilage at the tracheal bifurcation or near the cardiac end. Cicatricial strictures are usually single, but may be multiple. Stricture following impaction of a foreign body is located at the seat of impaction unless the tube has been injured by efforts at extraction, in which case multiple strict- ures may exist (Maylard). Strictures which result from swal- lowing boiling fluid or corrosive liquid are usually very exten- ^ American Text-book of Surgery. DISEASES AND INJURIES OF THE DIGESTIVE TRACT. 62 1 sive, and may be multiple. Syphilitic stenosis is due to the healing of a gummatous ulceration, but there is nothing char- acteristic of this kind of stenosis (Maylard). Tubercular stenosis is extremely rare. Cancerous stricture occurs in those beyond middle life, and is far more common in men than in women (see Morell Mackenzie). Any portion of the canal may be attacked, but the central portion is least often the seat of cancer (Maylard, Butlin). The majority of cancers of the esophagus are epitheliomata, but scirrhus, encepha- loid, or colloid may occur. Cancer soon ulcerates and involves adjacent parts by infiltration. The deep cervical and posterior mediastinal glands are involved (Maylard). Spasmodic or hysterical stricture, or esophagismus, which is commonest in women, is associated with the stigmata of hysteria, and especially with globus (a sense as of a ball rising in the throat) ; a bougie held against it is only tem- porarily obstructed. The contraction arises suddenly, and one passage of a bougie often causes it to disappear. Symptoms of Cicatricial Stenosis. — The condition may Fig. 198. — Esophageal instruments : a, b, forceps ; c, horsehair probang ; d, coin-catcher ; E, esophageal bougie. occur at any age. The chief symptom is difficulty in swal- lowing, at first slight, but becoming more and more pro- 622 MODERN SURGERY. nounced until swallowing is almost or quite impossible. The dysphagia is first manifested to dry solids, then to all solids, and finally to liquids. In some cases vomiting occurs after swallowing. If the stricture is high up, the vomiting is almost immediate ; if it is low down, the vomiting is delayed, especially if the canal is dilated above the stricture. From time to time the patient vomits independently of taking food, the ejected matter being saliva. Vomited matter is not bloody. The pa- tient feels weak and hungry, becomes exhausted and ema- ciated, and suffers from flatulence, gastralgia, and constipation. There is occasionally slight uneasiness or even pain in the region of the stricture, possibly " about the epigastrium or between the shoulder-blades" (Maylard). The stricture may be located with a bougie. The history of the case is of much importance in diagnosis. Inquire about impaction of a foreign body, or swallowing of acids, alkalies, or boiling fluids ; ex- amine for evidence of syphiHs. If there is no history of in- jury or syphilis, and the patient is over forty years of age, the indications point to cancer rather than cicatricial stenosis. The easy passage of a bougie when the patient is anesthet- ized shows that spasm is the cause, and not organic disease. Narrowing due to external pressure is marked by positive symptoms of the causative disease.^ Treatment. — Gradual dilatation through the mouth is a method employed for at least a time in almost every case. Begin with the largest bougie which will easily pass. Warm the bougie, oil it, pass it gently, and hold it in position for several minutes, prolonging the time of retention of the bougie as treatment progresses. Pass an instrument every second or third day, gradually increasing the size. Symonds advocates the insertion of a tube through the stricture and leaving it in place until dilatation is distinct, and then replacing the tube with a larger instrument. The patient is fed through the tube. Gradual dilatation from below has been practised in cases where a bougie could not be passed from the mouth. A gastrostomy is performed and after the fistula has become sound the patient is made to swallow "a shot to which is attached a silk thread" (May- lard). The silk thread is brought out through the fistulous orifice and is attached to a bougie, and the dilating instru- ment is pulled up through the esophagus. Forcible dilata- tion can be employed through the mouth or through a gastrotomy opening by means of bougies, tents, or divulsing instruments. Electrolysis is used by Fort and others. Some ^ See the excellent article in Maylard's Surge7'y of the Alimentary Canal. DISEASES AND INJURIES OF THE DIGESTIVE TRACT. 623 surgeons perform internal esophagotomy through the mouth with a special instrument ; some advocate external esopha- gotomy ; some incise the esophagus above the stricture and pass bougies from the wound through the region of stenosis. Abbe of New York devised a very ingenious operation. He performs a gastrotomy, passes a conical rubber bougie from the mouth into the stomach or from the stomach into the mouth, ties a piece of braided silk to the bougie, with- draws the instrument and leaves the silk in place. One end of the silk emerges from the mouth and the other end from the gastrotomy wound. In some cases he opens the stomach and also opens the esophagus above the stricture, one end of the string comes out of the esophagotomy wound and the other end out of the gastrotomy wound. The string is used as a string or bow-saw, the stricture is divided, the silk is withdrawn, full-sized bougies are passed, and the wound or wounds are sutured. In very bad cases gastrostomy is per- formed to keep the patient from starving. Svinptonis of Cancerous Stenosis. — The patient is over forty years of age, is usually a male, and presents the same diffi- culty of swallowing met with in cicatricial stenosis. The vomited matter is apt to contain blood, the use of the bougie causes bleeding ; there are generally decided pain and very great emaciation. The seat of obstruction is located by the bougie and by listening over the spine while the patient is attempting to swallow water. The stomach is the seat of pain ; the mouth is dry and there is often great thirst. As the disease infiltrates the involvement of adjacent regions pro- duces other symptoms. Dyspnea may result from tracheal pressure. Pleuritis, pericarditis, or pneumonia may arise. Treatment. — The disease is of necessity fatal, and treatment is only palliative. Successful excision is not feasible. Feed upon soft, bland diet in small quantities given frequently. When trouble is experienced even with such food, pass a bougie every third or fourth day. When the patient be- comes entirely unable to swallow soft food we may insert a Symond's tube or do an esophagostomy (if this can be performed below the stricture), or perform gastrostomy. In every doubtful case of esophageal stricture giv^e a course of iodid of potassium before performing any operation (the younger Gross). Diverticula of the Esophagns, — Maylard tells us that these pouches may be due to one of four causes — they may be congenital ; may be due to stricture ; may be caused by pressure from within, upon a weak spot of the wall ; may 624 MODERN SURGERY. be due to traction from without, by the heahng and con- traction of an area of inflammation. Symptoms. — When the diverticulum is in the neck a lump forms during deglutition, and this lump may be obliterated by pressure. Food will pass into the stomach only when the diverticulum is full. A bougie cannot be passed unless the pouch is full of food, at which time it may pass or may not. This latter symptom, the variability in the passage of the bougie, is the evidence reUed on for diagnosis in infra- thoracic diverticula. By listening with a stethoscope fluid may be heard to pass into the pouch. Treatme7it. — Extirpation and suture, as performed by von Bergmann, Hearn, and others. Injuries of the Esophag-us. — Injuries of the internal sur- face are more common than injuries from without. Burns and scalds are among these injuries. Wounds may be in- flicted by foreign bodies. These injuries cause pain on swal- lowing. A severe injury causes bleeding, the blood being both coughed up and vomited. A severe wound may involve a large vessel and cause violent or fatal hemorrhage. If the bronchus or trachea is involved there will be " cough and expectoration of blood, mucus, and food " (Maylard). The pleural or pericardiac sacs may be perforated. Treatment. — Feed purely by the rectum. Give morphin hypodermatically. Do not feed by the mouth for ten days, and even then give only fluid food and jelly. Symptoms are met as they arise. In burns by caustics administer the anti- dote ; give large draughts of water and wash out the stomach. Injuries of the esophag-us from outside, ■without in- volvement of other structures, are rare. Esophageal in- juries, as a rule, are associated with serious damage to adja- cent structures. These injuries may be due to stabs or to bullets. Besides the obvious external signs of the injury there will be difficulty in swallowing, cough, bloody expec- toration or vomiting ; and mucus or the contents of the stomach may run out of the wound. Treatment. — Suture the wound, and feed by the rectum for ten days. Foreign Bodies Lodged in the Esophag-us. — These acci- dents occur especially to children and lunatics, and women are more apt to suffer from them than are men. An elaborate list of bodies which have been swallowed will be found in Poulet's elaborate treatise. There are three spots where a foreign body is especially apt to lodge — viz. opposite the cricoid cartilage, at the level of the diaphragm, and at the DISEASES AND INJURIES OF THE DIGESTIVE TRACT. 625 point where the left bronchus crosses the gullet. Small and sharp bodies may lodge anywhere. Symptoms. — The symptoms are variable ; if the body is large, there will be pain and difficulty in swallowing, and, in some cases, dyspnea from pressure upon the trachea or bronchus. Death may result from asphyxia. In some other cases the symptoms are very slight. If the body is sharp, there will be hemorrhage and severe pain. The blood may be hawked up, or may be swallowed and vomited. A patient may grow accustomed to a foreign body and cease to notice it ; but, on the contrary, the foreign body may produce in- flammation, and even may ulcerate into the windpipe, the pleura, the pericardium, or the aorta. In many cases of im- paction a patient makes violent efforts to hawk it up, and produces aphonia. There may be violent retching. Even after a foreign body has been removed by swallowing or otherwise a sensation is apt to remain as if it were still lodged. The diagnosis is made by the history, the detection of the body by external manipulation, by feeling it with an esophageal bougie, and, if bone or metal, seeing it with the fluoroscope or obtaining a skiagraph. Treatmait. — The surgeon should find out if possible the size, shape, weight, and nature of the foreign body, and locate its point of impaction. In metal bodies or bone the exact point of lodgement is determined by the Jf-rays.^ An anesthetic is usually necessary in a child, a nervous woman, or a lunatic, and is sometimes necessary in a man. If the for- eign body is soft, external manipulation may succeed in alter- ing its shape, so that it may be swallowed or ejected. If the foreign body is hard, external manipulation may shift its posi- tion. It is usually impossible to reach the foreign body through the mouth by means of the fingers (when the body is in the rear of the pharynx it may be pulled forward or pushed down). Sharp foreign bodies may be entangled and carried down when the patient eats mush, bread, or boiled potatoes. The administration of emetics is an old plan which occasionally succeeds, but which is often unsafe. It is not to be advised. Maylard says that when a mass of food is impacted it is occasionally possible to soften and disintegrate the mass by administering a mix- ture containing pepsin. The horsehair probang is a very useful instrument (Fig. 198, c). It may be used to push a body downward into the stomach, or to catch the body and pull it up. When this instrument is withdrawn it opens like an um- 1 See cases of White, Keen, Alfred Wood, Maclntyre, and others. 40 626 MODERN SURGERY. brella. Maylard quotes Morris Richardson to the effect that in an adult the diaphragmatic opening is about fourteen and one-half inches from the incisor teeth, a point to be remem- bered in deciding whether to push down or pull up the im- pacted article. Esophageal forceps (Fig. 198, a, B)are valuable in some cases. The coin-catcher (Fig. 198, d) is a useful in- strument. Crequy's plan of removal is to take a tangled mass of threads, tie a stout piece of string about the middle of it, coat it with sugar, and have the patient swallow it. It may pass the foreign body ; if it does so, on withdrawal it may entangle the object and extract it. To remove a fish-hook with line attached, the following plan may prove successful : stick the line into a metal catheter, carry the catheter down to the hook, and push the hook out. If efforts at extrac- tion through the mouth are futile, it may be necessary to perform esophagotomy. The cut is made on the left side, between the trachea and larynx in front and the carotid sheath behind, the center of the incision being opposite the cricoid cartilage. After the foreign body is extracted the mucous membrane is sutured with chromic catgut, and the superficial structures are closed with silkworm-gut. The patient is fed by the rectum for eight or ten days. In cases where the impaction is low down gastrotomy is performed. In White's case of jackstone in the gullet gastrotomy was performed. A string was tied about some rolls of gauze, the string was passed by mean^ of a whalebone from the stomach into the mouth, and the body was entangled and drawn out. XXVII. DISEASES AND INJURIES OF THE ABDOMEN. Contusion of the Abdominal Wall without Injury of Viscera. — In some cases of contusion of the abdominal wall only the parietes are contused ; in other cases the viscera or the abdominal tissues are injured. Contusion may involve the skin alone, or may involve the skin, muscles, and perito- neum. In simple contusion there is considerable shock if the injury is severe. There is pain, increased by respiration, motion, pressure, and attempts at urination or defecation. When tenderness appears some days after the accident there is deep-seated injury. Extensive ecchymosis may appear. In even a severe case there may be no discoloration, and in even a slight case there may be much discoloration. There is great ecchymosis in anemic persons, victims of hemi- plegia, in obese individuals, opium-eaters, and drunkards. In severe cases the tissues are pulpefied and sloughing inevi- DISEASES AND INJURIES OF THE ABDOMEN. 627 tably ensues. Abscess occasionally follows contusion. The prognosis after abdominal contusion is always uncertain. In treating simple contusion place the patient at rest in a supine position, with the thighs flexed over a pillow ; obtain reac- tion from the shock ; and give morphin for pain. After the patient has reacted it is advisable to place an ice-bag ov^er the injury from time to time, and in the intervals of its appli- cation use lead-water and laudanum locally. If much blood is extravasated, aspirate and apply a binder. After twenty- four hours apply intermittent heat by the hot-water bag, employ an ointment of ichthyol, and move the bowels, if necessary, by salines. Regard every contusion as serious, and watch carefully for the development of signs of internal hemorrhage or visceral injury. Muscular Rupture from Contusion. — In this injury there are severe shock and pain (increased by respiration and move- ment). Separation between the fibers of the muscle is dis- tinct at first, but it is soon masked by effusion of blood. Such injuries may cause death, or they may lead to hernia. The rectus is the muscle most apt to rupture. The rupture is due to sudden contraction rather than to a blow. The treatment is the same as for simple contusion. Al- ways apply a binder. A hernia is returned and a compress is applied over the opening through which it emerged. If strangulation occurs, operate at once. Injuries with Damage to the Peritoneum or the Viscera. — Rupture of the Peritoneum. — The peritoneum may be involved in an abdominal contusion. It may rupt- ure even without any visceral injury or muscular contusion. The uterine peritoneum, the parietal peritoneum, the visceral peritoneum, or the mesentery may rupture. Rupture of peritoneum causes intra-abdominal hemorrhage (page 627). The treatment consists in opening the abdomen, arresting the hemorrhage, and bringing about reaction. An injury to the peritoneum creates a point of least re- sistance, and at such a point peritonitis may develop. The peritonitis is usually local, but may become general. After any severe intra-abdominal injury the symptoms of perito- neal shock appear (peritonism), and the patient may rapidly die. In the condition of peritonism the temperature is sub- normal ; the extremities are cold ; the face is pallid and sunken ; the pulse is small, weak, and very frequent ; the respiration is shallow and sighing ; there is great thirst ; the patient is restless and tosses about. Vomiting almost always occurs. In some cases there is regurgitation rather than 628 MODERN SURGERY. vomiting. The abdomen is the seat of a violent, persistent pain. The patient is fearful of impending death. As the symptoms develop in a grave case they will point to one of two conditions, hemorrhage or peritonitis. In intra-abdominal hemorrhage the subnormal temperature and other evidences of shock persist. Vomiting ceases, but nausea exists. The patient is uncontrollably restless and tosses about in bed. The thirst is great. The abdomen is not rigid. Fainting-spells occur. Blood-examination shows a great fall in the percentage of hemoglobin. Percussion shows the existence of an effusion which alters its position as the patient's position is altered, and which gradually increases in amount. Dulness is first met with in the loins. Rectal or vaginal examination may aid in diagnosis. If peritonitis develops, the vomiting becomes worse, the pain intensifies, and the abdomen grows rigid and distended. Rupture of the Stomach without Bxtemal Wound. — The usual cause of rupture is a violent blow, although the accident may happen in washing out the stomach. Rupture is more apt to occur when the stomach is distended with food than when it is empty. The rupture may be partial, the perito- neal coat not being torn. The rupture may be complete. The region of the pylorus is most apt to be lacerated. The symp- toms of rupture are collapse, severe pain over the entire abdo- men, great thirst, excessive tenderness, especially over the epi- gastric region, occasionally vomiting, the vomited matter being usually, but not invariably, bloody ; tympanitic distention and muscular rigidity coming on after a few hours. Gas may enter the abdominal cavity and cause the disappearance of liver-dul- ness, but liver-dulness can be abolished by great intestinal dis- tention. After incomplete rupture local peritonitis is frequent ; in complete rupture the escape of food into the peritoneal cavity causes septic peritonitis. To diagnosticate between complete and incomplete rupture, endeavor to distend the viscus with hydrogen gas : in incomplete rupture the contour of the dilated stomach can be made out upon the surface ; in complete rupture the viscus cannot be distended and the gas passes into the peritoneal cavity, producing the physical signs of tympanites (Senn). The treatment in complete rupt- ure is as follows : if signs of hemorrhage are absent, en- deavor to bring about reaction before operating. If these signs are present, operate at once. Open the abdomen ; if the rent is not visible, find it by inflating the stomach with hydrogen ; flush out the stomach and the peritoneal cavity with hot salt-solution ; sew up the stomach-wound with a DISEASES AND INJURIES OF THE ABDOMEN. 629 double row of silk sutures, the first row being buried and including the muscular coat and mucous coat, the second row being Halsted sutures ; drain ; close the wound in the parietes with silkworm-gut ; feed by the rectum for four days, and then begin the administration of a very little food by the mouth. In incomplete rupture the danger is perforation. The patient is put to bed, and after reaction has taken place, is fed by the rectum for several days, and morphin is given hypodermatically. Rupture of the Intestine without Kxternal Wound. — The symptoms of this injury are profound shock, tympan- ites, and pain, rapidly followed by peritonitis if the patient survives. Vomiting comes on soon after the accident, the vomited matters being possibly at first bloody and then stercoraceous. The respiration is thoracic, the tongue is dry, and great thirst exists. The pulse, which is slow at first, becomes small and rapid. A high-tension pulse accompanies tympanites, because the distention of the bowel greatly decreases the amount of blood in its coats, and thus in- creases the amount of blood in the rest of the system. Any portion of the intestine may rupture, but the ileum is most liable to this accident. Blood in the stools rarely appears early enough to be of diagnostic value. The escape of gas into the peritoneal cavity may cause disappearance of normal liver-dulness. By anesthetizing the patient hydrogen gas insufflated into the rectum will come from the mouth if there is no perforation in the stomach or the intestine ; if a perforation exists, tympanites is much increased. To apply rectal insufflation of hydrogen, generate the gas in a bottle by means of zinc and sulphuric acid, catch the gas in a large rubber bag, and attach the tube from the gas reservoir to a tip which is inserted in the rectum. Give the patient ether to relax the abdominal muscles, direct an assistant to press the anal margins against the rectal tip, and when the patient is unconscious turn on the stopcock and press upon the reservoir (Senn). Treatment. — If symptoms point to dangerous hemorrhage operate at once, otherwise do not operate until reaction has been obtained. Give stimulants by the rectum, and a hypo- dermatic injection of morphin and atropin ; asepticize and anesthetize. Perform a laparotomy ; check hemorrhage ; find the rent, and close it by Helsted sutures if possible. The hydrogen gas test of Senn will discover a perforation. It may be necessary to perform an end-to-end approxima- tion or a lateral anastomosis. Flush out the abdominal 630 MODERN SURGERY. cavity with hot saline solution. Some surgeons cleanse the abdomen by wiping with gauze. Finney eviscerates, wipes out the abdominal cavity, and wipes the intestines as he restores them. Whatever method is used to cleanse the abdomen remember that infectious material is apt to accu- mulate between the liver and diaphragm and in Douglas's pouch. Drainage is to be used. " In abdominal operations it is frequently imperatively necessary that the large intestine be recognized with cer- tainty or the small bowel be positively identified. The size of the tube will not always aid in this recognition, as a small intestine may be distended enormously and a large intestine may be contracted to the size of a finger because of obstruc- tion above. The longitudinal muscular fibers of the large bowel are accentuated in three portions ; these accentuations constitute the three longitudinal bands which begin at the cecum and terminate at the end of the sigmoid flexure of the colon. Each band is composed of a number of shorter bands, the shortness of these constituent bands permitting the sacculation of the large intestine. Longitudinal bands and sacculation are not met with in the small gut, their pres- ence or absence being a means of identification in many cases ; but when the colon is much distended the bands cannot be seen distinctly and the sacculation disappears. From the large intestine only spring the appendices epiplo- icse (small overgrowths of fat in pouches of peritoneum), but they are sometimes not well marked except upon the transverse colon, and when emaciation exists they may almost entirely disappear. The relatively fixed position of the large intestine and the free mobility of the small bowel are important points of distinction. The foregoing indicates that it is not always easy to distinguish between colon and small gut, and that, according to old rules, it may often be necessary to make large incisions, to see as well as feel, and to handle a large extent of the bowel. Any scrap of knowl- edge that will shorten an abdominal operation, that will per- mit of as certain work through a smaller incision, and that will diminish handling of intraperitoneal structures, tends to increase the chances of recovery. For these reasons the writer suggests a method of bowel-identification which rests upon the facts that each bowel has a posterior attachment, that the origin of the attachment differs according to the bowel it supports, that a single finger can detect the origin of the peritoneal support of any section of the bowel, and, this origin being known, the portion of the bowel it supports DISEASES AND INJURIES OF THE ABDOMEN. 63 1 is with certainty deducible. In an exploratory operation, for instance, the finger comes in contact with the bowel : to de- termine whether it is a large or a small bowel, note first if the structure is movable or is firmly fixed ; next, pass the finger over the bowel and let it find its way posteriorly. If dealing with a small bowel, the finger will reach the origin of the mesentery between the left side of the second lumbar vertebra and the right sacro-iliac joint ; if dealing with the large bowel, the finger will reach the origin of the meso- colon, or the point where the colon is fixed posteriorly and to the side.'" Rupture of the liver may be caused by a blow, a fall from a height, or the concussion of a railroad collision. Occa- sionally the ends of fractured ribs are driven into the organ. The symptoms are those previously set forth as attending severe intra-abdominal injury (page 627). In addition there are tenderness over the liver, and often pain in the abdomen and back. As a rule, the signs of hemorrhage are present. Sugar may appear in the urine. The respiration is much embar- rassed. After a few days the skin may itch and become jaundiced, but this is rare. In these cases operate at once if hemorrhage is severe ; otherwise operate after bringing about reaction. Stop bleed- ing in the liver by cautery, by suture, or by packing. In a superficial tear introduce sutures of catgut or silk. In a deep tear suture the liver to the belly-wall, pack with gauze, and surround the rent with gauze. Rupture of the Gall-bladder and the Bile-ducts. — Rupture of the gall-bladder or the ducts is most apt to happen from injury when gall-stones exist. Peritonitis, gen- eral or local, is almost certain to follow such ruptures. Be- sides those symptoms common to all severe abdominal injuries, there is often intense jaundice (Deaver). Treatment. — Suture the laceration or make a biliary fistula. Rupture of the Spleen. — The spleen may be dislocated as well as ruptured. Rupture of the spleen is rare without other serious injuries. An enlarged spleen is far more liable to injury than a normal organ. The usual symptoms of abdominal injury are present. In addition there are pain over the spleen and heart, tenderness over the spleen, and great shortness of breath. Hemorrhage is generally violent. Treatment. — At once remove the spleen. Rupture of the Kidney (page 770). 1 The author, in Medical News, June 9, 1S94. 632 MODERN SURGERY. Rupture of the Ureter (page 772). Wounds of the Abdominal Wall. — Non-penetrating- ■wounds are to be treated on general principles. Suture with great care and apply external support. Ventral hernia may follow a large wound. Penetrating- "Wounds. — The symptoms of penetrating wounds of the abdominal wall are usually those of shock and hemorrhage, and later of septic peritonitis. Emphysema is apt to occur. Viscera may protrude. In an incised or a lacerated wound some of the contents of the abdomen may protrude. If protruding viscera are uninjured, they are cleansed with hot sterile normal salt solution and returned into the abdomen, the wound being enlarged if necessary. The belly is flushed out with hot salt solution to remove blood-clots, a drainage-tube is inserted, the peritoneum is sutured with catgut, and the muscles and integument are ap- proximated with silkworm-gut. If the viscera are injured, treat them appropriately. In punctured and in gunshot- wounds, when the intestine has been perforated, rectal insuf- flation of hydrogen will often disclose the fact, but eviscera- tion may be necessary. Always arrest bleeding. In punct- ured wounds enlarge the wound of entrance, examine for injury of viscera, close perforations if any are found, flush out the belly, drain, and close the wound. In gunshot- wounds the bullet may be located by the ^-rays. In a case of gunshot-wound look if there is a wound of exit, and de- termine if the ball is lodged. If the symptoms point to severe hemorrhage, open the belly at once in the middle line, arrest the hemorrhage (page 267), examine the viscera, and endeavor to repair damage. If the bullet is found, remove it. If the symptoms do not point to hemorrhage, bring about reaction before operating. When the patient is ready for oper- ation follow the track of entrance by means of a knife and a grooved director ; open the peritoneum at the point the bullet entered ; arrest hemorrhage ; look for perforations and close them ; examine viscera ; search for the ball, but do not search long, and if it is found, remove it ; flush out the belly with hot salt solution ; dry with gauze pads ; drain ; and close the wound. In some cases of penetrating wounds of the abdomen enterectomy and end-to-end approximation will be required. All punctures or tears must be sutured (en- terorrhaphy). Irrigation of the cavity is only required when the contents of the stomach or the bowel have escaped or when a considerable hemorrhage has taken place. The surgeon DISEASES AND INJURIES OF THE ABDOMEN. 633 should drain when the contents of the stomach or the in- testines have escaped, when hemorrhage is severe, or when the liver, pancreas, kidney, or spleen is damaged. Active stimulation and artificial heat are needed immediately after the operation to combat shock. In many cases intravenous transfusion of normal salt solution is of great value. It may be given during and after operation. Enteroclysis of hot saline fluid is useful. The after-treatment consists of rest, opium in small amounts to arrest peristaltic action, avoid- ance of food by the stomach for forty-eight hours, and the administration of brandy and water from time to time. Feed by the rectum for two days. On the appearance of the first sign of peritonitis, forty-eight hours or more after the operation, give a saline cathartic. It is not wise to purge during the first forty-eight hours after the operation. When there is no sign of peritonitis, do not purge until the fourth day. After forty-eight hours liquid food can usually be given by the stomach. Solid food may be given after seven or eight days, but the patient must not leave his bed until the wound is solidly united, because of the danger of ventral hernia. A support should be worn for a long time. Stomach and Intestines. Foreigfn Bodies in the Alimentary Canal. — These accidents are rare except in children, insane people, or drunkards. Most foreign bodies swallowed are passed with the feces, but some lodge. Any body which can pass the esophagus is not too large to pass through the intestines. A foreign body may lodge in the stomach. In some cases there are no symptoms. In other cases symptoms are vio- lent. The severity of the symptoms depends upon the shape and character of the body. In some cases it is possible to feel the body from without. A metal body in the stomach will deflect a magnetic needle held over the viscus (Pollailon). Many foreign bodies can be skiagraphed. It is not wise to attempt to recov^er the body by inducing vomiting. In some cases gastrotomy is necessary. When a foreign body has been swallowed the usual treatment is as follows : a purgative should ucz'cr be given to expedite the passage of a foreign body, because increased peristalsis means increased danger of impaction or of perforation. Endeav'or to encrust the foreign body, and thus lessen the danger of perforation, by feeding with bread and milk only for several days, and at the end of this period 634 MODERN SURGERY. give a mild laxative. An exclusive diet of mush or of mashed potatoes has been suggested. Pain is relieved by opium. A foreign body rarely lodges in the duodenum, but may lodge lower down, and may cause ulceration, perforation, abscess, or intestinal obstruction. Operation may be neces- san.' in such cases. Cancer of the Stomach.. — Innocent tumors and sarco- mata occasionally attack the stomach, but they are infinitely rare in comparison with primary' cancer. This disease is rare before the age of fort}% and is more common in men than in women. In a ver}' few instances cancer has been found to have arisen from an ulcer. The forms of cancer met with, set forth in their order of frequency, are, according to Osier,, epithelioma, encephaloid, scirrhus, and colloidal. Cancer may be limited to the body of the stomach (either cur\'ature or either wall), the pyloric end, or the cardiac end, but it may involve two of these regions, or almost the entire stomach, or, being multiple, may be found in many parts. It is fatal in from four months to two years. Symptoms. — The disease comes on gradually, usually with indigestion and physical weakness. The patient has persistent dragging pain, which is increased by eating and pressure, and attacks of vomiting are frequent. After a short time the patient becomes very weak and excessively anemic, and it is often possible to feel a tumor in the stomach. The vomiting of gastric cancer is at first only occasional, but as the case progresses becomes more and more frequent. Vomiting soon after eating occurs when the cardiac region is involved ; vomiting an hour or so after eat- ing occurs when the pyloric end is involved. When the body of the organ is the seat of disease, vomiting may be absent. The vomited matter is often mixed with a small amount of altered blood (coffee-ground vomit). In most cases free hydrochloric acid is not found in the stomach, but lactic acid is found. Examine with care a patient in whom cancer is suspected. Distend the stomach with gas or fluid and map out its outlines. Feel for a tumor. A tumor can usually be felt if it involves the pylorus, greater cur\^ature, or anterior wall, but not in other regions. Give a test-meal, siphon off con- tents of stomach, and examine for free hydrochloric acid and for lactic acid. Ewald's test-breakfast is usually em- ployed. It consists of a dr}^ roll and three-fourths of a pint of weak tea or warm water. It is given on an empty stomach. After an hour the stomach-tube is introduced. The fluid is DISEASES AiVD INJURIES OF THE ABDOMEN. 635 removed by a pump or by abdominal compression (May- lard). Cancer of the cardiac end interferes ^vith the entrance of food into the stomach, and in such a case the stomach is shrunken and the esophagus is dilated immediately above the growth. In cancer of the pylorus the food is partially or completely arrested as it passes to emerge from the stomach, and the stomach becomes much dilated. The vomited matter in a case of cancer rarely contains recog- nizable fragments of the growth, but fluid with which the stomach has been irrigated may contain pieces which can be identified as cancer (Rosenbach). In cancer of the stomach the general course of the tem- perature is normal, but there are occasional deviations to below or above normal. In many cases the urine contains albumin, indican, acetone, and casts. Cancer of the stomach is apt to involve adjacent organs or structures, especially the liver. In many cases exploratory incision is justi- fiable. Treatment. — The medical treatment consists in lavage, milk-diet, and the use of morphin. In order to perform lavage introduce a soft-rubber stomach-tube. Grease the tube with glycerin, hold the patient's tongue with the left index finger, carry the tube to the posterior wall of the larynx, and tell the patient to swallow while the tube is being urged in by the surgeon. A funnel is inserted into the raised tube and fluid is poured in. After a time the tube is lowered and the patient is asked to expel the fluid. This proceeding is re- peated till the fluid becomes clear. Surgical treatment aims at the removal of the growth, or obviating the effect of obstruction at one of the orifices of the stomach. In cancer of the body of the stomach, if the growth is not extensive, excision may be performed ; if it is extensive, it is useless to attempt it unless the growth is absolutely non- adherent, Schlatter of Zurich has successfully removed the entire stomach and attached the esophagus to the small intestine. In this patient digestion is satisfactorily performed, although the stomach is gone. Very rarely will cases be found suitable for such a radical proceeding. In stricture of the cardiac orifice of the stomach the surgeon usually keeps the passage open as long as possible by the frequent passage of a tube, and through this tube introduces liquid food. Some- times a small tube is introduced and permanently retained. If a tube cannot be introduced gastrostomy is performed, and 636 MODERN SURGERY. through this artificial opening the patient is fed (page 678). In cancer of the pylorus limited in extent and without lym- phatic involvement, pylorectomy (page675) maybe performed; but in cancer which has widely infiltrated the coats of the stomach and has involved the lymphatic glands, gastro- enterostomy is performed as a palliative measure, the patient during the rest of his life subsisting upon liquid or semi- liquid foods and submitting to frequent irrigation of the stomach to remove food-residue. In cases of ineradicable cancer it is usually best to create the opium-habit. Peptic Ulcer of the Stomach. — Ulcer of the stomach is a condition due to digestion of a portion of the stomach- wall by very acid gastric juice, the destroyed portion having been the seat of lowered vitality. Ulcers are more common in females than in males, and are more frequent in young women than in those of middle or advanced age. Men about forty and women under forty are liable. There is usually a single ulcer, but in some cases there are two or more. The ulcer may heal or may perforate. The most common seats of ulcer are the pos- terior wall and lesser curvature, especially in the pyloric region. Only 2 per cent, of ulcers on the posterior wall perforate (Alderson), as they tend to form adhesions to adja- cent structures. Ulcers on the anterior wall are unusual, do not tend to form adhesions, and are apt to perforate. Dis- order of menstruation may develop ulcer, so may tight lacing, and habitually bending over, as in making shoes. Chlorosis is associated with ulcer in many cases. Traumatism and swallowing corrosive liquid may lead to ulceration. Alderson believes that alcoholism, syphilis, and mental anxiety may lead to the condition. Ulcers due to syphilis and tubercle are not, be it remembered, peptic ulcers. Symptoms. — Acid dyspepsia exists, associated with much flatulence. In most cases, though not in all, food aggra- vates the condition. In many of these patients vomiting occurs about two hours after eating. The vomited matter contains much hydrochloric acid. Hemorrhage from the stomach tends to occur. The blood may be brought up with food, and is then black and clotted, or may be vomited clear and in large amount. In some cases blood from the stomach is passed by the bowels in part or wholly. Paroxys- mal pain exists, which is usually, but not invariably, aggra- vated by taking food. The pain is very violent in the abdo- men, and also passes to the back, being located between the eighth and ninth lumbar vertebrae (Alderson). DISEASES AND INJURIES OF THE ABDOMEN. 637 In gastric ulcer it is usual to find tenderness developed by abdominal pressure. If the ulcer does not cicatrize, but progresses, causing pain and hemorrhage, the patient becomes thin, anemic, weak, and even exhausted. It is highly probable that many cases of gastric ulcer are unrecognized ; in fact, as Habershon says, diagnosis is rarely made unless hemorrhage exists, and in certain latent cases both vomiting and bleeding are absent. A gastric ulcer may cicatrize and thus become cured, but the cure of the ulcer may prove the ruin of the stomach by producing stenosis of one of the stomach orifices, or hour- glass contraction of the body of the stomach. An ulcer may perforate, causing violent pain, shock, and acute peritonitis. Perforation occurs after a meal or after drinking liquid, and is brought about by muscular effort. Alderson calls atten- tion to the fact that the sudden perforation of an ulcer may be mistaken for poisoning, and he cites the death of the Duchess of Orleans in 1670.^ Treatment. — Medical. — Rest in bed. Rectal feeding for a time, followed by the use of a bland diet. Lavage twice a day. To some cases Carlsbad salts are given (Ziemssen), to others silver nitrate, bismuth subnitrate, or oxalate of cerium. If pain is severe opium is required. Surgical. — If the patient grows worse in spite of medical treatment, if the hemorrhage has been profuse, if the pain is violent, or if tenderness is marked, open the abdomen and inspect the stomach. An ulcer may be removed by an ellipti- cal incision in the long axis of the stomach, the coats being su- tured by the usual method. If the patient is bleeding to death because of an ulcer, open the abdomen while an assistant is giving an intravenous injection of salt solution, open the stomach, turn out clot, find the source of bleeding, and ex- cise the ulcer. In perforation bring about reaction from shock, open the abdomen, excise the ulcer, wash out the stomach, sew up the perforation, wash out the abdomen, and close. Of late a number of cases have been success- fully operated upon (see Barling, etc.). Cicatricial stenosis of the orifices of the stomach results from the healing of an ulcer, the swallowing of a cor- rosive substance, or a traumatism from a foreign body. Con- striction of the cardiac orifice is indicated by gradually increasing difficulty in swallowing. After a time the esopha- gus above the stricture dilates or pouches ; the fluid food 1 Provincial Med. Jour., Dec. 2, 1S95. 638 MODERN SURGERY. passes into the stomach, but the sohd food lodges in the esophageal pouch and is soon regurgitated. The site of the stricture is located by a bougie, and by having the patient swallow while ausculting over the esophagus and cardiac end of the stomach. If the constriction be malignant, the patient will be found to be beyond middle life, the vomit is occasionally bloody, emaciation is rapid and decided, and occasionally the supraclavicular glands are enlarged. A tumor of the cardiac end of the stomach can rarely be felt. If the constriction be cicatricial, the history will exhibit the cause. Constriction of the pyloric orifice causes retention of food and dilatation of the stomach. Dyspeptic symptoms will be found to have been long present. A tube passed into the stomach permits of the injection of fluid so as to fill the stomach. When the fluid runs out it contains portions of undigested food eaten days before, and measurement of the liquid shows that the capacity of the stomach is enormously increased. If hydrogen be forced through the tube, the outline of the distended stomach is at once made clear. The usual method of distending the stomach is by a Seidlitz powder : two solutions are made ; the bicarbonate solution is swallowed at once, and the tartaric solution is taken afterward in small amounts at a time. Percussion over the distended stomach indicates the size of the viscus. In malignant disease of the pylorus a tumor may often be made out ; there are tenderness and considerable persistent pain, great emaciation and sometimes enlargement of the supraclavicular glands. Vomiting of bloody fluid occurs. In cicatricial stenosis of the pylorus there may be paroxysms of pain, there is no tenderness, emaciation is not so rapid in onset, and the supraclavicular glands are never enlarged. Vomiting occurs, but the ejected matter is not bloody. Illumination of the stomach by the gastrodiaphanoscope may aid the diagnosis, the area of malignant growth inter- fering with the transmission of light. Treatment. — Cardiac stenosis requires dilatation with bougies and the maintenance of the restored caliber. If this dilatation from above is unsatisfactory, perform a gas- trotomy, push a small bougie from the mouth into the stomach, tie a string to the bougie, draw the string through the stricture, use the string as a saw to cut the fibrous bands, pass a full-sized bougie, close the wound in the stomach, and maintain the caliber by the repeated passage of dilating instruments. If no instrument can be passed DISEASES AND INJURIES OF THE ABDOMEN. 639 through the stricture from above, perform a gastrotomy, introduce an instrument from below, and use Abbe's string saw. If no instrument can be passed from below, convert the gastrotomy into a gastrostom)-. Pyloric stenosis is treated by a gastrotomy and digital divulsion of the strict- ure (Loreta's operation), by pyloroplasty (Heineke-Mikulicz operation), by gastro-enterostomy, or by pylorectomy. Intestinal Obstruction (Ileus or Enterostenosis). — Intestinal obstruction is a condition in which fecal move- ment is mechanically impeded or prevented. It may be either partial or complete. Acute obstniction is due to a sudden narrowing or occlusion of the lumen of a portion of the intestine. Chronic obstructioji is due to a gradual narrowing of the lumen of a portion of the intestine, and it may at any time become acute. If obstruction to circulation in the wall of the bowel occurs, the condition becomes one of strangulation. Intestinal obstructions are classified ^ as follows : 1. Strangulation by bands or in apertures, the commonest form, is due to peritoneal adhesions, but the band may come from the omentum. Strangulation may take place by Meckel's diverticulum, a structure due to persistence of the vitelline duct, and coming off from the ileum from twelve to thirty-six inches above the ileocecal valve. Strangulation may take place beneath an adherent appendix, a Fallopian tube, a portion of mesenter}^ or the pedicle of an ovarian tumor, or it may take place in an omental or a mesenteric aperture. Strangulation by bands or in apertures usually involves the ileum, and sometimes the colon. This form of obstruction is identical with hernia, excepting in the absence of an external protrusion. 2. Volvulus, or twisting of the bowel. The twist may be about the mesenteric axis or on the axis of the bowel itself, or two intestinal coils may be twisted together. Volvulus is commonest in the sigmoid flexure. 3. Intussusception is the invagination of a portion of bo\\'el- wall into the lumen of an adjacent part. One-third of all cases of obstruction are due to this cause (Treves). Most cases of obstruction in children are due to intussusception. There are four varieties : the ileocecal, in which the ileum and the ileocecal valve pass into the cecum and colon ; the colic, in which the large intestine is prolapsed into itself; the ileal, in which the small intestine alone is involved ; and the ileocolic, in which the ileum prolapses through the ileocecal ^ After Treves, in Heath's Dictionary. 640 MODERN SURGERY. valve. The first variety is the commonest. Intussusception is due to active peristalsis. 4. Stricture of the intestine, which may be either cicatricial or cancerous. 5. Obstruction by Tumors of the Bowel arid by Foreign Bodies. — Tumors may be innocent or malignant. Foreign bodies include besides certain substances that have been swallowed, gall-stones, and enteroliths or intestinal calculi. Foreign bodies are apt to lodge in the lower portion of the ileum or in the cecum, and they may cause ulceration at the seat of lodgement. If a gall-stone is sufficiently large to cause obstruction, it cannot have passed the duct, but must have ulcerated into the bowel from the gall-bladder (Treves). 6. Obstruction by tumors, etc. outside the bowel, among the causes of which are retroflexion or retroversion of the womb, especially in pregnancy, cysts or tumors of the kidneys, ovaries, uterus, etc., floating kidney, and enlarged spleen. Obstruction from any of the above causes takes place in the rectum or the sigmoid flexure. 7. Obstruction from fecal accumulation is due to paresis or paralysis of the bowel and the diminution or abolition of peristalsis. Obstruction may follow an abdominal opera- tion. Paresis or paralysis arises in the colon. Treves mentions among the rare forms of obstruction kinking of the bowel, adhesions matting the bowels together or com- pressing the gut, and shrinking of the mesentery. Symptoms of Acute Obstruction. — Severe colic comes on suddenly, the pain varying in intensity, but at no time entirely ceasing ; there is constipation which soon becomes absolute, not even wind being passed ; vomiting is early — first of the contents of the stomach, next of bilious matter, and finally of feces (stercoraceous) ; the abdomen becomes distended and tender ; some fever may be found at the start, but collapse soon arises ; the temperature becomes subnor- mal ; the face Hippocratic ; the pulse rapid and feeble. The amount of urine passed is very small. In obstruction of the upper third of the ileum true fecal vomiting cannot occur. The tongue is dry, the mind is clear, and muscular cramp may occur. Intestinal peristalsis above the obstruction may be detected through the abdominal wall. If obstruction is high up in the small intestine, tympanites does not occur. Symptoms of Chronic Obstruction. — At intervals there arise attacks of pain which become gradually more frequent and severe and are linked with vomiting and constipation. DISEASES AND INJURIES OF THE ABDOMEN. 64 1 the vomiting not being stercoraceous and the constipation not being absolute. Between the painful seizures the patient complains of constipation alternating with fluid diarrhea, distention of the belly, some abdominal uneasiness, ano- rexia, and dyspepsia. The attacks recur with increasing frequency and severity, and acute obstruction may arise or the patient may be worn out by pain, vomiting, and want of food. Diagnosis. — The determination of the seat of lesion re- quires rectal examination. An intussusception may some- times be felt. Vaginal examination may be demanded. Pain is apt to arise at the seat of obstruction or to radiate from there. Palpation may detect a tumor. Rectal insufflation of hydrogen may locate the obstruction by causing great distention below it. Entire suppression of urine, early vomit- ing which is not truly stercoraceous, absence of abdominal distention, and rapid collapse, mean obstruction in the duo- denum or in the jejunum. Early vomiting, which is often stercoraceous in a rapidly progressive case with great dis- tention of the umbilical region, means obstruction of the ileum or the cecum (Pepper). Distention of the entire abdomen and of the flanks, linked with tenesmus, with less intensity of symptoms, less rapidity of progress, and less diminution of urine than in the above-cited forms, means obstruction low down in the colon or in the rectum (Pepper). A test for obstruction in the adult large intes- tine is an injection by a fountain syringe : if six quarts can be introduced, there is no obstruction in the large intestine ; if less than four quarts can be introduced, there is probably obstruction in the large intestine. The passage of a sound in the rectum is generally useless and is often unsafe. TJic determination of the causative condition is always diffi- cult and is often impossible. Intussusception is the common cause in children. A sausage-shaped tumor can usually be felt in the right iliac fossa, tenesmus exists, and bloody mucus is passed. The abdomen is rarely distended or tender. Vom- iting occurs, but it is seldom stercoraceous. The prolapse may sometimes be detected by digital exploration of the rec- tum. In obstruction from bands, internal hernia, etc. there is a record of antecedent peritonitis, of a traumatism, of a vio- lent effort, or of pelvic pain. The attack is sudden in onset, is fierce in character, and is usually excited by violent exer- cise or the taking of food. Vomiting is early and intractable, and it soon becomes stercoraceous ; pain is violent ; peristal- sis above the obstruction is forcible; tympanites and ab- 41 642 MODERN SURGERY. dominal tenderness appear after the attack has lasted for some httle time; obstruction is complete, no wind even being passed ; collapse soon appears ; no tumor can be detected, and rectal examination is negative. Volvulus, which is usually located in the sigmoid flexure, is preceded by con- stipation. The symptoms come on with explosive sudden- ness, and rapidly attain great severity. Constipation is abso- lute ; vomiting is late and is rarely stercoraceous ; no tumor can be detected ; rectal examination is negative ; abdominal distention and tenderness are early and pronounced ; peris- talsis above the volvulus is vigorous ; collapse is not so rapid nor so grave as in the previously-considered forms. Obstruction by a foreign body may sometimes be inferred by the history of some such body having been swallowed. The obstructing body may occasionally be felt during palpa- tion, or may be discovered with the X-rays. Abdominal distress may exist for days or weeks before obstruction occurs. Vomiting is late and is rarely severe, but pain, tenderness, and distention are marked. In obstruction from gall-stones there will be a record of one or more attacks of hepatic colic. Pain is early and acute, and vomiting is invari- able and usually becomes stercoraceous. In obstruction from fecal accumulation chronic obstruction evolves into acute obstruction, pain and vomiting are late or even absent, and the dough-like mass of feces may often be felt by rectal ex- amination or by abdominal palpation. In some cases the fluid elements of the feces pass, but the soHd elements agglu- tinate to the walls of the bowel (the diarrhea of constipation). Obstruction from stricture or from pressure comes on acutely after a prolonged period of disturbance, during which period attack after attack of temporary obstruction, complete or partial, takes place. A history of blood or pus in the stools would indicate tumor of the bowel ; a history of blood or pus having been absent would indicate pressure from without (Pepper). In functional obstruction there is no local pain, no tenderness, no tumor, no tendency to collapse, but simply distention and absolute constipation, and possibly non-fecal vomiting occurring in a neurotic or hysterical subject. A phantom tumor due to a local distention of the intestine from limited muscular spasm disappears under ether. Obstruc- tion may follow an abdominal operation (post-operative ob- struction) ; it may arise a day or so after operation ; it may arise in ten or twelve days after operation ; it may not arise for weeks or months (Legeve). It may be due to some cause at the seat of operation (adhesion of the bowel to a DISEASES AND INJURIES OF THE ABDOMEN. 643 raw surface, volvulus, catching under adhesions, etc.). It may be due to some cause distant from the seat of operation (displacement of intestine, bands, etc.). It may arise from paralysis of a portion of the bowel, which may or may not be due to sepsis.^ Separation of Intestinal Obstructioji from Other Diseases. — Always examine for a strangulated hernia at every hernial outlet. If obstruction is complicated with an irreducible hernia above the seat of lesion, the hernia will always en- large and become tender because of accumulation of feces (Pepper). Functional obstruction may attend peritonitis or may follow the reduction of a hernia. Appendicitis with peritonitis may cause symptoms similar to those of obstruc- tion, but there are fever, a history of trouble in the right iliac fossa, and the vomiting is not stercoraceous. Acute hemor- rhagic pancreatitis produces symptoms so nearly identical with those of intestinal obstruction that a diagnosis cannot always be made. Poisoning by arsenic or by corrosive sublimate should not be confounded with intestinal obstruction. Prognosis. — Without surgical interference most cases of acute intestinal obstruction die within ten days, usually within seven days. Death may be due to shock, to exhaustion, to perforation, to peritonitis, or to obstruction of respiration and circulation by tympanites. Recovery occasionally happens by the formation of a fistula externally or into another por- tion of the bowel. In acute obstruction from foreign bodies the obstructing body occasionally passes. Volvulus and strangulation by bands are almost invariably fatal unless an operation is performed. In intussusception recovery occa- sionally follows the sloughing away of the prolapsed gut, but stricture almost inevitably follows this rare event. Func- tional obstruction gives a good prognosis. The prognosis of chronic obstruction depends upon the causative lesion, and is not nearly so grave as is that of acute obstruction. Treatment. — In any abdominal case, where the diagnosis is uncertain and the patient is shocked, give an enema of brandy and hot water, wrap the patient in blankets, surround him with hot-water bottles, and study the development of symp- toms and signs. In half an hour, as a rule, reaction will be brought about, and a probable diagnosis may be made (Greig Smith). In acute obstruction it is usually customar}^ to empty the stomach by lavage and to evacuate the rectum by means of copious injections given while the patient is in the knee-chest position. Hutchinson's method of taxis and 1 Legeve, Gaz. des Hop., Nov. 23, 1895. 644 MODERN SURGERY. massage is uncertain, and is more liable to inflict harm than to confer benefit. Some surgeons apply constant compres- sion to the abdomen by means of straps of adhesive plaster. Puncture of the intestine with an aseptic hypodermatic needle introduced obliquely to relieve gaseous distention is a de- cidedly dangerous proceeding. The passage of a small tube from the anus to the sigmoid flexure will empty the colon of gas if no obstruction intervene. In intussusception give no food by the stomach; give opium and belladonna to stop peristalsis, wash out the rectum with copious injections, give an anesthetic, and insufflate hydrogen gas or carbonic acid gas in order to distend the bowel. Some surgeons treat intussus- ception by forcing air into the rectum by means of an ordinary bellows, and others inject water by a fountain syringe, the reservoir standing at a height of three feet. D'Arcy Power believes in the value of hydrostatic pressure in intussuscep- tion in children. He states that the child should be anesthet- ized and the large intestine filled gradually with hot saline fluid, the reservoir not being raised more than three feet above the patient. The fluid should be retained for ten minutes. The author is of the opinion that injections of gas or liquid should be tried during the first twenty-four hours of the attack, but not later, because later ulcer or gangrene may exist. Pressure cannot be closely regulated, and if the bowel is much damaged may lead to rupture. If the case is not seen until after the first day, or if injections have been used and have failed, laparotomy should be performed. Frederick Holme Wiggin has made a study of the reported cases of laparotomy for infantile intussusception, and con- siders that operation done within the first forty-eight hours will give a mortality of 22.2 per cent.^ (see Operation for In- tussusception, page 694). In obstruction from fecal impaction use large rectal injec- tions and give small repeated doses of salines or a mixture of castor oil and oil of turpentine. If there are signs of inflamma- tion, do not give cathartics, even in small doses, but give opium and belladonna to arrest vomiting and to relax spasm. Im- pactions in the rectum can be spooned away. In acute intesti- nal obstruction, if the symptoms grow worse, do not wait, but open the abdomen before collapse comes on and find the cause of the obstruction. If it is a gall-stone or entero- lith, try to crush it without opening the intestine ; if this fails, push it up a little distance, incise the bowel, remove the stone, and close the incision with Halsted sutures. If there is fecal 1 Med. Record, Jan. i8, 1896. DISEASES AND INJURIES OF THE ABDOMEN. 645 obstruction, break up the masses by pressure and push the fecal plug down without opening the bowel. If there is intussusception, reduce the prolapse and shorten the mesen- tery ; but if reduction is impossible, perform an anastomosis, or a resection and enterorrhaphy, or make an artificial anus. In volvulus untwist and shorten the mesentery ; but if this is impossible, treat as an irreducible invagination. In obstruc- tion from adhesions try to separate them and straighten out the bowel, stitching healthy peritoneum over each raw spot to prevent recurrence. Anastomosis may be necessary. In flexion separate the intestines, remove the flexion by a V-shaped incision, and suture the wound in the bowel (Senn). In chronic obstruction it is often advisable to perform an ex- ploratory laparotomy and determine by the condition what is to be done. Some tumors external to the bowel are re- moved. Growths in the bowel-wall may be removed by resec- tion of the involved portion of intestine. Anastomosis may be performed, or an artificial anus may be necessary. Post-oper- ative obstruction coming on soon after a surgical operation is often not recognized for a time, and the surgeon will be in doubt as to whether he is dealing with peritonitis or intesti- nal paresis. When in doubt wash out the stomach with warm salt solution, administer salines in small doses fre- quently repeated, and employ enemata. If these measures are not soon successful, open the abdomen ; never wait for the advent of stercoraceous vomiting (see Legeve). Fecal Fistula. — A fistula is an abnormal opening in the intestine through which gas or a portion of the feces escapes (Fig. 199). If all the intestinal contents escape through the Fig. 199 — Fecal fistula : a, direction of fecal flow ; b, b, belly-wall. Fig. 200. — Artificial anus, showing spur: «, spur ; b, b, belly-wall ; c, direction of fecal flow. opening, it is called an artificial anus (Fig. 200) (Senn). A surgeon may make a fistula deliberately (intentional fistula). A fistula may be the product of disease or injury (accidental fistula). Senn gives the following as the causes of accidental fistula: wounds, injury of the intestine, intestinal ulceration, intestinal strangulation, foreign bodies in the intestinal canal, malignant tumors, actinomycosis, pelvic and abdominal ab- scess, appendicitis, injury of the bowel during an abdominal 646 MODERN SURGERY. operation, the application of ligatures, catching by sutures, and the employment of drainage-tubes. Treatment. — Many fistulae close spontaneously. This can only be hoped for if the opening is quite small, if the general health of the patient is good, when the cause has passed away, when the fistula is not lined with mucous membrane, and when there is no spur (Figs. 199, 200). In most cases of fistula not high up it is well to give nature a chance. The part is cleansed frequently with peroxid of hydrogen, the pa- tient is kept recumbent, food is given which does not leave much residue, pads of gauze with pressure are applied, and the bowels are kept regular. If the track is lined with granulations, it may be touched with lunar caustic; if it is lined with mucous membrane, with the actual cautery; any collection of pus which exists should be drained. If these methods fail, an operation must be performed. The fistula may be sutured by extraperitoneal manipulation (Greig Smith) ; it may be covered with skin (Dieffenbach) ; the spur may be removed by means of a clamp; or resection may be performed. In some cases exclusion of the fistulous part is necessary, the bowel being divided above the fistula, the end near the fistula sutured, and the other end anastomosed to the bowel below the fistula. Ulcer of the Bowel. — In typhoid fever and in dysentery ulceration occurs. An ulcer may be due to tuberculosis or cancer. Ulcer in the duodenum sometimes follows a severe burn of the surface (Curling's ulcer). An ulcer may heal, and by causing thickening and constriction produce intestinal ob- struction. It may perforate, causing collapse and subsequent peritonitis. In perforation the liver-dulness is greatly dimin- ished or disappears because of free gas in the peritoneal cavity. Perforation of a typhoid ulcer is accompanied by marked leukocytosis ; there is great shock, which is usually followed by a temporary reaction, severe pain as a rule, tenderness, costal respiration, abdominal distention, vomit- ing which may become eventually stercoraceous, constipa^ tion, percussion-dulness of the flank, and Hippocratic face. Treatment. — The intestinal obstruction due to the healing of an ulcer is treated by intestinal anastomosis or resection. If an ulcer perforates, the surgeon aims to bring about re- action. If this attempt succeeds, the abdomen is opened and is flushed out with hot saline fluid, special care being taken to flush away infected material from the pelvis and from between the liver and diaphragm. The perforation is to be found and sutured. It is not necessary to excise it. A suprapubic in- DISEASES AND INJURIES OF THE ABDOMEN. 647 cision in addition to the first incision renders drainage better, and in some cases posterior drainage is inserted through the right kidney pouch. A drainage-tube is placed in each in~ cision, and a tube is inserted in the suprapubic incision and is carried into Douglas's pouch, and the upper incision is left open, strands of iodoform gauze being placed over the area of rupture and in several places among the intestines. In perforation Finney always eviscerates, closes the perforation, wipes out the peritoneal cavity with gauze pads, and returns the bowels slowly into the abdomen, wiping them carefully. Malignant Tumor of the Intestine. — Sarcoma is very rare, but does arise sometimes in young persons and enlarges very rapidly. Cancer is not uncommon, attacking especially the middle aged. It is particularly common in the neighbor- hood of the ileocecal valve and in the sigmoid flexure. It produces pain at the seat of growth, and after a time intestinal obstruction. It is usually possible to feel the tumor, which is hard and immovable. The patient wastes rapidly and is apt to occasionally pass blood at stool. The growth is not very rapid and glands are not involved early. In some cases the supraclavicular glands enlarge. Treatment. — Early in the case exploratory laparotomy should be performed, followed if possible by excision with end-to-end approximation. If excision is impossible, the growth should be sidetracked by performing lateral anasto- mosis. In advanced cancer of the large bowel make an artificial anus above the tumor. Appendicitis. — Appendicitis, which is an inflammation of the vermiform appendix of the cecum, is almost invariably the primar}^ lesion of all of those various conditions known as typhlitis, perityphlitis, paratyphlitis, etc. — terms which no longer imply pathological entities, and are in most instances well relegated to obscurity. The appendix is a diverticulum (musculomembranous in structure) which comes from the posterior and internal part of the head of the colon, and which has no physiological function (in herbivora and rodents it is a functionally active organ). The structure of the appen- dix is identical with the structure of the colon, except that the muscular structure is ill developed and trivial in amount. The appendix averages about four and a half inches in length, and its diameter is, as a rule, about equal to that of a No. 9 English bougie ; its canal is narrow and is partly closed by the valve of Gerlach (Talamon). The appendix enters the cecum at its posterior internal part, which is usually the seat of the most intense pain in inflammation, and corresponds to 648 MODERN SURGERY. a point on the surface two inches from the spine of the ilium, on a hne drawn from the umbilicus to the anterior superior iliac spine, which is known as " McBurney's point." The free part of the appendix in one-third of all persons is in relation with the posterior surface of the cecum ; in almost one-third of all persons it is fixed in the iliac fossa, so that if perforation occurs the contents will be voided in the retroper- itoneal tissue (ihac abscess). In some cases it is external to the cecum ; in some it passes downward, and in some inward. In about two-thirds of all cases the appendix is completely covered with peritoneum ; in one-third of all cases it is in contact, in some part of its length, with cellular tissue (Talamon). Robinson has called attention to the fact that the appendix is frequently in contact with the psoas muscle in men. Etiology and Pathology. — Appendicitis is very rare in in- fants, but is common at any period beyond childhood, being more frequent in young and middle-aged people than in the aged. Appendicitis is a bacterial disease. It is produced occasionally by pus cocci, but most commonly by the action of the bacterium coli commune of Escherich. These microbes, which normally inhabit the appendix, are harmless when the appendix is healthy, but become active for harm when the diverticulum is bruised, obstructed, or in a state of catarrhal inflammation. When non-traumatic inflammation occurs swelling of the mucous membrane occludes the opening into the colon, and the lumen of the appendix dilates and fills up with a thick or mucopurulent fluid. Ulcers some- times form, which may only involve the mucous membrane, may pass deeply into the coats, or may even perforate. Dieu- lafoy ^ maintains forcefully that appendicitis is due always to the conversion of the appendix into a closed cavity. Various conditions may bring about this transformation. Partial ob- struction may be caused by calculi, which are composed of stercoral material mixed with salts of Hme and magnesia. These calculi are not formed in the colon, but are formed in the appendix. Dieulafoy speaks of the condition as appen- dicular lithiasis, and says the condition has a tendency to run in family lines, and has a kinship with gout and rheumatism. Obstruction may be caused by local infection of a catarrhal area, by the formation of a fibrous stricture, or by several causes acting in unison. The theory that concretions form in the colon, and are forced into the appendix by peristalsis, has been very largely abandoned. Talamon taught that the 1 Progrh Medicale, No. 11, 1896. DISEASES AND INJURIES OF THE ABDOMEN. 649 appendix resents the presence of the concretion, reflex contrac- tion of the muscular coat taking place, which is accompanied by violent pain (appendicular colic). The muscular structure is so rudimentary that it does not seem probable that at- tempts at contraction, even should they arise, would produce violent pain and distant symptoms. Pozzi believes that ap- pendicular colic may be caused by torsion, or bending of the appendix, or malposition of the diverticulum, and holds that pain may arise when there is no lesion in the appendix and no inflammation of the peritoneum or pericecal structures.^ Foreign bodies, such as pins, fish-bones, nails, buttons, date- stones, cherry-stones, and grape-seeds, may enter the appen- dix, but they do so far less often than is generally supposed, most alleged grape-seeds from the appendix being only fecal concretions. Fitz found concretions is 1 5 cases out of 300. Ranvier collected the records of 459 post-mortems, and found reported 179 fecal concretions and 16 foreign bodies. Ap- pendicitis due to a foreign body, such as a grape-seed or a pin, is known as trminiatic ; appendicitis in which a concretion is the assumed cause is know^n as stercoral. A foreign body may produce instant perforation at the site of the body. If impaction of a foreign body or concretion occurs, the orifice of the appendix is closed, the circulation is soon cut off, the secretions are retained, the coats become congested, the diver- ticulum enlarges enormously, microbes multiply with great rapidity, and the wall of the congested appendix inflames and may become gangrenous or ulcerated, and is finally perforated. Interference with the blood-supply of the appendix will pre- dispose to appendicitis. This may be brought about by twists, bruises, adhesions, concretions, pressure, or bands ; and the psoas muscle may play a part in the production of these con- ditions. In women appendicitis is occasionally secondary to tubo-ovarian disease. Appendicitis is rarer in w'omen than in men, probably because the appendix of a woman has a better blood-supply, the additional supply coming through the folds of the appendiculo-ovarian ligament. Catarrhal conditions of the intestine, habitual constipation, indiges- tion with flatulence, predispose to appendicitis. Some hold that catarrhal appendicitis may result from extension of a ca- tarrh of the colon, and may also arise from external trauma- tism. If before perforation the appendix adheres to the cellu- lar tissue behind the cecum, cellulitis or abscess without peri- tonitis may result. When appendicitis goes on to perforation, there is always some peritonitis ; but if the steps to perfora- ^ Progres Medicale, No. 19, 1S96. 650 MODERN SURGERY. tion are gradual, the peritonitis may be local, and will some- times by formation of adhesions make a barrier between the appendix and the peritoneal cavity before perforation occurs. When perforation takes place suddenly diffused septic perito- nitis is inevitable. Peritonitis may arise without perforation by contiguity of structure or by migration of the bacterium coli commune through the congested walls of an obstructed appendix. In some cases perforation takes place into the peritoneal cavity, but pus is circumscribed by matting to- gether of the intestines with plastic exudate. The appendix may become gangrenous very rapidly or after some time. A case of appendicitis in which gangrene and perforation come on very quickly is spoken of as fulminating appendicitis. In some cases, if the perforation is very small and the appendix is swathed in lymph, or if perforation does not occur, the in- flammation may subside. Perforation rarely occurs from liquid pressure or from the pressure of concretion ; it is generally due to ulceration produced by the action of micro- organisms. Appendicitis which subsides may at any time recur, and the life of the patient is under constant menace. An enormous number of people have had appendicitis. Toft recorded 500 autopsies, and in 36 per cent, of them there were positive signs of past attacks. The disease is occasion- ally unsuspected during life. These facts prove that the dis- ease may subside without the aid of surgery. Porms of Appendicitis. — In what is known as appendicu- lar colic the appendix is temporarily obstructed because of swelling of the mucous membrane of the outlet, and the stercoral contents are retained in the diverticulum. This condition is called by Fergusson " constipation of the appen- dix." It is not appendicitis, but if not relieved will rapidly eventuate in appendicitis. Simple parietal or catarrhal appendicitis is not limited to the mucous membrane ; hence the term catarrhal is not strictly correct. Forty-eight hours after the mucous coat begins to inflame the peritoneal coat will probably be in- volved. In simple appendicitis the diverticulum enlarges, fills up with mucus, and its coats become infiltrated with inflammatory exudate. This inflammation may undergo resolution or suppuration, or may become chronic. In a catarrhal inflammation secondary to catarrh of the colon the case may be chronic from its origin. If the lumen of the appendix is gradually obliterated, the condition is de- nominated obliterativc appendicitis (Senn). This progressive obliteration may result from repeated attacks of inflamma- DISEASES AND INJURIES OF THE ABDOMEN. 65 I tion or may be simply a degenerative change. In appen- dicitis with a concretion the attack may subside, the fluid elements may be absorbed or flow back into the bowel, and resolution of the exudate may take place ; but if the con- cretion remains in the appendix, recurrence is probable. Recurrent appendicitis, it is said, may be due to inordinate size of the mouth of the appendix, making of this diverticu- lum a drag-net for foreign bodies ; but it is more probable that it is due to smallness of the opening, so that it quickly closes and converts the appendix into a closed vase filled with septic material. Suppurative appendicitis is due to purulent infiltra- tion of the walls. Pus in the lumen is not purulent appen- dicitis. Gangrenous appendicitis is a moist or septic gangrene, due to interference with the circulation and to tissue-destruc- tion by the action of micro-organisms. Perforations occur, and they are often multiple. The entire appendix may slough off. Interference with circulation may be caused by an ob- struction, by a bend, or twist, or bruise of the appendix, or by the action of virulent organisms on an appendix whose tissue-resistance is lowered by injury or disease. In gan- grenous cases the vessels of the meso-appendix are usually obstructed by thrombi or the changes of arteritis (Van Cott). Fowler suggests the follow^ing classification of cases of appendicitis: (i) endo-appendicitis ; (2) parietal appendicitis; (3) peri-appendicitis ; (4) para-appendicitis. As a matter of fact, appendicitis is always one disease, which varies in intensity, and it is useless to divide it into a great number of symptomatic groups. In rare instances appendicitis is due to tubercular ulceration and typhoid ulceration. Genuine appendicitis may arise during typhoid fever. Symptoms. — In what is known as appendicular colic there are colicky pain about the umbiHcus and right iliac fossa, nau- sea and vomiting, and usually constipation, but no tenderness in the iliac fossa and no abdominal rigidity. This condition, if not soon relieved, is followed by the evidences of inflamma- tion. The symptoms of genuine appendicitis are as follows : in some cases the patient feels out of sorts for a day or two. Constipation is very generally present, but in rare cases there is diarrhea. The sufferer complains of anorexia, dys- pepsia, flatulence, colicky pain, and a feeHng of weight, sore- ness, or pain in the right iliac fossa. Nausea is often present, and vomiting may occur. The tongue is coated. Examina- tion discovers tenderness, rigidity, fullness, and pain in the right iliac fossa. The tenderness is most marked about 652 MODERN SURGERY. McBurney's point. There is moderate fever, and the pulse is about 100 or less. The patient may get well, the symptoms gradually passing off. He may get gradually worse. The tenderness increases ; the pain becomes agonizing and radi- ates toward the umbilicus, and the patient draws up the right leg to relieve it. Pressure upon the left side often causes pain in the right iliac region, A rectal or vaginal examination may make out tenderness, or enable the surgeon to feel a lump. The pulse increases in frequency, the fever rises, the abdominal distention and rigidity become more marked, vomiting begins and becomes worse, and the res- piration becomes shallow and thoracic. There are great thirst, anorexia, constipation, and mental anxiety. Absolute obstruction sometimes takes place. The urine is scanty and highly colored. Hiccoughs develop. If the inflammation continues for one or two days, swelling is often observed in the right iliac fossa, or is detected by a vaginal or rectal examination, or by bimanual palpation, or by examination under ether. It is not wise to forcibly palpate in acute ap- pendicitis, as it may cause rupture. If the appendix is enlarged, and the individual has a thin abdomen which is not rigid, it is often possible to palpate the appendix. Some- times it may be felt when the patient is anesthetized, though it could not be detected before. A case of appendicitis may come on suddenly with pain, pre- monitory symptoms having never occurred. There are nausea and bilious vomiting, constipation, and distention of the abdo- men. Such attacks are not to be considered as colic from the lodgement of a calculus. They are inflammatory, and are associated with fever and the other symptoms previously set forth. Examination detects tenderness in the right iliac fossa. The point of greatest tenderness is known as " Mc- Burney's point," This is apt to be about two inches from the anterior superior spine of the ilium, on a line drawn from the spine to the umbilicus. Pain at McBurney's point is linked with local muscular rigidity and hyperesthesia of skin. Such a case, like the former cases described, may get well or may get worse. In some cases all the symptoms are violent from the beginning, the attack tends to linger, and is followed by persistent soreness of the appendix and harassing digestive disturbances. Any case of appendicitis may become suddenly desperately grave because of perforation or gangrene. The temperature falls, hiccough begins, abdominal distention, pain, and tenderness become marked and general, and the pulse becomes very rapid. In some cases these grave symptoms DISEASES AND INJURIES OF THE ABDOMEN. 653 are present almost from the start (fulminating cases). A sud- den perforation produces collapse, and, if reaction takes place, suppurative peritonitis arises. Peritonitis, be it remembered, often arises without either perforation or gangrene (Dieula- foy). If pus forms, it may be unlimited by adhesion. In such cases there is the rapid onset of fatal peritonitis and septicemia. Pus may be limited by adhesions and be practi- cally extraperitoneal. In such a case a lump is felt in the right iliac region ; and dusky discoloration and edema of skin sometimes exist. In an abscess case there are usually irregu- lar fever and sweating. A limited collection of pus may be liberated into the peritoneal cavity by rupture of the abscess- wall. Such a rupture may be caused by pressure or muscular effort, and it gives rise to shock, and is followed by diffused peritonitis. An abscess may rupture externally, or into the vagina, intestinal tract, or bladder. Terminations. — Appendicitis may terminate in recovery, in death, or in a condition of lowered vitality, renewed attacks being certain to occur. Adhesions may form as a result of appendicitis, general peritonitis may arise, the appendix may slough or become perforated, or abscess may ensue upon local peritonitis. Pylephlebitis and abscess of the liver may follow appendicitis. Treatment. — In appendicular colic give a saline cathartic, apply a hot-water bag to the right iliac fossa, and watch the development or abatement of the symptoms with anxious care. Many surgeons give a purgative in the beginning of a case of even undoubted appendicitis. This plan of treat- ment was begun with the belief that an inflammation of the appendix was associated with fecal impaction in the head of the colon, an idea which has been entirely exploded. It does not seem safe to give a purgative in genuine appen- dicitis, because violent peristalsis and increased tension may serve to produce perforation. In mild cases leech over the right iliac fossa, apply an ice-bag, give an enema, place the patient on a bland liquid diet, administer antipyrin for the pain, and maintain rest in bed. If the case is not better in thirty-six hours, operate. If it becomes worse within that time, operate at once (if pulse becomes very rapid, if fever rises, if sweats are observed, if temperature is very oscil- lating, if distention, rigidity, pain, or tenderness become more marked, if shock arises). In any severe case operate at once. Opium should not be used. It masks the symp- toms, makes the patient feel comfortable, and gives a false sense of security. In an appendicitis even with slight symp- 654 MODERN SURGERY. toms many surgeons maintain that an operation should be performed at once, because the mildness of the symptoms is no assurance that even in an hour or two gangrene or per- foration will not occur. Early operation is comparatively safe ; operation after perforation, gangrene, or septic peritonitis arises must be done, but it is not unusually futile. Murphy, Deaver, and others operate at once in every case. Keen, Senn, White, Grieg Smith, and others strongly oppose this plan. Other surgeons, in a first attack, if the symptoms are mild, wait and temporize, apply a hot-water bag over the right iliac fossa to favor plastic exudation, and give opium in full doses. Some begin treatment by the administration of salines, apply an ice-bag over McBurney's point, and after a free movement of the bowels give opium and keep the patient on liquid diet. If the symptoms become worse, they recommend operation. The author does not believe that it is proper to always operate. Such a rule makes decision easy, but not of necessity right. In a case with severe symptoms operate at once, but in an ordinary mild case watch the patient for a few hours. McBurney says, if six hours after the beginning of the attack the patient is no worse, there is no pressing danger, and if in twelve hours symptoms are not intensified, they will soon begin to abate ; but if in the twelve hours the case has become worse, operation is neces- sary.^ It is well, if possible, to operate in an interval in preference to operating in an attack. McBurney says, if in twenty-four hours from the onset of an attack the severity of the symptoms lessens, it is usually possible to wait for an interval ; but if during the second twenty-four hours the abatement in symptoms has not gone on and there is doubt as to the condition, operate at once. It is not safe to delay operation in a pus case, hoping that the pus may become well limited. It may become limited, but it may instead pass up toward the liver or down into the pelvis, and delay is fraught with peril. The interval operation can be performed about three weeks after the attack, or later. If there has been but one acute attack, there may never be another, and operation need not be done unless tenderness persists or there are colicky pain and tenderness after exercise. But if a man has had two attacks, he is certain to have others, and an interval operation must be performed (see Opera- tion for Appendicitis). ^ yV". Y. Polyclinic, Jan. 15, 1897. DISEASES AND INJURIES OF THE ABDOMEN. 655 The Peritoneum. Peritonitis. — In rare instances peritonitis is said to be primary, following a cold ; but most surgeons doubt this. Plastic peritonitis is due to an aseptic cause (traumatism or chemical irritation) ; it remains limited, and is really a process of repair rather than of inflammation. The symp- toms of plastic peritonitis are local pain, tenderness, and rigidity. Fever exists, due to the absorption of fibrin-fer- ment and the products of tissue-change ; adhesions form, which may be either temporary' or permanent. Recovery is the rule. The treatment comprises saline purgatives followed by rest, a liquid diet, and local heat (hot-water bag or fomentations). Diffuse septic peritonitis is apt to destroy life even before the peritoneum presents any marked change. Death ensues from the absorption of toxic alkaloids. Septic peritonitis may arise during puerperality, through lymphatic infection ; it may be due to infection from without by an operation or an accident ; to perforation of an ulcer ; to gangrene of a portion of the intestine ; to rupture of an abscess into the peritoneal cavity ; or to migration of micro-organisms through a damaged wall of the bowel. It is made mani- fest by a chill, shock, or rapid collapse ; veiy rapid pulse, which is at first wiry and later gaseous ; a temperature which may be at times febrile, but which is apt to be subnormal or which soon becomes so ; dvf tongue, delirium, and persistent vomiting. Rigidity may exist, and also intestinal obstruction ; often, but not invariably, there is distention. In puerperal peri- tonitis or septic peritonitis from operation there is often no pain ; in perforative peritonitis there is acute pain. Patients usually (lie within five or six days. Treatment is rarely successful. Stimulants are strongly pushed. The patient is fed upon liquids (koumiss especially). The abdomen is opened in the middle and also upon one or both sides. Any perforation is closed. In some cases a suprapubic incision is also made, in other cases an opening is made in the loin. In a woman Douglas's sac is opened through the vagina. The peritoneal cavity is wiped out with gauze pads or is flushed out with gallons of hot normal salt solu- tion. Special attention is given to cleansing Douglas's pouch and the space between the liver and diaphragm. The Avounds are left open, and drainage is maintained by strips of iodoform gauze. In fibrinoplastic peritonitis the septic organisms are 656 MODERN SURGERY. fewer or less virulent, the products of germ-action are lim- ited and surrounded by adhesions, and circumscribed sup- purative peritonitis is apt to arise. Suppurative peritonitis differs clinically from septic peri- tonitis in the fact that it is more apt to be circumscribed and less apt to be fatal. The causes of both are identical. In septic peritonitis death occurs from absorption of tox- ins before obvious pathological changes occur in the peritoneum ; in suppurative peritonitis the microbes are fewer, are less virulent, or vital resistance is more decided, and suppuration follows marked changes in the peritoneum. In suppurative peritonitis the pyogenic bacteria are always present, and there exists in the peritoneum a wound or damaged area to constitute a point of least resistance. Symptoms. — Chilliness or a rigor is common, followed by fever, the temperature rising to 102° or 104° ; pain is intense, and is accentuated by motion and pressure ; the attitude of the patient is assumed to relieve pain (he lies upon his back, with the shoulders raised and the thighs drawn up) ; there are vomiting, obstinate constipation, and distention and rigidity of the abdominal walls. The pulse is rapid ; is at first wiry, but may become gaseous. The constipation may be due either to tympanitic distention or to the shock of a perforation inhibiting intestinal peristalsis. Vomiting is fre- quent. In perforation gas often passes into the peritoneal cavity and obscures the liver-dulness ; in tympanites without perforation the liver is pushed up and its dulness usually remains, but on a higher level. Pus unconfined by adhe- sions will gravitate to the most dependent part of the peri- toneal cavity. Circumscribed suppurative peritonitis presents the signs of a deep abscess (swelling, dulness on percussion, local rigidity, irregular temperature, sweats, and possibly edema of the belly-wall). In some cases of suppurative peritonitis there is no tympanitic distention or rigidity ; in some cases there is no fever, and a subnormal temperature may even exist. The high-tension pulse of peritonitis is due to the tympanitic distention emptying the bowel-walls of blood, and thus increasing the amount of fluid in the other vessels of the body. Treatment. — In the beginning of ordinary peritonitis with- out perforation give a saline cathartic, which will empty the peritoneal cavity of fluid, will favor the elimination of mi- crobes, and will combat inflammation. The old-time remedy was opium, but Tait proved its inefficiency, and showed that it masked the symptoms and often created a false sense of DISEASES AND INJURIES OF THE ABDOMEN. 657 security in the very midst of imminent dangers. The usual method of administering salines is to give oj of Rochelle salt and .^j of Epsom salt every hour until a free movement occurs. This treatment will often cut short a beginning- peritonitis, and will frequently prevent a peritonitis after an abdominal operation. Give an enema of turpentine at the same time as the saline. If this treatment fails, open the belly, explore for the causative condition, remedy it, flush, and drain. In perforative peritonitis do not give cathartics : they will only increase the extravasation and prevent its lim- itation by lymph. As soon as the patient has reacted from the shock of the perforation perform a laparotomy, suture the perforation, flush out the belly, and drain. A circum- scribed abscess is to be opened and the primary lesion sought for and, if found, removed. Do not tear the lymph-barriers in an attempt to find the primary lesion ; rather let it go un- discovered. Pack iodoform gauze against the intestines to reinforce the barrier of lymph, and insert a tube. In some cases make incision for drainage in the opposite side of the belly, above the pubes or through the right kidney pouch. It is frequently advisable to leave the wounds open and drain with iodoform gauze. Every patient with peritonitis requires stimulants and frequent feeding with liquid food. Tubercular peritonitis is seen by the surgeon as a pri- mary local tuberculosis, though it occurs also as an associate of phthisis and as a part of a general tuberculosis. Abdom- inal section with or without drainage cures not a few cases. Why it cures is doubtful. Abbe thinks that the fluid acts as a culture-medium for bacilli. When the fluid is removed the tissues regain their powers of resistance, and the inflammation which follows the operation, plus the vital resistance of the tissues, causes fibroid transformation of the peritoneal tuber- cles ; but aspiration will not cure, while incision will. Subphrenic Abscess. — A subphrenic abscess is a col- lection of pus beneath the diaphragm. The pus, as a rule^ occupies a part of the lesser peritoneal cavity ; in rare in- stances it is extraperitoneal (when it is of renal origin) ; in some cases it is contained in the area between the diaphragm, car- diac end of the stomach, and liver or spleen. It is an unusual, thing for such an abscess to break into the general cavity of the peritoneum, but it may break into the pleural sac (Maydl). Causes. — Perforation of a gastric ulcer, perforation of the gall-bladder or gall-ducts, ulceration of the duodenum, disease of the liver, spleen, pancreas, intestine, appendix, or kidney,, hydatid disease, internal injury, metastasis, external injur}',. 42 658 MODERN SURGERY. caries of rib, or disease of the pleura may be responsible for a subphrenic abscess (Maydl). Symptoms. — There are the constitutional symptoms of suppuration and a swelling in the subdiaphragmatic region, these symptoms ensuing upon one of the causative conditions before mentioned. In many cases the abscess- cavity contains gas as well as fluid. Empyema and sub- phrenic abscess resemble each other. In empyema the upper limit of the fluid is concave ; in subphrenic abscess it is convex. In empyema the flow of pus through an aspirat- ing-needle will be most marked during inspiration ; in abscess, during expiration — the same is true of the rush of gas. In empyema the needle does not oscillate ; in abscess it does.^ The fact that an abscess contains gas is shown by the ex- istence of a tympanitic percussion-note over a part of the cavity and an alteration in the area of tympany with an alteration in the position of the patient. An abscess of the liver does not contain gas and alters decidedly the outlines of the organ. Treatment. — Incision and drainage. The incision in some cases may be made through the abdominal wall (epigastric region, iliac region, hypochondrium, or loin). In other cases the chest-wall is incised, a rib is resected, the pleura is opened, and the diaphragm is incised. The Liver and Gall-bladder. Wounds of the I/iver. — A wound of the liver causes vio- lent hemorrhage which is usually rapidly fatal. Such a wound is apt to divide bile-ducts and allow of the escape of bile into the peritoneal cavity. Bile if sterile will do Httle harm, but if it contains organisms will produce a diffuse peritonitis. Patients do not always die from a serious traumatism of the liver. Some recover because operation has been performed. Some few recover without operation. This last fact is proved by reports of autopsies in which scars were found in the liver- parenchyma (Nussbaum). The fatality which usually ensues on a liver injury may be due to hemorrhage or peritonitis. If a surgeon is called to a patient suffering from wound of the liver, he must open the abdomen to arrest hemorrhage. In a penetrating wound, the wound in the abdominal wall must be enlarged. If the left lobe of the liver is wounded, or if the question as to which lobe is wounded is uncer- tain, the incision should be median. If the right lobe ^ Wharton and Curtis, Practice of Surgery. DISEASES A. YD INJURIES OF THE ABDOMEN. 659 is wounded, make a curved incision along the line of the costal cartilages. In some cases these two incisions are joined/ The convex surface of the liver can be reached by Lannelongue's plan. In this the eighth, ninth, tenth, and eleventh costal cartilages are resected and the ends of the ribs are drawn well out. When the wound in the liver is found deep sutures of catgut should be inserted in the liver and the capsule should be stitched with fine silk (Schlatter). If sutures fail to arrest hemorrhage, stitch the liver to the belly- wall and employ gauze packing. It is useless to try packing without first attaching the li\-er, because pressure will simplx' push the liver awaj' and will not stop the bleeding. The cauter}- should not be used if the wound is large, be- cause, even if it arrests primary hemorrhage, secondaiy hemorrhage will be apt to occur. After arresting hemor- rhage wash out the abdomen with hot saline fluid, insert drainage, and close the abdominal wound. Hydatid cysts of the liver may be of small size and pro- ductive of no signs or symptoms ; or may be of large size and productive of the signs of tumor. In the epigastrium the mass may be prominent and may fluctuate. In cyst of the right lobe the dulness is found in the axillary line and the growth encroaches on the pleura. In a large c}'st fluctu- ation and hydatid fremitus ma}- exist. Hydatid fremitus is a vibration imparted to the palpating fingers of one hand when the fingers of the other hand knock upon the cyst. There may be no discomfort produced by even a large cyst, but, as a rule, the patient suffers from a dragging sensation in the epigastrium, and pressure-symptoms. Suppuration in the cyst produces the symptoms of septicemia. Rupture of the cyst produces shock, and even death. If the shock is re- covered from, inflammation arises, the area of which depends upon the structures damaged. The escape of even a small quantity of hydatid fluid into the peritoneal cavity produces urticaria (hydatid toxemia). Aspiration for diagnostic pur- poses is not advisable. Treatment. — Explorator}' incision may be necessaiy to confirm the diagnosis, and the operation is completed at this time. After exposing the cyst it is packed around with gauze and a trocar is introduced. When the fluid is evacuated the sac is incised and is drawn partly through the wound and is attached to the wound-margins. The endocyst can be re- mov^ed by the hand or by irrigation. A large drainage-tube is introduced (marsupiaHzation). If there is a considerable 1 See Schlatter, Beitrage zur Klinischen Chirurgie, Bd. xv., Heft ii., 1896. 66o MODE FN' SURGERY. thickness of liver-tissue over the cyst, incise the liver with the cautery-knife. Bond devised the following operation for hydatid cyst : open abdomen, draw up the cyst and surround it with gauze, evacuate contents by means of a trocar and cannula, open cyst, turn out the endocyst, irrigate cyst with corrosive sublimate, dust in iodoform, sew up the cut in the cyst-wall, drop the cyst back into the belly, and close the abdominal wound. Abscess of the liver may be due to the presence of ameba coli. An abscess so caused is usually single, is known as a tropical abscess because of its frequency in hot climates, and is usually preceded by dysentery. Such an abscess may last from four weeks to several years. Abscess of the liver may follow upon a blow in the hepatic region, or upon suppuration of the gall-passages. It may be metastatic, such abscesses being multiple. It may be caused by foreign bodies and parasites (Osier). Symptoms. — Osier tells us that the solitary abscess in rare instances produces no symptoms for a considerable time, death usually ensuing from rupture. As a rule, the liver is distinctly enlarged, tender, and painful. There may be pain in the right shoulder and back. The patient loses flesh ; there is a septic fever, with evening rises and morning remis- sions, and severe sweats, except in very chronic cases, when there may be no pyrexia. The skin and conjunctivae show the existence of slight jaundice. In some cases there is diar- rhea, in others constipation. An abscess may lead to pyo- thorax, may break into the lung, may rupture externally, or into the bowels, stomach, or pericardial sac. In pyemic abscess the liver is enlarged and tender, there is slight jaun- dice, and the general symptoms of pyemia are present. Treatment. — In tropical abscess make an exploratory in- cision. If the abscess is adherent to the parietal peritoneum, and is not covered by liver-substance, at once proceed to operation. If it is not adherent, or is covered by a con- siderable layer of liver-substance, stitch the visceral peri- toneum to the parietal peritoneum and postpone further interference for forty-eight hours. The operation consists in evacuating the pus with a trocar and cannula, incising the abscess, stitching its edges to the edges of the abdominal wound, irrigating, and inserting a drainage-tube. If the abscess is covered by a layer of liv-er-tissue, after locating it with a cannula open into it with a cautery-knife and arrest hemorrhage by packing. When the parietal and visceral peritoneum are adherent, packing will arrest bleeding; if they DISEASES AND INJURIES OF THE ABDOMEN. 66 1 are not adherent packing will only push away the movable liver (John O'Connor). If pyothorax exists, resect a rib, open the pleural sac, and reach the abscess in the liver by an incision through the diaphragmatic pleura and the diaphragm. A pyemic abscess should not be operated upon unless it points, because in this condition multiple abscesses invariably exist. Displaced I^iver. — This condition is very rare. It is due to relaxation of the ligaments of the liv^er. It may occur alone, but is more often a part of a general abdominal relaxation (Glenard's disease). The liver may descend into the lower abdomen. Treatment. — By the use of a support. If this fails to give relief, open the abdomen and fasten the liver to the abdominal wall (hepatopexy). Ramsay, in a case, rubbed the upper surface of the liver with gauze to promote ad- hesion, and transfixed the round ligament with a suture, which was also carried around the cartilage of the seventh rib. Richelott, Areilza, and Treves have operated for this condition. Gall-stones. — Gall-stones are formed during life in the gall-bladder, or bile-ducts, by the agglutination of materials which have precipitated from bile. The conditions of the body which lead to the formation of gall-stones are desig- nated by the term cholelithiasis (Brockbank). But one stone may be present, or great numbers may exist. Solitary stones may be nearly round or cylindrical. When several stones, or many stones, exist the mutual pressure often leads to the formation of facets (Naunyn). Brockbank gives the following varieties of gall-stones : pure cholesterin stones, stra<:ified cholesterin stones, common or gall-bladder cal- culi, mixed bilirubin calcium calculi, pure bilirubin calcium calculi, and certain rare forms. Gall-stones usually take origin in the gall-bladder, but may arise in the common duct, the cystic duct, the hepatic duct, or the smaller ducts of the liver. As a rule, however, calculi in the common or cystic duct were not formed there, but were transported from the gall-bladder or hepatic ducts. Causes. — The chief causes are advancing years, insufficient exercise, excess of nitrogenous food, gouty tendencies, ca- tarrhal inflammation of the bile-ducts, conditions which inter- fere with the emptying of the gall-bladder, typhoid fever, car- diac disease, and cancer of the liver. The disease is more common in the insane than in the mentally sound, and in women than in men. The special liability of women may be 662 MODERN SURGERY. brought about by tight lacing, pregnancy, inactivity, or movable right kidney. There are two forms of the condi- tion to be considered. The acute type, due to efforts made by the gall-bladder or duct to expel the concretion, and the chronic condition, in which a calculus is lodged for a long time, or in which, as soon as one calculus is passed into the intestine, "another begins its journey" (Brockbank). Symptoms. — The formation of a stone requires several months, and during the antecedent period of gastro-intes- tinal catarrh, " the prodromal state " of Kraus, certain symp- toms usually exist, viz. : constipation, flatulence, loss of appetite, migraine, uneasy sensations in the epigastrium or right hypochondrium, salldwness of skin, slight yellowness of the conjunctivae, scantiness of urine, which excretion is satu- rated with uric acid, and may after a time contain a little bile. If this condition is not arrested by treatment it grows worse. The abdomen becomes decidedly distended, pressure over the stomach or liver may cause distinct uneasiness, or even pain ; acid indigestion is very troublesome, violent attacks of migraine occur, constipation becomes more decided, the feces become clay-colored, gastralgia may occur, the skin is apt to be slightly jaundiced, itching is complained of, the patient is irritable and sleeps poorly. The liver is found to be enlarged, and the urine contains distinct amounts of bile. When the patient reaches this stage gall-stones are very liable to form. These symptoms may pass away even if a concretion forms. It is quite true that in some cases a stone exists for years without causing trouble, but, as a rule, it greatly aggravates the condition. When a stone forms pain is apt to become a marked feature of the case. A sense of pressure or of soreness in the hepatic region has added to it sudden and transient paroxysms of pain, due to the passage of thick bile from the gall-bladder and small ducts, or of gravel from the small ducts urged on by bile- pressure. When a stone begins to pass from the gall-blad- der violent colic is experienced. Such a colic usually comes on very suddenly, and often about three hours after a meal. It may, however, come on gradually, the patient complaining greatly of flatulence. The pains are violent, spasmodic, and paroxysmal, and are over the hepatic and epigastric regions, " radiating upward over the right half of the thorax " (Kraus). The patient is profoundly nauseated, and usually vomits, the abdomen is distended, and a con- dition almost of collapse is soon reached. The attack lasts a variable time, and terminates by the stone passing into the DISEASES AND INJURIES OF THE ABDOMEN. 663 intestine or falling back into the bladder. After its conclu- sion, if the feces are examined carefully during several days, the stone may be discovered. The fact that no stone is discovered does not prove that no stone was passed, because a cholesterin stone will be destroyed in the intestinal canal. Jaundice almost invariably follows the attack. If the stone is impacted, after a time the pains become less violent, but again and again the patient suffers from aggravation of them. An individual may get about with impacted stone, but again and again fierce attacks of colic occur, and the patient be- comes and remains deeply jaundiced. In certain cases attacks of gall-stones are accompanied by febrile seizures resembling malaria. Gall-stones may lead to suppurative inflammation of the gall-bladder or bile-passages, ulceration, occlusion of the neck of the gall-bladder, dilatation of the stomach from the formation of adhesions which kink the pylorus, abscess, peri- tonitis, empyema of the gall-bladder, and cancer of the gall- bladder. Treatment. — In the prodromal stage and after recovery from an attack insist on the patient taking considerable out- door exercise. Order him a cold sponge -bath every morn- ing, move the bowels freely every day, and order a simple diet. The patient should avoid all highly seasoned foods, pastry, rich soups, fatty food, cheese, alcohol, and sweets. Alkalies internally are of value. During the attack give an enema and apply hot turpentine stupes over the hepatic region. Give a hypodermatic injection of morphin and atropin. If vomiting does not occur, let the patient drink a large amount of warm water to favor it. After the attack give a purgative. When the attack has terminated look carefully for any evidence of inflammatory trouble in the hepatic region. In certain cases operation becomes necessary. Mayo Robson advises operation in the following cases : ^ in fre- quently recurring biliary colic without jaundice, whether the gall-bladder is enlarged or not ; in cases of enlargement of the gall-bladder without jaundice, even if there is no pain ; in persistent jaundice which was ushered in by pain, painful seizures occurring, whether or not febrile attacks occur; in empyema of the gall-bladder ; in peritonitis beginning in the gall-bladder region ; in intrahepatic abscess and in abscess about the liver, gall-bladder, or bile-ducts ; in some cases where the stones have been passed, but adhesions ^ Mayo Robson on the Gall-bladder and Bile-ducts. 664 MODERN SURGERY. remain and produce pain ; in fistula cases ; in some cases of persistent jaundice due to obstruction of the common duct, although there may be a possibility of cancer existing ; in phlegmonous cholecystitis and gangrene of the gall-bladder. Besides these conditions which may be produced by gall- stones, Robson operates for wounds of the gall-bladder, rupture of the gall-bladder, infective and suppurative cholan- gitis, and for some conditions of chronic catarrh of the bile- ducts and gall-bladder.^ The common operation is cholecystotomy (or cholecystost- omy), which consists in opening the gall-bladder, removing the stones, and closing the bladder again, or in making a fistula of the gall-bladder (page 697). If calculi exist in the common duct, it may be possible, after celiotomy, to manipulate them back into the bladder. In some cases cholecystotomy is per- formed, or a fistula is made, and the duct and bladder are fre- quently irrigated. In other cases the stone may be crushed by the fingers manipulating the duct and the concretion within it. The duct may be opened, and after the removal of the stone closed by sutures (choledochotomy). If the stone is impacted near the outlet of the duct, the duodenum is incised and the stone removed (choledocho-duodenot- omy). A dilated bile-duct may be anastomosed to the bowel (choledocho-enterostomy) or to the surface (chole- dochostomy). The obstruction may be side-tracked by anastomosing the gall-bladder to the bowel (cholecystenter- ostomy) (page 697). The Pancreas. Hemorrhage. — Pancreatic hemorrhage is a recognized cause of sudden death. The symptoms arise without warning, and comprise severe pain, nausea, vomiting, abdominal ten- derness, distention, great restlessness, constipation, and col- lapse. The blood may collect in the lesser peritoneal cavity, or about the spleen and left kidney (Prince and F. W. Draper). Acute Pancreatitis. — Hemorrhagic pancreatitis occurs in people in middle fife, and especially in tipplers. It begins suddenly : there are violent pain, nausea and vomiting, moder- ate fever, constipation, distention, and rapid collapse (Regi- nald Fitz, and Osier and Welch). Inflammation of the pan- creas with pus-formation is, as a rule, more chronic. The ^ Robson's treatise, from which the above is taken, is a valuable exposition of the surgery of the gall-bladder and bile-ducts. DISEASES AND INJURIES OF THE ABDOMEN. 665 symptoms are similar at the beginning of the attack and a septic fever develops. In some cases the pancreas becomes gangrenous. Treatment. — In view of the difficulty of distinguishing acute pancreatitis from intestinal obstruction and perforated ulcer of the stomach, in any case where either of these con- ditions is suspected an exploratory laparotomy is indicated. Osier speaks of cases of hemorrhagic pancreatitis in which operation was followed by recovery. Cysts of the pancreas occasionally follow injury. They are due, as a rule, to obstruction of the orifice of the common duct or of the pancreatic duct by calculi, tumor- pressure, or cicatricial contraction. These cysts may grow rapidly or slowly. They usually produce considerable pain and gastro-intestinal disturbance. Examination of the abdo- men maps out a mass which is usually median, is elastic, and is dull at some parts but resonant at others (where it is crossed by the colon). The fluid of the cyst is apt to con- tain urea, and will convert starch into sugar. Treatment. — Tapping is contraindicated. It might do much damage. In Keen's case, if an aspirating-needle had been introduced it would have perforated both walls of the stomach. Confirm the diagnosis by an exploratory incision. It may be possible to extirpate, but it is better to incise the cyst, stitch its edges to the belly-wall, and drain. The Spleen. Wounds and Rupture. — A wound of the spleen causes great hemorrhage, and if no surgical aid is offered will rapidly produce death. The treatment consists in celiotomy and splenectomy. Rupture of the spleen produces the signs and symptoms of intra-abdominal hemorrhage. It can only be certainly recognized after exploratory celiotomy. If such a con- dition is suspected while intravenous saline transfusion is being employed, the surgeon opens the abdomen, and if the spleen is ruptured, removes it. Abscess of the spleen is a rare condition which is metastatic in origin. Pain is felt, and enlargement is noted in the splenic region, and the symptoms of pyemia exist. The treatment consists in incision and drainage. Wandering Spleen. — The spleen may wander into any part of the general peritoneal cavity. This condition is almost never met with except in women. It is most com- 666 MODERN SURGERY. mon in women who have borne children (J. Bland Sutton). A wandering spleen may undergo atrophy, engorgement, or axial rotation (J. Bland Sutton). The organ, when dis- placed, drags upon the stomach, producing dilated stomach ; it may interfere with the bile-duct, causing jaundice ; it may cause intestinal obstruction by forming adhesions, or may cause uterine retroflexion or prolapse by passing into the pelvis. J. Bland Sutton says this condition may endanger life, as it may lead to rupture of the stomach, intestinal obstruction, splenic abscess, or splenic rupture.^ A wandering spleen can be identified by the fact that it has a notch upon its edge, and can be pushed about the abdomen. When this con- dition exists the spleen may be missed from its normal situation. Always examine the blood in order to deter- mine if leukemia or malaria exists. Treatment. — Greiffenhagen advocates suturing the organ in place (splenopexy). Most surgeons prefer to perform splenectomy. Splenectomy should not be undertaken if leukemia exists. In such a case apply a support and employ medical treatment for the existing disease. Operations upon the Abdomen. Abdominal Section (Celiotomy; Laparotomy). — In opening the abdominal cavity for exploratory purposes or to gain access to some area of abdominal or pelvic disease, the patient is carefully prepared as for any other operation. The instruments required depend upon the nature of the case. As a rule, there are required scalpels, scissors, a dry dis- sector, two pairs of dissecting-forceps, hemostatic forceps, pedicle-forceps, Hagedorn needles, calyx-eyed intestinal nee- dles, a needle-holder, drainage-tubes, gauze pads, sponges, silk, catgut, silkworm-gut, the Paquelin cautery, an electric light, also a bag, a tube, and a saline solution for hypo- dermoclysis or transfusion. Always count the instruments, sponges, and pads, and write down the number, and count them again after operation. This rule is adopted so that no instrument, sponge, or pad will be left in the abdomen. The abdominal pads and sponges are not used when dry. Dry sponges injure the peritoneum and favor the subse- quent development of adhesions (Sanger). The pads and sponges should be wrung out in normal salt solution before using. * British Med. Journ., Jan. i6, 1897. DISEASES AND INJURIES OF THE ABDOMEN. 667 Operation. — In some cases the patient is placed recum- bent, in others is put in the position of Trendelenburg (Fig. 201). The patient is to be care- fully protected from cold, the ex- ^^Tx tremities and the chest are cov- «^m^, \ ered with blankets, and sterilized 7^^-^ " ^ sheets are placed well around the a J\ * - J^^jh "■ - field of operation. The surgeon ^/_ __/A s j^^r^^^aia^^ip^' ^ steadies the skin of the belly with lll f — ^ " -'^^ the fingers of his left hand, and, f.g. 201, -The Trendelenburg holding the knife in the right hand, makes an incision about two inches long. This in- cision is often made in the middle line midway between the pubes and umbilicus, but may be in the semilunar line, in the epigastric region, or in some other situation. The first cut goes to the aponeurosis. Clamp the vessels. Do not hunt for the linea alba below the umbilicus, but go right through or be- tw'een the recti muscles. Above the umbilicus the linea alba is very distinct and the surgeon often cuts through it. Divide the transversalis fascia, beneath which is a little fat, and expose the peritoneum. The latter structure is recognized by its glis- tening appearance, by the ease with which it can be pinched up between the finger and thumb, and by the readiness with which its opposed surfaces may be made to glide over each other. On identifying the peritoneum, catch it at each side of the incision with forceps, raise a fold, nick it with a knife, and open it with scissors to the length of the external wound. To prevent stripping of the peritoneum a good plan is to anchor it to the belly-wall with a stitch on each side of the incision. Through the wound thus made the abdomen and its contents are explored, the trouble located, and deter- mination made as to whether or not further operation is advis- able, and, if it is advisable, what form it shall take. It may be necessary to enlarge the wound. This is done by placing the index and middle fingers of the left hand in the belly, with their pulps against the peritoneum, in the line where the surgeon will cut, to serve as supports to the scissors and as guards to intraperitoneal structures. The scissors are introduced and the wound is enlarged upward around the umbilicus if necessary. As soon as the incision is complete it is a good plan to push a large pad into Douglas's pouch and leave it there until the operation is completed. Slender adhesions are broken off with the finger or are pushed off with gauze ; firm adhesions are tied and cut. The toilet of the peritoneum is important after the opera- 668 MODERN SURGERY. tion is completed. Following a clean laparotomy, when but little blood has flowed into the cavity, flushing out is not required ; if much blood has flowed or if any septic matter has passed into the peritoneal cavity, after removing the sponge from Douglas's pouch flush out the belly thor- oughly with hot normal salt solution, empty out most of the fluid, but let a pint or more remain in the abdomen. The retention of saline fluid in the belly minimizes shock. If there is widespread infection, eviscerate, wipe out the peri- toneum with pads soaked in hot normal salt solution, and wipe the intestines carefully, slowly returning them as they are wiped. Extravasated septic matter is apt to collect between the liver and diaphragm, and this area must be carefully wiped or irrigated. In some cases it is desirable to drain through a lumbar incision. Rutherford Morrison has pointed out that on the right side a lumbar opening will drain a pouch which holds over a pint of fluid, and which, with the patient recumbent, is the most dependent portion of the peritoneal cavity. In some cases a drainage-opening is made on each side of the belly or above the pubis. In septic cases it may be advisable to pack with iodoform gauze instead of inserting tubes. Before closing the wound stop hemor- rhage and count the instruments and sponges. In most instances drainage is not needed, but it must be used in septic cases and when hemorrhage has been severe. We may drain by a rubber tube, strands of gauze, or a glass tube. If a glass tube iS used, it is introduced at the lower angle of the wound and reaches the bottom of the pouch of Douglas. This tube is repeatedly emptied during the prog- ress of the case by means of a syringe. In closing the wound some surgeons close the peritoneum with a continu- ous catgut suture and close the belly-wall with interrupted sutures of silkworm-gut ; some operators close with inter- rupted silkworm-gut sutures, including peritoneum, muscles, and skin in each stitch. In badly infected cases the wound is often kept open. Dress with aseptic gauze and wood- wool, and apply a flannel binder. For nonsuppurative appendicitis the incision is two inches internal to the anterior superior iliac spine and per- pendicular to a line drawn from the spine to the umbilicus (Fig. 202). The incision is usually one and a half to two inches in length, but if there are many adhesions it may be necessary to make it longer. After opening the perito- neum find the appendix by the following method : follow the parietal peritoneum outward with the finger, then back- DISEASES AND INJURIES GF THE ABDOMEN. 669 ward, then inward ; the first obstruction it encounters is the colon. Pass the finger down to the head of the colon, find the appendix, usually posterior and internal, and lift it into the wound. In some cases it will be advisable to deliver Fig. 202. — Resection of the vermiform appendix, incision through the abdominal wall (Kocher) : a, external oblique muscle ; h, internal oblique muscle ; c, aponeurosis of external oblique ; d, aponeurosis of internal oblique ; e, peritoneum ; f, outer border of rectus abdom- inis muscle (under it the deep epigastric vessels). the head of the colon from the belly ; in other cases this will not be necessary. Surround the appendix with iodoform gauze to prevent infection. In most cases the neck of the appendix is tied with strong silk, the appendix is cut off, and the stump is cauterized with pure carbolic acid and is inverted into the coats of the colon by Lembert sutures. An excellent method is to turn up a cuff of peritoneum, pull down the other coats, ligate at the base, cut through the tube, let the musculomucous stump retract, and tie or suture the perito- neal cuff over the stump. This plan was devised by Barker 6/0 MODERN SURGERY. Fig. 203. — Barker's technique of operation for removal of the appendix. (Fig. 203). Some remove the appendix by an elliptical incision around its base, and close the colon-wound by Lembert sutures. Some invaginate the appendix into the lumen of the colon. If there is no abscess, perforation, or gangrene, and no pus within the appendix or in its coats, drainage is unnecessary ; otherwise it is necessary. If the operation is in a distinct interval, pus is absent, and we can proceed without appre- hension. Such an operation should not be performed until three weeks have passed since the acute attack. If there is any question as to the presence of pus, surround the ap- pendix zone with iodoform gauze before breaking down adhesions and liberating the appendix. This gauze protects healthy structures from in- fection. In an interval case McBur- ney proceeds as follows : he makes the skin incision in the direction of the fibers of the external oblique muscle, sepa- rates the fibers of this muscle by blunt dissection, retracts them, separates the internal oblique fibers by blunt dissec- tion and retracts them, separates the fibers of the transver- salis in the same way and retracts them, opens the transver- salis fascia and peritoneum. No muscle-fibers are cut, and hernia is not apt to follow. Such a wound is closed as fol- lows : a continuous catgut suture for the peritoneum, suture of kangaroo-tendon for transversalis fascia, muscles restored to place, and skin closed by a subcuticular stitch. If an abscess is believed to exist, make an incision parallel with Poupart's ligament and over the area of dulness on percussion (Willard Parker's oblique incision). If the abscess is adherent to the belly-wall, such an incision will not enter the free peritoneal cavity. If after opening the abdomen an abscess is thought to exist, although it is not adherent to the belly-wall, surround the abscess with gauze before opening it. This gauze is placed under the margins of the incision in the peritoneum all around the appendix area ; a piece is carried toward the pelvis and another piece toward the liver. Over- lay this gauze with gauze pads (Van Hook). Adhesions are broken through with the finger, and when pus appears it is at once wiped away. If the appendix lies loose in the abscess-cavity, if it is sloughed off or but loosely attached to the abscess-wall, remove it. If the appendix is firmly DISEASES AND INJURIES OF THE ABDOMEN. 6/1 fixed in the abscess-wall, do not remove it. To remove it under these circumstances may rupture the wall and allow pus to enter the peritoneal cavity where it is not protected by pads and gauze. Deaver, Murphy, and others tell us to alwa\-s try to remove the appendix. We do not believe this to be a safe rule to follow. To insist on removing the appendix may cause death. When the appendix is left it usually sloughs away. It is true a fecal fistula may result, but this usually heals spontaneously. Even if it does not heal the surgeon acted properly, because a fecal fistula may be remedied by another operation, but there is no remedy for death. There are very few cases on record where an appendix has subsequently given trouble when left after operation. When Deaver decides to remove such an appen- dix he makes an incision in the median line of the abdomen, packs around the periphery of the abscess with gauze, opens the abscess, disinfects, inserts drainage, and then removes the surrounding gauze and closes the median incision. Irriga- tion should not be employed in appendicular abscess. The force of the stream may break down barriers of lymph and spread infection. After the evacuation of the pus, whether the appendix was removed or not, take out the pads, but leave the long strands of iodoform gauze in place (Van Hook). Introduce iodoform gauze into the abscess-cavity and insert a rubber tube, partially suture the wound, and dress with dry gauze. In forty-eight hours all the gauze is removed and fresh pieces are inserted for drainage. After this the gauze drain is changed daily. An interval case should be up and about in from ten days to two weeks after operation. An abscess case may require a much longer time for complete recovery, and a fecal fistula sometimes results in cases in which the appendix was not removed. Morris maintains and proves that these large pieces of iodoform gauze some- times cause intestinal obstruction and sometimes iodoform- poisoning, but the risk must be taken. Bnterorrhaphy, or Suture of the Intestine. — Sur- gical opinion has greatly altered in regard to this oper- ation since the day when John Bell wrote his famous attack on Benjamin Bell. John Bell said : " If in all surgery there is a work of supererogation, it is this operation of sewing up a wounded gut." To-day we know that if in all surgery there is a proceeding of imperativ^e necessity, it is the sewing up of a wound in the intestine. To perform this operation take fine sterile silk and thread a thin, round, straight calyx- eyed needle with it (Fig. 204). This needle is very useful, 6/2 MODERN SURGERY. as it can be threaded rapidly by pushing the calyx eye down upon the silk thread while the latter is kept taut. Lemberfs suture (Fig. 205, a) is at right angles to the wound. It goes Fig. 204. — Eye of the calyx-eyed needle. Fig. 205 — Enterorrhaphy : a, Lembert's suture; b, Dupuytren's suture. down to, but not through, the mucous membrane. It is formed by picking up a fold of the intestine (one-twelfth to one-eighth of an inch wide) one-eighth of an inch from the edge on one side of the wound, passing the needle through, picking up a fold on the opposite side of the wound, and passing the needle through. On tying the threads the serous membrane is inverted and peritoneum is brought into contact with peritoneum. For many years it was taught that this suture should include only the serous coat, but Halsted, in 1887, showed that it must include the tough submucous coat. The submucous coat is strong, and will hold a suture. The other coats are thin, tear easily, and Fig. 206. — Cushing's right-angled suture (Senn). will not hold a suture. So thin are the coats that a surgeon could not suture the serous coat alone were he to try. Sutures which include both muscular and serous coats tear out easily. The needle should catch up the submu- cous coat, but should not penetrate the intestine.^ Dupuy- 1 Halsted, Am. Jour. Med. Sciences, Oct., 1887. DISEASES AND INJURIES OF THE ABDOMEN. 673 trc7i's suture (Fig. 204, b) is simply a continuous Lembert suture running obliquely across the wound. Cusliing's 7'igJit- anglcd suture (Fig. 206) is a continuous suture catching up the submucous coat and serving to invert the serous layer. Halsted's mattress or quilt su- ture is shown in Fig. 207. Each stitch picks up the submucous coat. Mattress sutures do not tear out easily, they oppose evenly considerable surfaces, and do not constrict the tissue as much as Lembert stitches. The Czerny-Lenibert suture is a suture passed through the serous mem- brane on one side of the wound, made to perforate the mucous membrane, and to emerge at a corresponding point of the serous membrane. A Lembert suture is added (Fig. 208). As at present used, the Czerny suture is carried to, but not through, the mucous membrane. Gus- -.: ) Fig. 207. — A, Halsted sutures untied; B, Halsted sutures tied and serous sur- face inverted. Fig. 208. — Czerny-Lembert suture. Fig. 209.- -Czerny-Lembert suture as at present used. Fig. 210. — Gussenbauer's suture. senbauer's is similar to the Czerny-Lembert suture, except that it applies the Czerny and the Lembert with one suture, 43 6/4 MODERN SURGERY. and this suture does not pass through the mucous mem- brane (Fig. 210). Wolfler's suture unites broad layers of the serous coat, the knots being tied internally (Fig. 211). Senn says that after suturing a large wound of the stomach or of intestine a strip of omentum ought to be laid over the wound and fastened by catgut sutures (omental graft). These grafts adhere and are a safeguard against leakage. For other methods of enterorrhaphy, Fig. 211'— Wolfler's suture. sec lutcstinal Rcscction and Anas- tomosis. Digital Dilatation of Pylorus for Cicatricial Ste- nosis (I/Oreta'S Operation). — For a week before operation feed the patient by enemata supplemented by the stomach administration of peptonized milk, and wash out the stomach once a day. A few hours before operation wash out the stomach again. Place the patient recumbent and administer ether. Make a vertical incision in the linea alba. The in- cision begins one inch below the ensiform cartilage and should be five inches in length. When the peritoneum has been opened the stomach is drawn out of the wound, any adherent omentum is separated, and the pylorus is carefully examined. The stomach, after being surrounded with gauze pads, is opened near the center of its anterior surface, " but rather nearer to its pyloric end " (Jacobson). Insert the index finger through the stomach wound and follow that with the middle finger. The pylorus can be well dilated by separating the fingers. If the stenosis is so tight as to prevent the entry of a finger, first introduce a pair of hemostatic forceps and open the blades a little when they are within the lumen of the constricted area. The wound in the stomach is closed by Halsted sutures of silk and the abdominal wound is closed. Pyloroplasty (Heineke-Mikulicaj Operation). — Pre- pare the patient as for Loreta's operation. Open the ab- domen in the middle line. Draw up the pylorus as well as possible and pack hot moist gauze pads around it; make an incision through the stricture and in a direction correspond- ing to the long axis of the stomach and bowel. Catch an aneurysm-needle under the upper margin of the incision and draw it up, and an aneurysm-needle over the lower margin and draw it down. The effect of traction is to convert the DISEASES AND INJURIES OF THE ABDOMEN ^J^ transverse wound into a vertical one. The sutures are ap- plied so as to maintain the wound in a vertical line. The mucous membrane is sutured with a continuous suture of silk, and interrupted Halsted sutures of silk close the peri- toneal and muscular coats. Pylorectomy (Bxcision of the Pylorus). — Prepare the patient as directed above. A removal of any portion of the stomach constitutes a gastrectomy, and pylorectomy is a gastrectomy in which the pylorus is removed. The best in- cision through the abdominal wall is transverse over the mid- dle of the tumor. A small incision is made first to permit of exploration, and if the growth is found to be removable the incision is enlarged. The center of the incision is over the most prominent part of the tumor, and the direction of the incision corresponds with the long axis of the pylorus. Draw the tumor into the wound, and tuck pads about the stomach and the pylorus to catch extravasated fluids. Free the pylorus ; incise between forceps the great omentum near the greater curvature of the stomach, and ligate each end in segments ; treat the lesser omentum in the same manner. The greater and the lesser omentums are divided only to an extent sufficient to permit removal of the growth. Repack the gauze pads and tie a rubber tube around the duodenum below the growth. In making the excision remember that the stomach-wound will be much larger than the duodenal wound, and a special method of suturing will be required to approximate the two wounds in size. The lines of incision are shown in Fig. 212. The stomach is cut with scissors until two-thirds of its depth is divided, and the organ is washed out. After stopping hemor- rhage this cut is closed by a contin- uous suture for the mucous membrane and by Halsted sutures for the other coats. The remaining portion of the stomach is cut through. The duo- denum is cut through its upper half below the growth, and is fastened to the stomach by Halsted sutures at the '^" ^"■~~ ^ oreaomy. upper border and Wolfler's sutures at the posterior borders, Wolfler's sutures are applied from inside ; pierce all the coats, and bring broad layers of the serous coat into appo- sition. The remainder of the duodenum is cut through, and its anterior and inferior parts are united to the stomach by a double row of sutures, as set forth above (Fig. 212), Stitch the edges of the cut omenta to the stomach, cleanse 6/6 MODERN SURGERY. the parts, replace the stomach, close the abdominal incision, and dress the wound. Give nothing by the mouth for twenty-four hours. Thirst can be relieved by enemata of water or by the hypodermatic injection of boiled water. After twenty-four hours begin with stomach-feeding, start- ing with dessertspoonful-doses of peptonized milk every hour. Another method of performing pylorectomy is to excise the growth as directed above, suture the opening in the stomach, and implant the duodenum in the anterior or posterior wall of the stomach, making an incision through the stomach-wall to permit of it. Kocher advocates implan- tation of the duodenum in the posterior wall of the stomach. Kocher's method of pylorectomy is shown in Figs. 213, 214. Fig. 213. — Kocher's method of pylorectomy : L, liver; D, duodenum; P, pylorus; C, carcinoma; T C, transverse colon; a, separation-place of the ligature gastrocolicum ; i, separation-place of the lesser omentum; c, separation-line of the stomach; d, place where the stomach is kept closed by the middle and index fingers. The junction between the duodenum and the posterior wall of the stomach may be effected by a large Murphy button. Gastrototny. — This term is used to designate the opera- tion of opening the stomach for the accomplishment of some purpose, and immediately closing the incision in the gastric wall when that purpose is accomplished. Gastrotomy may DISEASES AND INJURIES OF THE ABDOMEN. 677 be performed to permit of the removal of foreign bodies, of exploration of the stomach and its extremities, of divulsion of the pyloric orifice, of the treatment of an esophageal Fig. 214. — Kocher's method of pylorectomy : D, duodenum at the posterior wall; a, continuous suture of the peritoneum ; b, posterior line of peritoneal continuous suture of the ring ; /, assistant's thumb pressing the stomach against the duodenum so as to close its lumen ; /, incision in the posterior gastric wall. stricture, or a stricture of the cardiac orifice of the stomach, or of the removal of a foreign body in the esophagus. The patient is prepared as for pylorectomy. The incision may be vertical in the middle line or identical with the in- cision for pylorectomy. If a large foreign body can be felt, the incision is made directly over it (Jacobson). When the peritoneal cavity is opened the surgeon decides as to the point where the stomach is to be incised, and draws this por- tion out through the wound, packing gauze pads under and around it. The stomach is opened by means of scissors, the cut being at a right angle to the long axis of the viscus (Jacobson). Any bleeding vessel is ligated with catgut. The purpose for which the stomach was opened is now to be car- ried out, the interior of the stomach and the surface of the extruded portion are irrigated with hot salt solution, and the stomach-wound is sutured with silk. A row of deep sutures is introduced. These sutures pass through all the coats. A row of Halsted sutures is then inserted. The abdominal wound is closed without drainage. 6;8 MODERN SURGERY. Gastrostomy is the making of a permanent gastric fistula, through which opening the patient can be fed. The opera- tion is employed in cases of esophageal obstruction. The surgeon must endeavor to perform an operation which will i§: Fig. 215. — Witzel's method for gastros- tomy, showing application of sutures in wall of stomach, embedding tube ob- liquely therein. Fig. 216. — Sutures tied, completely embed- dmg tube for some distance. not permit of leakage. Prepare the patient as for gastrotomy. In Witzel's method an incision is made four inches long, run- ning to the left from the middle line, just below the border of the ribs. After opening the peritoneal cavity seize the stomach, bring it out of the wound, and pack gauze around it. Introduce a rubber tube into the stomach and enfold it by a double row of Lembert sutures (Figs. 215, 216). This tube should be five inches long and of the same diameter as a No. 25 French bougie. The opening in the stomach is to- ward the cardiac extremity, the tube is placed parallel with the belly-wound, and the outer end of the tube emerges in the median line. The stomach is returned, and is stitched by three sutures to the abdominal wall. The tube is retained in place by a catgut stitch through the wall of the tube and the stomach-wall. The abdominal incision is sutured and a DISEASES AXD IXJURIES OF THE ABDOMEN. 679 clamp \s, placed on the tube. When the patient is fed a fun- nel is slipped into the tube, the clamp is removed, and liquid food is poured into the funnel. After the wound heals it is not necessan- to permanently retain the tube. It is passed when the patient desires food. Kader has modified Witzel's method. A small incision is made in the stomach and a tube is introduced. Two Lembert sutures are passed so as to form a fold on each side of the tube and turn the stomach- wall inward around the tube. Lembert sutures are inserted in the furrow on each side of the tube. Two more folds are formed over the first two. The stomach-wall is stitched to the parietal peritoneum and sheath of the rectus muscle (Willy Me\-er). The Ssabanejew-Frank operation is preferred by many surgeons. Fenger's incision is made (a cur\"ed incision at the margin of the costal cartilages of the left side). A cone of the stomach is pulled out of the wound and is passed under a bridge of sldn which has been prepared for it. The stomach is fixed above the margin of the ribs and opened (Figs. 217, 218). Van Hacker makes the gastric fistula through the left rectus muscle, and Hahn between two of the rib cartilages (Willy Meyer). Emanuel Senn dexised Figs. 217, iiS — Frank's method of gaitrostomy in .;-ir>:...:::.. :e escpBagUS. the follo\nng method : a cone of the stomach is pulled out of the abdominal wound, and this cone is puckered by the insertion of two dra\\-ing-string sutures of chromic catgut through the serous and muscular coats. A cuff of gastro- cohc omentum is sutured bv silk around the neck of the 68o MODERN SURGERY. puckered cone. The stomach is sutured to the belly-wall with silk, the sutures, including the omental cuff, the serous and muscular coats of the stomach, and the structures of the belly-wall, except the skin. The skin is partially sutured. The stomach may be opened at any time. Gastro -enterostomy (Senn's method) is the establish- ment of a permanent fistula between the stomach and the small intestine, in order to side-track the pylorus. The stom- ach is irrigated as before pylorectomy. In the operation of gastro-enterostomy a median incision is made through the abdominal wall, from below the xiphoid cartilage to the um- bihcus. An opening is made in the stomach, in the direction of the long axis of the viscus, and its edges are stitched with a continuous catgut suture. The contents of the bowel are forced along to below the point where an incision is to be made ; a rubber tube is fastened, around the bowel above this point, and another below it; an incision is made in the long axis of the bowel, and the margins of the wound are sutured in the same manner as the stomach-wound. Bone plates are in- troduced into the stomach and intes- tine, and the ligatures are tied as in intestinal anastomosis (page ^'})']^. Catgut rings or rubber rings may be used. Fig. 2 1 9 shows Wolfler's meth- od of gastro-enterostomy. Kocher's method is as follows : after opening ''^' ^'^(^ter^W5iflerr°^'°'"^ the abdomcn, lift up the omentum, pull up a loop of intestine and find the point where the jejunum appears from under the meso- colon. Select a loop sixteen inches from the origin of the jejunum and prepare to attach it to the stomach. Wolfler showed that the intestine should be applied to the stomach in such a manner that the direction of peristalsis in the bowel must correspond to the direction of the stomach-tide. This can be accomplished by having the proximal portion of gut to the left, and the distal portion to the right. The operation is to be so performed that after its completion the stomach-con- tents pass into the distal portion of the gut, and the intesti- nal contents do not tend to enter the stomach. In order to accomplish this Kocher hangs the intestine to the stomach- wall in such a manner that the proximal portion of the loop is posterior and ascending, and the distal portion is anterior and descending. The bowel is hung to the stomach by a con- tinuous serous suture of silk, the ends of which are left long. DISEASES AND INJURIES OF THE ABDOMEN 68 1 The intestine is opened by a curved incision, the convexity of which is downward. The stomach is opened so that the convexity of the cut is upward. The valve-Hke portion of the bowel-wall is sutured to the stomach below the incision in that viscus. The two openings are well approximated by sutures. Gastro-enterostomy may be quickly performed by the use of a large-sized Murphy button. Murphy says that in some reported cases the button has slipped back into the stomach, but this accident can be prevented by the use of an oblong button and by making the anastomosis on the posterior stom- ach-wall. The same surgeon advises us to scarify the peri- toneum to hasten union, and says supporting sutures about the button are not required, except when considerable ten- sion exists. There is no question that an anastomosis on the anterior wall, accomplished by a Murphy button, can be speedily performed. Anastomosis on the posterior wall can- not be performed speedily, and it sacrifices the great advan- tage of the button operation — that is, speed. In spite of the reported cases, we can truthfully assert that the danger of the button producing grave trouble is slight. Gastrogastrostotny is an operation' performed for hour- glass contraction of the stomach, a condition which occasion- ally ensues on the healing of an ulcer. In this operation an anastomosis is effected between the pyloric and cardiac ends. Wolfe, Watson, Wolfler, and Eiselberg have performed this operation. Weir and Foote maintain that double gastro- enterostomy, " tapping each sac," is a preferable procedure.^ Gastroplication (Brandt's Operation of Stomach- reefing for Dilated Stomach). — Apply sutures in the ante- rior wall so as to form reefs, then tear throuo-h the crreat omen- tum and apply sutures in the posterior wall. The sutures pass through the serous and muscular coats, and 150 to 200 are inserted. This operation is of questionable value, and must never be used if stenosis of the pylorus exists, and stenosis of the pylorus is the most common cause of gastric dilatation. Bnterectomy, or Resection of the Intestine with Anastomosis by Circular i^nterorrhaphy, — After open- ing the abdomen isolate the loop of intestine it is intended to resect. Push a rubber tube through the mesentery close to the bowel, above the seat of operation, and pass a rubber tube through the mesentery below the seat of operation. Empty this segment of bowel by squeezing and stroking, tighten the ' F. S. Watson, in Boston Med. and Surg. Jour., April 2, 1896; Weir and Foote, Medical News, April 25, 1896. 682 MODERN SURGERY. rubber tubes, and clamp thern to keep the bowel empty. In- stead of tubes, strips of iodoform gauze may be used to en- circle the bowel. The diseased intestine is resected, each in- cision being carried through a healthy segment. The lumen of each end of the divided gut is irrigated with salt solution. The divided surfaces are approximated by a double row of sutures — a continuous suture for the mucous membrane, and Lembert's, Dupuytren's, or Cushing's suture to effect inver- sion. Thoroughly satisfactory approximation can be effected by one row of Halsted sutures. If a redundant fold of mesen- tery is left, it can be stitched at its raw edge. Many surgeons remove a V-shaped piece of mesentery and tie the mesen- teric vessels. The tubes are removed, and the wound is cleansed, closed, and dressed. Fig. 220 shows the tubes Fig. 220. — Excision of bowel : first step (Esmarch and Kowalzig). Fig. 221. — Excision of bowel with en- terorrhaphy and stitching of the redun- dant mesentery : second step (Esmarch and Kowalzig). fastened for excision of the bowel, and Fig. 221 shows enter- orrhaphy with stitching of the redundant mesentery. Senn effects invagination by means of a ring (Fig. 223). If the two segments of bowel are unequal in size, the nar- rower part of the bowel should be cut obliquely and the larger part should be cut transversely. To meet this com- plication Billroth devised lateral implantation. Suppose the cecum has been resected : its lower end is closed by Lembert sutures, an opening is made in the long axis of the periphery of the colon opposite the mesocolon attachment, and the end of the ileum is sutured into this incision. Senn advises the insertion of an anastomosis-ring in the ileum, the invagination of the colon as the ring is pulled into place, and firm suturing of the line of junction. By Senn's method the ileiim may be implanted into the end of the colon or into a slit in the wall of a large bowel after the end of the colon has been closed. In some cases, where one portion of bowel DISEASES AND INJURIES OF THE ABDOMEN. 683 is larger than the other, lateral anastomosis is the prefer- able method. For a full week after an intestinal resection the patient is fed chiefly by nutrient enemata. During the first twenty-four hours nothing is given by the stomach but ;l 1 ;,■.. V ''X x Fig. 222. — Resection of intestine : a, h, the two halves of the button ; c, the two portions clamped together; d, introduction of the sutures for holding each half of the button in place. The lower figure shows the completed union of the intestine by the Murphy button ; the slip in the mesentery has been closed by linear union (after Zuckerkandl). bits of ice, and for the next six days but a very little liquid food is allowed to be swallowed. The use of Murphy's button permits of rapid approximation after resection (Fig. 222, r). This button closely approximates the portions of the intestine within its bite, rapid adhesion taking place. The diaphragm of tissue undergoes pressure- atrophy, and liberates the button, which is passed per anum. It is claimed that the button-opening contracts but slightly. 684 MODERN SURGERY. For end-to-end or side-to-side approximation of the small intestine a No. 3 button is used. For similar operations on. the large intestine a No. 4 button is employed (Murphy), After the resection one-half of a button is inserted into each segment, and is held in place by a purse-string suture of silk which passes through all the coats (Fig. 222). The redun- dant mucous membrane is tucked in or clipped off, so that it will not be interposed between the serous surfaces. The serous surfaces are scratched with a needle and the two halves of the button are locked (Fig. 222). It is not necessary to surround the margin of junction with sutures. Murphy says that liquid nourishment should be given as soon as the patient has recov- ered from the effects of the ether, and that the bowels should be moved at. an early period and frequent evacuations should be maintained. If the button does not pass in four weeks,. Fig. 223. — Senn's modification of Jobert's invagination method; A, upper end lined with ring; .5, invagination sutures in place ; C, lower end. examine the rectum for it.^ The situation of the button can be ascertained by the X-rays. After intestinal resection Halsted performs circular enterorrhaphy by means of his mattress-sutures. Maunsell has devised a most ingenious method of cir- cular enterorrhaphy. The two portions of bowel are at- tached by two fixation-sutures which penetrate all the coats (Fig. 224). An incision one and one-half inches in length is made through the wall of the proximal seg- ment of gut, about one inch from its edge. The fixa- tion-sutures are brought through this opening, traction is made upon them, the distal portion of the bowel is in- vaginated into the proximal portion, and the ends emerge from the opening, their peritoneal surfaces being in contact 1 John B. Murphy, in Med. News Feb. 9, 1895. DISEASES AND INJURIES OF THE ABDOMEN. 685 (Fig. 224). Sutures of silk are passed through both sides of the area of invagination, the threads are caught up in the cen- ter, cut, and tied on each side. The fixation-sutures are cut off The invagination is reduced by traction. The longitudinal cut is closed by Lembert sutures. Fig. 224. — Maunsell's method of anastomosis (after Wiggin). Fig. 225. — Robson's decalcified bone bobbin. Mayo Robson performs circular enterorrhaphy over a bobbin of decalcified bone (Fig. 225). Allingham uses a bone bobbin the shape of two cones joined at their 686 MODERN SURGERY. apices. The bobbin is decalcified except an area at the center (Fig. 226). Kocher performs circular enterorrhaphy as follows : a fixation-suture is introduced through the bowel Fig. 226. — Allingham's decalcified bone bobbin. at the mesenteric attachment and another is inserted at an opposite point. The intestinal ends are approximated by a continuous silk suture, which passes through all of the Fig. 227.— Harris's method of circular enterorrhaphy. coats, but which includes more of the serous than of the mucous coat. The suture-line is overlaid by a continuous Lembert suture which includes the serous and a portion of DISEASES AND INJURIES OF THE ABDOMEN. ^^J the muscular coat. Harris removes a portion of mucous membrane from the distal end by means of a curet. Three needles are threaded with fine silk. The first needle is pushed through the bowel-wall to one side of the mesentery. The point of the needle picks up a portion of the distal end transversely. The needle is used as a lever to invaginate the distal end into the proximal end. The same procedure is carried out with the other needles. When invagination is effected the needles are pulled through and the threads are tied. The free end of the bowel is now sutured to the in- vaginated part by interrupted sutures or by a continuous suture broken once (Fig. 227).^ Some surgeons employ inflatable rubber cylinders in making an end-to-end anastomosis (Halsted, Downes, Re- der). Halsted shows that the use of the inflatable rubber cylinder enables the surgeon to finish the operation more quickly and to dispense with clamps ; arrests the vermicular motion of the intestine; makes easy the adjustment of two pieces of intestine of unequal size ; and renders it possible to apply stitches rapidly, evenly, and securely.^ Three presection Fig. 228. — Use of Halsted's inflated rubber cylinder in circular enterorrhaphy. sutures are inserted ; a portion of bowel and a V-shaped piece of mesentery are resected, the mesenteric incision being so made as to leave a vessel uncut at each edge to supply each end of the divided intestine. The mesenteric vessels are 1 Chicago Med. Record, ]3.n., 1897. ^ Phila. Med. Jour., Jan. 8, 1898. 688 MODERN SURGERY. ligated and the ends of the bowel are pulled together by the presection stitches, two of which are tied. The col- lapsed rubber cylinder is pushed into the bowel by means of forceps and is inflated with a syringe (Fig. 228). Twelve mattress sutures are inserted and the bag is collapsed and withdrawn and the sutures are tied, the stitch a being tied first (Fig. 228). The slit in the mesentery is sewed in such Fig. 229. — Suture of the mesentery after circular enterorrhaphy (Halsted). a way that the mesenteric vessels which nourish the bowel are not interfered with (Fig. 229). I' to suture the ureter. The tissues above the ureter are sutured and a drainage-tube is carried to the ureter (Fenger). If the stone cannot be reached by the extra- peritoneal method, open the peritoneal cavit)' and incise the ureter. After removing the stone suture the wound in the ureter with silk inversion-sutures, fasten an omental graft over the suture-line (Fenger), and drain. Uretero-ureterostomy (Van Hook's Operation). — In this operation ligate the lower end of the divided ureter with silk or catgut. About one-fourth of an inch below the liga- ture make an incision in the long axis of the tube. This incision is in length equal to twice the diameter of the tube. Each end of a piece of fine catgut is threaded to a fine ' See Oscar Bloch in British Med. Jour., Oct. 17, 1S96; also, reports of Czemy, Bardenheuer, Tuffier, Kiimmell. 784 MODERN SURGERY. needle. This thread is passed through the upper end of the ureter (Fig. 286). The needles are made to enter the lower end of the tube through the door made by the sur- FlG. 2 Van Hook's method of ureteral anastomosis. geon. They are pushed through the wall of the ureter one- half an inch below the window (Fig. 286). Traction upon the strings causes invagination and the ligature-ends are tied. If the operation is intraperitoneal, the ureter is wrapped about with peritoneum. Diseases and Injuries of the Bladder. Retention of Urine. — By this term is meant an inability to empty the bladder. The retention may be complete, not a drop emerging, or it may have been complete, a dribbling setting in after a time, due to paralysis of the bladder, which cannot contain more fluid, expulsion of the overflow from the ureters being produced by atmospheric pressure. This con- dition is known as the engoi^gement, the overflow, or the in- continence of retention. There may be a partial retention from enlarged prostate, a portion only of the urine being voided. Retention may be caused by — (i) obstruction, result- ing from urethral stricture, hypertrophied prostate, inflamed prostate, occluded meatus, impacted calculus, urethral tumors, complete phimosis, fecal impaction, and pressure from large tumors, or by (2) defective expulsion, resulting froin paralysis, DISEASES OF GENITO-URINARY ORGANS. 785 disease or injury, atony, reflex inhibition, shock, muscular weakness of fevers, and the action of such drugs as bella- donna, opium, or cantharides. Symptoms. — In acute retention there is an agony of desire to urinate, the patient making acutely painful straining-efforts, during which feces are often passed. There are severe pain and aching in the abdomen, thighs, perineum, and penis. All the symptoms rapidly increase, a typhoid state is inau- gurated, and death closes the scene unless relief be given. If retention is from time to time alleviated by the passage of a little water, the symptoms are slower in evolution and are less intense, and the case is said to be chronic. Some cases of gradual onset, due to atony, are very insidious, the patient feeling no particular pain and complaining only of the dribbling, which is really the overflow of retention, and is not a sign that the bladder is successfully emptying itself. In any case of retention the bladder rises above the pubes, and there is found a pyriform, elastic, fluctuating tumor (dull on percussion) in the hypogastrium, which tumor gradually enlarges until the bladder is evacuated or incontinence sets in. The flanks give a clear percussion-note, and the tumor is. Fig. 287— Gouley's tunnelled catheter, threaded over a filiform bougie. more prominent when the patient is erect than when recum- bent. Long continuation of obstructive disease, producing partial retention with or without attacks of complete reten- tion, disorganizes the kidneys. Acute and complete retention may induce rupture of the urethra or urinary suppression. Treatment. — Place the patient upon his back, keep him warm, and if instrumentation does not rapidly succeed, give an anesthetic. Be sure that every instrument is aseptic. In organic stricture try to pass a soft catheter; if this fails, endeavor to insert a hard catheter. Try a large size first, and gradually go to smaller sizes if the larger instru- ment will not pass the obstruction. When the instrument enters the bladder draw off but half of the urine, withdraw the instrument, wait a few hours, insert it again and then empty the bladder and wash out the viscus with hot boric- 50 785 MODERN SURGERY. acid solution. To draw off all of the urine at once is dan- gerous, because the sudden relief of pressure from distended veins leads to bleeding from the mucous membrane and hemorrhage into the bladder-walls. Fig. 289 shows several varieties of rubber catheters, and Fig. 291 shows a silk catheter. Fig. 290 shows the proper curve and the im- proper curve for a metal instrument. After the bladder has been emptied the patient is wrapped in blankets, a bag of hot sand is placed against the perineum, and a hot-water bag over the hypogastric region ; when he recovers from the effect of the anesthetic he is given suppositories of opium and belladonna, and tablets of salol and boric acid are administered for several days. If it is found impossible to insert a rubber instrument or a metal catheter, make an attempt to carry a filiform bougie into the bladder. Fig. 288 shows filiform bougies. If the stricture is known to be organic from previous histor}^, at once insert a filiform bougie. On this bougie Gouley's tunnelled catheter can be threaded (Fig. 287) and carried into the bladder, the viscus being half emptied. Instead of carrying in the / <; I catheter, we can leave the filiform in place, and fasten it. The filiform bougie will act as a capillary drain, and in a few hours will empty the bladder. Then insert an- other bougie beside the first, and so on for several days, using also opium, order- FiG. 288.— Points ing rest in bed, and making no attempt to w gu'rdes. ^^^^^' dilate the stricture forcibly until retention has ceased and inflammation has subsided. If no bougie can be passed, aspirate or perform cystotomy (su- prapubic or perineal). In spasmodic stricture hold a good-sized metal catheter firmly against the face of the spasmed area : relaxation will occur and the instrument will eventually pass. An individual who has an organic stricture which has given but little trouble may develop attacks of retention because of inflammatory edema of the mucous membrane and spasm of the urethral muscles. These attacks are temporary, and an instrument can usually be inserted when employed as above •directed. In inflmnviations give a hot hip-bath and sup- positories of opium and belladonna, and then use a hot sand-bag to the perineum and a hot-water bag over the hypogastrium. If these fail or if the symptoms are urgent, pass a soft catheter. In the occluded meatus of the nezv- borri incise with a tenotome. In a congenital cyst of the sinus pocularis pass a steel bougie, which will rupture DISEASES OF GENITO-URINARY ORGANS. 787 the cyst. In complete phimosis split up the prepuce. In impacted stone try to pull it out with urethral forceps ; if this fails, push it in or cut. In fecal impaction scrape out with a spoon. In enlarged prostate insert a coude cath- eter (Fig. 289, U) strengthened by the insertion of a filiform Fig I. — a, French olivary gum catheter; /', Mercier's elbowed catheter (coude); c, Mercier's double-elbowed catheter ; d, curved gum catheter. bougie nearly to the beak (Brinton), or pass a silver instru- ment with a large curve. In retoition from expidsive defect use a soft catheter. Cases of retention require warmth, con- finement to bed, the administration of laxatives, free action of the skin, and the use of such drugs as salol, boric acid, and quinin to asepticize the urine. In some few cases no instrument can be inserted in the bladder. In most of such cases aspirate — which may be done several times if necessary — and in a day or two, when swelling and congestion abate, an instrument can be passed. A small trocar or an aspirator- needle is pushed into the bladder, the trocar or needle being inserted in the median line, just above the pubes, and taking a course downward and backward. The parts are first pre- pared antiseptically, and the puncture is dressed with iodo- form and collodion. Only half of the urine is withdrawn at a first aspiration. Rectal puncture is now obsolete. The perineal incision is not advocated for retention unless rupture of the urethra has taken place. When a catheter is used for retention the patient must be recumbent to minimize shock. Injuries of the Bladder. — This viscus is so deeply situ- ated, and the abdominal walls are so elastic, that it is rarely injured when empty. If the bladder be full and the abdomen be tense — which is common in alcoholic intoxication — force applied upon the abdomen may injure the bladder. Contusion of the Bladder. — In this condition there are noted, vesical hematuria, tenesmus, severe cystitis, and an impediment to the flow of water because of clots. Hemor- 788 MODERN SURGERY. rhage may be very severe and sepsis may arise, even causing death. When contusion exists retention is relieved by a clean soft catheter; if this fails because of occlusion of the eye of the catheter with blood-clot, there must, from time to time, be forced through the catheter by an irrigator a solu- tion of sodium bicarbonate in cooled boiled water. Gross's blood-catheter can be used, or the evacuator of Bigelow may be employed. The patient is put to bed, a hot-water bag is apphed to the hypogastrium, morphin is administered in moderate doses, the bladder is washed out several times Fig. 290. — A B E shows the proper curve (reduced in size) for unyielding male urethral instruments ; C B D shows an improper curve. a day with boric-acid solution to disintegrate and remove blood-clots, and the urine is diluted and rendered aseptic by the stomach administration of salol, boric acid, and hquor potassii citratis. Hemorrhage usually ceases on relieving distention ; if it does not, some more radical measure must be employed (see Hematuria). Besides contusions, the bladder maybe injured by bullets; by stabs or punctures through the abdomen, the vagina, or the uterus ; or by penetration by a fragment of a fractured pelvic bone. The symptoms of such conditions are those of rupture of the bladder (^. •z/.). In any intraperitoneal wound at once open the abdomen, suture the wound in the bladder-wall, irrigate the peritoneal cavity, and drain the bladder by means of a retained catheter, a perineal section, or a suprapubic cystotomy. In an extraperitoneal wound drain the wound by a tube, and drain the bladder by a re- tained catheter, a perineal section, or a suprapubic opening. Rupture of the bladder occurs in three forms : (i) intra- peritoneal — a rupture involving the peritoneal coat ; (2) ex- traperitoneal — a rupture of a portion of the bladder not covered by peritoneum ; and (3) subperitoneal — a rupture of the mucous and muscular coats, the urine diffusing under DISEASES OF GENITO-UFINARY ORGANS. 789 the peritoneal investment. The catiscs are of two kinds, predisposing and exciting. Predisposing causes are — disten- tion of bladder ; drunkenness ; ulceration ; degeneration or atony of the bladder-coats. Exciting causes are — obstruc- tion to outflow of urine (by stricture or enlarged prostate) ; external violence ; falls upon the feet and the buttocks, as well as upon the abdomen ; lifting ; straining at stool, in micturition, or during parturition ; and the forcing of injec- FiG. 291. — English silk-web catheter. tions into the bladder. This accident is commoner in men than in women (10 to i), and is rare in children. Syjuptovis, Diagnosis, and Treatment. — The symptoms are not always definite, and every characteristic one may be for a time absent, the patient seeming in some rare instances to possess the power of retaining his urine and of voiding it. As a rule, however, there are found some or all of the follow- ing symptoms, following an accident or occurring during the progress of a causative disease : collapse ; excessive desire to urinate ; inability to do so ; a catheter, when used, brings away pure blood or a veiy little bloody urine ; the catheter occasionally slips through the tear into a cavity, and more bloody water comes away ; severe hypogastric pain comes on after a temporary sense of relief from retention ; shock is so severe that death may ensue ; if reaction follows, there is delirium, often septicemia and peritonitis ; extensive infil- trations of urine may occur. In intrapeintoneal rupture gen- eral peritonitis is certain to arise, but its appearance may be postponed for several days if the urine is healthy. In these cases the extravasation is noted as a simple swelling, probably on one side only. In extraperitoneal rnptnre the urine may infiltrate the perineum, the scrotum, the thighs, and under the integuments of the abdomen and the back, and may soon induce sloughing. In subperitoneal rnptnre peritonitis is apt to arise. Injecting fluid fails to lift the bladder into the hypogastric region so as to be recognizable on percussion. If there is injected a measured amount of fluid, less will run out than went in. In doubtful cases pump air into the bladder. A bicycle pump can be used (Brown), or a Davidson syringe (Keen). Keen's directions are to insert a catheter, empty the blad- der of urine, and connect to the catheter a disinfected 790 MODERN SURGERY. Davidson's syringe, a mass of absorbent cotton being fast- ened over the distal end of the syringe. Air after it has filtered through the cotton is pumped into the bladder : an unruptured bladder will rise above the pubes as a pyriform tumor, tympanitic on percussion ; a ruptured bladder will not so rise, but the air will pass into the general peritoneal cavity. In intraperitoneal rupture the general peritoneal cavity will be distended with the air. In extraperitoneal rupture injection will produce emphysema of the extravesical connective tissues. On removing the syringe the air rushes out again if the bladder is unruptured, but little if any comes aw^ay if it is ruptured. Senn recommends injecting hydrogen gas instead of air. The treatment of rupture of the bladder is the same as that for wounds of the bladder. Atony of the bladder is a condition in which the expul- sive power of the bladder is diminished or lost because of impairment of muscular tone. The bladder is very thin, and the muscles are flaccid and often the seat of fatty degen- eration. Sometimes the bladder is very large and sometimes it is very small. A slight degree of atony is physiological after middle age. The causes are senility, distention from true paralysis, chronic over-distention from obstruction, and acute over-distention. Symptoms. — In atony of the bladder the patient passes water frequently (a symptom probably existing for some years), and especially at night ; he may even do so while asleep. The stream, when voluntarily passed, has no pro- jection, but drops at once from the end of the penis. Resid- ual urine exists for years and may at any time set up cystitis, and retention with incontinence is apt to occur. This con- dition is not vesical paralysis resulting from a lesion of the nervous system. Treatment. — In treating atony of the bladder measure the residual urine : if it amounts to four ounces, use a soft catheter night and morning ; if it amounts to six ounces, use the catheter every eight hours ; if it amounts to eight ounces, use the catheter every six hours (J. W. White). The patient should be taught how to use the catheter and how to keep it sterile. (For methods of disinfecting cath- eters see article on Hypertroph}^ of the Prostate Gland.) The bladder is from time to time washed out with gr. iij to the ounce of boric-acid solution at a temperature of iOO° F. Strychnin, electricity, ergot, and cantharides may be ordered. Vesical Calculus, or Stone in the Bladder. — The salts normally in solution in the urine may deposit as calculi DISEASES OF GENITO-URINARY ORGANS. 79 1 and may be imprisoned in any portion of the urinary tract. The commonest calcuh are those composed of uric acid, urates, calcium oxalate, and fusible phosphates. The for- mation of uric-acid and urate calculi is explained under Renal Calculus (page 772). Vesical calculi are usually renal calculi that have passed the ureter and become enlarged by new accretions. Phosphatic calculi may be formed in the bladder when chronic cystitis causes and maintains an alkaline urine. Uric-acid calculi are smooth, round or oval, and hard, but easily broken. On section they present the color of brick-dust and are marked by concentric rings. Their nuclei are dark by comparison. They are soluble in dilute potassium hydrate, and with effervescence in nitric acid. They are combustible, and leave scarcely any ash. Urate of sodium and urate of ammonium often occur together in stones, and these calculi are not in rings, are not so hard as the uric-acid stones, and are fawn-colored on section. Oxalate-of-lime stones are round with many projecting nodes like the mulberry, hence the term " mulberry calculus." They are very hard, and section shows the color to be brown or green and that they possess wavy, concentric rings. This form of calculus is soluble in hydrochloric acid. Fusible calculus, which is composed of magnesic ammonic phosphate with phosphate of lime, constitutes the commonest form of phosphatic stones and of large stones. It is light, soft, smooth, and white, and shows no laminae on section. Some rare forms of stone are composed of xanthic oxid, cystic oxid, calcium phosphate or carbonate, and magnesic ammonic phosphate (triple phosphate). A stone may be formed having layers of different sub- stances ; for instance, there is often found a uric-acid nucleus surrounded by phosphates, the latter surrounded by uric acid or urates, and these again by phosphates. In some cases oxalate of lime alternates with uric acid, urates, or phosphates (Bowlb)^). Bowlby states that the alternating uric-acid and phosphatic layers are due to the altering reac- tions of the urine; that when the urine is acid uric acid is deposited on the stone, but when cystitis makes the urine alkaline the stone receiv^es a phosphatic coat. Anything that favors the formation of an excessive uri- nary deposit may cause vesical calculus, and among such causes are defective digestion, failure in processes of oxida- tion, excess of solids and nitrogenous elements in the diet, deficient exercise, etc. If to the urinary condition estab- 792 MODERN SURGERY. lished by the above conditions a catarrh of the genito-uri- nary tract is added, pus or mucopus in the concentrated urine may induce stone. Children are predisposed to uric-acid stones, and old people to phosphatic stones. In an old man with enlarged prostate and chronic cystitis a stone forms rapidly about any accidental nucleus. The nucleus may be phosphate-crystals glued together by mucus, a blood-clot, uric-acid gravel, or a foreign body. Stone is rare in females because of the shortness, the large diam- eter, and the ready dilatability of the urethra. Stone is very rare in the negro. Gout, rheumatism, lithemia, enlarged prostate, vesical atony, urethral stricture, and catarrhal in- flammation of the kidney, the ureter, and the bladder, are predisposing causes. Symptoms. — In not a few cases the vesical symptoms are antedated by an attack of nephritic colic. The severity of the symptoms depends more on the roughness of the stone than on its size. A small, rough calculus will produce intoler- able anguish, whereas several large, smooth stones will cause but moderate pain, A patient with stone in the bladder complains of frequency of micturition, particularly in the daytime, the desire being sudden, uncontrollable, and in- voked or aggravated by exercise. This symptom is more positive in youth than in old age. Pain of a sharp, burning character is experienced at the end of micturition, due to the contraction of the empty bladder upon the stone. The usual seat of this pain is the under surface of the head of the penis, a little behind the meatus, and the pain may con- tinue for some time. By pulling on the penis to relieve this pain the prepuce often becomes pendulous. This pain varies in severity, being worse during cystitis and after exercise ; it may be absent in encysted stone, it may even almost disap- pear, and it is always worse in the young than in the old. Stone in chronic cases of atony and in cases of vesical paralysis causes neither marked pain nor frequency of micturition.^ Attacks of cystitis in a man with calculus are spoken of as attacks of stone. When a stone is small it may during micturition roll into the urethral orifice, and so cause a sudden interruption of the flow of water, the stream again starting when the patient changes his position. This symptom is rare in the old, the stone in them dropping into the sac back of the prostate and below the urethral orifice. Hematuria may or may not be noted ; it is most usual after exercise, and occurs at the end of the urinary act. Pus or ^ American Text-book of Surgery. DISEASES OF GENITO-URINARY ORGANS. 793 mucopus will be observed if cystitis occurs. Priapism occurs in some cases. Pain of a reflex nature may be felt in the rectum, in the perineum, or in some distant part. The above symptoms, even if all are present, do not prove that an individual has a stone in the bladder. To prove the presence of a stone, it must be touched with a sound and the contact must be felt and heard. To sound a patient, have the bladder well filled with water, and place him recumbent with the knees drawn up. Never sound a person while he is standing, because of the danger of syncope. In an ordi- nary case use a sound with a very slight curve ; in a man with hypertrophied prostate use a sound with a short and decided curve. The caliber of a stone-sound is No. 13 French. The instrument is carefully boiled and anointed with glycerin. Examine the entire bladder systematically, and never operate unless a stone be both heard and felt. The stone may be hard to find, or it may elude the instrument entirely when it is encysted, when it rests in a diverticulum, when it is fixed to the roof or anterior wall of the viscus, or when it is crusted with lymph or blood-clot. In doubtful cases always insist on a second examination, giving ether if the first was VQ.ry painful. Occasionally a small stone will be found by using a Bigelow evacuator, the current causing the calculus to knock against the tube. In many cases stone in the bladder may be detected by means of the A-rays. A stone, when it is detected, should always be measured by an arrangement like a lithotrite. The composition of the stone is assumed from an examination of fragments which pass by the urethra or which adhere to the measure. Remember that the outer layer of a calculus may be soft phosphate and the inner portion may be the harder uric-acid, urates, or oxalates. Examine for stone in females with a straight sound, and in cases of uncertainty dilate the urethra and explore the bladder with the little finger. Treatment. — In people predisposed to stone (for instance, by lithemia) the physician should foresee the danger and essay to antagonize it. Insist on the urine being kept dilute by the freest use of water and of milk, and reduce to a minimum the amount of alcohol, meat, sugar, and fat which is taken. Let the patient live chiefly on green vegetables, salads, bread, fruit, eggs, fish, poultr)^, w'eak tea or coffee, water, milk, and, if desired, a little red wine. Continued purging does harm by concentrating the urine, though a laxative may be employed w'hen indicated. Moderate open-air exercise is of immense importance, sunshine and fresh air being Nature's correctives 794 MODERN SURGERY. for a condition of imperfect oxidation power. If the urine be very acid, use piperazin, gr. xv to gr. xx daily, liquor potassii citratis, phosphate of sodium, or borocitrate of magnesium. If the urine be phosphatic, order mineral acids and strychnin, or what seems to be very efficient, urotropin. Urotropin is given in gr. v capsules four times daily. If the urine be filled with oxalate, use the mineral acids with an occasional course of phosphate of sodium. Travel and rest at the seaside or at some spa are often of service in all forms. Always endeavor to prevent cystitis, and treat it at once when it does occur. When a stone is once formed it is an idle dream to think of dissolving it. An operation must be done. The operation selected depends upon the age, the state of the bladder and the prostate, the dilatability of the urethra, the kidney con- dition, the size and composition of the stone, and the number of calculi present (see Operations on the Bladder). Cystitis. — Inflammation of the bladder is, as a rule, a complication of some other disease of the genito-urinary tract, but it may arise from cold and wet. Traumatism from a catheter, the presence of a stone, the spread of a urethral inflammation, pus infection, the existence of tuberculosis or cancer, and the use of such a drug as cantharides, may pro- duce it. It appears not unusually during an exanthematous fever or in conditions of vesical paralysis ; it often follows retention, frequently accompanies enlarged prostate and ure- thral stricture, and sometimes arises from concentration of urine or accompanies bladder growths. Acute cystitis causes discoloration and swelling of the bladder-walls, and there is present a catarrhal discharge which is mixed with urinary elements, serum, mucus, often pus and epithelial debris. Ul- ceration, sloughing, or false-membrane formation may occur. Chronic cystitis is an inflammatory condition always due to bacteria. We frequently speak of a chronic cystitis as due to stone in the bladder, hypertrophy of the prostate gland, or tumor of the bladder. These conditions do not cause chronic cystitis, but act by rendering the bladder vulnerable to micro-organisms. Among the causative organisms we may mention the bacillus coli communis, the gonococcus, the bacillus tuberculosis, the bacillus typhosis, and the various pyogenic bacteria (Leonard Freeman). In chronic cystitis there is an enormous production of thick, sticky mucus and the urine becomes alkaline. The excessive secretion of mucus and the great number of bacteria convert the urea into carbonate of ammonium, and this production, being irritant to the bladder-walls, makes DISEASES OF GENITO-URINARY ORGANS. 795 the inflammation worse. In chronic cystitis the bladder is contracted and has very thick walls, and the mucous mem- brane is thick, edematous, congested, and filled with large veins. The bladder may be ulcerated or be encrusted with urinary salt. The urine contains bacteria, triple phosphate, pus, blood, and mucus, the blood emerging with the last drops of water. Pyelitis may arise as a result of chronic cystitis. Symptoms of Acute Cystitis. — Great frequency of mic- turition, with the passage at each act of a very small quan- tity of urine ; the desire to urinate is almost constant, and there is intensely painful straining (tenesmus). The pain is acute and scalding, and may be felt above the pubes or in the perineum ; it often runs into the loins and the thighs and radiates over the sacrum. Pain above the pubes indi- cates involvement of the fundus, and pain in the perineum and in the head of the penis points to inflammation of the bladder-neck. The urine, at first clear, loses its transparency, becomes full of thick mucus, and often contains a little blood or pus. The patient not unusually has some fever. A rectal examination causes violent pain. If ischuria takes place, there will be a chill and high fever, and anuria may occur or vesical rupture may ensue. Treatment. — In treating acute cystitis try to remove the cause. If cystitis arises from the administration of canthar- ides, put the patient in bed and give him liquor potassii citratis. If it comes from the use of a clean sound, order rest in bed, suppositories of opium and belladonna, diluent drinks, and the use of ammonii benzoas or of lupulin. If the inflammation is septic (as from the use of a dirty sound), or is very acute, put the patient in bed, keep him warm, and use a hot sand-bag to the perineum and hot fomentations or poultices to the hypogastrium. Hot hip-baths may be used. The hips had best be elevated and the bowels be emptied by salines and glycerin enemata. An exclusive milk-diet is desirable. The patient should drink copiously of sweetened water containing a few drops of aromatic sulphuric acid or of milk of almonds. An excellent remedy is the combina- tion of equal parts of the infusion of herba herniare and chenopodium ambrosioides. three glassfuls, sweetened with sugar, being given every day (v. Zeissl). If the pain and straining still continue, order — R. Ext. sem. hyoscyamin., grs. viij ; Ext. cannabis indicse, grs. viij ; Sacchar. alba, grs. xlviij. — M. Div. in pulv. No. xx. Sig. One powder every three hours. (Von Zeissl.) 796 ' MODERN SURGERY. Or, R. Camphora, grs. viij ; Ext. cannabis indicse, grs. viij ; Sacchar. alba, grs. xlviij. — M. Div. in piilv. No. xx. Sig. One powder every three hours. (Von Zeissl.) Suppositories of extract of belladonna are of great value. Suppositories each containing gr. j of ichthyol are of service ; and one should be used every four hours. If these remedies fail, the surgeon will be driven to opium, which, unfortu- nately constipates ; when it is used, secure evacuations by glycerin suppositories or by enemata. Give a suppository containing gr. j of powdered opium and gr. \ of the extract of belladonna every three or four hours. Hypodermatic in- jections of morphin may be required. If retention occurs, use a soft catheter. If much blood is passed, give internally the tinctura ferri chloridi and blister the perineum, A very acute cystitis is rarely arrested within a week or ten days. Symptoms of Chronic Cystitis. — This condition may be a legacy from acute cystitis, or it may appear without any acute precursory phenomena. There will be found frequency of micturition, but not so great as in the acute form ; there will be slight tenesmus, and moderate pain from time to time, running toward the head of the penis. Constitutional symp- toms arise only when kidney-damage has become pronounced or sepsis has occurred from absorption. The urine is ammo- niacal, fetid, and turbid; it is filled with viscid, tenacious mucus or with muco-pus ; it contains a great excess of phosphates, and occasionally clots of blood. The condition of chronic cystitis with the production of immense quanti- ties of thick mucus is often called " chronic catarrh of the bladder." This state of the bladder may eventuate in the formation of stone or in the production of serious diseases of the bladder, the ureters, and the kidneys. It often occa- sions retention. Chronic cystitis may be due to tuberculosis. Some cases come on suddenly, many tubercle bacilli being found in the urine. In many cases no tubercle bacilli are found. The tubercular products caseate or fibrous organi- zation takes place. A cystitis for which no cause can be found, and which is accompanied by pyuria and pain, is possibly tubercular. The cystoscope in these cases should only be used by an expert. Treatment. — In treating chronic cystitis remove the cause if possible, get rid of a stone, evacuate residual urine fre- quently, dilate a stricture, and remove a tumor. For chronic DISEASES OF GEXITO-URINARY ORGANS. 797 cystitis there are used certain remedies by the mouth. Water is drunk in large amounts, also iron spring-water (Marienbad, etc.). Salol and boric acid, gr. v of each four times a day, are very valuable. Salol in fluid extract of triticum repens does good; so does chlorate of potassium, gr. x daily. Alum, tannic acid, uva ursi, copaiba, cubebs, buchu, and turpen- tine have all been recommended, and possibly may be of some benefit. Urotropin is useful in cases of chronic cyst- itis. This drug prevents the development of bacteria in the urine (Nicolaier), and antagonizes the tendency to sepsis and urinary poisoning. It is given in 5 -grain capsules, from four to six being giv^en daily. Whatever remedy is used, see that the bowels move once a day, and that the skin is active. Champagne and beer must be avoided in chronic cystitis. If residual urine gathers, a soft catheter must be regularly used. If it is possible to introduce a catheter of consider- able size, catheterization may be all that is needed in the case. If it is not possible, or if the case is very severe, the bladder must be washed out daily with peroxid of hydrogen (25 to 40 per cent, solution), nitrate of silver (i : 8000), boric acid (5 to 10 per cent), carbolic acid (i : 500), corrosive sublimate (from I : 5000 to i : 20,000), or permanganate of potassium ( I to 4000). If nitrate of silver or permanganate of potassium is used, first rinse out the bladder with distilled water. If any other agent is used, wash out the bladder with boiled water. The daily injection of a 2 per cent, solution of ichthyol may prove useful. Some surgeons occasionally employ, at intervals of a number of days, strong silver solutions (30 or 40 grains to the ounce). If a strong solution is used, after the drug flows out wash out the bladder with a solution of common salt. The bladder is usually washed out by attaching to the free end of a soft catheter, the other end of which is in the blad- der, a tube which is connected with a graduated bottle, the force being obtained by elevating the reservoir (fountain irrigation). The bladder can be irrigated without using a catheter, the resistance of the compressor muscle of the urethra being overcome by the pressure of a column of water. The reservoir is raised to the height of six feet. The patient sits in a chair. The tube of the reservoir has upon it a clamp to control the flow, and in its end a large bulbous tip which will fill the meatus. The tip is inserted into the urethra, the clamp on the tube is loosened, and the patient is directed to take a deep inspiration. In a short time the bladder fills with water, the tube is removed, and the patient empties the viscus naturally (Felick). In some 798 MODERN SURGERY. cases it is necessary to wait quite a while for the column of water to tire out the muscle. If the fluid will not enter, direct the patient to urinate, and then make another attempt. After a little practice a patient learns how to admit the fluid. In tubercular cystitis ColHn advises the instillation of the following mixture into the bladder and posterior urethra: 5 gm. of guaiacol, i gm. of iodoform, 100 gm. of sterile olive oil. About 30 minims of this are injected (1.2 c.c.) once a day. In ordinary non-tubercular cystitis he uses a i per cent, solution in oil of guaiacol carbonate. If these methods fail to improve a chronic cystitis and the patient's health is breaking down, drain by perineal or suprapubic cystotomy (see Perineal Section, page 736) and through the incision wash the bladder frequently and thoroughly. Tumors of the Bladder. — These tumors may be either innocent or mahgnant, the latter being the commonest. Innocent tumors are papillomata or villous tumors, mucous polypi, and fibrous polypi ; malignant tumors are sarcoma (rare) and carcinoma, encephaloid (rare), epithelioma (com- mon). Symptoms. — The innocent tumors rarely cause cystitis or irritation, though by obstructing the ureters or the urethra they may induce disease of the kidneys. Often hemorrhage is the only phenomenon produced by a papilloma or a mucous polyp. Malignant tumors cause cystitis, and the urine contains mucus, blood, and pus. Innocent tumors are hard to feel with the sound, but malignant tumors are easily felt. In some cases a tumor can be detected by a bimanual examination (a finger in the rectum and the fingers of the other hand on the abdomen). Make a careful study to determine whether or not growth has infiltrated the pros- tate, the seminal vesicles, the rectum, or the perivesical tis- sues. The bleeding in bladder-growths is apt to be profuse, and it occurs intermittently. Bleeding follows the use of a sound. The urine should be examined microscopically to see if it contains villi, portions of fibroma, colonies of cancer- cells, or fragments of epithelioma (White). A cystoscope should be employed in order to reach a diagnosis. In doubtful cases exploratory suprapubic cystotomy is advis- able. The treatment is by suprapubic cystotomy and removal of the growth. The perineal operation only enables the surgeon to reach and remove growths of small size, pedun- culated growths, and growths near the neck of the bladder DISEASES OE GENITO-URINARY ORGANS. 799 (sec Operations on the Bladder). Chismore has suggested the removal of polypoid growths by means of Bigelow's evacuator. When the growth catches in the eye of the instrument it is torn off by slight traction and gentle rock- incr and the suction which is being made carries it into the reser\'oir. Operations on the Bladder. — Lateral Lithotomy. — LitJiotoviy is the remoxal of a stone from the bladder. Lateral lithotomy is an operation which is ever)' )'ear be- coming less popular, but which is still employed by many famous surgeons, especially for stone in children. This operation should not be performed if the stone is over tw^o inches in its short diameter; it is rarely justifiable if the stone weighs three ounces or more (Cage) ; and it must not be performed for encysted stone, or on a person with a deep perineum, a narrow pelvic outlet, or an enlarged prostate. For one week before the operation keep the patient in bed, wash out the bladder daily with hot boric-acid solution, and administer salol and boric acid by the mouth, gr. v of each four times a day. The night before the operation give a saline, order a hot bath, and have the perineum, the scrotum, the buttocks, and the inner sides of the thighs cleansed and dressed antiseptically. In the morning an enema is to be given. At the time of operation the bladder should contain several ounces of urine. The instruments required are a lith- otomy-knife, a straight probe-pointed bistoury, a grooved staff, a stone-sound, stone-forceps and scoops, a tenaculum, an aneurysm-needle, a fountain syringe, curved needles and a needle-holder, hemostatic forceps, a tube with chemise (Fig. 52), a Paquelin cautery, a Clover crutch, and a litho- trite. In performing the operation, place the patient upon his back and find the stone by sounding. If the stone is not dis- covered by the sound, do not operate. Place the buttocks so that they project beyond the edge of the table, introduce the staff into the bladder, flex the legs and thighs, and fasten the patient in the lithotomy position with a crutch. During the first incision the handle of the staff is held toward the belly ; after the first cut the staff is set perpendicularly and is hooked up under the pubes. An incision is made, start- ing just to the left of the raphe of the perineum and one and a quarter inches in front of the edge of the anus, and passing downward and outward to between the anus and the ischial tuberosity, but one-third nearer the former than the latter. In the adult this incision is three inches lon^. The 8oO MODERN SURGER V. first incision is superficial and does not reach the staff, but it is this incision which may cut the rectum. After makings the first cut the nail of the left index finger feels for the groove of the staff, the staff is hooked up, the knife is entered into the groove and is pushed into the bladder, and as it is withdrawn the wound is enlarged. As the knife enters the bladder there is a gush of fluid. The finger fol- lows the knife and stretches the wound, the staff is with- drawn, and the stone is felt for and extracted with forceps. Lister showed years ago the value of keeping the finger in the wound. This maneuver retains some water in the blad- der, and as a consequence causes the stone to rest at the lowest part of the viscus, and when the forceps are in- troduced they at once come upon the stone. In with- drawing the stone make traction in the axis of the pelvis, and do not rotate the calculus until it is entirely out of the prostatic urethra. Wash or scrape away debris or incrustation, see that no other stone is present, syringe out the bladder with hot salt solution, insert a tube, apply antiseptic dressings around the tube, and put on a T-bandage. The end of the tube which is external to the dressings is fastened to the tails of the T-bandage. A rubber cloth is put on the bed, under the body and legs, and the patient's buttocks rest upon a mass of old linen, the scrotum being raised on a pad. The knees are bent over pillows. Change the linen as soon as it becomes wet. Remove the tube in forty-eight hours. The urine begins to come by the urethra from the eighth to the twelfth day. In children the incision is not so long, and is dilated with forceps instead of with the finger ; no tube is required. In lateral lithotomy the prostatic and membranous portions of the urethra are opened, the prostate gland is partly divided with the knife, and the wound is dilated with the finger. Suprapubic Lithotoniy. — This operation is the removal of a stone through an opening over the pubes. It is in many instances the preferable operation. It is used for the removal of multiple calculi, for very hard stones, for stones above one and a half inches in diameter, for calculi in men with enlargement of the prostate, for foreign bodies incrusted with sediment, Avhen the perineum is deep, when the pelvic outlet is narrow, and when the urethra will not permit the use of a lithotrite. The patient is prepared as for lateral lithotomy, except that the pubes are shaved, and the lower part of the abdomen and the upper part of the thighs are disinfected. DISEASES OF GENITOURINARY ORGANS. 8oi During the operation the penis is wrapped with a piece of antiseptic gauze. The instruments required are a scalpel, a probe-pointed bistoury, scissors, a tenaculum, blunt hooks, hemostatic forceps, retractors, dissecting-forceps, a dry dis- sector, an electric forehead-light, a rectal bag, a brass syringe or a bicycle-pump, a sound, rubber tubing, rubber catheters, stone-forceps and scoops, a bladder-tube, curved needles and a needle-holder, and a graduated glass jar for injecting the bladder. In performing the operation place the patient in the Tren- delenburg position. It is necessary to distend the bladder and raise it in order to have a prevesical space uncovered by peritoneum. Have an assistant oil the rectal bag and push it above the sphincters. Draw off the urine with a soft catheter, wash out the bladder with warm boric-acid solution (i : 32), and inject the bladder with the same solution. In a child under the age of five inject three to four ounces ; in an adult inject ten to twelve ounces. Withdraw the catheter and tie a tube around the penis to prevent the escape of fluid. Bristow suggested the injection of air. Some surgeons simply inject air by means of a catheter and a brass syringe or a Davidson syringe. If air is injected, a rectal bag is not used, and the patient is placed on his back rather than in the position of Trendelenburg. The best method of in- jecting air is that of F. Tilden Brown, by means of a bicycle- pump. A catheter is introduced, the bladder is washed out, the catheter is fastened to a bandage, the bicycle-pump is attached, the operation is proceeded with, and when the transversalis fascia is exposed the bladder is filled with air, the soft catheter is clamped, and the bladder is opened.' After injecting the bladder with fluid, if the viscus is not well lifted, inject the rectal bag with water and clamp its tube with forceps. In a child inject from two to four ounces of warm water into the rectal bag; in an adult inject ten ounces. Make a three-inch longitudinal incision in the median line of the hy- pogastric region, terminating over the symphysis. When the perivesical connective tissue is reached, cut it. If the peri- toneum should appear, push it up. Hold the wound-edges apart by retractors. The large veins are seen, giving the bladder a blue color. Avoid these veins if possible, but even if they should be cut bleeding will stop when the bladder is opened and the rectal bag is removed. Clamp bleeding ves- sels ; catch the bladder transversely with a tenaculum at the upper angle of the wound ; open the viscus in the middle line ^ F. Tilden Brown, Annals of Surgery, Feb., 1897. 51 802 MODERN SURGERY. above, and cut toward the pubes ; catch the edges of the bladder with hemostatic forceps, and remove the tenaculum. Explore the bladder, remove the stone or stones, scrape away incrus- tations, ligate bleeding vessels outside the bladder, and irrigate the viscus with hot sahne solution. Introduce a tube into the bladder, and attach to its external end a long tube to siphon off the urine. The bladder can be drained very satisfactorily by Keen's siphonage apparatus (Fig. 292). Fig. 292. — Keen's siphonage apparatus : X, cavity to be drained ; A, reservoir ; K, tube from cavity ; B, tube from reservoir; H, clamp on tube from reservoir; Z,, i^, /?, glass tubes; C, rubber tube connecting cavity-drain with reservoir-drain ; E, S-shaped rubber tube main- tained in shape by hooking up ai F : G, vessel containing antiseptic fluid. Suture the muscles and fascia at the upper part of the wound. Dress with dry antiseptic gauze and a rubber- dam, the dressings and binder being split to go around the tube. Catch the urine which siphons over in a bottle con- taining some antiseptic fluid. Change the dressings as often as they become wet Take out the tube in four or five days, and allow the wound to heal by granulation. The patient may get up in two weeks. Many Continental surgeons advo- cate immediate suture of the bladder after incision. The suture-material should be silk or catgut. Albert, Vincent, Bassini, DeVlaccos, and others advocate immediate suture. After suture a catheter is kept in the bladder to drain the viscus. Immediate suture may be employed in patients of any age, but DISEASES OF GENITOURINARY ORGANS. 803 should not be used if the urine is very septic or if pyeloneph- ritis exists. In some cases the attempted closure will fail ; in others it will only partially succeed ; in the majority it will prove successful ; but even if it only partially succeeds it will tend to prevent dissemination of urine in the prevesical cellu- lar tissue. Crushing of Vesical Calculi. — This is now done in one sitting, the old operation of Civiale, requiring repeated crush- ings, being obsolete. Litholapaxy (Bigelow's operation, or rapid lithotrity) is the operation for removing a stone in the bladder in one sit- FiG. 293. — Bigelow's latest evacuator. ting by thoroughly crushing the stone and completely wash- ing away the fragments. Sir H. Thompson says this method is suited to twenty-nine cases out of thirty. Litholapaxy should be employed if the bladder will hold at least six ounces of fluid and is in a fairly healthy condition ; if the urethra is tolerant and penetrable by instruments ; if the stone is not too hard, does not weigh over two and three- quarters ounces, and is not over two inches in diameter. It is not suited for multiple calculi, for large and hard calculi, for encysted stones, or for a patient with enlarged prostate, with vesical atony, or with cystitis. An easily dilatable strict- 8o4 MODERN SURGERY. ure need not prevent the surgeon from doing litholapaxy. The stricture can first be dilated, and later Bigelow's opera- tion can be performed, but firm, gristly strict- ures demand a cutting operation. If the ure- thra is intolerant of instrumentation, the pa- tient being prone to febrile attacks when it is attempted, cut instead of crushing. People with kidney disease will do better after this operation than after cutting (Cage). In dia- betes, locomotor ataxia, and conditions of exhaustion patients are best treated by Bige- low's operation, unless cystitis exists. Fig. 294. — Bigelow's lithotrite. Fig. 295. — Thompson's Fig. 296. — Forbes's lithotrite. lithotrite. The preparation of the bladder is the same as for Hth- otomy. Be sure to measure the stone, and to ascertain DISEASES OF GENITO-URINAKY ORGANS. 805 also whether a hthotrite can readily be introduced and ma- nipulated. The instruments required are a stone-sound, lithotrites (several sizes) (Figs. 294-296), an evacuating-bulb and tubes (straight and curved) (Figs. 293, 297), soft catheters, a glass irrigator to inject the bladder, and instruments in case the surgeon is forced to cut. The patient is anesthetized and is placed upon his back, a pillow is inserted under the pelvis and he is well wrapped up. The urine is drawn and a measured amount of warm boric acid is allowed to flow into the bladder. This plan is better than having the patient retain his urine, as in the latter case there is no certainty as to the amount of fluid in the viscus. It is well to introduce at least five or six ounces of fluid if pos- sible. If the bladder will not hold four ounces the opera- tion is unsafe (Thompson). The Hthotrite is now intro- duced, the handle being grad- ually raised to a vertical posi- tion as the penis is drawn up on the shaft, but not being depressed until the instrument has passed by its own weight into the prostatic urethra. Thompson's plan for catching the stone is as follows : after introducing the Hthotrite, let its lower end rest for a few seconds on the bottom of the blad- der, so that currents will subside ; then draw back the male blade, wait a moment, close the blades, and in al- most every instance the stone ^'^ 297.-Thompson-. evacuator. will be caught. If the stone is caught, press firmly to see that the calculus is well held, lock the instrument, and break the foreign body by screwing. When resistance suddenly ceases the stone has either slipped or has been crushed ; if crushed, the blades should have been felt forcing through the stone and the calculus should have been heard to break. When resistance ceases catch and crush again as above directed. Rapid movements with the Hthotrite are improper, as they establish currents which are apt to push away the stone. If 8o6 MODERN SURGERY. the above maneuver does not catch the stone, see if the cal- culus be near the neck of the bladder. Pull the instrument close to the vesical neck, and open it, not by pulling the male blade, but by pushing the female blade. If the operator still fails to catch the stone, or if, after crushing, a large fragment knocks against the evacuator, which fragment cannot pass, conduct a careful search : turn the blades to the right side, open, and close ; then to the left side, open, and close ; next turn the point around behind the prostate, open, and close. In these side turns of the lithotrite, in order to crush, turn the instrument very slowly, so as to detect the catching of the bladder-wall if it has occurred, and crush the stone in the middle of the bladder with the blades up. After crushing several times, proceed to evacuate. Fill the aspirator with warm saHne fluid. Insert an evacuating catheter, its point being in the center of the bladder, let the fluid and fragments run out, and attach the aspirator to the catheter ; turn the valve, and compress and relax the bulb so that an ounce or more of fluid is forced in at each squeeze, the compression coinciding with expiration. The debris falls into a bulb, and the pumping is continued until fragments cease to pass, whereupon the point of the catheter is pushed against the floor of the bladder and another trial is made. If fragments which cannot gain exit are felt knocking against the tube, withdraw the evacuator, crush again, and again use the aspi- rator. When no more debris comes away and no more frag- ments are felt, withdraw the tube and carefully sound the bladder. Keyes advises the operator to seek for a final frag- ment by listening with a stethoscope while pumping at the bulb and searching the bladder with the tube. This operation will rarely occupy over forty minutes, though Bigelow has protracted it for three hours, the patient recovering. A seri- ous complication is severe bleeding, due to damage done with the instrument or to the presence of a tumor which easily bleeds. The injection of moderately hot water usually checks hemorrhage, but if bleeding is dangerous in amount the operation of litholapaxy should be abandoned and a suprapubic lithotomy be performed. If clogging of the lithotrite with fragments occurs, forcible pushing of the blades together repeatedly will probably amend it ; but it will never happen if the sur- geon uses a proper form of instrument. A lithotrite with a fenestrated blade will not lock. Forbes's lithotrite is a very powerful instrument, the blades of which will not lock. If the blades of a lithotrite should become forcibly and DISEASES OF GENITO-URINARY ORGANS. 807 hopelessly locked, make a perineal section, clear out the blades, close them, and then withdraw the instrument. Aftcr-trcatmciit. — Put the patient to bed, apply a bag of hot water to the hypogastrium, and give him a hypodermatic injection of morphin as he recovers from ether. Give a hot hip-bath every night, and administer liquor potassii citratis in moderate doses every day. If urethral fever occurs use quinin and morphin, wash out the bladder several times daily with warm boric-acid solution, and tie in a rubber catheter. If retention occurs use the catheter. If cystitis appears treat as in an ordinary case. The urine ceases to be bloody in two or three days, and the patient may get up in a week. Litholapaxy in Male Children. — It was considered until quite recently that a child, because of the small size of its bladder, the small diameter of the urethi'a, and the readiness with which the mucous membrane is lacerated by even slight violence, was a bad subject for crushing. Lateral lithotomy is known to be eminently successful when per- formed upon children. The elder Gross did this oper- ation upon 72 children with only 2 deaths. Keegan, how- ever, has persuaded the profession that rapid lithotrity is perfectly applicable to children : he shows that the bladder of a child of even less than two years of age is quite large enough to allow the surgeon to manipulate an instrument, that the mucous membrane is in no danger if the operator be careful, and that the urethra is by no means so small as was supposed. The urinary meatus must often be incised, and after doing this, Keegan states, there can be passed in a boy of from three to six years a No. 7 or 8 lithotrite (English), and in a boy of from eight to ten years a No. 10 or even a No. 14. It is, however, just to state that the operation is more delicate than a like procedure on older persons, and that no one is justified in doing it who has not had considerable experience in adult cases. Further- more, it should be noted that Keegan's mortality by this operation has been 4.3 per cent., while Gross's mortality from lateral lithotomy on children was 2.67 per cent. Special points of litholapaxy on male children are as fol- lows : use well-fenestrated lithotrites ; have a stylet to punch out the fragments blocking the evacuator ; and crush the stone to a fine mass. There can usually be employed a No. 8 lithotrite and a No. 8 evacuating-tube. Operation for Stone in "Women. — If the stone be small give the patient ether, place her in the lithotomy position^ MODERN SURGERY. ■dilate the urethra with a uterine dilator until it admits the index finger, and remove the stone with the finger, the scoop, or the forceps. If the stone is found to be too large to pass, crush it with a lithotrite and get rid of the debris by the evacuator. Large stones (two ounces) may require a suprapubic lithotomy. Vaginal lithotomy is never required. If done it is very likely to leave as a legacy a vesicovaginal fistula. In female children dilate the urethra, crush the stone, and evacuate. Cystotomy. — This term means the opening of the bladder, and it is usually applied to an opening made for drainage, for diagnosis, for the removal of stones and tumors, and for the treatment of ulcers. This opening may be done by (i) a suprapubic cut (as in suprapubic lithotomy), (2) a lateral perineal cut (as in lateral lithotomy), or (3) a median perineal cut (as in median lithotomy). Suprapubic Cystotomy. — The operation is employed to allow the surgeon to explore the bladder, to treat an ulcer, or to provide drainage, or to remove a tumor. If the oper- ation is for calculi, it is known as suprapubic lithotomy (page 800). After the bladder is opened its interior can be illuminated by the rays of an electric lamp, which appliance is fastened with a mirror to the forehead of the operator. The operation is described on page 801. If an ulcer is found, it is scraped with a curet or a spoon. Most cases of tumor require suprapubic cystotomy. It is true that a small single growth at the vesical neck is accessible by median cyst- otomy, but the area for manipulation is very narrow and the growth cannot be seen. Every large growth, all cases of multiple tumors, and all cases of tumor with great depth of perineum or with enlarged prostate require suprapubic cyst- otomy, an operation which allows one to feel and to see the growth, which gives room for manipulation, and which permits thorough exploration of the entire bladder. The patient is put in the Trendelenburg position if water dis- tention is used, but is placed horizontally if air distention is employed. After opening the bladder as for stone (page 800) hold the edges of the incision apart by a speculum (speculum of Keen or Watson) or by retractors and throw in the electric rays. Growths when seen can be twisted off, a pair of forceps holding the base and another pair being used to twist. Broad growths are transfixed, li- gated, and severed. Some growths (as cancer) are removed piece by piece with Thompson's forceps, the base being scraped. Soft growths are scraped away with a curet, a DISEASES OF GENITO-CRINARY ORGANS. 809 spoon, or a finger-nail. If bleeding is severe, check it by pressure, by iced water, or even by the actual cautery. JMcdian Cystotomy. — The same incision is made in the perineal raphe in median cystotomy as for median lithot- omy. A grooved staff is introduced and is hooked up under the pubes ; an incision is made into the membranous urethra and is extended backward for three-quarters of an inch, and a finger is carried into the bladder. If searching Fjg. 298. — Thompson's ve' little pain on micturition, rarely chordee or marked irritability of the bladder. Irritative or Abortive Gonorrhea. — In this disease the symptoms, which are identical with those of beginning clap, do not increase, but are apt to disappear within ten days. Chronic Urethral Discharges. — Chronic Urethral Catarrh, which may follow gonorrhea, is characterized by the occasional presence of a drop of clear, tenacious liquid. This discharge becomes more profuse as a result of sexual excitement or the abuse of alcohol. The persistence of a small amount of milky discharge, because of localization of inflammation in one spot or the production of a granular patch or a superficial ulcer, charac- terizes chronic gonorrhea. There is some scalding on urina- tion ; erections produce aching pain ; there are pain in the back and redness and swelling of the meatus. All the symp- toms are intensified by sexual excitement, by coitus, by violent exercise, or by alcoholic excess. Gleet. — If a chronic urethritis lasts over ten weeks it is called gleet. In gleet the lips of the meatus are stuck together in the morning, and squeezing them discloses a drop of ' Schutz's method, as set forth by R. \V. Taylor in his work upon Venereal Diseases. 52 8l8 MODERN SURGERY. opalescent mucopurulent fluid. During the day the dis- charge is rarely found. There are frequency of micturition, pains in the back, and dribbling of urine, and a bougie will usually find a stricture of large caliber. A discharge may be maintained by chronic prostatitis. In this condition there are frequency of micturition ; a sense of weight or dull pain in the perineum ; diminished projectile force of the stream of urine ; there is often a tendency to sexual excitement and premature emission. In chronic anterior urethritis there is a discharge from the meatus or sticking together of the lips in the morn- ing. In chronic posterior urethritis there is no discharge of pus from the meatus. If two beaker glasses are placed upon a stand and the patient is directed to urinate first in one and then in the other, if he suffer from chronic anterior urethritis, only the first portion will be cloudy and show shreds ; if he suffers from posterior urethritis of not very long standing, both portions will be a little clouded, the first with clap shreds, the second with hook-shaped shreds. In a very chronic case neither sample will be cloudy, but the first portion will contain shreds. Treatment of Acute Gonorrhea. — Abortive treatment should be tried if the case is seen early. The writer formerly believed that by cleansing the urethra several times a day with peroxid of hydrogen, following the hydrogen by the injection of oil of cinnamon and benzoinol, many cases of gonorrhea could be quickly aborted. Further observations confirmed by bacterial investigation have shown that he was in error. True gonorrhea cannot be aborted by the above- mentioned plan. Other abortive methods are the use of hot retro-injections of corrosive-sublimate solution (1:20,000), two pints being run through the urethra once a day ; strong injections of nitrate of silver or of tannin ; scraping the meatus or the urethra adjacent with cotton, and injecting 15 drops of a 3 per cent, solution of nitrate of silver. If in seventy-two hours the symptoms are not greatly improved, abortive treatment should be abandoned. Recent studies render it almost certain that there is no real abortive treat- ment. Abortive treatment, to be efficient, would have to be carried out before the gonococci penetrated the epithelial cells ; in other words, would need to be instituted before the symptoms of the disease appear. Janet says that we must alter our conception as to what constitutes abortive treatment, and he doubts if a case of true gonorrhea was ever really aborted.^ The method of irrigation with solutions of perman- 1 Ann. d. Dial. d. org. gen.-urin., 1896, p. 1031. DISEASES OF GENITO-URINARY ORGANS. 819 ganate of potassium is really a prophylactic treatment. Janet applies his treatment as evidences of trouble present them- selves, and before acute symptoms appear, and claims that in most persons the disease can be arrested in from eight to twelve days. The same plan of treatment is useful in a well- developed case. Janet's method is as follows : an irrigator is filled with a warm solution of permanganate of potassium (1 : 4000). The patient after emptying his bladder is seated upon a chair and his sacrum rests upon the extreme front edge of the chair (Valentine). The reservoir is joined to a glass nozzle by a rubber tube. The nozzle is introduced into the meatus, and the fluid is permitted to run gradually at first, with full force later. In anterior trouble the fluid runs out of the meatus by the side of the nozzle. The anterior urethra is always irrigated first, the reservoir being two feet above the chair. In posterior urethritis, after the anterior urethra has been irrigated, the reservoir is raised from six to seven feet above the bed, the meatus is held tight about the nozzle, and the fluid overcomes the force of the compressor urethrae muscles and bladder sphincter and enters the bladder. If the muscles do not quickly relax, continue the hydrostatic pressure for several minutes, when relaxation will usually occur ; but if it does not do so, tell the patient to urinate and then repeat the irrigation (Valentine). When the bladder is full the tube is withdrawn and the patient micturates. This procedure is practised once or twice a day for five or six days or even longer, and the strength of the solution is gradually increased up to I : 1000. It has been claimed that after one or two weeks of this treatment gonococci permanently disappear in the majority of cases. Valentine of New York ^ has con- structed the following table, which is of use to a practitioner who wishes to employ irrigations with permanganate of potassium in the treatment of acute gonorrhea : First day : two anterior irrigations, i : 2000, i : 4000. Second day : the same, 1 : 3000, i : 4000. Third day: one intravesical, i :6ooo; one anterior, i : 6000. Fourth and fifth da)-s : one intravesical, i : 3000. Sixth and seventh days : one intravesical, i : 3000 or 1 : 2000. Eighth and ninth days : one intravesical, i : 2000 or i : 1000. Tenth day: one intravesical, i : 1000; anterior irrigation, I : 5000. If a stricture exists, it is not advisable to employ this treat- 1 N. Y. Med. Record, June 5, 1S97. 820 MODERN SURGERY. ment. The author has had the best satisfaction from irriga- tions with fluid containing silver nitrate (i : 12,000 to i : 8000). In treating a developed case, order plain, non-stimulating diet and the avoidance of alcohol, sexual excitement, wet, and violent or prolonged exercise. The patient should sleep under light covers and drink much water daily (Seltzer, ApoUinaris, or ordinary water containing bicarbonate of so- dium). If the foreskin is long, the discharge should be caught by placing bits of absorbent cotton over the meatus and within the prepuce. If the foreskin is short, cut a small opening in a square piece of old linen, slip this linen over the glans, catch it back of the corona, and bring the ends forward with the prepuce. If the glans is completely naked, pin an old stocking-foot upon the undershirt and in it hang the penis. Order a man to wear a suspensory bandage. Irritative gonorrhea will subside in a few days. The above directions should be applied, and the anterior urethra should be washed out several times daily with peroxid of hydrogen, or irrigated once a day with a hot solution of per- manganate of potassium (i : 4000). In catarrhal gonorrhea, at once order injections (i grain to the ounce of sulphate of zinc; or zinci sulphas gr. viij, plumbi acetas gr. xv, water |viij ; or gr. v of sulphocarbolate of zinc to .?j of water ; or White's prescription of .^j each of acetate of zinc and tannic acid, .^iij of boric acid, 5vj of liq. hydrogen, peroxid.). For injecting use a blunt-pointed hard-rubber syringe of a capacity of three drams. Let the patient sit on a chair, his buttocks hanging over the edge ; throw in a syringeful and let it at once run out ; throw in another syringeful and hold it in from three to five minutes. In acute gonorrhea order two capsules three times a day, each capsule containing 5 grains of salol, 5 grains of oleoresin of cubebs, 10 grains of balsam of copaiba, and i grain of pepsin. After the patient micturates he should employ a mild astringent injection. If an astringent injection causes much pain, use a sedative injection — gij of boric acid, gr. viij of aqueous extract of opium, and Sviij of liquor plumbi subacetatis dilutus. As the inflammation subsides increase the strength of the injection. A good plan is to order an eight-ounce bottle and eight half-grain powders of sulphate of zinc. Direct the patient to fill the bottle with water, in which one powder is dissolved ; when this is used dissolve two powders in a bottleful of water, and so pro- gressively increase the strength. When the discharge ceases stop the injections gradually. Whenever a syringeful is taken from the bottle a syringeful of water is put into the DISEASES OF GENITOURINARY ORGANS. 82 1 bottle, and thus pure water is soon obtained, at which point injection is discontinued. Argonin, which is a combination of albumin, silv^er, and an alkali, is highly recommended by some authors as a local remedy for gonorrhea (Schaffer, Guthiel). A solution of this material is non-irritant, the silver is not precipitated by chlorids, and the agent destroys gonococci. It is used by injection or irrigation. If used by irrigation employ a i : 500 solution twice a day. If used as an injection employ a i : 200 solution six or eight times a day. When the discharge is found free from gonococci and remains free for three days, stop the argonin and use an astringent injection. Methylene-blue internally is occasionally of service in gonorrhea. A capsule containing gr. ij of the drug is given three times a day. It turns the urine greenish-blue and occa- sionally induces strangury. Ardor urines is relieved by urinating while the penis lies in hot water and by administering an alkaline diuretic. CJiordce requires a bowel-movement in the evening and sleeping in a cool room, under light covers, and on a hard mattress ; bromid is given several times daily, and a con- siderable dose is given at night ; it may be necessary to use suppositories of opium and camphor or to give hyoscin. Balanitis requires frequent washing with warm water, drying with cotton, and dusting with borated talc or with boric acid and subnitrate of bismuth (i : 6). Balanopostldtis requires lead- water and laudanum and injections of black wash under the prepuce until edema of the foreskin subsides, and then clean- liness externally and a powder. Phiuwsis requires soaking the penis in hot water, injections of hot water beneath the foreskin, followed by black wash and the use of lead-water and lauda- num externally. If this fails, circumcision must be performed. If paraphimosis occurs, grasp the head of the penis with the left hand, squeeze the blood out, and try to push the head back while with the right hand the penis is pulled upon, as if we intended to lift the individual by this organ. If this fails, cut the collar on the dorsum with scissors. Bi/bo requires iodin, ichthyol, or blue ointment, a spica bandage, and rest. If a bubo suppurates, it must be opened or aspirated. Acute pros- tatitis and cystitis require confinement to bed, a milk-diet, the use of alkaline diuretics, hot sand-bags to the perineum and hypogastrium, suppositories of opium and belladonna or ich- thyol, leeching the perineum, and the discontinuance of the bal- sams and injections. Abscess of the prostate requires instant opening. In retention of urine the patient should try to pass 822 MODERN SURGERY. the urine while in a hot bath ; if this fails, a soft catheter is used. After reHeving the bladder put the patient to bed and apply hot sand-bags as for prostatitis. Chronic prostatitis re- quires cold hip-baths, cold-water enemata, deep urethral injec- tions, plain diet, avoidance of alcohol and over-exertion, coun- ter-irritation of the perineum, and the relief of stricture or phimosis. Great benefit is occasionally derived from passing a soft bougie covered with blue ointment. In epididymitis put the patient to bed, stop injections, shave the hair from the groin and leech over the cord, elevate the testicles, keep the parts covered with lint wet with lead-water and laudanum, and from time to time apply an ice-bag. Give a cathartic, a fever-mixture, and suitable doses of bromid of potassium and morphin. The application of 20 drops of guaiacol in 3j of cosmolin or olive oil gives great relief. When swelHng lingers, after tenderness subsides strap the testicle with adhesive plaster. A lingering case is benefited by the inter- nal use of iodid of potassium and the local use of ichthyol. In gonorrheal ophthalmia secure a watch-crystal over the unaffected eye, put the patient in a darkened room, rub out the infected conjunctival sac with cotton soaked in a 2 per cent, solution of silver nitrate, wash out the affected eye often with hot boric-acid solution, keep the pupil dilated with atro- pin, leech the temple, give purgatives, and employ hot mus- tard foot-baths. Always send for an ophthalmologist. Treatment of Chronic Urethral Discharges. — Gradually dilate the urethra with metal sounds. In chronic gonorrhea try to locate any existing granular or ulcerated patch with a bulbous bougie. When the point is discovered apply to it, by a deep urethral syringe, a few drops of a 2 per cent, solu- tion of nitrate of silver. The strength of the silver solution can gradually be increased, or other solutions can be substi- tuted (sulphate of copper or sulphocarbolate of zinc). Pass a large bougie every other day. Copious retro-irrigation with hot solutions of corrosive sublimate (i : 20,000), permanganate of potassium (i : 3000), or nitrate of silver (i : 8000) does good. In many cases an electric endoscope is an indispensable in- strument. By means of it the surgeon is enabled to locate the trouble and treat it locally. A common cause of chron- icity is lingering inflammation of glandular structures and lacunae. These spots should be touched through an endo- scope tube, from time to time, with silver nitrate (3 per cent.). A granular patch should be treated in the same manner. In any lingering case of gonorrhea examine the urine, and direct suitable treatment for oxaluria, lithemia, or phosphaturia, DISEASES OF GENITOURINARY ORGANS. 823 if any one of these conditions exist. Such morbid states of the urine are occasionally responsible for great prolongation of the inflammation. In some cases a discharge is kept up by inflammation of the seminal vesicles (page 834). When may a man be considered well of gonococcus infection ? When shreds disappear from the urine ; when an examination on three successive days fails to find gonococci ; when the urine is free from pus, and when there has been no discharge for ten days. Gonorrhea of the rectum occasionally, though very rarely, occurs. It may result from pederasty, or in a woman from a flow of infectious material from the genitalia to the anus. Gonorrhea in the female may affect the vulva, the vagina, the urethra, or the uterus. The danger is the devel- opment of metritis or salpingitis. The treatment for V7(l- vitis is to place the patient upon a low diet and put her at rest with the pelvis elevated ; every two or three hours spray the parts with peroxid of hydrogen, dry them with absorbent cotton, and dust them with equal parts of starch and oxid of zinc. In severe cases purge, use hot baths, apply lead- water and laudanum locally or paint the vulva with silver solution (gr. xl to 5J), and leech the groins. If the vulvo- vaginal gland suppurates, open it. For vaginitis follow the same general directions. Syringe out the vagina eveiy two hours, first with Oj of hot solution of bicarbonate of sodium, next with Oj of hot water, and finally with Oj of astringent solution (a teaspoonful of lead acetate, a teaspoonful of zinc sulphate, a teaspoonful of alum, or four teaspoonfuls of tannin to the pint of hot water) (White). As the attack subsides, use vaginal suppositories, each containing gr. v of tannic acid. In some cases apply solutions of silver nitrate i : 200, and tampon with boroglycerid and ichthyol, 8 per cent. (Le Blonde). Metritis must be prevented, and it is a wise pre- caution to apply iodin from time to time. For urethritis use astringent injections locally and copaiba and cubebs by the mouth. In chronic cases use strong solutions of silver nitrate. The urethra and bladder may be irrigated with sil- ver nitrate (i : 8000). For uterine gonorrlica observe the same general management. Swab out the uterus with tincture of iodin ; use tampons of iodoform gauze and injections of peroxid of hydrogen. Stricture of the urethra, or narrowing of the urethral caliber, is divided into inflaviniatory , spasmodic, and organic. The so-called ijiflammatory or congestive stricture is not a stricture, but is an inflammatoiy swelling of the mucous 824 MODERN SURGERY. membrane. Spasmodic stricture does not exist alone, but complicates organic stricture, a hyperesthetic urethra, or an inflamed bladder. Organic stricture is a fibrous narrowing of the urethra, due, as a rule, to chronic gonorrheal inflam- mation or to traumatism. Traumatic strictures occur in the bulbous or membranous urethra, and are due generally to force applied to the perineum, the urethra being squeezed between the subpubic ligament and the vulnerating body. Strictures resulting from gonorrheal inflammation occur in the penile, bulbous, or membranous urethra. Stricture never forms in the prostatic urethra, except as a result of trau- matism. Recent strictures are soft and are easily distended. Old strictures and traumatic strictures are very dense. A resilient stricture is one which contracts quickly after dilata- tion. The nearer a stricture is to the meatus, the more fibrous it is. A congenital stricture is congenital narrow- ness of a portion of the urethra, usually the portion near the meatus. The more fibrous a stricture is, the more it narrows the urethra and the less dilatable it is. A stricture may be annular (forming a ring around the urethra), tubular (sur- rounding the urethra for a considerable distance), or bridle (when a band crosses the urethra from wall to wall). A stricture of large caliber will admit an instrument larger than a No. 15 French sound. A stricture of small caliber admits an instrument smaller than a No. 1 5 French sound. An impermeable stricture will not admit the passage of any instrument. Impermeable is more or less a relative term. A stricture may be impermeable when an anesthetic is not used, and permeable when the patient is anesthetized, or may be impermeable to one surgeon, but permeable to another. Impermeability is often a temporary condition due to inflam- matory edema about an organic stricture. Symptoms and Results of Stricture. — There is usually a history of repeated attacks of urethritis. A chronic dis- charge may exist, the amount of which is variable. There is a feeling of weight in the perineum, soreness of the back, hypochondriacal fancies, and frequency of micturition. There is difficulty in starting the stream in micturition ; the stream is small, twisted, often forked, and it dribbles long after the conclusion of micturition, so that the penis must be " milked " before it is returned within the clothing. The urethra back of the stricture dilates, a pouch forms, drops of urine collect and decompose, and a chronic inflammation results in the mucous membrane or the parts adjacent, which inflammation may go on to ulceration or to peri-urethral ab- DISEASES OF GENITO-URINARY ORGANS. 825 scess. A urinary fistula results from the opening externally of a peri-urethral abscess. Retention of urine may occur, not from obliteration of the tube by the growth of the stricture, but by edematous swelling in the neighborhood of the stricture, due to cold, wet, venereal excitement, the use of alcohol, over-exertion, etc. Spasm of the muscles re- sults, and contact of the urine increases the spasm, and spasm plus edema of the mucous membrane closes the urethra. Spasm may exist in the urethra itself and in the muscles of the neck of the bladder, but is only a temporary condition. In old strictures the bladder is hypertrophied and often fas- ciculated, and is very liable to cystitis. The diagnosis of stricture and of its location is made by the use of exploratory bougies. In this examination the author follows to a great extent the plan of Ramon Guiteras, which is as follows : ^ have the patient pass urine into two glasses. Examine the urine for clap-shreds. Cloudiness in the first glass shows that urethral discharge exists. Cloudiness in the second glass points to cystitis. The patient is placed recumbent with his shoulders elevated, and the urethra is washed out with warm salt solution. Bulbous sounds are inserted, beginning with No. 15 French. If this passes with ease, take a larger size and note where strictures are situated by the catch on with- drawal. If No. 1 5 does not pass, use a smaller size. Remember that the posterior layer of the triangular ligament catches a bulbous instrument on withdrawal. If the meatus is too small to permit of exploration, divide it with a curved bis- toury, cutting from within outward. After cutting the meatus bleeding is arrested with styptic cotton, and a piece of ab- sorbent cotton is tucked into the cut. After each act of micturition the patient inserts a fresh bit of cotton, and after three days the urethral examination is proceeded with. Treatment. — Strictures of large caliber in the deep urethra require gradual dilatation. A steel bougie is introduced every third or fourth day, the size being gradually increased. Never anoint a bougie with cosmolin, as it may become a nucleus for a stone in the bladder ; use oil or glycerin. Before pass- ing an instrument the patient urinates and his urethra is washed out with boiled water. The sound is rendered sterile by boiling before using. Gradual dilatation can be effected by the use of the dilator of Oberlander, the tube being distended to the extent of three millimeters every fifth day. If after dilatation there is urethral spasm, pain, or very frequent micturition, suspend the treatment for a number of days * ]\[ed. Record, Nov. 14, 1896. 826 MODERN SURGERY. and order each night a hot hip-bath and a dose of paregoric. In effecting gradual dilatation by sounds the instrument should be introduced every fifth day, and during the treat- ment the patient should not use alcohol, should refrain from sexual excitement, should avoid cold and damp, and should take internally capsules containing boric acid and salol. It is rarely necessary to dilate above No. 32 French. After the surgeon finishes treatment he teaches the patient to use an instrument and directs him to pass it once a month. Strictures in the pendulous urethra, if soft, are treated by gradual dilatation ; if fibrous and contractile, by internal urethrotomy. In performing internal urethrotomy prepare the patient carefully ; for several days before the operation give salol and boric acid by the mouth, and wash out the bladder repeatedly with boric-acid solution. Be thoroughly aseptic. Anesthetize the patient. Before cutting irrigate the urethra with warm normal salt solution, and after cutting irrigate again and tie in a rubber catheter. These precau- tions will prevent urethral fever. In cutting, insert Gross's urethrotome (Fig. 302) back of the stricture, spring out the blade, cut the stricture on the roof of the urethra, close the blade, withdraw the instrument, and pass a full-sized bougie. Stricture of the meatus requires incision with a knife and the use of a meatus bougie until healing is complete. Strict- ures of small caliber in front of the membranous urethra re- quire gradual dilatation and, if this fails, internal urethrotomy or divulsion. Internal urethrotomy can be performed with the urethrotome of Maisonneuve (Fig. 300). This instru- ment is shaped like a sound, has a groove upon its surface,, and into this groove a shaft carrying a triangular knife can be inserted. The staff is screwed to a guide, the guide is car- ried into the bladder, and the staff follows it. The point of the staff is carried to the prostatic urethra and the guide curls up in the bladder. The penis is held upon the stretch, the blade is inserted and pushed down through the stricture. This instrument cuts the stricture, but not the healthy ureter. For divulsion the patient is prepared as for inter- nal urethrotomy. The divulsor of Gross, or of Sir Henry Thompson, or of Gouley (Figs. 301, 303, 304) is intro- duced, the blades are separated, the instrument is with- drawn, a large bougie is passed, and a catheter is tied in the bladder. Strictures of small caliber in the deep ure- thra require gradual dilatation ; if this fails, employ external urethrotomy. In strictures of the deep urethra, if only a fill- DISEASES OE GENirO-URINARY ORGANS. 827 form bougie can be introduced, the bougie can be left in ])lace and in a day or two another can be .shpi)ed in beside it, until in a few days the channel is permeable by a metal bougie. A Fig. 299 — Syme's staff. Fig 300. — ^laisonneiive'.s urethrotome. tunnelled catheter can be sHpped over the filiform bougie, both be withdrawn, and a metal bougie passed. A tun- nelled and grooved staff can be carried in over the bougie 828 MODERN SURGERY. and external urethrotomy be performed. Thompson's dilator can be carried in over the filiform and the stricture be di- vulsed. Fort's method of electrolysis is of value. This surgeon treats stricture by linear electrolysis. His instru- ment looks like a whip, and it has a platinum blade pro- t Fig. 301. — Gross's urethral dilator. Fig. 302. — S. W. Gross's explora- tory urethrotome. jecting from about the center. The blade is connected with the negative pole of a galvanic battery and the positive pole is placed over the pubes. The guide carrying the blade is inserted into the urethra, and when the blade comes against the stricture the current is turned on and the platinum passes DISEASES OF GENITO-URINARY ORGANS. 829 rapidly through the constriction. The current is turned off and the instrument is carried onward until it strikes another stricture, when the current is again turned on, and so on. The necessary current-strength is 10 to 15 ma. The op- FiG. 303. — Thompson's divulsor. eration requires twenty to thirty seconds and causes but little pain. After its performance a sound is passed, a No. 22 of the French scale. The patient need not be confined to bed after this operation. By Fort's method we act Fig. 304. — Gouley's divulsor. purely upon the diseased tissue. In impassable stricture of the deep urethra perform external perineal urethrotomy without a guide (the operation of Cock or of Wheelhouse). Urethral Fever. — Any operation upon the urethra may be followed by a chill owing to shock (urethral shock), and this may be followed by a nervous fever. Urethral fever proper is a sapremia which may follow a urethral opera- tion. This condition is due to absorption of toxic elements which may be in the urine, may have been in the urethra, or may have been introduced from without. It usually follows the first urinary act after operation. It begins with a violent chill and presents the characteristics of a septic fever. It is accompanied by a marked tendency to urinary suppression, and may eventuate in septicemia or pyemia. Urethral fever can be prevented by rigid antisepsis. If this fever should arise, a catheter must be tied in the bladder, the bladder and urethra must be repeatedly irrigated with aseptic or anti- septic fluids, and the patient must be given urinary antiseptics and stimulants by the mouth. 830 MODERN SURGERY. Perineal section is external perineal urethrotomy. There are three methods, the operation of Syme, of Wheelhouse, and of Cock. Syme's Operation. — This operation is employed if a stricture is very contractile, if dilatation fails to cure, or if urethral instrumentation causes fever. The patient is anes- thetized, Syme's staff (Fig. 299) is introduced, and the sur- geon makes an incision in the midline of the perineum and exposes the staff just above the shoulder of the instrument. The knife is carried along the groove and divides the strict- ure. A catheter is passed into the bladder from the meatus and is retained for several days, and the wound is dressed antiseptically. After the catheter is removed it must be used every six hours -until the urine comes entirely by the meatus. From time to time, for the rest of the patient's life, a full-sized sound should be passed. "Wheelhouse's Operation. — This operation is employed for the treatment of impermeable stricture. Wheelhouse's staff is passed into the urethra until it blocks on the stricture. The perineum is incised down to the staff and in front of the stricture. The edges of the cut urethra are held apart with forceps, the surgeon seeks for the opening through the strict- ure, passes a fine probe through it, divides the stricture, carries into the bladder from the wound an instrument known as a gorget to dilate the canal and furnish a solid floor to facilitate the introduction of a catheter. With the gorget in place a metal catheter is carried from the meatus into the bladder. The gorget is removed and the catheter is tied in place. After three or four days the catheter is removed and is then passed frequently. The perineal wound is, of course, dressed antiseptically. Cock's Operation, — This operation opens the urethra back of the stricture and without a guide. The surgeon introduces into the rectum the index finger of the left hand, and the tip of the finger is rested upon the apex of the prostate gland. The surgeon incises the median line of the perineum, the back of the knife being toward the anus. When the point of the knife is felt to be near the finger the handle is lowered slightly, the blade is placed a little oblique, and the urethra is opened. A catheter is passed into the bladder from the wound and retained. epispadias is a congenital cleft in the corpora cavernosa, the roof of the urethra being absent. It is remedied by a plastic operation. Hypospadias is a congenital cleft on the floor of the DISEASES OF GENITOURINARY ORGANS. 83 I urethra, this channel being a gutter instead of a canal. It is remedied by a plastic operation. Chancroid (soft chancer ; the local venereal sore) is a p\'ogcnic ulcer, usually of venereal origin. The name chancroid was introduced by Clerc, who believed that a soft sore resulted from inoculating a person already syphilitic with the products of a hard sore. He further held that when a soft sore arose the syphilitic poison lost its infective prop- erties, and " could be transmitted as a soft sore to a healthy person, and not cause general infection." ^ This form of ulcer is not connected with the syphilitic poison and is not due to any special or chancroidal poison, but is produced by inflam- matory products or irritating secretions. In fact, soft sores may arise without a causative sexual intercourse, as is seen sometimes in cases of herpes in a man with gonorrhea, the herpetic ulcers becoming chancroids. As a rule, chancroids are of venereal origin, and result from contact with other chancroids, pus, mucopus, or areas of ulceration. There is no special germ. A chancroid appears soon after inter- course, usually within five days, always within ten days. It is first manifested by a pustule which ruptures and discloses an ulcer. This ulcer has sharply-defined and undermined margins ; it looks " punched out ; " the base is gray and sloughy ; the discharge is profuse, purulent, foul, and auto- inoculable, and causes fresh chancroids by flowing over the parts. The area around a chancroid is red and inflamed, and considerable pain is apt to be complained of The original chancroid spreads and new sores appear. The edge of a chancroid is not indurated unless caustics have been used or there is mixed infection with syphilis. Inflammatory indura- tion fades gradually into the tissues, but the induration of a hard chancre is sharply defined. When a chancroid after a time displays marked and sharply-outlined induration it points to mixed infection of chancroid and syphilis. Chan- croids are not followed by constitutional symptoms, but are apt to be accompanied by painful inflammatory buboes w^hich are prone to suppurate. In hospital practice about 30 per cent, of patients develop buboes. The bubo may be one- sided or bilateral. If pus forms, it does not contain organisms. The adenitis of chancroid is due purely to the absorption of toxins. Cases have been reported in which non-indurated sores were followed by syphilis. It is probable that a mixed infection existed, and that induration was overlooked, because a papular initial lesion w^as underneath the chancroidal ^ Syphilis, by Alfred Cooper. 832 MODERN SURGERY. ulcer. When inflammation in chancroids is high a rapidly destructive ulceration known as phagedena may arise, but this process is far more common in syphilitic sores. Treatment. — Ordinary cases of chancroid are treated by spraying with peroxid of hydrogen, drying with cotton, touch- ing each sore first with pure carbolic acid and then with pure nitric acid, and dusting with iodoform or with calomel. Every few hours after this application the patient soaks the penis in hot salt water (a teaspoonful of salt to half a pint of water), sprays the sores with peroxid of hydrogen, dries with cot- ton, and dusts with iodoform or with calomel. As soon as granulation begins the sores should be dressed with i part of ointment of nitrate of mercury to 7 parts of cosmolin. Mild cases do well without cauterizing, peroxid of hydrogen being frequently used and a drying powder being employed. In chancroids with phimosis slit up the foreskin, burn the edges of the wound with pure carbolic acid, and treat the sore by cauterization. A set circumcision often fails because of infection of the stitch-holes. Phagedena requires the in- ternal use of iron, quinin, and milk-punch, and the local use of powerful caustics (bromin or nitric acid or even of the actual cautery). In some cases continuous antiseptic irrigation is valuable. When a bubo first begins order rest, apply iodin or an ointment of belladonna or ichthyol, and make pressure by a spica bandage of the groin. Some surgeons advise the injection of 20-40 minims of a solu- tion of carbolic acid (gr. x to the ounce), but we have never seen any benefit from it. Some inject a i per cent, solution of bichlorid of mercury, but the proceeding causes intense pain. Welander recommends the injection of a I per cent, solution of benzoate of mercury. We have had no experience with these methods. If the bubo persists, even though it does not suppurate, it should be completely excised. If pus forms, several methods of treat- ment are open to us. Aspiration, injection with a solution of carbolic acid, squeezing out the acid and injecting 10 per cent, ointment of iodoform and glycerin, and sealing the opening with collodion (Scott Helms). Hayden makes a puncture, squeezes out the pus, washes out the cavity with peroxid of hydrogen and then with corrosive-sublimate solution, injects warm iodoform ointment, and dresses with cold, moist, corrosive-sublimate gauze to set the ointment. Otis, Fontain, Perry, and others commend this plan. We have often found it to succeed. If the above-mentioned plan fails, if it is not used, or if an ulcer or sinus exists, DISEASES OF GENITO-URINAKY ORGANS. 833 incise, curet, cauterize with pure carbolic acid, cut away hopelessly infiltrated skin, and pack the wound with iodo- form gauze. In some cases it will be necessary to extirpate fragments of gland. Phimosis is a condition of the prepuce that renders retraction over the glans impossible. It is usually congenital, but it may arise from inflammation. Congenital phimosis causes retention of sebaceous matter, which decomposes and lights up inflammation. The prepuce is apt to grow fast to the glans. Congeni- tal phimosis may induce irritability of the bladder, incontinence of urine, prolapse of the rectum, and various nervous symp- toms. The treatment is cirauncision. ^ Asepticize the parts. Grasp the foreskin fig. 305.-circumcis- and the mucous membrane with two for- ^dKoTaizigV '''"'''''' ceps, draw the prepuce forward, catch the skin (at the point it is desired to cut) horizontally between the handles of a pair of scissors, and cut off the redundant prepuce. Retrench the excess of mucous membrane by cutting around with scissors one-quarter of an inch from the glans, stitch the skin to the mucous membrane with catgut, and dress with sterile gauze (Fig. 305). Fracture of the penis, which is a laceration of the caver- nous bodies with extravasation of blood, occurs occasionally during coition. The treatment consists of cold and bandaging^ to arrest bleeding, and occasionally incisions to let out clot. Gangrene of the penis arises from phagedena, from tying constricting bands around the organ, from fracture with excessive hemorrhage, and from paraphimosis. If ex- tensive, it requires amputation. Cancer of the penis is commonest in persons with phi- mosis. In a limited epithelioma of the foreskin circumcision is performed and the glands of the groin are removed ; if can- cer affects the glans, amputation is required, and the glands are removed. Amputation of the Penis. — Ricord advised cutting off the organ with a single stroke of the knife, making four slits in the mucous membrane of the urethra, and stitching each of these flaps to the skin. Treves splits the skin of the scrotum along the raphe, separates the halves of the scrotum down to the corpus spongiosum, passes a metal catheter down to the triangular ligament, inserts a knife between the corpus spongiosum and the corpora cavernosa, withdraws the catheter, cuts the urethra across, detaches the urethra 53 834 MODERN SURGERY. from the penis back to the triangular hgament, cuts around the root of the penis, divides the suspensory hgament, detaches each crus from the pubes, sHts up the corpus spon- giosum half an inch, stitches its edges to the rear end of the scrotal incision, introduces a drainage-tube, ligates the ves- sels, and sutures the wound. Seminal Vesiculitis. — Inflammation of the seminal ves- icles is due to the extension of a gonorrheal inflammation or a pyogenic process. Acute inflammation is made evident by frequent and pain- ful micturition, pains in the anus, rectum, and perineum, and possibly the hip-joint, back, and thigh. Defecation and mic- turition are. excessively painful. Persistent erections may take place, and in some cases bloody ejaculations occur. Rectal examination detects the enlarged and tender vesicles external to the lateral lobes of the prostate and on a higher level. Treatment. — Abandon local urethral treatment and treat the patient as for acute prostatitis. Chronic vesiculitis may result from the acute form or may come on insidiously in an individual with gonorrhea. It is one of the causes of chronic urethral discharge. The patient suffers from imperative and frequent demands to micturate, and he has a gleety discharge which becomes worse and better, but does not disappear. This chronic inflammation is beHeved to persist because of narrowing of the duct, and consequent incomplete drainage of the vesicle. Treatment. — Treat the posterior urethritis by ordinary methods. Use hot rectal enemata. Milk the ducts by Fuller's method once every seven days. The patient's bladder should be full. He leans over a chair-back, the knees being straight and the body at a right angle to the thighs. The surgeon introduces his finger into the rectum and makes pressure over the pubes with the fist of the other hand. The finger comes in contact with the lower half of the vesicle ; it makes firm pressure for a moment, and is then drawn slowly toward the duct. This stroking is repeated several times. The other vesicle is treated in the same manner. This maneuver empties the vesicle and hastens the resolution of inflammation. After the completion of the stripping the patient makes water. Hypertrophy of the prostate gland is a senile change occurring only after the age of fifty, and being most apt to occur after the age of sixty. All the lobes may be enlarged equally, all may be enlarged but unequally, or only one lobe may be enlarged. Prostatic hypertrophy causes narrowing DISEASES OF GENITOURINARY ORGANS. 835 and lengthening of the urethra, and gives this tube a tor- tuous course. The opening of the urethra into the bladder is pushed to a higher level, and there forms behind it a pouch in which urine collects. This urine, which is known as rcsidiial urine, may collect in large quantity ; it cannot be voluntarily expelled, and it is apt to decompose, producing cystitis. The bladder enlarges, thickens, and becomes fas- ciculated, micturition becoming very difficult and sometimes impossible. An enlarged middle lobe will block the urine and the bladder inevitably becomes greatly distended. In hyper- trophy of the prostate the ureters, the renal pelves, and calyces may distend, and surgical kidney may develop. Symptoms. — In 80 per cent, of all cases there is only slight inconvenience. The stream of urine is slow to start and falls feebly from the end of the penis. The last drops fall entirely without control, and there are occasional episodes of noc- turnal frequency of micturition. In 20 per cent, of all cases the bladder cannot entirely be emptied and residual urine collects in the bladder. Frequency of micturition comes on, particularly at night ; the patient has to get up often ; the bladder never feels empty ; and cystitis is apt to arise. The urine, at first acid and clear, becomes neutral and cloudy, and finally ammoniacal and turbid, and contains bacteria, muco- pus, precipitates of phosphates, and blood. Above the pubes there is aching pain, soon spreading to the perineum, which pain is increased when the bladder is distended and during micturition. Enlargement of the lateral lobes can be detected by a finger in the rectum. The rectum becomes irritable, and piles form or prolapse of the mucous membrane occurs. Attacks of retention of urine may occur. The bladder be- comes thin and distended, or hypertrophied, rigid, and fascic- ulated. In rare cases true incontinence is caused by the median lobe growing toward the neck of the bladder and preventing closure. The health breaks down because of pain, restless nights, indigestion, and disorder of the bowels. The kidneys may become involved (inflammation of the pel- ves or calyces, or surgical kidney) and suppression may occur. Septic fev^er may arise. Calculi may form in the bladder. Death is due to exhaustion, suppression of urine, or septic cystitis. If a foul catheter is used, septic cystitis is certain to occur ; but micro-organisms sometimes enter by passing along the urethral mucous membrane. Treatment. — Many cases can be treated by regular cath- eterization. Alexander has formulated several sound rules as to when catheterization is the proper treatment. He says ; 836 MODERN SURGERY. if the patient is intelligent and dexterous, if cystitis is not severe, if the amount of residual urine is not very large, if obstruction is not great, if the bladder retains considerable expulsive power, and if catheterization is easy and painless, rely upon this simple plan of treatment. Prevent cystitis by emptying the bladder each evening with a coude catheter. If there is trouble in passing the catheter, strengthen the in- strument by inserting a filiform bougie as a stylet (Brinton). In some cases a metal instrument with a large curve is used. Teach the patient to use the instrument himself A dirty instrument may cause fatal infection. It is true that some people use dirty instruments for long periods without trouble, but in most cases there will be trouble if it is attempted. It is absolutely necessary to use only perfectly aseptic instruments. Metal instruments are sterilized by boiling in water. Rubber catheters can be cleansed by washing with soap and running water and boiling, or, after washing, soaking in corrosive-sublimate solution. Woven instruments can be placed in a glass cylinder, the bottom of which is like a sieve. This jar is placed for twenty-four hours in a vessel which contains formalin. The vapor of formalin is an excellent germicide, and does not injure the catheter. After sterilization the instruments are kept ready for use in a glass cylinder which contains calcium chlorid.^ Guyon scrubs the catheters with soap and water, dries them outside and inside, places them in a sealed jar, and ex- poses them to the vapor of sulphurous acid for forty- eight hours. If there are three ounces of residual urine, use the catheter only at night. If there are six ounces, use it night and morning. If there are more than six ounces of residual urine, add one more catheterization a day for every additional two ounces present until the catheter is used six times in the twenty-four hours. It should never be used oftener than this. Gradual dilatation with steel sounds is of benefit, but forcible dilatation is not advisable. TeW the patient to avoid violent exercise, cold, damp, sexual excitement, and the use of alcoholic liquor, prevent constipation and indigestion, and direct him to drink plenty of Poland water. A hot hip-bath at night adds to his comfort. Hot enemata are of value. If a large quan- tity of residual urine exists, or if cystitis begins, wash out the bladder daily with boric-acid solution, or normal salt solution, or nitrate of silver (i : 12,000), and give urotropin or salol and boric acid by the mouth. In some severe 1 R. W. Frank, in Berliner klifi. IVock., No. 44, 1895. DISEASES OF GENITO-URINARY ORGANS. 837 cases, if a large-size rubber catheter be tied in the bladder for a few days, great relief is obtained. Retention of urine can be relieved by the introduction of a coude catheter strengthened with a whalebone, of a silver instrument with a prostatic curve, or by aspiration. If the symptoms grow constantly worse, if the suffering becomes severe, if the patient cannot uri- nate without the use of an instrument, if catheterization is painful or impossible, if the patient is too careless or ignorant to trust with a catheter, if only a catheter of very small size can be introduced, if attacks of obstinate retention occur, if there is persistent cystitis or hematuria, if the residual urine gradually increases in amount, a radical operation should be performed. Suprapubic cystotomy may be performed, the opening being kept permanently patent (Hunter McGuire's oper- ation). Suprapubic prostatectomy may be performed. After the bladder is opened the mass of prostate is enucleated or cut away with scissors or with cutting-forceps. The suprapubic cut is allowed to heal. Perineal prostatotomy may be per- formed, the gland being split and perineal drainage tempo- rarily employed. McGill's operation is suprapubic pros- tatectomy, the gland being removed partly by enucleation and partly by the employment of cutting rongeur-forceps. Fuller performs a suprapubic cystotomy, makes a small incision through the mucous membrane of the gland, enucleates the gland with the finger, and drains through an incision in the membranous urethra. Belfield makes a suprapubic cut and a perineal cut, and with the finger in the perineum pushes the gland into easy reach of the finger in the bladder. Perineal prostatectomy may be employed. Some surgeons make a curved incision across the perineum and dissect out the gland. Nicoll first performs suprapubic cystotomy, opens the perineum down to the prostate, splits the capsule of the prostate, inserts two fingers of the left hand into the bladder, and pushes the prostate dow^n into the perineum. The surgeon enucleates the gland through the perineal wound without damaging the mucous membrane of the bladder. Alexander makes the suprapubic cut and uses it for the same purpose as Nicoll, but he opens the mem- branous urethra on a grooved staff, enucleates the gland, and inserts a drainage-tube through the perineal wound. Bottini of Padua, by means of a special instrument, cauter- izes the prostate repeatedly. This instrument is shaped like 838 MODERN SURGERY. a catheter and carries a platinum blade which is heated by an electric current. In 1893 J. William White introduced the operation of bilateral orchidectomy. He proved that removal of the testicles causes a rapid shrinking in an enlarged prostate. Part of this shrinking may be due to diminution of conges- tion and edema, but true atrophy undoubtedly occurs. Very remarkable results have been recorded. In most cases the patient becomes absolutely comfortable. Some cases dis- pense entirely with the catheter. Cystitis ceases, and desire to urinate frequently becomes less marked. Unilateral orchidectomy has been employed, but it is not satisfactory. Division of the vas deferens, vasectomy, may be employed instead of orchidectomy. It is slower in its results, but just as certain. In spite of the great simplicity of orchidectomy the mortality has been considerable (from 11 to 18 per cent.). In several instances mental disturbance has followed the operation, but there is no real evidence that it was due to this special form of operation and would not with certainty have followed any other. Retained and Malplaced Testicle. — The testicle may be arrested in its passage to the scrotum : it may remain in the lumbar region ; it may reach the internal abdominal ring ; it may lodge in the inguinal canal ; it may emerge from the external ring, but fail to enter the scrotum ; or it may pass into unnatural positions, as into the perineum or the crural canal. It may or may not be functionally active. A re- tained testicle is subject to attacks of orchitis and is apt to become sarcomatous. Sometimes a testicle descends after being retained for months. Treatment. — If one testicle is undescended one year after birth, and the other testicle is sound, the former should be removed if it is found impossible to draw the gland into the scrotum and fasten it. Always try to get a retained gland into the scrotum. Orchitis is inflammation of the testicle. Aaite orchitis may be due to cold, wet, traumatism or epididymitis, gout, mumps, rheumatism, or a specific fever. The testicle is round, swollen, tender, and ver}^ painful, the scrotum is red and swollen, the tunica vaginalis is filled with fluid, and there is fever. Chronic orchitis results from the acute form or from a chronic urethral inflammation, and is almost always com- bined with epididymitis. Syphilis or tubercle may be respon- sible for chronic orchitis. Tlie treatment of the acute form consists of rest in bed and DISEASES OF GENITO-URINAKY ORGANS. 839 applications as for epididymitis (see below). The cJironic form requires the removal of the causative lesion, a suspen- sory bandage, inunctions of ichthyol or •mercurial ointment, and iodid of potassium by the mouth. Strapping may do good. Castration may be required. Castration (Excision of a Testicle). — In this operation an incision is made over the cord, commencing just outside the external ring and running down over the base of the tumor. Clamp the cord and divide near to the ring, remove the testicle, ligate the spermatic artery alone, and then ligate the entire thickness of the cord. The cord is sutured with chromic gut or silk. Drainage is not required. It is often advisable to remove a considerable amount of scrotal skin. epididymitis, or inflammation of the epididymis, is usu- ally due to inflammation of the urethra. It is apt to occur in the stage of decline of a gonorrhea, and is announced by a complete cessation of the discharge. It may result from the passage of a urethral instrument, the voiding of urine which contains fragments of calculi, or as a complication of pros- tatic hypertrophy. Acute epididymitis is characterized by swelling about the testicle, pain in the groin, and tenderness over the posterior part of the testicle. The pain becomes acute, swelling rapidly increases, and the constitution sym- pathizes. The swelling is due partly to engorgement of the epididymis and partly to fluid in the tunica vaginalis (acute hydrocele). Chronic epididymitis is usually linked with orchitis, and it follows an acute attack or a chronic urethral inflammation. Treatment by puncture with an aseptic tenotome, if fluctuation is marked, relieves tension and pain. Leech- ing over the external abdominal ring, use of an ice- bag, elevation, lead-water and laudanum, laxatives, and opium are used in the acute stage. Painting with 1 5 drops of guaiacol in i dram of olive oil relieves the pain greatly. Strapping is employed as the inflammation subsides. The treatment of the chronic form is the same as that for chronic orchitis. Hydrocele (chronic hydrocele) is a collection of fluid in the tunica vaginalis testis. An enlargement of the testis may cause .it, but in most instances the cause is unknown and no signs of inflammation exist. The fluid is albuminous, but it does not coagulate spontaneously ; it is thin, straw-colored, and may contain crystals of cholesterin. The testicle is at the lower and back part of the sac. The pyriform mass fluctuates, is translucent, grows from below upward, and the 840 MODERN SURGERY. introduction of an exploring-needle permits the yellow fluid to flow out. Treatment. — Simply tapping the sac with a trocar is only palliative ; air must run in as fluid runs out, and suppura- tion may occur, which will be dangerous without drainage. Never tap a rigid sac. The injection of irritants should be abandoned, as it exposes the patient to serious danger because of inflammation occurring without provision for drainage. Hearn incises the sac, dries its interior with bits of gauze, swabs it out with pure carbolic acid, packs it with iodoform gauze, and dresses it antiseptically. The packing is removed in twenty-four hours and the wound is allowed to close. If the sac is rigid and will not collapse, either stitch it to the skin and pack it or excise a large portion of its parietal layer and insert a drainage-tube (Volkmann's operation). It has recently been proposed to tap the sac with a trocar and cannula, to leave the cannula in place as a drain for some days, and to dress antiseptically. Congenital hydrocele is hydrocele through an unclosed funicular process into the tunica vaginalis. If the pelvis is raised, the fluid runs back into the peritoneal cavity, from which it originally came. The treatment is a truss to oblit- erate the funicular process. Infantile hydrocele is a collection of fluid in a funicular process and the tunica vaginalis, the funicular process being closed above, but not below. The treatment is to puncture the sac and to scarify the sac-wall with a needle. Bncysted Hydrocele of the Cord. — In this variety the funicular process is obliterated above and below, but it is patent between these two points, and fluid collects. The treatment is the same as that for infantile hydrocele. If this fails, incise and pack. Funicular Hydrocele. — The funicular process is closed below, but is open above. Raising the pelvis causes the fluid to trickle back into the peritoneal cavity. The treat- ment is a truss. Encysted hydroceles of the testicles and of the epididymis may occur. Diffused hydrocele of the cord is simply edema of the cord. Hydrocele of a hernia is the distention of a hernial sac with peritoneal fluid. Hematocele. — Vaginal Jiematocele is blood in the tunica vaginalis, the result of traumatism, a tumor, or the tapping of a hydrocele. There is a pyriform tumor, which fluctu- ates, but which gradually becomes firmer ; the scrotum is livid, and the testicle is below and posterior to the tumor. AMPUTATIONS. 84 1 The encysted form of hematocele of the cord is a hydrocele of the cord into which bleeding has occurred. The diffused form is due to extravasation of blood into the cellular sub- stance of the cord. E/icysted hematocele of the testicle is due to effusion of blood into an encysted hydrocele of the testicle. Parenchymatous hematocele is extravasation of blood into the substance of the testicle. The treatment of a recent case of vaginal hematocele is to put the patient to bed, support the scrotum, and apply an ice-bag over the testicle. If the swelling does not soon abate, incise, irrigate, and pack. Varicocele is varicose enlargement of the veins of the pampiniform plexus. An irregular swelling exists in the scrotum and extends up the cord. This swelling feels like " a bag of earth-worms ; " it exhibits a slight impulse on coughing ; the scrotal skin and cremaster muscle are attenu- ated ; the testicle lies at the bottom of the swelling and is softer and smaller than normal ; the swelling diminishes on lying down and increases on standing or on making pressure over the external ring. There is usually some discomfort, aching, or dragging in the testicle or the groin, and even neuralgic pain in the cord. There is sometimes mental de- pression and hypochondria. Treatment. — In treating varicocele, reassure the patient : tell him there is no real danger of impotence ; order cold shower-baths, correct constipation and indigestion, give occa- sional tonics, and order the patient to wear a suspensory bandage. If the testicle becomes much atrophied, if the pain and the dragging are annoying, or if the mind is much depressed, operate (see page 261). XXXVII. AMPUTATIONS. An amputation is the cutting off of a limb or a portion of a limb. Removal of a limb or a portion of a limb at a joint is known as " disarticulation." Amputation may be necessary because of the existence of severe injuiy, of gan- grene, of tumors, of intractable disease of bones or joints, of ulcers which will not heal, of traumatic aneurysm, etc. A re-amputation may be required because of the existence of a defect or disease in the stump. Classification. — Amputations are classified as follows : (i ) As to time of operation after the injury : a primary ampu- tation is performed soon after the occurrence of the accident — as soon as the sufferer reacts from shock, and before he 842 MODERN SURGERY. develops fever ; a secondary amputation is performed some time after the accident, suppuration having supervened (Stokes); and an intermediate amputation is performed dur- ing the existence of fever, but before the development of suppuration. (2) As to the situation, where the bone is divided or according to which joint is cut through, (3) As to the form and situation of the flap. In performing an amputation maintain rigid asepsis ; com- pletely remove the hopelessly-damaged portion ; sacrifice as little of the sound tissue as possible ; prevent hemorrhage during the amputation, and carefully arrest it after the opera- tion ; have enough sound tissue in the flap to cover \h& bone, and enough skin to cover the muscles ; and secure drainage at a dependent point. Hemorrhage is prevented by the elastic bandage of Esmarch (Fig. 306). In an ordinary case apply this bandage from the periphery to well above the line of the prospective incision. Fig. 306. — Esmarch's elastic bandage. Fig. 307. — .Application of tourniquet. encircle the limb with the elastic band (not a thin tube), and remove the bandage. The bandage and band, which are asep- ticized before using, are applied to the limb, which has been carefully sterilized. After the band has been applied the limb should not freely or forcibly be moved, because of the danger of tearing muscles which are firmly set by the compressing band. When elastic compression is used in an operation the surgeon should be very careful to tie every visible vessel. AMPUTA TIONS. 843 The paralysis of the small vessels induced by pressure often prevents bleeding, and unless their mouths be found and the vessels be tied reactionary hemorrhage will occur. Reac- tionary hemorrhage is the great danger after the use of the Esmarch bandage, and paralysis or sloughing may also fol- low its employment. If there be an area of suppuration or of gangrene or an extra-osseous malignant growth, do not apply the bandage as directed above. One bandage can be applied from the periphery to near the lower border of the area of growth or infection, and another, from near the upper border of this area, up the limb. The contents of the area (tumor-cells and fluid or septic products) are not squeezed into the circulation. In cases like the abov^e many surgeons hold the extremity in a vertical position for five minutes, lightly stroking it toward the body with the hand, and at once apply the constricting band. As a matter of fact, this plan satisfactorily empties the limb of blood, and it is not necessary in any case to force the blood out by elastic compression. Some surgeons prefer the tourniquet. Figs. 308 and 309 show two forms of tourniquet. To apply Petit's tourniquet, place the plates in contact, apply Fig. 308. — Petit's spiral tourniquet Charriere's tourniquet. a small firm compress over the artery and a broad thick compress over the outer surface of the limb, buckle the tapes around the limb so that the plate is over the broad pad, and tighten the tourniquet by separating the plates with the screw (Fig. 307). When a tourniquet is applied to 844 MODERN SURGERY. arrest bleeding during transportation, bandage the limb, sew the compress pad to a bandage, and place the plates of the instrument over the pad. Signorini's horseshoe tourni- quet may be used upon the brachial artery. In hip-joint and shoulder-joint amputations Wyeth's pins are passed, and after the limb is emptied of blood the band is fastened above them. These pins prevent the bands from slipping. The instruments and appliances required are Esmarch's apparatus or tourniquet, amputating-knives, a bone-knife, scalpels, saws, a lion-jawed forceps, bone-cutting forceps, a periosteum-elevator, retractors of linen, dissecting-, hemo- static, and toothed forceps, a tenaculum, an aneurysm-needle, Fig. 310. — Catlin, knife, and saws for amputations. a probe, scissors, needles, ligatures, sutures of silkworm-gut, dressings, bandages, and solutions. A retractor has two tails for the thigh and arm and three tails for the leg and fore- arm : it is made by taking a piece of muslin eight inches wide and twelve inches long and cutting tails on one side eight inches in length. Methods of Amputating. — Circular Method (Fig. 311). — The surgeon should stand to the right of the limb and use a long amputating-knife which cuts from heel to point. After an assistant has retracted the skin the operator divides the soft parts by a series of circular cuts. Do not cut at once to the bone, but divide the skin and subcutaneous tissues. At the retracted edge of the first cut divide the superficial muscles, and after these muscles retract divide the deep muscles. Incise the periosteum with a bone-knife, push up the periosteum with an elevator, and after the application of the retractors saw the bone, starting the saw from heel to point. A periosteal flap can be made to cover the end of the bone, but it is unnecessary. In this amputation is formed a Fig. 311. — Amputation of arm by the circular method (Druitt). AMPUTATIONS. 845 cone whose apex is the bone and whose base is the skin- edge. In one form of circular amputation {amputation a la mancJu'tte) the retracted skin is cut by a circular sweep of the knife, a cuff of skin and subcutaneous tissue is freed and turned up. and the muscles are cut circularly at the edge of the turned-up cut (Fig. 312). The pure circular Fig. 312. — Circular amputation : dissecting up the skin-flap (Esmarch). amputation is performed on the arm and the thigh ; the amputation a la maiichcttc is performed chiefly through the wrist and the lower forearm. Modified Circular Method. — In this operation the cir- cular skin-cut may be modified by making a vertical incision to join the first wound, the muscles being cut by a circular sweep or by making two vertical skin-incisions. Liston's modification consists in dissecting up two short semilunar integumentary flaps and in dividing the muscles circularly. This is known as the "mixed method" (Fig. 313). The Fig. 313. — Modified circular amputation : skin-flaps and circular through muscles (Esmarch). modified circular can be used upon the thigh, the leg, the arm, and the forearm. 846 MODERN SURGERY. Elliptical Method. — This method stands midway between the circular operation and the operation by a single flap. An elliptical incision is made through the skin and subcu- taneous tissues, the tissues are pushed up or turned back, and the muscles are divided circularly or cut partly by transfixion. This method is employed particularly in certain disarticulations. Oval or Racket Method. — In an oval amputation the incision through the skin and subcutaneous tissue is an oval with a pointed end or a triangle, and the other parts down to the bone are cut from without inward. When a longi- tudinal incision down to the bone (Fig. 318, a, b) extends from the point of the oval {a, b) the operation is called the " racket " amputation. If the longitudinal cut joins a circular cut, the operation is known as a " T " am- putation. The oval or racket operation is performed at the metacarpophalangeal, metatarsophalangeal, and shoul- der-joints ; the T operation may be performed at the hip- joint. Flap Method. — A flap may be composed of skin only or of both skin and muscle, but the skin-flap must always be longer than the muscle-flap, so that the latter will be covered by it. A flap containing much muscle heals badly, but the best flap has a moderate amount of muscle (enough skin to cover the muscle and enough muscle to cover the bone). Flaps may be single or double. Double flaps may be lateral or antero- posterior, square or \S-shaped, equal or unequal, and they may be cut by transfixion (Fig. 314), Fig. 3i4.--Amputation of^the thigh by ^^ cutting from without inward, by dissection, or by cutting the skin from without inward and the muscles by transfixion. When an amputation is completed, tie the main vessels, pull down the nerves and cut them high up, smooth the flaps, take off the constricting band, and after arresting hemorrhage apply sutures. In some cases the deep parts are stitched with a continuous catgut suture and the super- ficial parts are closed with silkworm-gut ; in other cases the deep parts are not stitched at all, the skin alone being sutured with silkworm-gut. Drainage-tubes should be used except in amputations of the fingers and toes. AMPUTA TIONS. 847 Special Amputations. Fingers and Hand. — In amputating the thumb and in- dex finger save every possible scrap of tissue. In either of the fingers, if it be necessary to amputate above the middle of the middle phalanx, the attachment of the flexor tendons will be cut off and the finger will be liable to project directly back- ward, so that it is better with these fingers either to disarticu- late at the metacarpal joints or to stitch the flexor tendons to the periosteum. The flexor tendons have fibrous sheaths ex- tending from the proximal end of the distal phalanx to the metacarpophalangeal articulations, these sheaths being thin and collapsible opposite the joints, but being thick and rigid opposite the shafts of the bone. The fibrous sheath is known as the tlicca, and when it is cut in an amputation it should be closed, otherwise it may carry infection to the palm of the hand. The theca does not exist over the distal phalanx, and it is not distinctly visible over the joint between the distal and middle phalanges. To effect closure over the shaft of a bone, strip up the periosteum and pass catgut sutures vertically through the theca and the periosteum (Treves). In amputa- tion of the fingers and the thumb an Esmarch bandage is un- necessary, though pressure may be made upon the arteries at the wrist. Only two or three ligatures are necessary. Close with a very few sutures, so as to favor drainage between the threads. The distal phalanx is best removed by a long palmar flap (Fig. 315, a). The palmar flap (a) is marked out by cutting through the skin and subcutaneous tissue. The incisions are next carried to the bone, the flap is dissected from the bone, the fin- ger is strongly flexed, a transverse incision (b) is carried across the dorsum on a level ^''^ oPthl^niTr'*''"" with the base of the third phalanx, the soft parts are pushed back, the joint is opened, the lateral liga- ments are cut from within outward, the third phalanx is forcibly extended, and the remaining structures are cut from below upward. The middle phalanx can be removed by the same method (c). The proximal phalanx can be removed by a long palmar flap or by a long palmar and a short dorsal flap (d, e). Disarticulation of a metacarpophalangeal joint is best performed by the oval or racket method. The incision upon the dorsum (a) is begun just above the head of the metacarpal bone, is carried down to beyond the base of the 848 MODERN SURGERY. Fig. 316. — A, disarticu- lation of a metacarpopha- langeal joint; c, amputa- tion of a finger with the metacarpal bone. phalanx, and involves the skin only (Fig. 316). One incision sweeps around the finger at the level of the web, going only through the skin (b); the finger is extended and the palmar cut is carried to the bone ; each lateral incision is carried to the bone while the finger is bent in the opposite direction, the flaps are dissected back to the joint, the finger is strongly extended, the joint is opened fi-om the palmar side, and disarticulation is effected. Cutting off the head of the metacarpal bone improves the appearance of the stump but weakens the hand, hence in a workingman it must not be done unneces- sarily. If it is necessary to remove a metacarpal bone, the incision (c) is made from the carpometacarpal joint. Amputation of the thumb through its distal or proximal phalanx is performed identically as is an amputation of a finger. Amputation of the thumb, with a portion or the whole of its metacarpal bone, is performed by the oval or racket incision. Amputation of the wrist-joint can be done by the circular method or by a double flap. In the double-flap amputation a dorsal flap is made by carrying a semilunar skin-incision between the styloid processes ; the skin is lifted, the wrist is forcibly flexed, the joint is opened by a trans- verse cut, and a long semilunar palmar flap which includes only the skin and fascia is made by dissection. Amputation through the forearm may be effected by the circular method (Fig. 312), the modified circular, or the flap operation. An ex- cellent plan is to make a semilunar dorsal skin-flap and a semilunar skin-flap on the flexor surface. The flaps are raised, the muscles are cut circularly (Fig. 317), the interos- seous space is cleared with the knife, a three-tailed retractor is applied, the periosteum is pushed up, and the bones are sawn half an inch above the flap. In sawing the bones, start the saw upon the radius, draw it from heel to point, make a fur- row on the radius and ulna, and saw both bones at same time. After sawing, cut away any irregular edge with bone-pliers. In the lower third Teale's amputation may be done, the dor- sal flap being the long one. In Teale's amputation rectangu- lar flaps are made. The long flap is equal in width and length Fig. 317. — Modified circular amputation of the forearm (Bryant). AMPUTA TIOXS. 849 to one-half the circumference of the limb at the point where it is to be sawn. The short flap is equal in width to the long flap, but is only one-fourth its length. The two longitudinal cuts are at first taken onh- through the skin, but the two transverse cuts go at once to the bone. The flaps are dis- sected up from the interosseous membrane and the bone. In the middle or the upper third of a fleshy arm two semilunar skin-flaps can be cut from without inward, and the muscle can be cut by transfixion. Disarticulation of the elbow-joint can be done by the elliptical method or by a long anterior and short poste- rior flap. In the latter operation the forearm is partly flexed and a skin-cut marks out a long anterior flap, the knife being entered opposite the external condyle and being withdrawn one inch below the internal condyle. The muscles, which are bunched forward, are cut by transfixion. A posterior semilunar flap is made, which separates the attachments of the radius, the ulna is cleared, and the triceps is cut at its in- sertion (Bell). Gross advocated sawing through the olecranon and the inner trochlear surface. Amputation of the arm is best performed b>' marking out with a knife two equal semilunar anteroposterior flaps,. the first cut being carried through the skin alone, the mus- cles being then transfixed with a long knife. Teale's method is shown in Fig. 138. The circular or the modified circular amputation may be performed. Disarticulation at the Shoulder-joint. — In this oper- ation WVeth's pins must be passed to hold the Esmarch band in place. The anterior pin is entered at the middle of the lower margin of the anterior axillary fold, and emerges one inch within the tip of the acromion. The posterior pin is entered at a corresponding point on the posterior axillary fold, and emerges more posteriorly than the first pin and an inch within the tip of the acromion. The Esmarch band is applied above the pins. Larrey's Operation. — In this method of shoulder-joint disarticulation the limb is held from the side and an incision is made down to the bone, the incision beginning just below and in front of the acromion and running vertically for four inches down the outer sur- face of the arm (Fig. 318, a b). From the center of this incision an oval incision {cd, c c) is carried around the arm, the inner aspect of the oval reaching as low 54 Fig. 318. — Ampu- tation at the shoul- der-joint : a,b,c ,d,e, Larrey's operation ; y, g, Dupuytren's operation. 850 MODER N SUR GER Y. as the lower end of the vertical cut. The oval incision at first involves only the skin and subcutaneous tissues. The anterior structures are divided close to the bone, and the posterior structures are next cut. To di.sarticulate, cut the capsule transversely upon the head of the bone; while the arm is rotated outward cut the subscapularis, and while the arm is rotated inward cut the supraspinatus and infraspinatus and the teres minor. Cut away any tissue holding the hu- merus to the body; cut away hanging nerves, capsule-frag- ments, and tissue-shreds, and sew up the wound vertically. Bell advises an oval incision with a racket handle. Spence used an anterior racket incision. Dupu37-tren's Method. — In Dupuytren's shoulder-joint dis- articulation a U-shaped flap is marked out by a skin-incision (Fig. 318,/^). If the amputation is to be at the right shoul- der the arm is carried across the chest ; the knife is entered at the root of the acromion, follows the margin of the deltoid, and is withdrawn at the coracoid process, the arm being gradually abducted and pulled off from the chest. If the left shoulder is to be ampu- tated, the procedure is reversed (Treves). The knife now cuts through the deltoid and raises a flap composed of this muscle, the shoulder-joint is exposed, and disarticulation is effected as in Larrey's method. The knife is passed down back of the ^bone and a short internal flap is cut. Lisfranc's amputation is by transfixion with the formation of an ante- rior and a posterior flap, and can be performed very rapidly, but only a most skilful surgeon should attempt it. Fig. 319-Am- Amputation of the Toes and the Foot. putation 01 meta- ^ tarsal bones. — Ouly in the great toe is partial amputation performed, and it is effected by the formation of a long plantar flap, just as a long palmar flap is formed from the finger. Amputation at the metatarsophalangeal joints is performed by an oval or racket incision (Fig. 319, c). Amputation of a toe with removal of its metatarsal bone is shown in Fig. 319, « <5 and d c. Amputation at the Tarsometatarsal Articulation. — Lisfranc's method (after Treves). — In order to ampu- tate the right foot by this method begin an incision on the outer border of the foot, behind the tubercle of the fifth metatarsal bone ; carry the incision forward one inch and sweep it across the foot half an inch below the tarsometa- AMPUTA TIONS. 851 tarsal articulations ; bring the incision to the inner edge of the foot, half an inch in front of the tarsal articulation of the big toe, and carry the cut straight along the inner margin of the foot until it reaches a point three-fourths of an inch above the articulation of the metatarsal bone of the great toe. A very short semilunar dorsal skin-flap is thus formed. After the skin-flap is dissected back for a quarter of an inch the tendons are divided, and the flap, which now contains all the soft parts, is dissected back to above the joint. A long plantar flap is cut, reaching from the origin of the first flap to the necks of the metatarsal bones. The skin-flap is dissected up until the hollow behind the heads of the metatarsal bones is reached, when, with the toes in extension, the tendons are cut across and a flap composed of all the soft parts is dissected up to above the tarsometatarsal joint. Fig. 320 shows the line of Lisfranc at the tarsometatarsal articu- lation. The joint is opened from the outer side according to the following rule : in separating the fifth metatarsal direct the edge of the knife toward the distal end of the first metatarsal ; in separating the fourth metatarsal direct the knife toward the middle of the first metatar- sal ; in separating the third metatarsal carry the knife almost directly across. The separation is facilitated by bending down the front of the foot, and at the same time the tendons of the peroneus brevis and tertius are divided. Open the joint between the first metatarsal and the inner cuneiform bone, turning the knife toward the middle of the shaft of the fifth metatarsal, and at the same time divide the tibialis anticus muscle. Treves Fig. 320. — Lines in am- putations of the foot (Gross). Fig. 321. — Lisfranc's amputation : first step (Guerin) says that in disarticulation of the second metatarsal the knife is to be held as a trocar, it is to be thrust between the 852 MODERN SURGERY. base of the first and second metatarsal bones until the point strikes bone (Fig. 321), and is then to be raised to a perpen- dicular and the cut is to be made toward the external malle- olus to sever the ligament of Lisfranc (Fig. 322). Divide Fig. 322. — Lisfranc's amputation : second step (Guerin). any remaining ligaments, and also the tendon of the ^ero- neus longus muscle. The skin-incisions in the left foot are begun on the inner side, and in disarticulating the tarsal joint of the great toe is first opened. Fig. 323 shows the parts after disarticulation at the line of Lisfranc. Hey's Method. — In Hey's method the incision is practi- cally the same as that for Li.sfranc's amputation. The four external metacarpal bones are disarticulated, but the first metatarsal is removed by sawing a portion of the internal cuneiform bone. Guerin advised sawing all the bones across. Skey advised the division of the head of the second meta- tarsal. Fig. 320 shows the line of Hey. Amputation through the Middle Tarsal Joint. — Chopart's Amputation. — Make a transverse incision Fig. 323. — The parts after Lisfranc's amputation (Bernard and Huette^. Fig. 324. — The parts after amputation by Cho- part's method (Bernard and Huette). through the skin of the instep, two inches below the ankle-joint; cut the tendons and muscles, expose the tar- sus, and make on each side a small longitudinal incision AMPUTATIONS. 853 reaching to below and in front of the corresponding malle- olus. The flap thus formed is retracted. The plantar flap is made as in Lisfranc's amputation. Open the astragalo- scaphoid joint, then the calcaneocuboid joint, and disarticu- late. Fig. 320 shows the line of Chopart. Fig. 324 shows the parts after Chopart's disarticulation. In amputation through the tarsus Forbes of Toledo advises making flaps as in Chopart's amputation, disarticulating the scaphoid from the cuneiform bones, and sawing through the cuboid. Fig. 320 shows the line of Forbes. Amputation at the Ankle-joint. — Syme's Method. — The foot is held at a right angle to the leg, and a skin- incision is carried, from just below the external malleolus, straight across or a little backward across the sole to a corresponding point on the opposite side. Do not take this incision near to the inner malleolus, as to do so will endanger the posterior tibial artery. The incision is carried to the bone, the flap being pushed back and separated from the bone by means of a strong knife and the thumb-nail until the tuberosity of the os calcis has been reached. The foot is now extended and a transverse cut is made across the dorsum, joining the two ends of the first incision ; the ankle- joint is opened, the lateral ligaments are cut, disarticulation is effected, and the foot is finally completely removed by severing the tendo Achillis. A thin piece of bone including both malleoli is sawn from the tibia and fibula. The flap is perforated posteriorly to secure drainage. Fig. 325.— Lines of section of the os calcis and the bones of the leg in Pirogoff's amputation. Pirogoff's Method. — In this method of ankle-joint ampu- tation the incisions are the same as those for Syme's ampu- 854 MODERN SURGERY. Fig. 326. — Sedillot's amputation of the leg (Wyeth). tation. Do not dissect the flap from the posterior portion of the OS calcis, but saw off this bony projection obHquely and leave it adherent to the tissues. The saw is used after disarticulation of the ankle-joint; it is passed behind the astragalus, cutting downward and forward. The ends of the tibia and fibula are sawn off, and the sawn os calcis is brought into contact with the sawn tibia and fibula. The lines a and b (Fig. 325) show the sections made by the saw. Amputations of the I^eg. — In am- putations of the leg by the long anterior flap, cut through the skin, dissect up the anterior muscles with the flap, and cut all the posterior tissues with a single trans- verse sweep. Amputation by the rectan- gular flap, Teale's method, is very useful (see page 848). The long flap is anterior, and is in length and breadth equal to one- half the circumference of the limb. The short flap is one-fourth the length of the long flap. The flaps are dissected up, the bones are sawn, the long flap is turned upon itself, and its edges are sutured to the edges of the short flap. Sddillot's leg-amputation (Fig. 326) is by a long exter- nal flap. A longitudinal incision is made along the inner edge of the tibia, the tissues are drawn toward the fibula, a knife is introduced and passed to the outer edge of the tibia, just touching the fibula, and is brought out posteriorly, thus transfixing the calf-muscles and cutting an external flap. A convex incision is made on the inner side, the bones are cleared and are sawn one inch above the flaps, half an inch more being taken from the fibula than from the tibia, and the tibia being bevelled anteriorly. Modified Circular Amputation of the Leg". — Cut semi- lunar skin-flaps, lay them back, and cut circularly to the bone at the edge of the turned-up flap. Another method of modified circular amputation is by adding to the circular cut a vertical incision down the front of the leg. In sawing the bones of the leg the surgeon, who stands to the outer side of the right leg or to the inner side of the left leg, divides the fibula first, and at a higher level than the tibia, and bevels the anterior surface of the tibia. In sawing the left fibula the saw points to the floor ; in sawing the right fibula it points to the ceiling. AMPUTA TIONS. 855 Amputation of the Leg- by a Long- Posterior and a Short Anterior Flap. — In this operation a posterior U-shaped flap is made, equal in length and breadth to the diameter of the limb. The skin-incision is begun one inch below the point where the bone is to be sawn, and behind the inner edge of the tibia, and is carried to a point posterior to the peronei muscles. The gastrocnemius muscle is divided trans- versely at the level of the flap, the soft parts on either side in the line of the flap being cut to the bone. Through these vertical cuts the muscles are lifted from the bones and are divided through their lower part by cut- ting from within outward. The anterior flap is formed by making a semilunar skin-flap and by cut- ting the muscles across at its re- F'G- 3f7.-Amputation of the leg by ° , , , a long posterior flap (Gross). tracted edge (rig. 327). Ampu- tation of the h'g by lateral flaps is not a popular operation, as it offers too much encouragement to subsequent protrusion of the bone. Bier endeavors to broaden the support after amputation by performing a cuneiform osteotomy and bend- ing the lower fragment to a right angle with the upper, and obtaining union of the fragments. Amputation just below the Knee. — The seat of election is one inch below the tuberosities. No muscle is needed in the flap. Cut two flaps of skin, equal in size and semilunar in shape, these flaps beginning anteriorly two inches below the tuberosity of the tibia. One flap is antero-external and the other is postero-internal. The flaps are pulled up, the anterior muscles are cut as high up as possible, and the pos- terior muscles are cut through the middle of the portion ex- posed (Bell). The bone is sawn one inch below the tuber- osity. Disarticulation of the Knee. — In disarticulation by the long anterior flap, make a long anterior skin-flap, incise the ligament of the patella, turn up the flap with the patella, open the joint, and complete the disarticulation by cutting from within outward and downward. The knee may be dis- articulated by means of a long anterior and a short posterior flap. Amputation through the Femoral Condyles. — Syinc's Method by a Long Posterior Flap. — Carry a skin-incision, with a very slight downward curve from one condyle to the other, across the middle of the patella. Cut down to the bone, retract the flap, and cut the quadriceps above the patella. 856 MODERN SURGERY. Insert a long knife at one angle of the wound, pass it back of the femur, and make it emerge at the opposite angle, cut- ting a posterior flap eight inches long. Retract the posterior flap, clear for sawing, and section the condyles horizontally. Garden made a curved section of the condyles at their widest part. In children Buchanan showed that we can easily sepa- rate the lower femoral epiphysis. In Gritti's supracondyloid amputation an oblique incision is made. The upper end of the incision is posterior and just above the condyles. Its lower end is anterior and two finger-breadths below the patella (Kocher). The ligament of the patella is cut, the flap is turned up, the femur is sawn at the base of the condyles, the articular face of the patella is sawn off, and the sawn patella is fastened to the sawn femur and the flaps are sutured. Sabanejeff makes an anterior flap, opens the knee-joint from behind, saws the condyles at their broadest part, takes a bone-flap from the anterior portion of the tibia and fastens it to the femur. Amputation of the Thigh. — In thigh-amputation in the lower third either a flap or a circular operation may be per- FiG. 328. — Amputation of the thigh (Bryant). formed. In a double-flap operation a semilunar skin-incision should be made from without inward, and the muscles should be cut by transfixion (Fig. 328). In the lower third Teale's flap or the long anterior flap may be employed. The ampu- tation by a long anterior flap consists in making a lengthy skin-flap, reflecting it, cutting the anterior structures to the bone, again entering the long knife at one angle of the incision, pushing it back of the femur, bringing it out at the other angle, and cutting the structures behind the bone directly AMPUTA TIONS. 857 backward. Bell amputates by a long anterior semilunar flap and a short posterior flap. In amputations in the upper two-thirds of the thigh the best plan is to mark out equal anterior and posterior semilunar skin-flaps, di- vide the skin with a scalpel, enter the long knife at one angle of the anterior flap, bring it out at the other angle, and cut the muscles by transfixion. Cut the posterior flap in the same manner. Some surgeons prefer a long ante- rior semilunar flap and a 'short posterior semilunar flap. The pure circular amputation is not adapted to the thigh. Disarticulation at the Hip-joint. — Disarticulation at the hip-joint can be effected while the circulation is controlled by Macewen's method of compression of the aorta (Fig. 329). Fig. 329. — Macewen's method for compression of the abdominal aorta {American Text-Book of Surgery). The weight of the assistant's body is thrown upon the patient's aorta by the right fist, placed slightly to the left of the umbilicus. McBurney has suggested the prevention of bleeding by making a small abdominal incision and having an assistant make direct digital pressure upon the iliac artery. In the bloodless method of Wyeth (Fig. 330) the band of the Esmarch apparatus is held up by Wyeth's 858 MODERN SURGERY. pins, the outer pin being inserted one and a half inches below and a little internal to the anterior superior spine of the ilium, and brought out just back of the great tro- chanter. The inner pin is entered one inch below the level of the crotch, and internal to the saphenous opening, and it emerges one and a half inches in front of the tuber- osity of the ischium. The hip is brought well over the edge of the table, a circular incision is made down to the deep fascia six inches below the constricting band, and is joined by a longitudinal skin-cut reaching from the band to the level of the circular incision, and the cuff is reflected to the level of the lesser trochanter. The muscles are cut by a circular sweep at the level of the retracted cuff, the capsule is opened freely, the cotyloid ligament is cut posteriorly, the thigh is bent upward, forward, and inward to dislocate the head of the bone, and, using the thigh as a handle, the round liga- ment is incised and the limb removed. After ligating the vessels and introducing tubes the flaps are sewn together ver- tically. The old transfixion operation is practically extinct Fig. 330. — Amputation at the hip-joint : Wyeth's bloodless method. A "X -amputation may be employed. It consists of an external straight incision down to the bone, starting over the great trochanter, down the outer side of the limb, and a circular incision through the skin five inches below the constricting band, the muscles being cut by a circular sweep at the level of the retracted skin. This method affords easy access to the joint. The bloodless method of Wyeth, as applied to the hip-joints and shoulder-joints, is one of the most notable modern advances in the art of surgery. Larrey amputated DISEASES OF THE BREAST. 859 by lateral flaps, and Listen by anteroposterior flaps. For- neaux Jordan's method consists in dividing the soft parts low down, tying the bloodvessels on the face of the stump, shelHng out the femur from the soft parts, and disarticulating. XXXVIII. DISEASES OF THE BREAST. Mammillitis and Fissure. — The nipple may inflame as a result of injury, but the condition is rarely encoun- tered except in a woman who is nursing a baby. It is most common after a first pregnancy, when the nipple is deformed or when the skin is delicate. The nipple is slightly injured during nursing, and the epithelium is macerated by the milk and saliva. If the inflammation is not arrested, an area ex- coriates or an irritable ulcer forms (a fissure). This fissure is often surrounded by an area of acute inflammation, and nursing causes intense agony. Because of the pain the mother is apt to extend the intervals between nursing, and as a consequence the breasts become swollen with retained milk. The ulcer not unusually bleeds when taken by the child. Besides the fact that a fissure causes pain to the mother, it often leads to grave trouble. It is a suppurating area, and as such may lead to abscess of the mother's breast, or may impair the health of the nursing child. Prevention of Fissure. — During pregnancy the nipples should be carefully attended to. They should be washed often in sterile water and bathed in alcohol, and if retracted ought to be drawn out repeatedly. During lactation the nipples are washed in sterile water, dried, and dusted with borated talc powder as soon as an act of nursing is com- pleted. Washing the nipples regularly with the following solution tends to prevent the formation of a fissure : iodid of mercury, gr. ij ; alcohol, sjss ; glycerin and distilled water, ad a pint (Lepage). If a small abrasion appears, order the woman to wear a nipple-shield during nursing, and after each act of nursing to wash the part with hot sterile water, dr}% and dust borated talc over the surface. If a fissure forms, wean the child at once, and dry up the milk in both breasts. It is useless to try to dry it up in one breast. Milk may be dried up by applying ointment of bella- donna locally and administering iodid of potassium inter- nally; by strapping the breasts with adhesive plaster (Parker); or by applying to the nipples six times a day a 5 per cent, so- lution of cocain in equal parts of glycerin and water (Joise). The fissure is not treated by ointments. These preparations 86o MODERN SURGERY. are septic, prevent drainage, and aggravate maceration. Wash the fissure twice a day with peroxid of hydrogen, dress it with gauze wet in boric-acid solution (gr. x to 3J of water), and cover the dressing with waxed paper. If the fissure resists treatment, touch it with lunar caustic. Acute Mastitis and Abscess. — Acute inflammation of the breast, as a result of injury of the breast or nipple, may occur in either sex at any time of life. Very commonly in both sexes a few days after birth the breast becomes dis- tended with a material which in reahty is m.ilk. The fluid is usually small in quantity. The process is physiological, and, as a rule, ceases spontaneously (GuelHot). If it lingers, the application of belladonna ointment will stop secretion. If the nurse meddles with and tries to squeeze out the fluid, acute mastitis is apt to arise in one gland, or occasionally in both. The skin of the breast reddens, the gland swells and becomes tender and painful, the child loses its appetite and becomes feverish, restless, and sleepless. Such a condition is treated by the local use of lead-water and laudanum. If pus forms, the local signs and constitutional symptoms are aggravated. Evacuate the pus, dress with hot antiseptic fomentations, and be sure that the child is well nourished. Tonics and stimulants are indicated. A condition identical with the secretory activity of the glands of the new-born may occur in either sex at puberty. The methods of treatment are the same in both cases. As a matter of fact, rarely more than one lobule at this period in- flames, and suppuration is most unusual. Mastitis is most usually met with in a woman who is nurs- ing a child, and is due to bacterial infection. Primipara are particularly liable to develop mastitis. So are women with deformed nipples. In many cases an abrasion of the nipple exists, and through this breach of continuity organisms gain entrance to the breast-tissue. The abrasion may be so slight that it can only be detected when the nipple is examined through a magnifying-glass (Marmaduke Shield). Strepto- coccic infections are very generally due to inoculation of a fissure of the nipple. Organisms may pass up the milk-ducts, coagulating the milk and penetrating through the walls of the acini. Staphylococci usually adopt this route in reaching the breast-tissue. Occasionally causative organisms reach the breast through the arteries (in septicemia and in septic wounds of the genital organs). Symptoms. — There are pain, swelling, and tenderness in the breast, and in most cases a fissure or abrasion exists. DISEASES OF THE B HE AST. 86 1 There is a febrile condition. Occasionally a chill ushers in the attack. Treatment. — Stop nursing. Arrest the secretion of milk. Treat the nipple as advised on page 859. Support the breast and apply ichthyol ointment or lead-water and laud- anum. A mastitis may undergo resolution ; it may terminate in or- ganization and induration ; it may eventuate in suppuration. Acute abscess of the breast follows an acute mastitis. There may be but one area of suppuration, or multiple foci may exist, which eventually fuse. The symptoms of mas- titis, local and constitutional, are greatly aggravated. After a time the skin becomes dusky and edematous. The axillary and superficial cervical glands enlarge. The abscess will eventually open spontaneously at one or more points, leaving branching fistulse. A superficial abscess is situated just beneath the nipple, and pus may flow from the nipple. An intramammary abscess is in the depths of the gland. There are often multiple foci of suppuration. Nodules are felt in the gland, pus may run from the nipple, but cutaneous redness is late in appearing. Retromammary abscess is a rather rare condition. It may occur alone or be associated and connected with an area of intramammary suppuration. This condition may result from metastasis or from caries of a rib. The breast is lifted up by the fluid beneath it. Treatment. — Open a superficial abscess by an incision radiating from the nipple. Treat as any other acute abscess. An intramammary abscess should be opened by a radiating incision, and pockets of pus should be broken into with the finger. An examination is made to determine if a retromammary abscess also exists. If this is found to be the case, an incision is made at the point of junction of the thorax and mammary gland, and at the lower border of the gland. The gland is raised from the chest-wall, the pus evacuated, and a drainage-tube is inserted. If retro- mammary abscess exists alone, make the last-named incision in the first place. Chronic Mastitis. — This condition may be present in only a portion of the breast, or may attack many lobules (lobular mastitis). The ordinary form may arise after weaning a child, or may be due to a blow, to the pressure of corsets, or to numerous slight traumatisms. It may occur in the young, the middle aged, or the old. The patient has slight pain at times in the gland. Examination detects a firm, 862 MODERN SURGERY. elastic area, which is somewhat tender and does not present distinct edges. The skin is not adherent to the mass unless suppuration occurs. If the mass is pressed against the chest by the surgeon's fingers, it becomes evident that no real tumor exists. Treatment. — Remove any cause of irritation. Support the breast in a sling. Apply ichthyol ointment. During the night employ a hot-water bag. If pus forms, treat as before directed. Chronic lobular mastitis is a condition in which numerous lobules become indurated. The real cause of this condition is unknown. It may occur at any age after puberty, and often attacks both breasts. Such a breast is apt to be painful, especially at the menstrual periods ; it feels unnatural, solid, and careful examination detects numer- ous indurated areas, each of which is of small size. At the menstrual period the breast enlarges and new nodules may be detected. In some of these cases violent neuralgic pains are present in the gland (mastodynia). Chronic lobular mastitis is apt to lead to cyst-formation. When cysts form fluid may occasionally discharge from the nipple. Treatment. — Support the breast and apply ichthyol oint- ment or belladonna ointment. Examine the generative organs and correct any existing abnormality. Improve the general health by good food, tonics, and open-air life. In cases where multiple cysts are known to exist the question of treatment is uncertain. There seems to be no doubt that such cases tend in some instances to eventuate in cancer. We believe that the proper treatment is extirpation of the breast. Tuberculosis of the Mammary Gland. — (See page io8.) Cysts and Tumors of the Nipple and the Mam- mary Gland. — Tumors are rare in the nipple, but do some- times occur. The following growths are occasionally seen : fibroma, angeioma, papilloma, myxoma, myoma, and epithe- lioma. Sebaceous cysts of the nipple and areola are not very unusual. A cancer of the nipple may be a primary growth, or may be secondary to gland cancer. Primary epithelioma of the nipple presents the same general characters as epithelioma in any other region. It begins as an indurated area in the areola, or an excoriation of the nipple. Ulceration soon occurs. The ulcer is irregular in outline, has hard edges, fur- nishes a foul red flow, and the discharge is sanious and fetid. The mammary gland becomes infiltrated at an early period. The subclavian glands enlarge, and later the axillary glands. DISEASES OF THE BREAST. 863 This growth must not be confounded with a chancre of the nipple. Treatment of Tumors of the Nipple. — Innocent tumors are to be excised and the breast need not be removed. EpitheHoma of the nipple requires the complete extirpa- tion of the breast, and also the clearing out of the lymphatic contents of the axilla, and possibly of the subclavian triangle. Paget' s Disease of the Nipple (Malignant Derma- titis). — This condition is a chronic inflammation of the epithelial layer of the nipple and areola occurring in women beyond middle life, and is a not unusual precursor of epi- thelioma of the nipple and of duct cancer. Paget's disease is not a simple eczema, it is not associated with the usual causes and attendants of eczema either local or constitu- tional, and is not cured by remedies which control the ordinary disease. The diseased area is raw and red, and from it exudes copiously a thick, yellow discharge. In some cases Paget's disease is secondary to duct cancer, auto-infection of the nipple having been effected by the fluid flowing from the ducts. Investigations have shown the presence of psoro- sperms in an area of Paget's disease. Treatment consists of removal of the entire breast and clearing out of the axilla and subclavian triangle. Tumors of the Mammary Gland. — These tumors may be innocent or malignant. The innocent tumors are Fibro-adenomata or Cystic Adenomata, Myxomata, Villous Papillomata, and Angiomata. — It is maintained by most authorities that any innocent tumor of the gland may and often does become malignant. Pibro-adenoma. — The nomenclature of these growths is in a state of great confusion. The name of fibro-aden- oma was given by Cornil and Ranvier to the same sort of growth which the younger Gross called a fibroma, Billroth an adeno-fibroma, and Sir Astley Cooper a chronic mam- mary tumor. It is doubtful if a pure fibroma ev^er occurs in the mammarj^ gland (Senn). A fibro-adenoma consists of acini surrounded by fibrous tissue. Each of these structures proliferates, but the fibrous tissue does so much more rapidly than the glandular. A growth of this character is surrounded by a capsule, and is moveable. It is firm, elastic, lobulated, superficially situated, and of slow growth. It is unassociated with retracted nipple, glandular enlargement, adhesion to the skin, or cachexia, and may occur at any age up to fifty, but is most common between 864 MODERN SURGERY. twenty and thirty (J. Bland Sutton). Such a tumor is rarely very painful, but it may be tender on rough handling and may be painful at the menstrual period. As a rule, there is but one of these tumors in a mammary gland, but one may exist in each gland. Treatment. — Extirpation of the tumor. Cystic adenoma (adenocele) is a rare form of slowly- growing tumor, which is apt to grow to a large size, which is nodular in outline, hard to the touch, and firmly attached to the breast, but mobile upon the chest. A cystic adenoma has a distinct capsule. This form of tumor is painless, and is most apt to occur in women between thirty and forty who have born children. The growth is adherent to the skin, but the cutaneous surface is not discolored, the cuta- neous veins are not distended, the axillary glands are not enlarged, and the nipple is not retracted. From the walls of the dilated acini papillomatous growths are apt to arise (intracystic vegetations). Treatment. — Removal of the breast. Myxoma is a rare tumor, and only occurs in a person of middle age. The growth is solitary, is soft, may be round or lobulated, and occasionally fungates. The nipple is not retracted, the superficial veins are not distended, and the axillary glands are not enlarged. Treatment. — Removal of the mammary gland. Angioma. — This form of tumor is very rare. It may arise secondarily to a nevus of the skin (Sutton). The diagnosis of angioma of the skin is readily made. In a cavernous angioma of the breast it will be found that the tumor can be lessened in size by pressure, and will be increased in size by coughing, laughing, and holding the breath. Pulsation may be detected and a bruit may be audible. Treatment. — For treatment of nevus see page 226. If a cavernous angioma exists in the mammary gland, it will be necessary to extirpate the gland. Cysts of the Mammary Gland. — Involution cysts (cystic degeneration of the mamma) occur in women who are approaching the menopause. They occur earlier in those who are sterile than in those who have born chil- dren, and may arise after chronic mastitis. The paren- chyma of the gland undergoes atrophic change, but the ducts remain, become blocked and dilated. Numerous small cysts form, and both glands, as a rule, suffer. Villous growths may arise in the walls of the ducts. In some cases DISEASES OF THE BREAST. 865 there is much white fibrous tissue between the cysts (cystic fibroma). The subjects of this disease are often nervous, hysterical, and despondent. One or more ill -defined indurations are detected. Frequently there is a history of discharge from the nipple and of attacks of lancinating pain in the breast. Cystic breasts are dangerous, because the intracystic vege- tations are liable to eventuate in duct cancer. Treatment. — In such cases, after confirming the diagnosis by an exploratory incision, remove the entire breast (Snow). Lacteal cyst (galactocele) is an accumulation of milk brought about by blocking of some of the milk-ducts. It arises soon after the delivery of the child, and grows rapidly. A large quantity of milk may collect, and rupture of the cyst-walls can occur, the fluid passing into the glandular connective tissue. A galactocele is rounded, fluctuates distinctly, and increases in size during nursing. There is little or no pain. In some cases the contents of the cyst coagulate and a solid mass is formed. Treatment. — Incision and drainage. Hydatid cysts are rare, but do occasionally occur. Treatment. — Excision. Maligfnant tumors of the mammary gland are ten times more common than innocent tumors. Sarcoma. — Sarcoma of the mammary gland is a very rare growth (less than 10 per cent, of breast tumors). It may occur at any age from pubert}' to old age, but is most common from twenty to thirty-five. The growth may be composed of round cells or spindle cells, both varieties may be present, and myeloid cells may be found. Circumscribed sarcoma arises usually between the ages of twenty and thirty; it is firm to the touch, as it contains much fibrous tissue, is painless, does not grow very rapidly, glands are not involved, and there is no cachexia. The nipple is not retracted. The growth may adhere to the skin. It is composed of giant-cells or spindle- cells, and rarely returns after extirpation of the breast. Diffused sarcoma is composed of small round cells, arises in the center of the breast, and grows with great rapidity. It is most commonly met with about the age of thirty-five, and a history of injury can often be elicited. The tumor is soft, some parts being softer than others because of cyst-formation. It is usually mobile upon the thorax, though it soon becomes adherent to the skin. The tumor reaches a very great size, and soon fungates through the 55 866 MODERN SURGERY. skin. There is little or no pain. The cutaneous veins over the tumor are distended, the nipple is not retracted, and the axillary glands are not often enlarged. Diffuse sarcoma is apt to recur after removal. Treatment. — Remove the breast, and if the muscles of the chest-wall are infiltrated, remove them. The axillary glands are removed if they are enlarged, but not otherwise. Opera- tion will not cure when metastases exist. If the case is in- operable, we can try the use of Coley's fluid. If the toxins of erysipelas fail to arrest the progress of the disease, keep the patient as comfortable as possible by the administration of cocain and morphin. Carcinonia or Cancer of the Mammary G-land. — The great majority of mammary tumors belong to the genus carcinoma. Cancer is due to proliferation of the epithelium of the acini (acinous cancer) or of the ducts (duct cancer). Acinous cancer is vastly commoner than duct cancer. Usually there is much connective tissue and but little parenchyma in the growth (scirrhus cancer). In some cases there is little connective tissue and much parenchyma (encephaloid or medullary cancer). If colloid degeneration of the parenchyma or stroma occurs, the growth is spoken of as colloid cancer. Scirrhus, the common form of acinous cancer, is almost as hard as stone. On section it is concave, and Sutton says " resembles an unripe pear." The tumor is without a cap- sule, and the epithelial cells are surrounded by masses of fibrous tissue. Portions of tissue, even some distance away from the tumor, contain foci of proliferating embryonic epi- thelial cells. In atrophic or withering scirrhus the fibrous stroma contracts and epithelial cells undergo fatty degenera- tion (Senn). Causes and Symptoms. — Scirrhus is more common among women who have born children than among those who have not. Heredity is manifest in only about lo per cent, of cases (Bryant). The younger Gross found it in one case out of nine. Trauma has no apparent influence in producing can- cer. The disease is rare before the age of thirty-five, and is most common between forty-five and fifty. The author operated for scirrhus of the breast on a woman only twenty-seven years of age. Henry saw a woman of twenty-one with cancer. It is frequently met with in the aged. These tumors are rare in the negro race. A hard nodule is found in the breast, usually under the nipple, but possibly far away from it. The growth is nod- DISEASES OF THE BREAST. 86/ ular, and is immobile from the beginning. In a large, fat breast there is often a deceptive sense of mobility, because some of the breast-tissue moves with the tumor. The cancer may have been present for a considerable time before being discovered. In obscure lesions of bones and viscera examine the mammar>^ glands, because the trouble might be due to metastasis from an undiscovered carcinoma of the breast. Retraction of the nipple is present in over one-half of the cases (S. W. Gross). It occurs when the grow'th is near the nipple, and is due to the contracting fibrous tissues of the tumor pulling on the milk-ducts. If the growth is far away from the nipple, a dimple is apt to form on the skin of the breast because of the pulling upon the suspensory fibers. Glandular enlargement in the axilla soon follows the ap- pearance of a scirrhus ; the glands become very hard and adherent. In ov^er 60 per cent, of persons the glands of the axilla are felt to be enlarged when the patient first comes for treatment. Because the surgeon cannot feel enlarged glands is no proof that there are none. As a matter of fact, the glands are usually involved within two months of the beginning of the disease, but the involvement can rarely be detected ex- ternally until months later. Enlargement of the axillary glands is follow^ed by enlargement of the glands in the pos- terior cervical triangle and in the mediastinum. Herbert Snow has shown that the blocking of the axillary glands often leads to regurgitation of lymph containing cancer-cells, the cells being thus deposited in the head of the humerus and the thymus gland. Cells in the thymus, after a time, cause a projection of the sternum (the sternal symptom). When the axillary lymphatics are extensively involved the arm swells from obstruction to the lymph-flow (lymph edema) or pressure upon the vein. The tumor usually grows rather slowly unless lactation is established, then it grows rapidly. As it grows it infiltrates adjacent structures (the pectoral fascia, pectoral muscles, subcutaneous cellular tissue, and skin). When the skin is destroyed an ulcer forms, and around this ulcer the skin becomes red and filled with cancerous nodules, which feel like shot in the skin. Metas- tases are apt to occur into the bones, liver, brain, pleura, spine, thymus gland, and rarely the eye. Pain is usually present in scirrhus carcinoma. It is lan- cinating and neuralgic in character, and not brought on or increased by handling. It ceases if colloid degeneration be- gins. The general health is usually unimpaired until ulcer- ation takes place, when cachexia arises. The cancer en cui- 568 MODERN SURGERY. rassc of Velpeau is a condition in which the lymphatic vessels of the skin are extensively invaded, the growth itself being adherent to the wall of the thorax. In this condition the chest-wall is fixed, respiration is difficult, and the temperature is commonly somewhat elevated. In atrophic or withering scirrJius the contraction is so great that it seems as though the mammary gland had been removed. The duration of scirrhus, when left to run its course, varies, but the disease generally produces death ■within two and a half years. Occasionally it causes death within a year. In atrophic scirrhus the patient may live for many years. Duct cancer is not a common growth. It arises from the duct-walls in conditions of cystic degeneration of the mam- mary gland. The tumor is softer than the acinous growth, and is not nodular. There is no pain, no retraction of the nipple, no skin dimple. Serous or bloody fluid may often be squeezed from the nipple. A duct cancer grows, infiltrates slowly, and involves adjacent glands later than does scirrhus. Treatment of Carcinoma of tJie Mammary Gland. — The treatment is early and thorough operation, the earlier and the more thorough the^ better. The older surgeons oper- ated simply to prolong life a few months ; the modern surgeon operates with the hope of curing the patient. In 1878, Billroth's statistics showed only 8 cures in 143 cases. In 1896, W. Watson Cheyne reported 12 cures out of 21 cases (57 per cent.). The operation should remove the breast and much of the skin above it, the pectoral fascia, and often the pectoral muscles ; the fat and glands of the axilla, and sometimes the fat and glands of the subclavian triangle. If three years after an operation there has been no return, we regard the case as cured (Volkmann's limit). Cer- tain cases are unsuited for a radical operation : cases in which metastases exist ; cases of cancer en cuirasse ; cases where axillary involvement is very great. Cheyne would also rule out cases where large glands may be felt above the clavicle, believing that in such cases the mediastinal glands must be cancerous.^ Halsted's Operation. — Halsted performs a very radical operation. He removes suspected tissue in one piece, and thus prevents carcinoma cells falling in the wound, for it is well known that if such cells should fall into the wound they may grow just as may a graft of healthy epithelium. The neck, shoulder, the arm to the elbow, the entire surface of 1 See Objects and Limits of Opej'ations for Cancer, by W. Watson Cheyne. DISEASES OF THE BREAST. 869 the chest down to the waist, the breast itself, the axilla, the side and the back must be sterilized. It is necessary to have, besides scalpels, and the ordinary instruments for an opera- tion, a great number of hemostatic forceps (80 to lOo). Place the patient recumbent, with a sand-pillow under the shoul- der of the affected side. The shoulder is right at the edge of the bed, and a nurse holds the arm from the side. Hal- sted describes his operation as follows : ^ The skin incis- ion is made as shown in Fig. 331, and is carried at once through the fat. The triangular skin flap {a, b, r,) is turned '"^C"^^ Fig. 331. — Halsted's operation for carcinoma of the breast : the first incision. down. The costal insertions of the great pectoral muscle and the muscle are split between the clavicular and costal portions and up to a point on the clavicle opposite to the scalene tubercle, and at this point the clavicular portion of the muscle and the tissue overlying it are cut through close to the clavicle, and the apex of the axilla is at once exposed. The cellular tissue under the clavicular portion of the muscle is dissected from the muscle, and the splitting of the muscle is continued on to the humerus. The part of the muscle to be removed is cut through close to its humeral insertion. The whole mass circumscribed by the first incision (skin, breast, areolar tissue, and fat) is raised with considerable force in order to put the submuscular fascia on the stretch as it is stripped from the thorax close to the ribs. It is well to in- clude the delicate sheath of the pectoralis minor muscle. The lower and outer boundary of the lesser pectoral having 1 Johns Hopkins Hasp. Reports, vol. iv. ; Annals of Sitrg., Nov., 1894. 8/0 MODERN SURGERY. been passed and exposed, the muscle is cut at a right angle to its fibers and a little below the middle. The tissue over the minor muscle near its coracoid insertion is divided as far out as possible, and is then reflected inward to prepare for the reflection upward of this part of the minor muscle. The upper portion of the minor muscle is retracted upward (Fig. 332). The small blood-vessels under the minor mus- cle are carefully separated from it, are dissected out very ^\ Fig. 332. — Halsted's operation for carcinoma of the breast : the mass turned down. clear, and are ligated close to the axillary vessels. Having exposed the subclavian vein at the highest possible point below the clavicle, the contents of the axilla are dissected away with a sharp knife and the vein and its branches are stripped absolutely clean. The loose tissue about the artery and the nerves should also be removed. When the vessels are cleared the axillary contents are rapidly stripped from the inner walls of the axilla and the lateral wall of the thorax. The fascia which binds the mass to the chest is cut close to the ribs and the serratus magnus muscle. Just before reaching the junction of the posterior and lateral walls of the axilla, an assistant draws the triangular flap of skin outward in order to spread out the tissue which lies upon the subscapulars, teres major, and latissimus dorsi muscles. The operator cleans the posterior wall of the axilla from within outward. The subscapular vessels are clearly exposed, and are caught before they are cut. In some cases the subscapular nerves are removed, in others they are permitted to remain. Having passed these nerves the mass SKIAGRAPHY, OR EMPLOYMENT OF RONTGEN RA YS. 87 1 is turned back into its normal position and severed from the body of the patient by a stroke of the knife from b to c, repeating the first cut through the skin. Every bleed- ing point, however small, is tied with fine silk, from 60 to 100 ligatures, or even more, may be required. After the completion of the operation the wound into the axilla is closed with a subcuticular stitch of silver wire ; if a cut has been carried above the clavicle, it is closed in the same man- ner, and the edges of the elliptical opening are brought nearer together by a purse-string subcuticular stitch. Thiersch grafts cut from the patient's thigh are used to cover the gap. Silver foil is placed over the wound, this is covered with gauze, bandages are applied, and the dressing is overlaid by a plas- ter-of-Paris bandage, which includes the head, neck, chest, and arm. The area from which grafts were taken is dressed with sterile gauze or an ointment containing boric acid. XXXIX. SKIAGRAPHY, OR THE EMPLOYMENT OF THE RONTGEN RAYS. The cathode rays were discovered by Hittorf, in 1869, while passing an induction current through a vacuum-tube. Crookes of London greatly improved the vacuum-tube, and obtained a rarefaction which left in the tube but the one- millionth of an atmosphere. This last-named observer found that when an interrupted current of high potential is passed through a vacuum which is nearly perfect, fluorescence takes place. In a Crookes tube the positive electrode is placed at some indifferent point, and the current from the negative elec- trode flows not to the positive, but directly to the wall of the tube opposite the cathode, and at this point the phospho- rescent glow is detected. In 1895, Rontgen of Wiarzburg, while making a study of cathode rays as developed in Crookes's tubes, discovered the energy which he named the A'-rays. Rontgen showed that at the wall of the Crookes tube opposite the nega- tive electrode a new and hitherto unknown energy is gen- erated. Because of the uncertain character of this energy he gave to its manifestation the name of the X or unknown rays. The A'-rays are invisible ; cannot be deflected, reflected, refracted, or concentrated ; are not influenced by the mag- net ; and produce none of the ordinarily recognized effects of heat. They cause fluorescence in certain substances, notably in tungstate of calcium (Edison), platinocyanid of 872 MODERN SURGERY. barium (Rontgen), and platinocyanid of potassium. They have a marvellous power of penetration, and pass through many substances which are opaque to sunlight, ultraviolet light, and ordinary electric light. They are readily trans- mitted by water, organic substances, leather, cloth, paper, and flesh. Bone transmits them less easily, and metal still less easily, but no substance absolutely prevents their transmission. An ordinary dry photographic plate is sensitive to the rays. If the rays are intercepted by a body not readily permeable which is placed between the Crookes tube and the photographic plate, a shadow will be cast, and a picture of this shadow will be formed upon the plate. Such a picture is known as a skiagraph or radio- graph. If a body more or less resistant to the rays is placed between the tube and a fluorescent screen, the body casts a shadow on the screen, and the portion of the screen free from shadow glows with fluorescence. Such a screen is known as a fluoroscope. It will thus be seen that the X- rays enable the surgeon to look beneath the skin and to see those things which before the discovery of Rontgen were unseeable during life.^ The real nature of the X-rays is unknown. They are not heat-rays ; they are not ultraviolet rays. Rontgen thinks they are longitudinal ether-waves. Monell says, " They appear to be originated at the site of the greatest electrical activity within the tube, and their real nature is as unknown as the nature of heat, gravity, electricity, mind, and of life itself" To obtain the rays a good apparatus is essential. An ordinary medical battery is incapable of producing them, as it is absolutely necessary to have a current of high tension. The discoverer used a Ruhmkorff coil, but this is by no means the most satisfactory apparatus to employ. Some experi- menters have made use of a " powerful static machine and transformer coils" (Monell). Swinton uses twelve half-gallon Leyden jars and discharges them through the primary coil, the secondary circuit being a Tesla oil coil. The current is best taken from the street-light circuit. Monell says that this current should be controlled by an interrupter, the interruptions of which are 100 per second. The interrupted current is to be passed into an induction coil, and the secondary current is to be conveyed into the Crookes ^ See Rontgen's report to the Physico-Medical Society of Wiirzburg, Dec, 1895 '1 ^'so t^s article upon the X-rays by S. H. Monell, in the Brooklyn Medical Journal, May, 1896. SKIAGRAPHY, OR EMPLOYMENT OF RONTGEN RA YS. 873 tube by two wires. The secondary current thus produced will furnish a spark five or six inches long. When the surgeon is about to use the .\-rays, he must re- move from the person of the individual anything that might cause confusion or lead to error. If the foot is to be exam- ined, remove the shoes, because shoes contain nails ; if the hand is to be examined, remove the gloves if they are fast- ened with buttons of bone or metal ; if the thigh is to be examined, remove coins, keys, knives, etc., from the pocket ; a garter, if it has a metal clasp, should be taken off. In order to get the best results from the Rontgen rays, not only must the apparatus be good, but the man who uses it must be expert. Pictures taken by an unskilled man lack clearness of outline, and may even lead to positively erro- neous conclusions. Nevertheless, a person used to the em- ployment of scientific apparatus can very soon become suffi- ciently expert to take fairly clear pictures which should not lead to error. Morris H. Richardson^ maintains that the Rontgen rays can be employed successfully in the routine office practice of a general practitioner. The surgeon may utilize the A'- rays by means of a fluoro- scope. P^dison's fluoroscope consists of four sides of a box, one end being open and made to fit tightly over the observer's eyes, the other end being closed with cardboard made fluorescent by smearing it with mucilage, and, before the mucilage is quite dry, sprinkling it with crystals of tungstate of calcium. If it is desired to examine the hand with a fluoroscope, the extremity is held opposite an excited Crookes tube and from six to ten inches away from it, the end of the fluoroscope which is covered with fluorescent paper is placed near the surface of the hand which is away from the tube, and the observer looks through the other end of the instrument. The flesh seems but a dim haze and the shadows of the bones are distinctly outlined. The fluoroscope can be easily used, and gives reliable results in studies upon the hands and feet, but when deeper struct- ures are to be investigated, or when absolute accuracy is essential, it is better to take a skiagraph. The value of fluoroscopy is constantly increasing as better electrical appli- ances and Crookes's tubes are being made. If thick tissues require to be penetrated by the rays, if great accuracy is necessary, or if a permanent record is to be retained, a skiagraph must be taken. In taking these pictures dry plates can be used ; the plate need not be re- ' Medical News, Dec, 1S96. 874 MODERN SURGERY. moved from its wooden case during the process, and it is not necessary to conduct the proceeding in a dark room. The tube should be from twelve to fifteen inches away from the surface of the body. The plate must be fastened to the surface exactly opposite the tube. It is necess-ary to ob- serve care in the adjustment of the plate, because the X- rays travel only in straight lines, and any carelessness of adjustment will lead to curious and misleading aberration in the picture. The length of exposure necessary varies with the thickness of the tissues, the structure of the part, the nature of the body we wish a picture of, and the perfection of the apparatus, from three minutes to one hour. Prolonged exposure is undesirable if it can be avoided, as it may produce an JT-ray " burn." The so-called X-ray " burn" is not a burn at all. A burn is due to the contact of heat, is accompanied with pain from the moment of application, and is followed by inflam- matory changes, beginning on the surface. An JT-ray "burn" is not manifest for several days or even several weeks after the application of the rays, at which period an inflammatory or a gangrenous process arises, which begins within the tissues and subsequently involves the surface.^ These burns are often accompanied by loss of hair or nails in the damaged area, they require months to heal, if they heal at all, are very painful, and are not improved by treatment which relieves ordi- nary burns. In some cases the consequences are very serious. In a case reported by J. P. Tuttle, it became necessary to ampu- tate the thigh." The lesions occasionally produced by the X-rays are probably trophic changes. Sections made by Vissman from Tuttle's case indicated that the lesion was a gangrenous process due to arteritis of the smaller vessels. These A''- ray injuries are most liable to occur when a Ruhmkorff coil is used, and no such condition has been caused by a static machine (Tuttle). It has been suggested that a thin piece of aluminum placed upon the part while it is exposed to the A'-rays will prevent the occurrence of these injuries. Skin-grafting may succeed in remedying an ulceration, but, as a rule, the grafts do not grow, or if they adhere, are very apt to break down after a time. In many cases the best treatment is excision (Powell). The uses of the A-rays are legion. They are of the greatest possible value in the location of foreign bodies, especially bodies of metal, glass, or bone, such as bullets, 1 E. B. Bronson, in the debate on J. P. Tuttle's case, Medical Record, March 5, 189S. ^ Med. Record, May 5, 1898. RONTGEN RAYS. Plate 7. ^2 3 1. Gunshot-wound of the Lung. Rib-resection for secondary hemorrhage into the pleural sac ten days after the injury; bullet not removed. Hemorrhage arrested by pack- ing with gauze. Skiagraph taken three months afterward shows the bullet. (Author's case ) 2. Fracture of Lower End of the Femur. Reduction of fragments impossible because of the liiicrposition of a loose piece of bone and much muscle between fragments (Author's case.) 3. Case shown in Figure 2, Three Months after the Operation of Wiring. Nine months after operation, the man is walking about with ease, and the wire is still in place. (The above skiagraphs are from the A'-Ray Laboratory of the jtjfferson Medical College Hospital.) SKI A GRA PH W OR EMPL O YMENT OF R ONTGEN RA I '.9. 875 and needles, glass, splinters, etc. Bullets are readily de- tected in the extremities ; have been found in the lun<,r- substance and bronchi (Rowland), in the brain (Schier, Bris- saud and Londe, Henchen and Sennauer, Bruce, Willy Meyer), in the abdomen, the pelvis, a joint, the spine, and the eye. The A'-rays will enable us after an abdominal operation to locate a Murphy button and tell when it has loosened and descended. Foreign bodies, especially if Fig. 333. — W. M. Sweet's A'-ray apparatus for locating foreign bodies. metallic, in the esophagus, stomach, intestine, and air-pas- sages ; enteroliths, and mineral calculi in the salivary ducts, bladder, ureter, and kidney, can be detected. Henry Morris tells us that a calculus in the kidney may exist and yet escape detection with the rays, because the kidney is very deeply placed, is under the ribs and close to the verte- bral column. Occasionally a drainage-tube lost in the pleural sac may be discovered. Gall-stones cannot be discerned. The rays may fail to disclose a foreign body because of its being overshadowed by a bone(Carless), but prolonged expos- ?,76 MODERN SURGERY. ure or the taking of another picture with the part in another position will bring it into view. In many cases a skiagraph does not indicate how deeply in the tissues a foreign body lies, or upon which side of a bone it is lodged.^ If there is doubt, take several pictures from different positions (tri- angulation), skiagraph over a surface marked in squares, insert guide-needles into the tissues before taking the final picture, or employ Sweet's apparatus. Sweet's apparatus has been used successfully for the location of foreign bodies in the eye, but a modification of the original apparatus has recently been used to skiagraph other regions of the body. Fig. 333 shows this apparatus. The negative ex- hibits the pointers, and the position of the foreign body can be determined by the use of projection-Hnes (Figs. 334, 335). In detecting fractures and dislocations the Rontgen rays are of great value, especially when there is much swelling, when there is little displacement, and when the fracture is in or about a joint. The rays enable us to determine the nature of the injury, the amount of splintering, the exist- ■O. Fig. 334. — Outlines of negative taken by Sweet's method. ence of impaction, the question whether or not the frag- ments are in contact or can be brought into contact ; the direction of the line of fracture, the variety of deformity, the existence of more than one fracture, the presence of epiphyseal separation or dislocation alone or with a fracture, 1 Battle's case in Lancet, Feb. 29, 1896. SKIAGRAPHY, OR EMPLOYMENT OE RONTGEN RA YS. 877 the existence of an ununited fracture, and the question if the sphnts are holding the fragments in accurate apposition. Fractures of the skull, if in\'olving both tables of the vault, may be recognized ; it is possible that fractures of the inner table may be found ; fractures of the base can be seen, but with difficulty (White). Fractures of the spine never show very clearly. To take a picture of a fractured rib, first limit chest-motion by bandaging (White). Morris tells us to be Fig. 335. — Sweet's projection-lines for locating foreign bodies in the eye: a, transverse section ; b, vertical section. The same principle is used in locating foreign bodies in other structures. somewhat skeptical in accepting unreservedly the evidence offered by a skiagraph, as slight carelessness in taking the picture may mean great distortion and consequent error. The A'-rays ma}' be of value in enabling the surgeon to recognize rheumatoid arthritis ; bone- and joint-tuberculosis (the tuber- cular area being lighter than the sound bone) ; the amount of acetabular rim present in congenital dislocation of the hip-joint 8/8 MODERN SURGERY. (Rowland) ; the state of the bones in a crushed Hmb (J. Hall Edwards) ; bone deformity ; osseous tumors ; bone displace- ment (as in Morton's foot) ; osteomyelitis ; caries ; necrosis ; and osteosarcoma. By skiagraphy we are enabled to decide on the proper situation to perform osteotomy, and if a deformity of the foot can be amended without operation (Willard). The position of the fetus in utero can be definitely made out. Applied to the soft parts, the new process has obtained interesting but not as yet many practically useful results. Fibrous tumors can be seen, but malignant tumors, unless they contain calcareous or fibrous elements, cannot be defi- nitely made out ; loose bodies in a joint can often be detected. The shadow of the heart can be made out, and the outlines of the diaphragm, kidney, and liver can be thrown upon the screen. If the stomach is distended with gas, it shows as a light area upon a dark background (Hedley). If food is eaten after being mixed with subnitrate of bismuth, the out- line of the viscus becomes fairly distinct. Thickened pleura, pleural effusion, pulmonary consolidation, pericardial effu- sion, aortic aneurysm; cavities in the lungs, and atheromatous blood-vessels may be made out with more or less distinctness. If a sinus is injected with iodoform emulsion, a picture of it can be taken, because the emulsion casts a shadow when placed in the path of the X-rays (J. Hall Edwards). Up to the present time no positive evidence has been offered to prove that the Rontgen force is possessed of any therapeutic value. XL. INJURIES BY ELECTRICITY. Bffects Produced by I/ightning. — An individual may be struck directly, or he may be shocked by an induced cur- rent, the lightning having struck a nearby object. A person can be struck while in a room, but there is more danger when exposed especially in the open country. To be under a single tree during a thunderstorm is dangerous, but to be in a wood or under a hedge is reasonably safe. The victim of lightning may be killed instantly. Death is the fate of over one third of those struck. Tidy states that out of 54 cases, 21 died and 33 recovered. Post- mortem examination may fail to reveal a lesion, but in many cases severe burns are discovered ; in some there are laceration of tissue, crushing of bones, and fearful injury. Burns are especially apt to occur at the points where the current entered and emerged. The clothes are usually /iVJURIES BY ELECTRICITY. 879 singed and torn. The typical lightning-marks are arborescent tracings, representing the course of blood-vessels, produced by disorganization and effusion of blood as the fluid travels through it. Occasionally metal objects, such as buttons, knives, money, keys, etc., are fused, and spread as a metallic film over a considerable portion of the surface of the body. Bichat stated that in death from lightning rigor mortis does not occur. This statement is now known to be an error (see the three cases reported by M. Tourdes). As a rule, there is early vigor mortis, retained fluidity of blood, and disten- tion of the brain with venous blood. The cause of death by lightning was supposed by Hunter to be due to destruction of muscular contractility, and by Richardson to the resolu- tion of the blood into gases. It seems probable that some deaths are due to actual disorganization of vital structure and that others are due to shock or inhibition. In many cases struck by lightning recovery will take place even when the individual is apparently dead. Sestier reported yj cases struck by lightning, and in 7 of them the persons were apparently dead for a number of hours. ^ Brouardel says in such cases the death-like state may be ascribed to inhibition, caused by a inaxiniuin degree of stimulus.^ When death from lightning is not immediate the condition may be as above outlined, the individual being apparently dead, without ob- vious respiration or pulse. He may be insensible, with slow and labored respiration, a weak and irregular pulse, and dilated pupils, and may remain in this condition for a few minutes or for several hours. The above condition is not to be distinguished from severe concussion of the brain. Every individual suffering from the effects of lightning should have his entire body carefully examined to see if physical injuries exist (fractures, wounds, burns, ecchymoses, arborescent tracings). The consequences of lightning-stroke are many and various. There may be rapid and complete recovery, gradual recovery, traimiatic neurasthenia, sloughing burns, partial paralysis, which is usually recovered from (Noth- nagel), but which may be permanent, hysteria, blindness, change of character, and actual insanity. Treatment. — Do not pronounce a person dead until a thor- ough attempt at resuscitation has been made. Do not give alcoholic stimulants. If the respiration is feeble and apparently ^ Sestier, De la Eotidre, Paris, 1866. Quoted by Brouardel in his lectures upon "Death and Sudden Death.'' ' Benham's translation of Brouardel's lectures upon " Death and Sudden Death." 88o MODERN SURGERY. absent, make tongue traction and artificial respiration. Apply the stream of a cold douche to the head, rub the limbs with mustard, put a mustard plaster over the heart and another to the back of the neck, wrap the individual in hot blankets, and give enemata of hot saline fluid. In some cases venesec- tion has seemed to be of benefit. When the individual reacts treat any existing condition symptomatically, and treat par- ticular physical injuries according to their character. Kffects of Artificial Currents. — Workmen for electric companies ; pedestrians in the streets of a city which is lighted by electricity or in which trolley cars are em- ployed; roofers and firemen are liable to be injured by electricity. An alternating current is decidedly more dangerous than a continuous current of equal strength. An artificial current acts like lightning. It may produce instant death ; it may produce unconsciousness, delirium, ster- torous respiration, Cheyne-Stokes' breathing, or clonic spasms. Its effects can be often recovered from. Not unusually the victim is apparently dead, but subsequently recovers. D'Ar- sonval reports the case of a man who was apparently killed by the passage of 4500 volts. No attempt at resuscitation was made for one-half an hour, and yet he recovered when artificial respiration was employed. Donnellan reports a case of re- covery after the passage of 1000 volts. Slight shocks may cause temporary numbness, and even motor paralysis. An electric shock frequently causes burns or ecchymoses, and oc- casionally wounds. Wounds caused by electricity bleed pro- fusely and are apt to slough. An electric burn looks like a blackened crust ; it is surrounded by pale skin, and for twenty- four hours remains dry, when inflammatory oozing begins and the skin around it reddens. These burns are not as painful as are ordinary burns, but recovery requires a long time. When inflammation begins and suppuration occurs, tissue is exten- sively destroyed, tendons, bones, and joints may suffer, some portions become deeply excavated, and other portions show dry adherent masses of dead and dying tissue, and a burn which was at first small may be followed by a large area of moist gangrene ; ^ lack of tissue-resistance, due to trophic dis- turbance, is largely responsible for the progress of the slough- ing. Treatment. — If a person is in contact with a live wire, the first thing to do is, if possible, to shut off the current. If it is not possible to shut off the current, catch a portion of the ^ See the article by N. W. Sharpe on " Peculiarities and Treatment of Electrical Injuries," in Phila. Med. Jour., Jan. 29, 1898. INJURIES BY ELECTRICITY. 88 1 clothing of the victim and pull him away from the wire, but do not touch his body with a bare hand. If a pair of rubber gloves can be obtained, the subject can be moved with impunity and the wires can be safely cut. If it is not possible to drag a person away from electric wires, the sur- geon can wrap his hands in dry cloth and lift the portion of the body in contact with earth or wire, and thus break the circuit and permit of removal of the bod}'.' A dry cloth can be pushed between the body and the ground, and the body can then be removed from the wires. It may be possible to push the wires away by means of a dry piece of wood, or to cut them with shears which have wooden handles and which are perfectly dry. Treat the general condition in the manner set forth in the article on lightning-stroke (page 879). Very severe burns may be caused. The author has dressed a num- ber of electric burns with hot fomentations of salt solution during the first few days. This facilitates the separation of the sloughs and seems to aid the weakened tissues in resist- ing microbic invasion ; after sloughs separate, the part is dressed with dry sterile gauze. Antiseptic dressings can be used from the beginning, but they often fail entirely to arrest the sloughing. Iodoform produces much irritation. Ointments are very unsatisfactory. When the dressings are changed the part should not be washed with corrosive sublimate, as this agent produces much irritation ; peroxid of hydrogen should be employed, followed by hot normal salt solution. Sharpe removes sloughs by applying the following mixture : 2 parts of scale pepsin, i part of hydrochloric acid, U.S.P. ; 120 parts of distilled water. This mixture is washed off after two hours with peroxid of hydrogen. The same surgeon treats necrosis of bone by injecting every few hours a 3 per cent, solution of hydrochloric acid, using every second day the pepsin solution, and when necrotic areas come away packing with gauze. Skin-grafting by Reverdin's method or Thiersch's method is rarely successful. In some regions it is possible to slide a large flap in place to cover a granulat- ing area which will not heal. In a very severe case amputa- tion or resection may be necessary. ^ See the directions in Aled. Record, Dec. 28, 1895, from Med. Press. 56 INDEX. Abbe's catgut rings in intestinal anastomosis, 689 method of intestinal anastomosis, 690 operation for stricture of esophagus, 623 string saw, 639 Abdomen, diseases and injuries of, 626 operations upon, 666 Abdominal hernia, 699 nephrectomy, 782 section, 666 for appendicitis, 668 wall, contusions of, 626 gunshot-wounds of, 632 penetrating wounds of, 632 wounds of, 632 Abernethy's extraperitoneal method of ligat- ing external iliac artery, 306 Abscess, acute, 96 symptoms of, 99 appendicinal or appendicular, 100 treatment of, 103 Bezold's, 563 Brodie's, 312 cerebral, 560 cold, 105, 106 of lymphatic glands, 108 diagnosis of, 102 diffused, 98 dorsal, 107 extradural, 560, 564 forms of, 98 healing of^ 87 iliac, 107 intramammary, 861 ischiorectal, 721 large cold, 109 lumbar, 107 lymphatic, 98 mediastinal, loi metastatic, 99 of antrum of Highmore, loi, 596 treatment of, 103 of bone, 312 chronic, xo8 of brain, 100, 560 symptoms of, 561 treatment of, 103, 562 of breast, 101, 860 acute, 861 chronic, 108 treatment of, 103 of cerebellum, 577 of frontal sinus, 597 of hip, 414 of kidney, 774 of larynx, loi of liver, 100, 660 treatment of, 102 of lung, loi, 607 pneumotomy for, 611 treatment of, 103 of lymphatic glands, loB of mammary gland, cold, 109 of maxillary antrum, 596 Abscess of mediastinum, loi treatment of, 103 of prostate from gonorrhea, treatment of, 821 of scalp, 540 of spleen, 665 of temporosphenoidal lobe, 576 opening of, 104 Paget's, 99 palmar, loi, 511 perinephric, loi, 776 perinephritic, loi 776 postpharyngeal, 107 prognosis of, 102 prostatic, loi psoas, 107, 109 residual, 99 rest in, 63 retromammary, 861 retropharyngeal, 107 scrofulous, 98 shirt-stud, 105 subdural, 560 subphrenic, 100, 657 treatment of, 102 tubercular, 105 varieties of, 98 Acetanilid, 28 as a drying-powder, i66 AchiUodynia, 219 Acid, carbolic, as an antiseptic, 25 Acquired syphilis, 185 Acromegaly, 320 Actinomyces, 183 Actinomycosis, 18, 183 cutaneous, 183 of bone, 194, 309 treatment of, 184 "Active clot," 247 Active hyperemia, 48 Actol, 29 Acupressure in hemorrhage, 262 in secondary hemorrhage from atheroma- tous vessels, 273 in treatment of aneurysm, 255 in varix, 243 Acute abscess, 96, 98 symptoms of, 99 rheumatism, 425 tetanus, 144 Adamciewicz on cancer-cells, 211 Adams's operation, 477 saw, 475, 476 Adenitis, tubercular, 154 Adenocele of mammary gland, 864 Adenoid cancer, 236 Adenomata, 232 cystic, of mammary gland, 864 treatment of, 233 Aerobic bacteria. 23 Agnew's dressing for fracture of femur, 392 operation for webbed fingers, 521 splint for patella. 396 Air-passages, foreign bodies in, 599 883 884 INDEX. Albert's disease, 2ig, 514 Albuminuria in syphilis, ig8 Alcoholic unconsciousness, 547 Aleppo boil, 740 Alexander's method of prostatectomy, 837 method of treating snake-bite, 178 rules fur catheterization in hypertrophy of prostate, 836 Alexins, 32 Alimentary canal, foreign bodies in, 633 tuberculosis of, 153 Allingham"s decalcified bone bobbin, 685 method of excision of hemorrhoids, 716 Allis ether inhaler, 729 Aliis's rule for reduction of dislocation of femur, 465 sign, 384, 463, 464 Ailoxur bodies in the urine, 88 Almen's test for blood in urine, 764 Alopecia in syphilis, 195 treatment of, 203 Aluminum probe, Fluhrer's, 172 Alveolar sarcoma, 228 Ambulatory treatment of fractures, 336 Amotile bacteria, 17 Amputation, 841 a la manchette, 845 at ankle-joint, 853 Pirogofif's method, 853 Syme's method, 853 at elbow-joint, 849 at hip-joint, 857 by bloodless method of Wyeth, 857 Jordan's, 859 Larrey's method, 858 Liston's, 854 at knee-joint, 855 at metacarpophalangeal joint, 847 at middle tarsal joint, 852 at the shoulder-joint, 849 Dupuytren's method, 859 Larrey's method, 849 Lisfranc's method, 850 at tarsometatarsal articulation, 850 Hey's method, 852 Lisfranc's method, 850 at wrist-joint, 848 by transfixion, 846 Chopart's, 852 circular, 844 modified, 845 classification of, 841 during shock, 164 elliptical, 846 flap method, 846 for aneurysm, 254 for chondroma, 218 for compound fracture, 339 for gangrene, 131 for gunshot-wounds, 174 for malignant edema, 173 for osteoperiostitis, 311 for sarcoma of a long bone. 229 for snake-bite, 178 in diabetic gangrene, 127, 128 intermediate, 842 methods of, 844 modified circular, 845 of the arm, 849 of fingers, 847 distal phalanx of, 847 middle phalanx of, 847 proximal phalanx of, 847 of foot, 850 Chopart's, 850 Forbes's, 853 Hey's, 852 Lisfranc's, 850 ( Amputation of forearm. See Amputation tliro7igh /breariii. of hand, 847 of leg, 854 by lateral flaps, 855 by long posterior and short anterior flap, 855 by rectangular flaps, S54 Garden's method, 856 Gritti's method, 856 just below knee, 855 modified circular, 854 SabanejefTs method, 856 Sedillot's method, 854 Syme's method, 855 through femoral condyles, 855 through knee-joint, 855 of penis, 833 of thigh, 856 Bell's method, 857 of thumb, 848 of toes, 850 oval, 846 prevention of hemorrhage in, 842 primary, a42 racket, 846 secondary, 842 T-shaped, 858 through the forearm, 848 by Teale's method, 848 Wyeth's bloodless, of hip-joint, 857 Amyloid degeneration due to syphilis, 198 Anaerobic bacteria, 23 Anastomosis, intestinal, 681 rings, 681 Anatomical snuff-box, 282 tubercle, 152 Anderson's method of tendon-lengthening, 519 Anel's operation for aneurysm, 252 Anesthesia, 725 by freezing, 734 general, 725 local, 734 preparation for, 725 primary, 732 treatment of complications of, 730 Anesthetic state from ether or chloroform, 729 Anesthetics, 725 Anesthetization as a cause of shock, 162 Aneurysm, 245 acupressure in, 255 acute, 245 amputation for, 254 arteriovenous. 245, 255 by anastomosis, 245, 256 capillary, 246 causes of, 247 circumscribed, 246 cirsoid, 226, 246, 256 symptoms and treatment of, 257 consecutive, 245 cylindrical, 246 diagnosis, 249 from cyst or abscess, 249 from growths beneath a vessel, 249 dissecting, 245 electrolysis in, 254 embolic, 246 false, 245 forms of, 245 fusiform, 245 miliary, 246 -needle of Dupiiytren, 279 of bone, 245 of Saviard, 278 operation for, Anel's, 252 Antyllus's, 252 Brasdor's, 254 INDEX. 885 Aneurysm, operation for, Hunter's, 252 W'ardrop's, 254 operative treatment of, 252 Pott's, 255 pulsation of, 248 sacculated, 245 secondary, 246 spontaneous, 246 symptoms of, 248 traumatic, 245 treatment of, 250 by digital pressure, 251 by direct pressure, 251 by ligation, 252 by pressure, 251 by rapid pressure, 251 'Juffnell's plan of, 250 traumatic, 255 true, 245 varicose, 255 treatment of, 256 verminous, 246 Aneurysmal bruit, 248 varix, 255 symptoms of, 256 treatment of, 250 Angioma of mammary gland, 864 Angiomata, 225 capillary, 225 cavernous, 225 plexiform, 226 simple, 225 treatment of, 226 Angular curvature of spine, 583 Ankle-joint disease, 419 dislocations of, 471 Ankylosis, 435 extra-articular, 436 false, 436 treatment of, 437 fibrous, 435 intra-articular, 435 true, 435 treatment of, 435 Anodynes in inflammation, 76 Antagonistic microbes, 36 Antemortem thrombus, 133 Anterior angular splint, Stromeyer's, 421 triangle of the neck, 201 Anteroposterior curvature of spine, 582 Anthrax, 178 benign, 740 carbuncle, 179 edema of, differentiation from cellulitis, 179 external, 179 forms of, 179 internal, 1 79 intestinal, 180 pulmonary, 180 treatment of, 179 Antinosin, 28 Antiphlogistic regimen, 80 Antipyretics in inflammation, 76 Antisepsis, 42 Antiseptic poultice, 71 as a wound dressing, 166, 167, 175 Antistreptococcic serum, 36 in erysipelas, 142, 143 in septicemia, 138 Antitoxin of tetanus, 148 Antitoxins, 32 Antivenene serum, 178 Antrum of Highmore, diseases and injuries of, 596 inflammation and abscess of, 596 Antyllus operation for aneurysm, 252 Anus, diseases and injuries of, 713 fissure of, 724 Anus, imperforate, 722 prolapse of, 717 pruritus (jf, 724 Apathetic shock, 162 Aplastic lymph, 92 Appendicinal abscess, 100 Appendicitis, 647 abdominal section in, 668 catarrhal, 650 etiology of. 648 foreign bodies as a cause of, 649 forms of, 650 gangrenous, 651 obliterative, 650 operation for, 668 pathology of, 648 simple parietal, 650 stercoral, 649 suppurative, 651 symptoms of, 651 terminations of, 653 traumatic, 649 treatment of, 653 Appendicular abscess, 100 treatment of, 103 colic, 649, 650 lilhiasis, 648 Approximation of divided intestines, con- sideration of methods of, 693 Arachnitis, 557 Arcus senilis, 121 Ardor urinae in gonorrhea, treatment of, 821 Argonin, 29 Aristol as a drying-powder, 166 Arm, amputation of, 849 Arnot, grafts of the lining membrane of hen's egg, 760 Arterial filter, 715 pyemia, 139 sclerosis from syphilis, 198 sedatives in inflammation, 74 transfusion, 278 Arteries, ligation of, in continuity, 278 wounds of. 257 Arteriovenous aneurysm, 255 Arteritis, 243 acute, 243 treatment of, 244 chronic, 243 treatment of, 244 in syphilis, 196 obliterative, 244 syphilitic, 244 Arthrectomy, 485, 486 Arthritis, 408 acute infantile, 318 suppurative, 422 deformans, 426 symptoms of, 427 treatment of. 428 gonorrheal, 423 gouty, 426 in hereditary syphilis, 207 infective, 422 neuropathic, 429 rheumatic, 425 rheumatoid, 426, 'se.e. Arthritis deformans. tubercular, 408 pathology and symptoms of, 408 treatment of, 410 typhoid, 422, 423 Arthopathie des ataxiques, 439 Arthropathy, tabetic, 429 Articular neuralgia, 431 Artificial anus, 645 leech, Heurteloup's, 65 Ascococci. 20 Asepsis, 42 886 INDEX. Aseptic fever, 87 gauze, 46 pus, 93 Aseptic wounds, 161 Ashton's aseptic gauze pads, 44 Asphyxia, local, 126 Aspiration of joints, 488 Aspirator, pneumatic, 484 Assaky method of nerve-suturing, 531 Astringents in inflammation, 68 Ataxia from syphilis, 198 Atheroma, 243, 244 Atony of bladder, 790 Atrophy of bone, 309 concentric, 309 eccentric, 309 of muscles, 505 of thyroid gland, 743 Autotransfusion in shock, 164 Aveling syringe in transfusion, 277 Axillary artery, anatomy of, 286 ligation of, 286-288 Bacillus anthracis, 41 coli communis, 41 mallei, 41 of anthrax, 41 of glanders, 41 of gonorrhea, 39 of Koch, 149 of Loffler a cause of glanders, 182 of Lustgarten, 41 of malignant edema, 41 of Neisser, 39 of Nicolaier, 144 of syphilis, 41 of tetanus, 144 of tuberculosis, 40, 149 of typhoid fever, 41 pyocyaneus, 39 antagonistic to anthrax, 179 pyogenes foetidus, 39 tetani, 40 tuberculosis, 40, 149 ' Bacteria, 17 aerobic and anaerobic, 23 amotile, 17 distribution of, 30 effect of motion, heat, and cold upon, 23 life conditions of, 22 motile, 17 multiplication of, 21 parasitic, 19 pathogenic, 19 action of, 31 Bacterial proteid, 31 Bacteriology, 17-41 Bacterium coli commune, 41 termo, 41 Balanitis, 816 treatment of, 821 Balanoposthitis, 816, 821 Bald patch in syphilis, 194 Baldness from syphilis, 195 Bandage, American, of the foot, 751 Barton's, 347, 752 Borsch's, for eye, 753 circular, 748 cord, 758 cravat, 758 crossed, of angle of jaw, 753 of both eyes, 752 demi-gauntlet. 749 Desault's, 756 Esmarch's, 842 figure-of-8, of both eyes, 752 of jaw and occiput, 752 of thigh and pelvis, 754 Bandage, gauntlet, 749 Gibson's, 347, 753 Hamilton's, 347 handkerchief, 758 oblique, of jaw, 753 oblong, 758 of elbow, 755 of foot covering the heel, 751 not covering the heel, 751 French, 751 of neck and axilla, 755 plaster-of-Paris, 758 recurrent, of head, 757 of stump, 758 Ribbail's, 751 Selva's thumb, 750 silicate-of-sodium, 759 spica, of groin, 754 of instep, 751 of shoulder, 754 of thumb, 750 spiral, 748 of all the fingers, 749 of foot covering the heel, 751 of palm or dorsum of hand, 749 of upper extremity, 748 reversed, of lower extremity, 750 T-, of perineum, 758 triangle, 75S Velpeau's, 755 Bandages, 748 Barker's needle for wiring fractured patella, 398 operation for excision of vermiform appen- dix, 669 point, 539 Barton's bandage, 347, 752 fracture, 377 Basedow's disease, 745 Bassini, method of operating for femoral her- nia, 705 Bassini's operation for inguinal hernia, 703 Bayer, treatment of spina bifida, 578 Beast-mimicry in hydrophobia, 181 Bed-sore, 117, 130 Bees, stings of, 176 Belfield's'method of prostatectomy, 837 Bellocq cannula in packing nares, 268 Bell's amputation at shoulder-joint, 850 of thigh, 857 Benign anthrax, 740. See Carhmcle. tumors, 214, 231 Bent tibia, osteotomy for, 477 Bezold's abscess, 563 Bichat's fissure, location of. 535 Bier's method of amputation of leg by lateral flaps, 855 method of treating tuberculosis, 56 Bigelow's evacuator, 803 lithotrite, 804 operation, 803 Bigg's apparatus for bunions, 515 Bile-ducts, rupture of, 631 Billroth's method of lateral intestinal anas- tomosis, 682 Bites of insects and reptiles, 176 of snakes, 177 Black sarcoma, 228 Bladder, aspiration of, 787 atony of, 790 chronic catarrh of, 796 contusion of, 787 diseases and injuries of, 784 female, growths in, 809 hemorrhage from, 766 inflammation of, 794 nervousness of, 767 operations on, 799 INDEX. %zr Bladder, rupture of, 788 stone in, 790. See Vesical calculus. tumors of, 798 wounds of, 788 Blastomycetes, 18 Bleeding from kidney, 764 from ureter, 764 general, in inflammation, 73 local, in inflammation, 63 methods of, 64 Blind boil, 740 Blisters in inflammation, 72 Bleeders, 263 Bleeding. See Hemorrhage. Blood in urine, tests for, 763 loss of, 258 -serum, germicidal power of, 35. See Hem- orrhage. transfusion of, 276 Bloodletting in atheroma, 244 Blue ointment, 69 pus, 95 Bodine's method of colostomy, 695 Boil, 739. See Furuticle. Aleppo, 740 blind, 740 Bond's splint, 379, 380 Bone, abscess of, 312 symptoms of, 312 treatment of, 312 actinomycosis of, 309 atrophy of, 309 as a predisposing cause of fracture, 327 caries of, 313. See Caries. -chips for filling bone cavities, 317 Seun's decalcified, 48 chronic abscess of, 108 cyst of, 309 felon, 513 ferrule, Senn's, 481 -grafting, 316 gummata of, 309 healing of, 86 hypertrophy of, 309 inflammation of, 309 -marrow in treatment of osteomalacia, 321 necrosis of, 314 from osteitis, 310 sclerosis of, from osteitis, 310 tubercular diseases of, 154 tubercle of, 309 tumors of, 309 Bones, affections of, in syphilis, 195 diseases and injuries of, 309 diseases of, 309 of skull, diseases and malformations of, 535 operations upon, 475 Boric acid, 29 as a drying-powder, 166 Borsch's eye-bandage, 753 Bose's method, 603 Bottini's cauterization of prostate, 837 Bougie, esophageal, 621 filiform, 786 Bowel, obstruction of, 639 ulcer of, 646 Bow-legs, 522 Boyer's cyst, 514 Brachial artery, anatomy of, 284 ligation of, 284-286 Brain, abscess of, 100, 560 compression of, 545 concussion of, 543 diseases and malformations of, 541 -disease from suppurative ear disease, 562 hernia of, 557 inflammation of, 557 Brain, laceration of, 543 malformations of, 541 -operations, technique of, 573 syphilis, 190 tumor of, 562 water on, 559 wounds of, 554 Brainard's bone-drills, 482 Brandt's operation of stomach-reefing, 681 Brasdor's operation for aneurysm, 254 Breast, abscess of, loi, 860 acute abscess of, 861 chronic abscess of, 108 diseases of, 859 inflammation of, 860 Bridge, periosteal, in simple fracture, 332 Brodie's abscess, 99, 106, 312 joint, 430 Bronchocele, 743 Bronchus, foreign body in, 600 Brunonian movements, 17 Bruns's upward extension method of leduc- ing shoulder-joint dislocations, 453 Brush-burn, 167 Bryant's extension for fracture of thigh ir» children, 394 triangle, 384 Bubo, chancroidal, 831 in gonorrhea, treatment of, 821 syphilitic, 190 treatment of, 199 Buck's extension-apparatus, 386 Buffycoat, 62 Bunion, 515 Burns, 736 symptoms of, 736 treatment of, 736 A'-ray, 874 Bursitis, 514 gluteal, 414 Butcher's method of excision of metatarsal bone of great toe, 498 Button, Murphy's, 63i, 683 Calculus, renal, 772 vesical, 790. See Vesical calculus. Callous ulcer, 117 Callus, 333 Calmette's antivenene serum, 178 Calomel as a drying-powder, 166 fumigation in syphilis, 201 Calyx-eyed needle, 672 Cancers, 233. See Carcinomata. adenoid, 236 autotransference of, 212 causes of, 210-212 contagiousness of, 211 en cuirasse, 867 glandular, 236 •houses, 211 melanotic, 236 of lip, operation for, 618 of mammary gland, acinous, 866 duct, 868 treatment of, 868 of penis, 833 of rectum, 720 rest in, 63 of stomach, 634 symptoms of, 634 treatment of, 635 of tongue, differentiation of, from chancer, 189 Cancerous cachexia, 234 Cancrum oris, 129 Cannon-balls, wounds by, 171 Cannula 4 chemise, 270 Capillary angiomata, 225 INDEX. Caput medusae, 242 succedaneum, 543 Carbolic acid, 25 poisoning by, 26 Carbuncle, 740 treatment of, 741 Carcinoma, 233. See also Cancer. classification of, 234 colloid, 236 cylindrical-celled, 236 encephuloid, 236 hematoid, 236 of mammary gland, 866 scirrhous, 235 spheroidal-celled, 235 telangiectactic, 236 treatment of, 236 Carden's amputation of leg, 856 Cardia, stenosis of, 637 Carditis, 240 Caries, 313 necrotica, 313 of spine, 583 treatment of, 586 of vertebrae, Treves's operation for, 483 sicca, 313 symptoms of, 313 treatment of, 314 tubercular, 313 Carotid triangles, inferior and superior, 292 " Carrying function," loss of, as a symptom of fracture of internal condyle of humerus, 369, 370 Cartilage, healing of, 87 inflammation of, 54 Cartilages, floating, 437 Caseation of tubercles, 149 Caseous abscess, 98 pus, 95 Castration, 839 double, for myoma of prostate, 223 for sarcoma of testicle, 229 Catarrh, chronic urethral, 817 Catgut, 45 chromicized, 45 preparation of, 45 Catheter coude, 787 proper curve of, 786 Catheterization in organic stricture, 785 in spasmodic stricture, 786 Cauterization of snake-bites, 177, 278 Cautery, actual, as a hemostatic, 262 in umbilical hemorrhage, 269 in caries, 314 in treatment of anthrax wound, 179 Cavernous angiomata, 225 lipoma, 214 Celiotomy, 666 Cell-division, 85 Cell-proliferation in inflammation, 53 Cellulitis, 143 diffused, 96 Cellulocutaneous erysipelas, 143 Cementome, 219 Centipedes, sting of, 176 Cephalhematoma, 543 Cephalic tetanus, 145 Cephalodynia, 504 Cerebral abscess from ear disease, 563 concussion, 162 hemorrhage, 548, 549 irritability, 544 Cervical lymphadenitis, diagnosis of, from lymphadenoma, 155 Chalk-stone, 426 Chancer, 186 and chancroid, mixed infection, 188 diagnosis of, 188 Chancer, differentiation of, from cancer of the tongue, i8g from chancroid, 188 from herpetic ulceration, 189 from phagedenic ulcer, 189 hard, 187 Hunterian, 187 infecting, 187 multiple, 187 soft, 831. See Cha7zcroid. treatment of, 199 Chancroid, 1S8, 831 mixed infection, 188 treatment of, 832 Chancroidal bubo, 190 Charbon, 178. See Anthrax. Charcot, acute bed-sore of, 130 Charcot's disease, 429 joint, 429 spontaneous dislocation in, 439 Cheese-cloth dressings, 46 Cheesy abscess, 98 Cheiloplasty, 618 Chemical germicides, 24 Chemiotaxis, 17 Chemotaxis, 17 Chest, contusions and wounds of, 606 diseases and injuries of, 605 Chiene's method of locating fissure of Ro- lando, 536 Cheyne's operation for femoral hernia, 705 Chilblain, 738 Chionypha Carteri, 19 Chlorid of ethyl, anesthesia by, 734 Chloroform, administration of, 728 as a cause of shock, 163 as an anesthetic, 726 Cholecystenterostomy, 664, 697 Cholecystostomy, 664, 697 Choledochoduodenotomy, 664 Choledochotomy, 664 Cholelithiasis, 661 Cholesteatoma, 217 Chondromata, 217 treatment of, 218 Chondrosarcoma, 229 Chopart's amputation, 852 Chordee, 816 Chromicized catgut, 45 , Chronic abscess, 98 gangrene, 120 tetanus, 145 Choroiditis in syphilis, 196 Cicatricial stenosis of orifices of stomach, 637 Cicatrization, 83 Cinnamic acid, 29 Circumcision, 833 Circumclusion, 262 Circumscribed abscess, 98 Cirsoid aneurysm, 226, 256. See Aneurysm. Clap, 815. See Gonorrhea. Clavicle, dislocation of, 445 excision of, 498 fracture of, 358, 362. See Fracture. Clavus, 741 Cleft palate, 612 operation for, 615 Cloaca of bone, 315 Closure of wounds, 166 Clot, " active," 247 external, 257 internal, 257 removal of, from wounds, 165 Clove hitch, 453 Club-foot, 523. See Talipes. Club-hand, 523 Cocain hydrochlorate, anesthesia by, 734 Cocain-poisoning, 73 INDEX. 889 Coccidium oviforme as a cause of dilatation of bile-ducts in rabbit, 212 Coccus, 19 Coccygodynia, 358 Coccyx, fracture of, 357 Cock's operation of perineal urethrotomy, 830 Cohnheim, inclusion theory of, 210 Coin-catcher, 626 Cold abscess, 98, 105, 106 of lymphatic glands, 108 effects of. 738 Coley's method of treating sarcoma, 230 Colic, appendicular, 651 CoUes's fracture, 277 differentiation of, from backward disloca- tion of the wrist, 458 immunity, 185 law, 206 Collin's apparatus for transfusion, 277 Colloid carcinoma, 236 Colopexy, 718 Colostomy, inguinal, 694 Colpeurynter in rectal hemorrhage, 269 Coma, varieties of, 546 Common carotid artery, anatomy of, 293 ligation of, 293-295 Compression of brain, 545 diagnosis of, 546 differentiation of, from alcoholic uncon- sciousness, 547 from apoplexy, 547 from diabetic coma, 547 from hysterical coma, 546 from opium-poisoning, 547 from post-epileptic coma, 546 from uremic coma, 547 symptoms of, 546 treatment of, 547 of spinal cord, 592 Concealed hemorrhage, diagnosis of, from shock, 163 Concentric atrophy of bone, 309 Concrete pus, 95 Concussion, cerebral, 162 rest in, 62 of brain, 543 symptoms of, 544 treatment of, 545 of spinal cord, 591 Condylomata, flat, 193 in syphilis, 194 Congenital deformities of spine, 577 hernia, 712 hydrocele, 840 phimosis, 833 " rickets," 158 wry-neck, 520 Congestion of thyroid gland, 743 Congestive abscess, 98 Consecutive abscess, 98 Contagious pus, 95 Contraction, Dupuytren's, 519 of muscles, 509 Contused wounds, 167 Contusions, 160 of abdominal wall, 626 of bladder, 787 of chest, 606 of head, 543 of muscles, 507 of nerves, 530 of spinal cord, 591 symptoms of, 161 treatment of, 161 with gangrene, 161 Cooper's method of ligating external iliac artery, 408 Cooper's method of reducing shoulder-joint dislocations, 453 for reduction of elbow-joint dislocations, 455 Coraceous abscess, 99 Cord bandage, 758 Corn, 741 treatment of, 742 Cornea, inflammation of, 54 Corona venerea, 193 Corrosive sublimate, 24 Costal cartilage, fracture of, 352 Counterextension in fracture, 335 Counlerirritants in inflammation, 72 Counterirritation in ostitis, 311, 312 Coxa vara, 526 Coxalgia, pain in, 57 Coxitis, 411. See Tu/ierculosis of hip- joint. Craniocerebral topography, 535-539 Craniometrical points, 536 Craniotomy, linear, 577 Cravat, 758 Crawling paralysis, 592 Crepitation in fracture, 329 Crepitus in fracture, 329 Crequy's method of removing foreign bodies from esophagus, 626 Cretinism, 743 Cripp's operation, 720 Critical abscess, 98 Croupous lymph, 92 Cuneiform osteotomy, 475, 477 Cupping, 65 of blood-clot, 62 Curdy pus, 95 Curling's ulcer, 646 Curvature of spine, 580 angular, 583 anteroposterior, 582 lateral, 580 Cushuig's right-angled suture, 673 Cut throat, 598 Cutaneous erysipelas, 141 Cuticular membrane of echinococcus cyst, 239 Cyanosis from use of acetanilid, 28 Cylindroma, 229 Cyrtometer, 537, 539 Horsley's, 536 Cyst, lacteal, 865 of mammary gland, 864 Cystic goiter, 743 Cystitis, 794 acute, symptoms of, 795 treatment of, 795 chronic, symptoms of, 796 treatment of, 796 from gonorrhea, treatment of, 821 rest in, 63 tubercular, 798 Cystocele, 699 Cystotomy, 808 in cystitis, 63 median, 809 suprapubic, 808 for hemorrhage from prostate, 270 for myoma of the prostate, 223 Cysts, 237 dentigerous, 219 dermoid, 238 treatment of, 238 hydatid, 238 treatment of, 239 of pancreas, 665 sebaceous, 237 treatment of, 238 varieties of, 237 890 INDEX. Czerny-Lembert suture, 673 Czerny's method of tendon-lengthening, 519 Dactylitis in syphilis, 207 Dalton, suture of the pericardium, 240 " Dangerous area," 540 Darier, psorosperm, 212 D'Arsonval's case of electric stroke, 880 Davaine, method of treating malignant pus- tule, 180 Davy's director, 479 DecoUement of parietal pleura, 612 Decubital gangrene, 130 ulcer, 117 Decubitus, 117, 130 Deep abscess, 09 Degeneration, gelatiniform, 409 of muscles, 505 pulp}-, 408 reactions of, 527 Delayed union, treatment of, 341 Delirious shock, 163 Delirium in shock, 163 Delitescence of inflammation, 55 Demarcation, line of, 121 Demigauntlet bandage, 749 Demosthen's studies of action of Mannlicher rifle, 160 Dentigerous cysts, 219 Depletion in inflammation, 63 Depression-fracture, 522 Dermatitis venenata, 739 Dermoid cysts, 238 Desault's apparatus, 756 bandage in fracture of clavicle, 360, 361, 446, 447 in fracture of humerus, 364 in fracture of scapula, 362, 363 sign, 384 Descendens noni nerve as a guide to sheath of common carotid in ligation, 293 Diabetic gangrene, 127 Diapedesis in inflammation, 52 Diaphoretics in inflammation, 75 Diaphragmatic hernia, 713 Diarrhea of constipation, 642 Diastasis, 324 Diathetic abscess. 98 Dickinson's theory, amyloid degeneration, 415 Diday's operation for webbed fingers, 521 Diefienbach plan of treating old traumatic dislocations, 444 Diffuse lipoma, 214 Diffused abscess, 98 Digestive tract, diseases and injuries of, 612 Digital dilatation of pylorus, 674 Digits, supemumeraiy, 521 Diphtheria, tracheotomy in, 603 Diplococci, 20 Diplococcus of gonorrhea, 39 Direct cell-division, 85 Disarticulation at ankle-joint, 853 at elbow-joint, 849 at hip-joint, 857 at knee, 855 at metacarpophalangeal joint of hand, 847 at shoulder-joint, 849 at tarsometatarsal articulation, 850 Disease production, 31 of esophagus, 612 of genito-urinary organs, 763 of the head, 535 of the joints, 406 of kidney, 768 of lymphatics, 746 of mouth, 612 of rectum and anus, 713 of scalp, 539 Disease of skin and nails, 739 of thyroid gland, 743 of tongue, 612 Disinfection of hands, 43 of instruments, 44 of patient, 44 Dislocated kidney, 769 Dislocations at metacarpophalangeal articula- tions, 459 axillary, 449 bilateral, 439 complete, 438 complicated, 438 compound, 438 traumatic, 443 congenital, 439 consecutive, 439 double, 438 habitual, 439 incomplete, 438 Monteggia's, 467 Nelaton's, 472 of ankle-joint, 471 anteroposterior, 472 lateral, 471 upward, 472 of astragalus, 473 of carpal bones, 459 of clavicle, 445 acromial end, 447 backward, of sternal end, 446 sternal end, forward, 445 upward, 446 of costal cartilages, 461 of elbow-joint, 454 backward, 455 forward, 455 inward, 456 outward, 456 of femur, 461 downward into obturator foramen, 465 ischial, 467 on to dorsum of ilium, 462 on to the pubes, 466 into sciatic notch, 464 Monteggia's, 467 perineal, 4O7 subspinous, 467 suprapubic, 467 supraspinous, 466 with catching up of sciatic nerve upon reduction, 467 of fibula, 471 of forearm, lateral, 456 of head of femur with fracture of shaft, 467 of hip, anomalous, 466 congenital, operation for, 503 of hip-joint, 461. See Dislocations of fe^nur . of humerus, 448 of inferior radio-ulnar articulation, 459 of knee, 468 backward, 468 forward, 468 inward, 469 outward, 469 of lower jaw, 444 of metacarpal bones, 459 of metacarpophalangeal joint, 459 of metatarsal bones, 474 of muscles, 509 of patella, 469 edgewise, 470 of pelvis, 461 of phalanges, 460, 474 of radius backward, 457 forward, 456 outward, 457 INDEX. 891 Dislocations of ribs, 461 of scapula, lower angle, 448 of semilunar cartilages of knee, 470 of shoulder-joint, 448 diagnosis of, 451 reduction by extension, 452 symptoms of, 449 treatment of, 451 of spine, 592 of sternum, 461 of tarsal bones, 474 of tendons, cog of ulna at elbow-joint, 456 of ulnar nerve at elbow, 529 of the wrist, 458 backward, 458 forward, 458 old, 438 partial, 448 pathological, 449 primitive, 438 recent, 43S relapsing, 439 sacro-iliac, 461 secondary, 438 simple, 438 single, 438 spontaneous, 439 subastragaloid, 473 subclavicular, 449 subcoracoid, 448 subglenoid, 449 subspinous, 449 traumatic, 438 causes of, 440 compound, 443 diagnosis of, 441 old, 443 pathological conditions of, 440 recent simple, 442 special, 444 symptoms of, 441 treatment of, 442 unilateral, 438 with fracture, treatment of, 338 Dislocations, 438 Displaced liver, 661 Displacement in fracture, 327 in plastic surgery, 760 Dissection-wounds, 175 Diuretics in inflammation, 76 Diverticula of esophagus, 623 Division of sternocleidomastoid for wry-neck, 316 Donnellan'b case of electric stroke, 880 Dorsal abscess, 107 Dorsalis pedis artery, ligation of, 298, 299 Douche in inflammation, 69 Doyen, exploratory operation of, 573 Drainage, 47 of wounds, 166 Dressings, gauze, 46 of wounds, 166 Dropsy, 407 of joint in gonorrheal arthritis, 424 Dry aseptic method, 42 cold in inflammation, 66 gangrene, 119, 120 treatment of, 122 heat in inflammation, 71 Drying-powder in wound dressings, i66 Duality theory of syphilitic infection, 187 Dugas's sign, 449 Dupuytren's aneurysm-needle, 279 classification of burns, 736 contraction, 520 symptoms of, 521 fracture, 472 Dupuytren's operation for amputation at shoulder-joint, 850 splint, 403 suture, 673 Ear. affections of, in syphilis, 195 disease, cerebral abscess from, 563 brain-disease from, 562 Eberth's bacillus, 41 Eccentric atrophy of bone, 309 Ecchondroses, 218 Ecchymosis, 160 Echinococcus as a cause of hydatid cysts, 238 Eczematous urethritis, 815 Edebohls's method of treating mobile kidney, 770 of nephrotomy, 780 Edema, 91 from fracture, treatment of, 338 in anthrax, 179 malignant, from wounds, 175 of glottis, 598 of larynx, 598 periarticular, 407 treatment of, gi " Educated corpuscle," 34 Elbow, miners', 515 -joint disease, 420 dislocations of, 454 excision of, 490 Election, triangle of, 292 Electric stroke, effects of, 880 treatment of, S80 Electricity, injuries by, 878 Electrolysis in aneurj'sm, 250, 254 in angiomata, 226 Electropuncture for cirsoid aneurysm, 257 for delayed union of fractures, 341 Elephantiasis, 747 arabum, 747 Elevation in treating contusions, 161 in treating inflammation, 63 in treatment of hemorrhage, 262 Embolic abscess, 98 Embolism, 134 fat, 135 symptoms of, 134 treatment of, 135 Embryonic tissue, 53 formation of, in healing, 83 formation of, in inflammation, 91 Emphysema, gangrenous, 125 from wounds, 175 Emphysematous abscess, 98 Emprosthotonos in tetanus, 145 Empyema, 102, 605 En bissac, reduction of hernia, 710 Encephalitis, 559 Encephalocele, 541 Encephaloid carcinoma, 236 Enchondromata, 217. See Chondromata. Encysted abscess, 99 Endarteritis in syphilis, 196 Endo-appendicitis, 651 Endocyst, 239 Endospore, 22 Enterectomy, 681 Enteritis, rest in, 63 Enterocele, 699 Enteroclysis in shock, 163 Entero-epiplocele, 699 Enteroliths in obstructed bowel, 640 Enterorrhaphy, 671 Enterostenosis, 639 Enterostomy, 694 Epididymitis, 839 in gonorrhea, 816 892 INDEX. Epididymitis in gonorrhea, treatment of, 822 in syphilis, 196 Epigastric hernia, 713 Epilepsy, operative treatment of, 569 Epiphyseal separation, 324 Epiphysitis, acute, 318 symptoms of, 319 treatment of, 319 in hereditary syphilis, 207 Epiplocele, 690 Epispadias, S30 Epistaxis, treatment of, 268 Epithelioid cells, 83 of tubercle, 148 Epitheliomata, 234 Epulis, treatment of, 217 Equinia, 182 Equinovariis, 524 Erasion of a joint, 485, 486 Erethistic shock, 163 ulcer, 116 Erichsen suture in treatment of angiomata, 227 Erichsen's signs of dislocation of shoulder- joint, 450 Erysipelas, 140 antistreptococcic serum in, 142 cellulocutaneous, 142 clinical forms of, 141 cutaneous, 141 discoloration in, 59 forms of, 141 phlegmonous, 142 streptococcus of, 38, 39 varieties of, 140 Erysipele salutaire, 142 Erythema of syphilis, 192 Escherich, bacillus of, 41 Esmarch bandage in aneurysm, 251 use of, in shock, 164 Esmarch's cooling coil, 67 elastic bandage, 842 operation for ankylosis, 436 package of dressing for soldiers. 174 splint for excision of elbow-joint, 491 Esophagus, diverticula of, 623 foreign bodies in, 624 injuries of, 624 stricture of, 620 Estlander's operation, 6io Ether, administration of, 729 as an anesthetic, 726 spray, anesthesia by, 734 Ethereal soap of Johnston, 43 Ethyl bromid as an anesthetic, 733 Eucain hydrochlorate as an anesthetic, 735 Eucalyptol, 29 Europhen, 28 Evacuation, spontaneous, 98 Eversion of leg in intracapsular fracture of femur, 383 Ev/ald's test-breakfast in cancer of stomach, 634 Excision of ankle-joint, 496 of astragalus, 498 of bones and joints, 485 of clavicle, 498 of elbow-joint, 490 of hemorrhoids, 716 of hip-joint, 493 by anterior incision, 494 by lateral incision, 494 of knee-joint, 486, 495 of lower jaw, 502 of metacarpal bones, 493 of metatarsal bone of great toe, 498 of metatarsophalangeal articulation of great toe, 498 Excision of os calcis, 497 of phalanges, 493 of pylorus, 675 of rectum, 720 of rib, 499 of scapula, 499 of shoulder-joint, 487 by anterior incision, 489 by deltoid flap, 489 Senn's method, 490 of upper jaw, complete, 500 of wrist-joint, 491 Exfoliation, 315 Exophthalmic goiter, 745 Exostosis, 218 Exploratory laparotomy, 644 Explosive effects of projectiles, 169 Extension for reduction of shoulder-joint dis- locations, 452 External anthrax, 179 clot, 257 Extracapsular fracture of femur, 389 Extradural abscess, 560, 564 hemorrhage, 547, 548 ExtrameduUary hemorrhage, 266 Exuberant ulcer, 116 Eye, syphilitic affections of, 196 Fabricius' operation for femoral hernia, 706 Facial artery, ligation of, 297 Facultative-aerobic bacterium, 23 Farcy, 182 -buds, 182 Fasciotomy of plantar fascia, 517 Fat-embolism, 135 diagnosis of, from shock, 163 -hernia, 215 Fecal abscess, 99 fistula, 645 Senn's operation for, 694 Fehleisen's coccus, 39 streptococcus, 140 Fell's method of artificial respiration, 732 Felon, loi, 512 bone, 513 deep, 513 superficial, 513 treatment of, 513 Femoral artery, ligation of, 303-305 hernia, 712 Femur, dislocations of, 461 fracture of, 382 Fenestrated p!aster-of-Paris dressing for com- pound fracture, 340 Fenger's incision, 679 Fergusson's method of treating varix of leg, 274 operation for clefts of hard palate, 616 Ferment, 17 Fermentation, 17 Fever, aseptic, 87 essential phenomena of, 87 hectic, 89, 100 hemorrhagic, 259 in acute inflammation, 61 inflammatory, 61 of iodoform absorption, 27 of tension, 89 suppurative, 89 surgical, 87, 88 scarlet, 90 symptomatic, 61 syphilitic, 191 urethral, 829 traumatic, 87 Fibrinous pus, 95 Fibro-adenoma, 232 of mammary gland, 863 INDEX. 893 Fibromata, 215 treatment of, 217 Fibrosarcoma, 229 Fibrous epulis, 216 union, 333 Fibula, fracture of, 401 Filaria sanguinis hominis as a cause of lym- phangiectasis, 226 Filiform bougie, 786 Fingers, amputation of, 847 First intention, healing by, 82 Fish-mouth meatus, 816 Fiske's plan for detecting joint-effusions, 407 Fission of bacteria, 21 Fissure, 322 intraparietal, 538 of anus, 724 of Bichat, location of, 535 of nipple, 859 prevention of, 859 of Rolando, location of, 535 of Sylvius, location of, 537 Fistula, 118 fecal, 645 in ano, 722 treatment of, 723 Fixed dressings, 758 Flail-joints, 527 Flat condylomata, 193 foot, 525 Flexion, forced, as a hemostatic, 263 Floating cartilages, 437 kidney, 768 Fluhrers aluminum probe, 172 Fluorid of sodium, 29 Fluoroscope, 872, 873 for locating bullets, 173 in detecting fractures, 331 Fluoroscopy, value of, S73 Follicular abscess, 99 Forbes's lithotrite, 804 method of amputation through tarsus, 853 Forcible correction in Pott's disease, 587 Foreign bodies in air-passages, 599 in alimentary canal, 633 in bronchi, 600 in esophagus, 624 in larynx, 599 in rectum, 721 in trachea, 600 in urethra, 813 removal of, from wounds, 165 Formaldehyd, 29 Formalin, 29 -gelatin, 29 gut, 45 Formative lymph, 92 Formic aldehyd, 29 Fort's electrolysis of urethral stricture, 828 Fowler's catgut, 45 classification of appendicitis, 651 operation for inguinal hernia, 705 probe for gunshot-wounds of head, 556 Fox's clavicle-splint, 360 Fractures, 321-406 ambulatory, treatment of, 336 Barton's 377 bent, 322 by contre-coup, 324 by indirect force, 325 capillary, 322 causes of, 324 comminuted, 323 complete, 322 complicated, 321 complications of. 322 prevention and treatment of, 337 composite, •523 . Fractures, compound, 321 amputation for, 339 primary, 321 repair of, 334 secondary, 321 treatment of, 339 consequences ot, 332 counterextension in, 335 crepitus or crepitation in, 329 cuneated or cuneiform, 323 deformity of part in, 327 delayed union of, 334 dentate, 323 depression-, 322 diagnosis of, 330 by A'-ray, 330, 331 direct, 323 -dislocation of spmal cord, 593 symptoms of, 593 treatment of, c.93 displacement in, v>irieties of, 327 distinguishing of, from dislocation, 330 Dupuytren's, 472 ecchymosis in, 328 en coin, 323 en rare, 323 en V, 323 exciting causes of, 324 extracapsular, 324 extrav^-sation of blood in, 328 fissured, 322 from direct violence, 324 from external violence, 324 from muscular action, 325 green-stick, 322 hair, 322 helicoidal, 324 hickory-stick, 322 -hook of McBurney and Dowd, 338 immovable dressing in, 336 impacted, 323 in elbow-joint, 371 incomplete, 322 indirect, 324 intra-articular, 324 intracapsular, 324 intrauterine, 324 linear, 322 longitudinal, 322 loss of function in, 328 massage in, 336 multiple, 323 near elbow-joint, 371 nervous disease as predisposing cause of, 326 non-union of, 334 oblique. 322 spiroide, 323 of acetabulum, 356, 386 of bones of foot, 404 of both bones of leg. 403 of brim of acetabulum, 386 of carpus, 381 of clavicle, 358-362 acromial end of, j6i in the shaft. 358 complications of. 359 symptoms of, 358 treatment of, 359 sternal end of, 362 of coccyx, 357 of costal cartilage, 352 of false pelvis, 344 of femur, 382 at the base of the neck, 389 extracapsular. 389 impacted form, 390 great trochanter of, 390 intracapsular, 382-388 894 INDEX. Fractures of femur, intracapsular, differentia- tion of, from extracapsular, 385 just above condyles, 394 longitudinal, 395 separating either condyle, 395 separation of the epiphysis of the great trochanter, 391 separation of lower epiphysis, 395 shaft of, 391 upper epiphysis of head of, 390 upper extremity of, 382 of fibula, 401 lower third of, 402 upper two-thirds of, 402 of forearm, both bones of, 377 of humerus, 363 anatomical neck of, 363 at lower epiphysis, 373 at upper epiphysis, 367 base of, condyles of, 370 external condyle of, 369 head of, 366 inner epicondyle of, 369 internal condyle of, 369 lower extremity of, 369 shaft of, 367 surgical neck of, 364 T-fracture, 371 upper extremity of, 363 of hyoid bone, 348 of inferior maxillary, 346 complications of, 347 symptoms of, 347 treatment of, 347 of ischium, 357 of lachrymal bone, 343 of laryngeal cartilages, 349 of leg, 400 of malar bone, 345 of metacarpal bones, 381 of metatarsal bones, 405 of nasal bones, 342 treatment of, 342 of patella, 395 by direct force, 398 by muscular action, 395 transverse, 396 of pelvis, 354 of penis, 833 of phalanges, 381 of toes, 408 of radius, 375 above insertion of pronator radii teres muscle, 376 i\nd ulna near wrist, 381 below insertion of pronator radii teres muscle, 376 head of, 375 lower extremity of, 377 neck of, 376 shaft of, 376 of ribs, 349 causes of, 350 complications of, 351 symptoms of, 350 treatment of, 351 of sacrum, 357 of scapula, 362 acromion of, 362 coracoid process of, 363 glenoid cavity of, 362 neck of, 362 of skull, 549 base of, 551 vault of, 550 of spine, 592 of sternum, 353 causes of, 353 Fractures of sternum, complications of, 353 symptoms of, 353 treatment of, 353 of superior maxillary, 344 of tibia, by separation of lower epiphysis, 401 by separation of upper epiphysis, 400 inner malleolus, 401 lower end of, 401 shaft of, 400 upper end of, 400 of true pelvis, 355 of ulna, 373 coronoid process of, 373 olecranon process of, 373 styloid process of, 375 of zygomatic arch, 346 overlapping of fragments in, 328 overriding of fragments in, 328 pain in, 327 pathological, 323 penetration of fragments in, 328 Pott's, 402 predisposing causes of, 325 preternatural mobility in, 329 radish, 323 recent, operative treatment of, 480 reduction of, 335 repair of, 333 rest in, 62 secondary, 323 separation of fragments m, 328 simple, 321 repair of, 332 sound of cracking in, 327 spiral, 324 splinter-, 322 spontaneous, 323 starred, 324 stellate, 324 strain, 322 swelling in, 327 symptoms of, 327 circumstantial, 340 direct, 330 transverse, 322 treatment of, 334 of edema from, 338 of gangrene from, 338 of inflammation m, 339 of phlebitis from, 338 ^of sloughing in, 337, 338 T-shaped, 323 toothed, 323 torsion, 324 imion ol, fibrous, 333, 334 ligamentous, 334 membranous, 334 vicious, 334 ummited, 323, 334 operative treatment of, 482 treatment of, 341 varieties of, 321 V-shaped, 323 vicious union of, 334 wedge-shaped, 323 willow, 322 wiring of, 336 with crushing, 323 with dislocation, treatment of, 338 with penetration, 323 Freezing, anesthesia by, 734 Frontal sinus, distention and abscess of, 597 trephining of, 573 Frost-bite, gangrene from, 128 treatment of, 738 Fuller's method of " milking " the seminal ducts, 834 INDEX. 895 Fuller's method of prostatectomy, 837 Fulminating gangrene, 125 Fungi, 18 Fungous ulcer, 116 Fungus cerebri, 557 haematodes, 227 Funicular hernia, 712 Furuncle, 739 symptoms of, 740 Furunculosis, 740 Galactocele, 865 Gall-bladder, rupture of, 631 Gall-stones, 661 causes of, 661 symptoms of, 662 treatment of, 663 Ganglia, 512 treatment of, 512 Gangrene, 119 acute, 124 amputation for, 131 classification of, 119 chronic, 120 decubital, 130 diabetic, 127 discoloration in, 59 dry, 119, 120 foudroyante, 125 from contusion, treatment of, 161 from ergotism, 12S from fracture, treatment of, 338 from frost-bite, 128 from infective organisms, 125 fulminating, 125 hospital, 125 moist, 119, 124 of lung, 607 of penis, 833 postfebrile, 131 Pott'b, 120 Raynaud's, 126 senile, 121 septic, 119 symmetrical, 126 traumatic spreading, 125 Gangrenous emphysema, 125 from wounds, 175 Garel's sign, loi Gasserian ganglion, removal of, 533 Gastro-enterostomy, 180 for cancer of pylorus, 237 for pyloric obstruction, 639 Gastrogastrostomy, 681 Gastroplication, 681 Gastrostomy, 678 for cancer of esophagus, 237 Gastrotomy, 676 in cardiac stenosis, 639 Gauntlet, 749 Gauze, iodoform, preparation of, 46 Lister's cyanid, 47 pads, Ashton's, 44 sterilized, preparation of, 46 Gelatiniform degeneration, 409 Genito-urinary diseases, pain in, 766 organs, diseases and injuries of, 763 Genu valgum, 522 osteotomy for, 475 varum, 522 Germicides, chemical, 24 Giant-cell sarcoma, 228 Gibney, method of treating sprains, 434 Gibson's bandage, 347, 753 Gila monster, bite of, 178 Girdle-pain in tetanus, 145 Girdner's telephonic probe, 173 Glanders, 182 Glanders, diagnosis of, 182 treatment of, 182 Glandula: Pleiades of Ricord, 190 Glandular cancer, 236 Gleet, 817 Glenard's disease, 661 Gliosarcoma, 229 Globus, 621 Glottis, edema of, 59S Glovers' stitch, 46 Gliick and Bartholow, anesthetic mixture of, 735 Gluteal artery, ligation of, 308 bursitis, 414 Glutol, 29 in dressing wounds, 166 Goiter, 743 cystic, 743 exophthalmic, 745 fibrous, 744 pulsating, 745 symptoms of, 744 treatment of, 744 Gonococci, determination of, 817 Gonococcus, 39 Gonorrhea, S15 abortive, 817 acute inflammatory, 816 treatment of, S18 black, 816 catarrhal, 817 in the female, 823 irritative, 817 of rectum, 823 subacute, 817 Gonorrheal arthritis, 423 changes in ihe joints in, 424 ophthalmia, 822 rheumatism, 423 Gordon's pistol-shaped splint, 379 Gouley's divulsor, 826 tunnelled catheter, 785 Gout, rheumatic, 427. See Arthritis de/or- fnatzs. Gouty arthritis, 426 Graft, omental, 674 Grant's clamp, 697 operation, 478 Granulation, healing by, 84 -tissue, 53 in repair of fractures, 3j2 Graves's disease, 745 Gravitative abscess, 98 Green-stick fracture, 322 Gntti's amputation of leg, 856 Gross, antimonial and saline mixture, 74 incision of, 495 Gross's divulsor, 826, 828 method of amputation at elbow-joint, 849 rule for continuous treatment of syphilis, 200 urethrotome, 826, 828 Guerin's method of amputating fool, 852 Guiteras's (Ramon) method of examining for urethral stricture, 825 Gumma in tertiary syphilis, 197 Gummy pus, 95 Gunshot-wounds, 168 amputation for, 174 dressing of, 173 hemorrhage in, 171, 268 of arteries, 258 of head, 555 treatment of, 556 pain from, 172 shock from, 172 symptoms of, 171 treatment of, 172 896 INDEX. Gussenbauer's clamp in delayed union of fractures, 341 suture, 673 Guthrie's rule for treatment of hemorrhage, 263 Guyon's method of sterilizing catheters, 836 Hagedorn needle, >ise of, in ligation, 260 Hair, affections of, in syphilis, 195 Hahn, method of gastrostomy, 679 Hallux valgus, 525 varus, 525 Halsted's inflatable rubber cylinder for cir- cular enterorrhaphy, 687 mattress-suture, 673 method of lateral intestinal anastomosis, 691 operation for cancer of breast, 868 for inguinal hernia, 704 subcuticular stitch, 42, 704 Hamilton's bandage for fracture of inferior maxillary, 347 bone-drills, 482 Hammer-toe, 526 Hancock's method of excising ankle-joint, 497 Handkerchief bandages, 758 Hands of operator, disinfection of, 43 Hard chancer, 187 Harelip, 612 operation for, 613 Harris's method of circular enterorrhaphy, 687 Hayden's treatment of chancroidal bubo, 832 Head, contusions of, 543 diseases of, 535 gunshot-wounds of, 555 injuries of, 543 teianus, 145 Healing by first intention, 82 by granulation, 84 by second intention, 84 by third intention, 85 Healthy pus, 94 Heart, diseases and injuries of, 239 suture of, 240 tapping of, 274 wounds and injuries of, 240 -wounds, treatment of, 240 Heat as a germicide, 29 forms of, for use in inflammation, 70 intermittent, 69 Heberden's nodules or nodosities, 427, 428 Hectic fever, 89, 100 Heiman's case of arthritis from gonorrheal ophthalmia, 423 Heineke-Mikulicz operation, 639, 674 Helferich method of treating delayed union of fractures, 341 Heller's test for blood in urine, 764 " Helpless eversion," 383 Hematemesis, 271 Hematic abscess, 90 Hematocele, 840 encysted, of the cord, F41 of the testicle, 841 parenchymatous, 841 vaginal, 840 Hematoid carcinoma, 236 Hematoma, 160 of dura mater, 558 Hematuria, 763 renal, 764 Hemoptysis, 271 Hemorrhage, 258 actual cautery in, 262 acupressure in, 262 as a cause of shock, 162 capillary, treatment of, 267 Hemorrhage, cerebral, 548, 549 compression in, 262 concealed, diagnosis of, from shock, 163 consecutive, 272 constitutional symptoms of, 258, 259 elevation in, 262 extradural, 266, 547, 548 extrameduUary spinal, 266 following lateral lithotomy, 270 forced flexion in, 263 from bladder, 270, 766 from cerebral sinus, 266 from diploe, 265 from ear, 269 from femoral vein, 266 from intercostal artery, 265 from kidney, 270 from large bowel, 271 from leech-bite, 269 from lung, 271 treatment of, 260 from mammary artery, 265 from nose, 268 from palmar arch, 263 from prostate, 270 from punctured wounds, 265 from small bowel, 271 from stomach, 271 from tooth socket, 262, 266 from urethra, 269 from urinary meatus, 262 from varicose vein, 267 from vessels in bony canal, 265 from wounds, 162 arrest of, 165 in abdominal section, 267 in amputation, prevention of, 842 in gunshot-wounds, 171, 268 intercurrent, 272 intermediate, 272 intra-abdominal, 267 intracranial, 547 ligation in, 260 pressure in, 267 primary golden rules for procedure in, 263 reaction after, treatment of, 260 reactionary, 272 rectal, 269 recurrent, 272 renal, 270 secondary, 272 treatment of, 273 styptics in, 262 subcutaneous, 258, 269 subdural, 548, 549 syncope in, 259 torsion in, 261 treatment of constitutional symptoms of, 259 umbilical, 269 urethral, 766 uterine, 271 vaginal, 271 vesical, 270, 766 Hemorrhagic fever, 259 sarcoma, 228 ulcer, 117 Hemorrhoids, 242, 713 arterial, 715 capillary, 715 excision of, 716 external, 714 internal, 714 operative treatment of, 716 ligation of, 717 venous, 715 Hemostatic agents, 260 Hepatitis, pain in, 57 INDEX. 897 Hepatopexy, 66i Hcpatotomy, transthoracic, 103 Hereditary fragility of bones, 326 syphilis, 185, 205. Sec Sy/>hilis. Hereditation as a cause of tumors, 210 Hernia, abdominal, 699 anatomical, varieties of, 712 causes of, 699 congenital inguinal, 712 diaphragmatic, 715 direct inguinal, 712 -director, 702 encysted inguinal, 712 epigastric, 713 femoral, 712 Bassini's operation for, 705 Fabricius's operation for, 706 funicular. 712 herniotomy in, 711 incarcerated, 706 indirect inguinal, 712 infantile, 712 inflamed, 707 inguinal, Bassini's operation for, 703 Fowler's operation for, 705 Macewen's operation for, 701 into the foramen of Winslow, 713 irreducible, 706 Littre's, 709 lumbar, 713 -needles, 702 oblique inguinal, herniotomy in, 710 obstructed, 706 obturator, 713 of the brain, 557 of muscles, 509 perineal, 713 properitoneal, 713 pudendal, 713 reducible, 700 palliative treatment of, 700 radical cure of, 705 treatment of, 701 sciatic, 713 strangulated, 707 symptoms of, 708 treatment of, 709 umbilical, 713 herniotomy in, 711 radical cure of, 705 ventral, 713 Herniotomy, 710 Herpetic ulcer, differentiation of, from chan- cer, 189 Hetero-inoculation, 187 Heterologous tumors, 210 Heurteloup's artificial leech, 65 Hay, internal derangement of, 470 Hey's amputation at tarsometatarsal joint, 852 High tracheotomy, 602 Hilton's method of opening abscess, 104 Hip disease, 411. See Tuberculosis of hip- joint. differentiation from sacro-iliac disease, 413 from spinal caries, 413 excision of, 418 -joint disease, 411. See Tuberculosis of hip-joint. dislocations of, 461 excision of, 493 Hodgen's splint for fractures of the thigh, 393 Hoflfa's operation, 503 for congenital dislocation of hip, 503 Hollow-foot, 525 Horsley's cyrtometer, 537, 539 method of intestinal anastomosis, 691 of locating fissure of Rolando, 536 57 Hospital gangrene, 125 Hot-water bag, 71 Housemaid's knee, 514 treatment of, 515 Humerus, dislocations of, 448 fracture of, 363. See Fracture. Hunterian chancer, 187 Hunter's canal, 304 derivative of tuberculin, 157 operation for aneurysm, 252 Hutchinson's knee-joint splint, 419 teeth, 208 Hydatid cysts, 238 of liver, 659 of mammary gland, 865 treatment of, 239 fremitus, 239 Hydrargyrism, 202, 203 Hydrarthrosis in gonorrheal arthritis, 424 Hydrencephalic cry, 560 Hydrencephalocele, 542 Hydrocele, 839 congenital, 840 encysted, of the cord, 840 funicular, 840 infantile, 840 of a hernia, 840 Hydrocephalus, 542 acute, 542, 559 Hydronephrosis, 776 symptoms of, 777 treatment of, 777 Hydrophobia, 180 antitoxins of, 181 differentiation of, from lockjaw, 181 spurious, 181 treatment of, 180 Hydrophobic tetanus, 145 Hydrops articuli, 407 Hydrorrhachitis, 577 Hyoid bone, fracture of, 348 Hyperemia, active, 48 passive, 49 Hyperflexion, brachial, 263 Hypertrophy of bone, 309 of muscles, 505 Hyphomycetes, 18 Hypodermoclysis, 137 in erysipelas, 143 in hemorrhage, 259 in shock, 164 Hypospadias, 830 Hypostatic abscess, 98 Hysterectomy for uterine hemorrhage, 271 for uterine myomata. 223 Hysteria, traumatic, 589 Hysterical joint, 430 IcHORUS pus, 95 Ichthyol, 69 Ileus, 639 Iliac abscess, 107 arteries, anatomy of, 505 ligation of, 305, 307 Iliofemoral triangle of Bryant, 384 Immediate union, 83 Immunity, 34 Imperforate anus, 722 Incarcerated hernia, 706 Incised wounds, 167 treatment of, 167 Incision of Gross of excision of hip-joint, 495 Inclusion theory of Cohnheim, 210 Indian operation for rhinoplasty, 763 Indifferent tissue, 53 Indirect cell-division, 85 Indolent bubo, igo Induction-balance of Graham Bell, 173 898 INDEX. Infantile hernia, 712 scurvy, 160 Infection, septic, 137 Infective myositis, 505 sinus-thrombosis, 564 Infected wounds, dressing of, 166 arthritis, 422 Inferior maxillary bone, fracture of, 346 Infiltration-anesthesia, 735 purulent, 96 Inflamed hernia, 707 joints, rest in, 62 Inflammation, 48-82 as a cause of tumor, 210 causes of, 56 cell-proliferation in, 53 changes in perivascular tissue in, 53 chronic, 81 circulatory changes in, 48 classification of, 54 constitutional symptoms of, 61 treatment of, 73 cupping in, 65 definition of, 48 of secretions in, 61 derangement of absorbents in, 61 diapedesis in, 52 discoloration in, 59 disordered function in, 60 eff"usion of liqiior sanguinis in, go extension of, 55 exudation of fluids in, 51 fever in, 61 formation of embryonic tissue in, 91 from fracture, treatment of, 339 impairment of special function in, 61 in non-vascular tissue, 54 migration in, 52 of antrum of Highmore, 596 of thyroid gland, 743 oscillation in, 50 pain in, 57 plastic, 52 relaxation in, 63 retardation of circulation in, 50 serous, 51 stagnation of circulation in, 51 swelling in, 60 symptoms of, 56 tenderness in, 60 terminations of, 55, 90 treatment of, 62 tumefaction in, 60 varieties of, 54, 55 vascular and circulatory changes, 48 vascular changes in, 48 venesection in, 73 Inflammatory fever, 61 Ingrown toe-nail, 742 Inguinal colostomy, 694 Injury as a cause of tumor, 210 Innominate artery, anatomy of, 291 ligation of, 291 Inoculations, protective and preventive, 34 Insects, bites and stings of, 176 Insomnia in syphilis, 199 Instruments, disinfection of, 44 Intercostal neuralgia, 504 Interdental splint for fracture of inferior maxillary bone, 348 in fracture of superior maxillary bone, 345 Intermittent heat in inflammation, 69 Internal anthrax, 179 clot, 257 Interpolation in plastic surgery, 760 Intertrigo in hereditary syphilis, 207 Intestinal anastomosis, 681 lateral, 688 Intestinal approximation, 693 obstruction, 639 acute, 639 symptoms of, 640 chronic, 639 symptoms of, 640 diagnosis of, 641 differentiation from other diseases, 643 prognosis of, 643 treatment of, 643 tuberculosis, 153 Intestine, malignant tumor of, 647 resection of, 681 rupture of, without external wound, 629 suture of, 671 Intoxication, septic, 136 Intracapsular fracture of femur, 382-388 Intracranial hemorrhage, 547 tumors, 565 Intraparietal fissure, 538 Intubation of larynx, 604 for fracture of hyoid bone, 348 of laryngeal cartilages, 349 Intussusception, 639 operation for, 694 Inversion of leg in intracapsular fracture of femur, 383 Involucrum of bone, 315 lodism from syphilitic treatment, 205 Iodoform, 27 absorption, fever of, 27 emulsion, 27 gauze, 46 lodol, 29 Iritis, differentiation of rheumatic, from syph- ilitic, 196 in syphilis, 196 Irreducible hernia, 706 Irrigation of wounds, 45, 165 Irritable ulcer, 116 Irritants in inflammation, 72 Ischiorectal abscess, 721 Italian method of rhinoplasty, 763 Itrol, 29. Jacob's ulcer, 117, 235 Janet's method of treating gonorrhea, 819 Jerk-finger, 521 Jobert's suture, 673 Johnston's ethereal soap, 43 method of preparing catgut, 45 Joints, aspiration of, 484 diseases of, 406 and injuries of, 409 excision of, 485 floating cartilages in, 437 loose bodies in, 437 neuralgia of, 431 syphilitic affections of, 195 tubercular disease of, 154 tuberculosis, 154 wounds and injuries of, 432 Jones's nasal splint, 343 position for treatment of fractures, 372, 373 Jordan's amputation at hip-joint, 859 method of treating caries of spine, 586 Jury-mast of Sayre, 587 Juvenile tissue, 53 Kangaroo-tendon sutures, 46 Karyokinesis, 85 Keen's incision for reaching spinal accessory nerve, 520 treatment of Dupuytren's contraction, 521 Kelly, catheterization of ureters, 765 method of disinfecting operator's hands, 43 of preparing catgut, 45 Kelly's catheter, 765 INDEX. 899 Keloid, 216 spontaneous, 217 treatment of, 217 Kidney, abscess of, 774 bleeding from, 764 diseases and injuries of, 768 dislocated, 769 floating or wandering, 768 injuries of, 770 laceration or rupture of, 770 mobile, 76S symptoms of, 769 treatment of, 770 movable, 768 operations on, 779 perforating wounds of, 771 removal of, 781 surgical, 777 tuberculosis of, 778 treatment of, 779 tumors of, 768 Kile-shaped director, 479 Knee-joint disease, 418 excision of, 486 subluxation of, 470 Knock-knee, 522 osteotomy for, 475 Kocher, experiment of, 31 method of operating for inguinal hernia, 705 Kocher's excision of tongue, 619 incision for nephrorrhaphy, 783 (or nephrotomy, 780 method of circular enterorrhaphy, 686 of gastro-enterostomy, 680 of lumbar nephrectomy, 782 of pylorectomy, 676 of reducing dislocations of shoulder-joint, 451 Koch's bacillus, 4° circuit, 30 lymph, 35, 157 in tuberculosis, 156 tuberculin, 157 Konig's incision for nephrectomy, 781 Kraske, sacral resection of, 237 Kraske's operation, 720 Krause's method for removal of Gasserian ganglion, 535 of skin-grafting, 762 Kreolin, 27 Kyphosis, 583 Lacerated wounds, 167 Lachrymal bone, fracture of, 343 Lacteal cyst, 865 Lagoria's sign, 384 Laminectomy, 595 for spinal caries, 587 in extramedullary spinal hemorrhage, 266 La Mothe's method of reducing shoulder- joint dislocation, 453 Landerer's dry method, 43 Langenbeck's incision for abdominal nephrec- tomy, 7S2 operation, 494 Lankester, educated corpuscle, 34 Lannaiol, 29 Lannelongue's method of treating delayed union of fractures, 341 of exposing the liver, 659 operation for microcephalus, 541 Laparotomy, 666 for non-suppurative appendicitis, 668 Larrey's amputation at hip-joint, 858 operation for amputation at shoulder, 849 Laryngeal cartilages, fracture of, 349 Laryngotomy for fracture of laryngeal carti- lages, 349 Laryngotomy, quick, 604 Laryngotracheotomy, 604 Larynx, abscess of, 101 diseases and injuries of, 598 edema of, 598 foreign body in, 599 intubation of, 604 operations on, 601 wounds of, 598 Lateral curvature of spine, 580 sinus, location of, 539 Laudable pus, 94 Lawn-tennis arm, 508 Lead-water and laudanum, 68 Leech, artificial, 65 Leeches in osteitis, 311 Leeching, 64 Leg, chronic ulcer of, 113 ulcer of, 112 Leiomyomata, 222 Leiter's tubes, 67 Lemhert's suture, 672 for longitudinally torn vein, 260, 265 Leontiasis ossium, 320 Leptomeningitis, acute, 558 chronic, 559 Leptothrix, 21 Leukocytes in inflammation, 61 Leukocytosis, 53 Leukomains, 32 Leukomata in syphilis, 194 Levis's splint, 379, 460 Ligation by means of Hagedorn needle, 260 in inflammation, 65 in continuity, instruments for, 278 in the tabatiere, 282 in triangle of election, 294 of necessity, 294 of arteries for aneurysm, 252-25^ in continuity, 27S incision for, 279 of axillary artery, 286-288 in the first part, 288 in the third portion, 287 of brachial artery, 284-286 at bend of elbow, 285 at middle of arm, 286 of carotid artery, common, 293-295 external, 295 internal, 295 of dorsalis pedis arter)', 298, 299 of facial artery, 297 of femoral artery. 303-305 at apex of Scarpa's triangle, 304 in Hunter's canal, 305 of femoral vein, 266 of gluteal artery, 308 of iliac arteries, 305-307 by abdominal section. 3*6 external, by Abernethy's method, 306 of inferior thyroid artery, 290 of innominate anery, 291 of lingual artery, 296 of occipital artery, 298 of popliteal artery, 302 of pudic artery, internal, 308 of radial artery. 281-283 in lower third, 282 in middle third, 283 in upper third. 283 of sciatic artery, 308 of subclavian artery, 288, 289 of temporal artery, 297 of thyroid artery, superior. 296 of tibial artery, anterior, 299-301 posterior, 301 of ulnar artery, 283, 284 of vertebral artery, 288, 290 900 INDEX. Ligature, lateral 260 -material, 45 subcutaneous, for varicocele, 275 Ligatures, 260 Lightning, injuries by, 878 stroke, 87S treatment of, 879 Lilienthal's probe, 173 Line of demarcation, 121 Linear craniotomy, 577 Lingual artery, ligation of, 296 Lipoma, cavernous, 214 diffuse, 214 nevoid, 2^6 telangiectodes, 214 Lipomata, 214 treatment of, 215 Liquor puris, 94 sanguinis, effusion of, in inflammation, 90 Lisfranc's amputation at shoulder-joint, 850 at tarsometatarsal articulation, 850 Lister's abdominal tourniquet in aneurysm, 251 cyanid gauze, 47 experiment, 50 method for excision of vvfrist-joint, 491 Listen, amputation at hip-joint, 859 modified circular amputation, 845 silver-fork deformity, 378 Litholapaxy, 803 in male children, 807 Lithotomy, 799 lateral, 799 suprapubic, 800 Lithotrites, 804, 805 Littre's hernia, 709 Liver, abscess of, 100, 660 displaced, 661 hydatid cysts of, 659 rupture of, 631 wounds of, 658 Lizard, poisonous, bite of, 178 Lloyd's (Jordan) symptom, 773 Local anesthesia, 734 Locke and Hare, solution for intravenous in- jection, 277 Lockjaw, diagnosis of, from hydrophobia, 181. See Tetanus. Locus minoris resistentise, 31 Lordosis, 583 Lorenz's operation for congenital dislocation of hip, 439, 503 Loreta's operation, 639, 674 Loretin, 29 Lumbago, 504 Lumbar abscess, 107 hernia, 713 nephrectomy, 781 puncture, 543, 595 Lumpy jaw, 19. 183 Lung, abscess of, loi, 607 diseases and injuries of 605 gangrene of, 607 tubercular cavity in, surgical treatment of, 608 Lupus, 151 exedens, 132 hypertrophicus, 152 syphilitic, 297 vulgaris, 151 Lusk, method of skin-grafting, 760 Lustgarten's bacillus, 41 in syphilis, 185 Luxatio erecta, 449 Luxations, 438. See Dislocations. Lymph edema, 867 effusion of, 91, 92 Lymphadenitis, acute, 746 Lymphadenitis, chronic, 747 infective, 746 Lymphangiectasis, 226, 747 Lymphangioma, 747 circumscriptum, 747 Lymphangiomata, 226 treatment of, 227 Lymphangitis, 746 from septic wounds, 175 reticular, 746 tubular, 746 Lymphatic abscess, 98 glands, tuberculosis of, 154 nerves, 226 warts, 747 Lymphatics, diseases and injuries of, 746 Lymphomata, 221 idiopathic, 221 treatment of, 222 Lymphorrhea, 747 Lymphosarcoma, 228 Lyssa, 180. See Hydrophobia. MacCormac's rule for measuring for a truss, 701 Macewen's method' of compression ot aorta in amputation at hip-joint, 857 of operating in mastoid disease, 575 operation of osteotomy for genu valgum , 475 for inguinal hernia, 701 triangle, 539 Macroglossia, 226 Macular syphilides, 192 Maculo-papular syphilides, 192 Madura foot, 19 Maisonneuve's symptom, 378 urethrotome, 826 Malar bone, fracture of, 345 Malaria, fever of, 89 Malgaigne's hooks, 397 method of treating fracture of costal carti- lages, 353 Malignant edema following wound, 175 onychia, 742 pustule, 178. See Anthrax. excision of, 179 tumor of intestine, 647 tumors, 227, 233 Malingering by persons injured in accidents, 591 Mallet-finger, 522 Mammary gland, adenocele of, 864 angioma of, 864 cancer of, 866 carcinoma of, 866 cold abscess of, log cystic adenoma of, 864 cystic degeneration of, 864 cysts of, 864 fibro-adenoma of, 863 hydatid cysts of, 865 involution cysts of, 864 malignant tumors of, 865 myxoma of, 864 sarcoma of, 865 tuberculosis of, 108 tumors of, 863 Mammillitis, 859 Mannlicher rifle, velocity of bullet of, 169 Maraglinno's antitubercular serum, 158 Marginal abscess, 99 Marie's disease, 429 Marine sponges, preparation of, 47 Marsupialization, 659 Mason's pin, 343 Mastitis, acute, 860 symptoms of, 860 treatment of, 861 INDEX. 901 Mastitis, chronic, 861 lobular, 862 treatment of, 862 lobular, 861 Mastodynia, 862 Mastoid suppuration, operation for, 575 Mattress-suture, 673 Maunsell's method of circular enterorrhaphy, 684 operation for intussusception, 694 Maxillary antrum, inflammation and abscess of, 596 Maydl's operation, 694 Mcfeurney's method of compressing iliac ar- tery in amputation at hip-joint, 857 of reducing shoulder-joint dislocations with fracture, 455 removing vermiform appendix, 670 point, 648, 652 McCormick's operation, 530 McGill's operation, 837 McGuire's operation, 837 Mclntire's splint, 394 Mediastinum, abscess of, loi Melanotic cancer, 236 sarcoma, 228 Menard's method of treating delayed union of fractures, 341 operation for spinal caries, 5SS Meniere's disease in syphilis, 195 Meningitis, tubercular, 559 Meningocele. 541, 577 Meningomyelocele, 577 Mercurials, 69 Metastasis in the dissemination of sarcoma, 227 Metastatic abscess, 99 Metatarsalgia, 526 MetschnikofTs theory of phagocytosis, 34 Microbes, 17, 18 antagonistic, 36 of suppuration, 37 placental transmission of, 36 Microcephalus, 540 Micrococcus, 19 prodigiosus antagonistic to anthrax, 179 pyogenes tenuis, 38 Micro-organisms, 17 Microphyta, 18 Microscopic test for blood in urine, 764 Microzoaria, 18 Micturition, frequent, 767 " Middle lobe," 222 INIigration of cells in inflammation, 52 Milk abscess, 99 Milzbrand, 178. See Anthrax. Miners' elbow, 515 Mixed infection, 36 with chancer and chancroid, 188 Mixter's apparatus, 761 cannula in tubercular adenitis, 155 Mobile kidney. 768 Moist gangrene, 119, 124 Mole, 266 excision of, 217 Mollities ossium. 320. See Osteomalacia. Molluscum fibrosum, 216 Monococci, 20 Monsel's salt in hemorrhage from small in- testine, 271 solution in hematemesis, 271 Monteggia's dislocation, 467 Moore's dressing for fracture of clavicle, 360 Morbid growths, 209-239 Morbus coxae, 411. See Tuberculosis 0/ hip- joint. senilis, 428 Morbus coxarius, 411. See Tuberculosis 0/ hip-joint. Morphea, 217 Morris's measurement, 385 method of lumbar nephrectomy, 781 Mortification, 119 Morton's disease, 526 Mother's marks, 225 Motile bacteria, 17 Moulds, 18 Mouth, cleansing of, 45 Mucopus, 95 Mucous membranes, syphilitic affections of, 194 patches in syphilis, 194 treatment of, 203 Mulberry calculus, 791 MUller's law, 209 Multiple incision, 64 puncture, 64 Mummification, 122 Murphy button, use of, in gastro-enterostomy, 68 1 in intestinal anastomosis, 683 Murri, hydrophobia antitoxin, 35 Muscse volitantes in hemorrhage, 259 Muscles, atrophy of, 505 contractions of, 509 degeneration of, 505 dislocation of, 509 healing of, 86 hernia of, 509 hypertrophy of, 505 ossific.ition of, 506 rupture of, 508 strain of, 507 tumors of, 506 wounds and contusions of, 507 Muscular rheumatism, 504 Myalgia, 504 symptoms of, 504 treatment of, 504 Mycetoma, 19 Myomata, 222 intramural, 222 submucous, 222 subserous, 222 treatment of. 223 Myositis, infective, 505 ossificans, 506 Myxedema, 743 Myxoma of mammary gland, 864 My.xomata, 220 treatment of, 221 Myxosarcoma, 220, 229 Nails, affections of, in syphilis, 195 Nasal bones, fracture of, 342 polypi, 221 Necessity, triangle of, 292 Neck, anatomy of, 291 triangles of, 291, 293 Necrosis, acute, 311 central, 315 in ulceration, in of bone, 314 symptoms of, 316 treatment of, 316 Nelaton's dislocation, 472 line, ascent of great trochanter above, in intracapsular fracture of femur, 384 porcelain probe, 172 Neoplasms, 209 Nephrectomy, 781 abdominal, 782 for mobile kidney, 770 for sarcoma of kidney, 229 for tuberculosis of kidney, 779 902 INDEX, Nephrectomy for wounded kidney, 772 for wounds of kidney, 267 in renal hemorrhage, 271 lumbar, 781 partial, 782 Nephrolithotomy, 774, 780 Nephropexy, 783 Nephrorrhaphy, 783 for mobile kidney, 770 Nephrotomy, 779 Nerve, healing of, 86 inflammation of, 527 , -stretching, 531 -suture, 530 Nerves, contusion of, 530 diseases of, 527 operations upon, 530 pressure upon, 529 punctured wounds of, 530 section of, 528 symptoms of, 529 treatment of, 529 Nervous diseases as predisposing to fracture, 326 sclerosis from syphilis, 198 syphilis, 199 Nervousness of bladder, 767 Neuber's plan for treating knee-joint disease, 419 Neuralgia, 528 intercostal, 504 of joints, 431 of stumps, treatment of, 528 treatment of, 431 Neurasthenia, traumatic, 589 Neurectasy, 531 Neurectomy, 532 of inferior dental nerves, 533 of infra-orbital nerve, 532 of supra-orbital nerve, 533 Neuritis, 527 in syphilis, 199 Neurofibroma, 224 Neuromata, 224 false, 224 plexiform, 224 traumatic, 224 treatment of, 224 Neuroparalytic ulcer, 117 Neuropathic arthritis, 429 Neurorrhaphy, 530 Neurotomy, 531 Nevoid lipoma, 226 Nevolipoma, 214 Nevus, lymphatic, 226 Nicoladoni's operation, 524 Nicolaier's bacillus, 40 Nicoll's prostatectomy, 837 Nipple, cysts of, 162 fissure of, 859 prevention of, 859 malignant, dermatitis of, 863 Paget's disease of, 863 tumors of, 862 Nitrous-oxid gas as an anesthetic, 733 Nitze's catheter, 766 Nodes, 31 Noma, 129 streptococcus of, 39 vulvae, 129 Non-union of fractures, 334 Non-vascular tissue, inflammation of, 54 Normal salt-solution, intravenous injection of, 277 diseases and injuries of, 596 foreign bodies in, 596 Nosophen, 28 Nucleins, 29 Obligate-aerobic bacterium, 23 parasites, 19 Obstructed hernia, 706 Obstruction of intestine, 639. See Intestinal obstruction. Obturator hernia, 813 Occipital artery, ligation of, 298 triangle, 293 Odontomata, 219 treatment of, 220 O'Dwyer's operation, 604 Ogston's operation, 476 Oidium albicans, 18 Omental graft, 674 Omphalectomy, 705 Onychia, 742 in syphilis, 195 Oophorectomy for uterine myomata, 223 Operation, Abbe's, 623 Adams's, 477 Bassini's, for inguinal hernia, 703 Bigelow's, 803 Brandt's, of stomach-reefing, 58i Cock's, 830 Cripp's, 780 Estlander'S; 610 Fergusson's, 616 for mastoid suppuration, 575 for spina bifida, 594 for varicocele, 274 for varix of leg, 274 Grant's, 478 Halsted's, for cancer of breast, 868, 869 Heineke-Mikulicz, 639, 674 Hoffa's, 503 Kraske's, 720 Lannelongue's, 541 Langenbeck's, 494 Lorenz's, 503 Loreta's, 639, 674 Macewen's, 475 for inguinal hernia, 701 Maunsell's, 694 Maydl's, 694 McCormick's, 530 , McGiU's, 837 O'Dwyer's, 604 of Fabricius for femoral hernia, 706 Ogston's, 476 on abdomen, 666 on bladder, 799 on larynx and trachea, 601 on skull and brain, 571 on spine, 594 on vascular system, 274 Owen's, for cleft of hard palate, 617 Parker's, 494 preparations for, 43 Schede's, 611 Senn's, for fecal fistula, 694 Syme's, 830 Treve's, 483 Van Hook's, 783 Volkmann's, 840 Wheelhouse's, 830 Whitehead's, 717 White's, 838 Ophthalmia, gonorrheal, treatment of, 822 Ophthalmoplegia from syphilis, 198 Opisthotonos in tetanus, 144 Orange pus, 95 Orchidectomy, 838 Orchitis, 838 Orrotherapy, 35 Orthopedic surgery, 519 Orthotonos in tetanus, 145 Oscillation of blood in inflammation, 50 Ossification of muscle, 506 INDEX. 903 Ossifluent abscess, 99 Osteitis, 309 purulent, 313 suppurative, 313. See Caries. symptoms of, 310 treatment of, 311 tubercular, 154, 313 Osteo-arthritis, 462. See Arthritis de/or- tiians. Osteo-arthopathic hypertrophiante pneu- mique, 429 Osteocopic pains in syphilis, 195 Osteomalacia, 320 symptoms of, 32c treatment of, 320 Osteomata, 218 Osteomyelitis, acute diffuse, 317 as a cause of necrosis, 315 chronic, 319 of vertebrae, 579 Osteoperiostitis, 310 diffuse, 311 symptoms of, 310 treatment of, 311 Osteophytes in hereditary syphilis, 207 Osteoplastic periostitis, 312 resection of skull, 572 Osteosarcoma, 229 Osteotome, 475 Osteotomy, 475 cuneifnrm, 475, 477 for bent tibia, 477 for faulty ankylosis of hip-joint, 477 of knee-joint, 478 for genu valgum, 475 for hallux valgus, 479 for knock-knee, 475 for talipes equinovarus, 479 for talipes equinus, 480 for vicious union of fracture, 479 linear, 475, 477 longitudinal, for osteitis, 311 of shaft of femur below trochanters, 478 mallet, 475 through neck of femur, 477 Ovaries, removal of, in osteomalacia, 320 Overlapping of fragments in fracture, 328 Owen's operation for cleft hard palate, 617 for double harelip, 615 Oxycyanid of mercury, 29 Pachymeningitis, 557 externa, 557 interna, 558 lisemorrhagica, 558 Paget's abscess, 99 disease, 234, 427. ^^^ Arthritis deformans . of nipple, 863 Painful ulcer, n6 Palmar abscess, loi, 511 pad in hemorrhage from palmar arch, 264 Pancreas, cysts of. 665 hemorrhage from, 664 Pancreatitis, acute, 664 " Papering " of mastoid cavity, 576 Papillomata,23i treatment of, 231 villous, 231 Papular syphilides, 193 Papulosquamous syphilides, 193 Para-appendicitis, 651 Paracentesis auriculi, 274 pericardii, 274 thoracis, 608 Paralysis, crawling, 592 Paraphimosis in gonorrhea, 816 treatment of, 821 Parasites, facultative, 19 Parasites, obligate, 19 Parasitic bacteria, 19 origin of tumors, 211 Paratoloid, 157 Paratrimma, 130 Paresis from syphilis, 198 Parker's oblique incision, 670 operation, 494 Paronychia, 513 in syphilis, 195 treatment of, 203 Passive hyperemia, 49 Pasteur's preventive inoculations, 34, 35 vibrione septique, 41 Patella, fracture of, 395 wiring of, 483 Pelvis, fracture of, 355 Penis, amputation of, 833 cancer of, 833 fracture of, 833 gangrene of, 833 injuries of, 810 Peptic ulcer of stomach, 636 Perforating ulcer, 117 Pel i-appendicitis, 651 Periarteritis, 244 Periarticular edema, 407 Pericardial effusion, 240 Pericarditis, purulent, treatment of, 240 traumatic, 240 Pericardium, diseases of, 239 tapping of, 274 Perineal bruises, 810 section, 830 for hemorrhage from prostate, 270 Perinephric abscess, loi, 776 Perinephritis, 775 Perineum, bruises of, 810 Periosteal bridge in simple fracture, 332 Periosteum, inflammation of, 310, 311 nodes of, 311 slitting of, for osteitis, 311 Periostitis, 310, 311 chronic, 311 diffuse, 311 in syphilis, 195 osteoplastic, 312 simple, acute, 310, 311 Peritoneal tuberculosis, 153 Peritoneum, rupture of, 627 toilet of, after celiotomy, 667 Peritonism, 627 Peritonitis, 653 diffuse, septic, 85S fibrinoplastic, 655 plastic, 655 suppurative, 656 tubercular, 657 Pernio, 738 Peroxid of hydrogen, 27 Pes cavus, 525 planus, 528 Petit's tourniquet, 843 Phagedena, 129 differentiation of, from chancer, 189 sloughing, 125 treatment of, 832 Phagedenic ulcer, 112, 117 Phagocytes, 33 Phagocytosis, 33 Phenate of cocain as an anesthetic, 735 Phimosis, 833 in gonorrhea, 816 treatment of, 821 Phlebectasia, 241 Phlebectasis, 241 Phlebitis, 240 from fracture, treatment of, 338 904 INDEX. Phlebitis, symptoms of, 241 treatment of, 241 Phlebotomy, 275 in inflammation, 73 Phlegmonous abscess, 98 erysipelas, 142 suppuration, 96 Photophobia, 6t Phthisis, syphilitic, 198 Physiological activity as a cause of sarcoma, 211 decline as a cnuse of cancer, 211 Pick's table of dislocations of shoulder-joint, 450 Pilchei on treatment of Colles's fracture, 380 Piles, 242, 713. See Hemorrhoids. Pirogoff's amputation at ankle-joint, 853 Placental transmission of bacteria, 36 Piaster-of- Paris bandage, 758 Plastic infiltration, 53 inflammation, 52 lymph, 92 surgery, 759 Pleura, diseases and injuries of, 605 Pleurisy, rest in, 62 tubercular, 154 Pleuritic effusion, 605 Pleurodynia, 504 Plexiform angiomata, 226 sarcoma, 229 Plugging of nares for epistaxis, 268 Pneumococcus antagonistic to anthrax, 179 Pneumotomy, 607 for abscess of lung, 611 Pointing of abscess, 98 of pus, 95 Points douloureux, 58 Poisoned wounds, 174 Polydactylism, 521 Polyps, 220 fleshy, 222 nasal, 222 Popliteal artery, ligation of, 302 Port- wine stains, 226 Postfebrile gangrene, 131 " Post-operation rise," 83 Postpharyngeal abscess, 107 Potash soap, 29 Pott's disease, 583, 586 forcible correction in, 587 symptoms of, 584 fracture, 402 gangrene, 120 Poultice, antiseptic, 166, 167 Precentral sulcus, 538 Preparations for an operation, 44 Pressure in hemorrhage, 267 upon nerves, 529 Preventive inoculation, 34 trephining, 551 Primary infection, 36 syphilis, 186 union, 82 Proctotorny for stricture of rectum, 719 Profeta's immunity against syphilis, 185 Prolapse of anus and rectum, 717 treatment of, 718 Prolapsus ani, 717 recti, 717 Properiioneal hernia, 713 Prostate gland, abscess of, from gonorrhea, treatment of, 821 hypertrophy of, 834 prostatectomy for, 837 symptoms of, 835 treatment of, 835 Prostatectomy for hypertrophy of prostate, 837 Prostatic abscess, loi Prostatitis, acute, from gonorrhea, treatment of, 821 chronic, from gonorrhea, treatment of, 822 Protective inoculations, 34 Proteus vulgaris, 41 Protonuclein, 29 as a wound dressing, 166 Pruritus of anus, 724 Pieudofluctuation of lipoma, 214 Psoas abscess, 99, 107, 109 Psoriasis in syphilis, treatment of, 203 Psorosperm of Darier, 212 Psorospermosis, 212 Psychical traumatism, 590 Ptomains, 32 Ptosis in syphilis, 199 Ptyalism, acute, from syphilitic medication, 202 from use of corrosive sublimate, 25 Pudic artery, internal, ligation of, 308 Pulmonary phthisis, surgical treatment of, 608 tuberculosis, 153 Pulpy degeneration, 408 Pulsating goiter, 745 Pulse in shock, 162 Puncture, bloodletting by, 64 lumbar, 543, 595 multiple, 64 of spinal meninges, 595 Punctured wounds, 167 " Purse-string" suture in perforation of kid- ney, 771 Purulent infiltration, 96 pericarditis, 240 Pus, " aseptic," 93 -corpuscles, 94 forms of, 94 microbes, 37 -serum, 94 Pustular syphilides, 193 Pyelitis, 775 Pyelonephritis, 775 Pyemia, 138 arterial, 139 Pyemic abscess, 99 Pylorectomy, 675 for cancer of pylorus, 237, 636 for pyloric stenosis, 639 Pyloroplasty, 674 for pyloric stenosis, 639 Pylorus, digital dilatation of, 674 excision of, 675 stenosis of, 638 Pyogenic cocci, 20 microbes, 37 organisms as causes of osteomyelitis, 317 Pyonephrosis, 777 Quilt suture, 673 Quincke's lumbar puncture, 595 for hydrocephalus, 543 Rabies, 180. See Hydrophobia. Radial artery, anatomy of, 281 incision, 491 ligation of, 281. See Ligation, Radiograph, 872 Radish-fracture, 323 Radius, fracture of, 375 subluxation of head of, 457 Railway spine, 589 Ranula, 618 Rattlesnake bile in treating snake-bite, 178 Rawhide mallet for osteotomy, 475 Ray-fungus, 183 Raynaud's gangrene, 126 INDEX. 905 Reactionary hemorrhage, 272 Recium, cancer of, 720 cleansing of, 44 diseases and injuries, 713 excision of, 720 foreign bodies in, 721 gonorrhea of, 823 prolapse of, 717 stricture of, 719 ulcer of, 718 wounds of, 721 Recurrent hemorrhage, 272 Red thrombus, 133 Reducible hernia, 700 Reduction of fracture, 335 Reef-knot in ligation, 280, 281 Regurgitation in shock, 163 Reid, method of rapid pressure in aneurysm, 252 Relaxation in inflammation, 63 Reminders in the causation of syphilis, 185 in intermediate period of syphilis, 197 treatment of. 205 Removal of Gasserian ganglion, 533 Renal calculus, 772 symptoms of, 773 treatment of, 774 Repair, 82 Resection of intestine, 681 of rib, 610 of sacrum, 720 Residual abscess, 99 Resolution of inflammation, 55 Retardation of circulation, 50 Retention of urine, 784 from enlarged prostate, treatment of, 7S7 from gonorrhea, treatment of, 821 Retinal anemia from shock, 163 Retinitis in syphilis, 196 Retrenchment in plastic surgery, 760 Ketroclusion, 262 Retropharyngeal abscess, 107 Reverdin's method of skin-grafting, 760 Rhabdomyoniala, 222 Rheumatic arthritis, 425 gout, 427. See Arthritis de/ortnans. partial, 428 progressive, 429 torticollis. 504 Rheumatism, acute, 425 chronic. 425 gonorrheal. 423 muscular, 504 Rheumatoid arthritis, 426. See Arthritis de- /orntans. Rhigolene, anesthesia by, 734 Rhinoplasty, 763 Rhoad's apparatus, 447 Rhodius's case of lipoma, 214 Rib, excision of, 499 fracture of. 349 resection of, 610 Rickets, 158 a predisposing cause of fracture, 326 congenital, 1^8 treatment of, 159 Ricord, glandulae Pleiades, 190 Ricord's method of amputating penis, 833 Rider's leg, 508 Rifle bullets, wounds by, 169 Ri-^us sardonicus in tetanus, 144 Robson's treatment of spina bifida, 578 Robson's decalcified bone bobbin, 685 operation for meningocele, 542 Rodent nicer, 117, 235 Roger and Charrin's serum. 142 Rolando's fissure, location of. 535 Rontgen rays, employment of, 871 Rontgen rays in diagnosing fractures, 231 Rosenthal's test for blood in urine, 764 Roseola of syphilis, 192 Round-cell sarcoma, 228 Rubber-dam in dressings, 47, 166 Run-around, 742 Rupia, 193 in tertiary syphilis, 197 Rupture, 699. See Hernia. of abdominal wall from contusion, 627 of bile-ducts, 631 of gall-bladder, 631 of intestine without external wound, 629 of liver, 631 of muscle, 508 of peritoneum, 627 of a sinus, 549 of spleen, 631, 665 of stomach without external wound, 62S of tendons, 510 Sabanejeff's amputation of leg, 856 Saccharorayccs, 18 capillitii. iS Sacro-iliac disease, 410 Sacrum, fracture of, 357 resection of, 720 Saddle-back, 583 Salicylic acid, 29 Salivation from mercurial treatment of syph- ills, 202 Salol, 29 Sanderson, definition of inflammation, 48 Sanious pus, 95 Sapremia, 136 Saprophytes, 19 Sarcina, 20 Sarcocele, syphilitic, 196 treatment of, 203 Sarcoma, alveolar, 228 black, 228 clinical, varieties of, 228 giant-cell, 228 hemorrhagic, 229 melanotic, 22S mixed-cell, 228 myeloid, 228 of bone, 309 of mammary- gland, 865 plexiform, 229 round-cell, 228 spindle-cell, 228 Sarcomata, 227 species of, 228 treatment of, 229 Sardonic smile in tetanus, 144 Saviard, aneurj-sm-needle ot, 279 Sayre's adhesive-plaster dressing, 360 extension for knee-joint disease, 419 knee splint. 418, 419 jury-mast, 587 long splint, 416 plaster-of-Paris jacket, 587 Scalds, 736 of glottis, 737 Scalp, diseases of, 539 -wounds, 543 Scapul.1, excision of, 499 fracture of, 362. See Fracture. Scarification, 64 Scarlet fever, surgical, 90 Scarpa's triangle, 303 Schede's method of treating varix of leg, 274 operation, 611 Schizomycetes, 18 Schleich's fluid in operation for varicocele, 275 new general anesthetic, 733 solutions for infiltration-anesthesia, 735 go6 INDEX. Sciatic artery, ligation of, 308 nerve, stretching of, 532 Scirrhous carcinoma. 235 Scirrhus of mammary gland, 866 Scolices of echinococcus, 239 Scoliosis, 580 symptoms of, 581 treatment of, 581 Scorbutic ulcer, 118 Scorpion, sting of, 176 Scotch douche, 69 Scrofula, 151 Scrofulodermata, 152 Scrofulous pus, 95 Scurvy, 159 infantile, 160 treatment of, 160 Sebaceous cysts, 237 Second intention,, healing by, 84 Secondary hemorrhage, 272 treatment of, 273 infection, 36 syphilis, 191 Section of nerves, 528 Sedative poultice, 71 Sedillot's leg-amputation, 854 Segmentation of bacteria, 21 Selva's thumb bandage, 750 Seminal vesiculitis, 834 Senile gangrene, 121 Senn's apparatus for intracapsular fracture of femur, 388 bone ferrule, 481, 483 plate in lateral intestinal anastomosis, 688 decalcified bone-chips, 48 hydrogen-gas test, 628, 629 method for excision of shoulder-joint, 490 of gastro-enterostomy, 680 of intestinal anastomosis, 682 of making.fistula in gastrotomy, 679 operation for fecal fistula, 694 package of wound-dressing for soldiers, 174 probe for gunshot-wounds of head, 556 Separation of lower radial epiphysis, 370 Sepsis, 136 Septic gangrene, 119 infection, 137 intoxication, 136 wounds, 175 Septicemia, 136 true, 137 Sequestrotomy, 316 Sequestrum, 315 Serous inflammation, 51 pus, 95 Serpiginous ulcers in tertiary syphilis, 197 Serum-therapy, 35 Sheild, method of operating on mastoid dis- ease, 575 Shirt-stud abscess, 105 Shock, diagnosis of, 163 from gunshot-wounds, 172 from wounds, 162 operation during, 164 symptoms of, 162, 163 treatment of, 163 Shoulder-cap in fracture of humerus, 364, 366 -joint disease, 420 dislocation of, 448 excision of, 487 Signorini tourniquets in treatment of aneu- rysm, 251 Silicate of sodium bandage, 759 Silk sutures, preparation of, 46 Silkworm-gut, 46 Silver, 28 -fork deformity, 378 nitrate, 69 Silver-wire sutures, 46 Sinus, 118 -thrombosis, infective, 564 Skey's method of amputating foot, 852 Skiagraph, 872 for locating bullets, 173 of fractured bones, 331 method of taking, 873 Skiagraphy, 871 Skin and nails, diseases of, 739 Skin-grafting, 760 in treatment of tuberculosis, 156 Krause's method of, 762 Reverdin's method of, 760 'J'hiersch's method of, 761 Skull, fractures of, 599 osteoplastic resection of, 572 Sloughing, 129 from fracture, treatment of, 337 Smith's (Henry H.) method of treating dislo- cations of shoulder-joint, 452 Smith's anterior splint for fracture of femur. Snake-bites, 177 constitutional treatment of, 178 symptoms of, 177 treatment of, 177 Snuff-box, anatomical, 282 Soft palate, suture of, 616 Sorbefacients, 68 Souchon's apparatus for administering chloro- form, 728 Spectroscopic test for blood, 763 Sphacelin, 119 Spheroidal-celled carcinomata, 235 Spica bandage, 748 of groin, 754 of instep, 751 of shoulder, 754 of thumb, 750 Spiders, bites of, 176 Spina bifida, 577 operations for, 594 treatment of, 578 Spinal caries, 583 Spinal cord, compression of, 592 concussion of, 591 contusion of, 591 curvatures, 580 wounds of, 591 Spine, congenital deformities of, 577 fractures and dislocations of, 592 operations on, 594 surgery of, 577 tumors of, 578 Spirillum, 19 Spleen, abscess of, 665 rupture of, 631, 665 wandering, 665 • wounds of, 665 Splenectomy, 666, 698 for wounds of spleen, 267 Splenic fever, 168. See Anthrax. Splenopexy, 666 Splint, Agnew's, 396 anterior angular, in fractures near elbow- joint, 371 Bond's, 379. 380 Dupuytren, 403 Fox's, for clavicle, 380 Gordon's pistol-shaped, 379 Hodgen's, 393 internal angular, 365 in fracture of humerus, 368 Jones's nasal, 343 Levis's, 379, 460 Mclntyre's, 394 Sayre's, 416 INDEX. 907 Splint, Sayre's, for knee, 418 Thomas's, 416 Watson's swing-splint. 496 Splinter-fracture, 322 Spondylitis, 583 deformans, 428 Sponges, gauze, 45 marine, perforation of, 47 Spongiopilin, 71 Spontaneous keloid, 217 Spores, 21 Sporulation, 22 Sprain, 432 diagnosis of, 433 fracture, 433 prognosis of, 433 symptoms of, 433 treatment of, 434 Springfield rifle, velocity of bullet of, 169 Spurious hydrophophia, 181 Ssabanejew-Frank operation for gastrostomy, 679 St. Anthony's fire. See Erysipelas. Stagnation in inflammation, 51 Staphylococci, 20 Staphylococcus cereus flavus, 38 epidermidis albus, 38 flavescens, 38 pyogenes albus, 38 aureus, 20, 37 a cause of acute diffuse osteomyelitis, 317 as a cause of boils, 739 citreus, 38 Staphylorrhaphy, 616 Stasis of blood in inflammation, 51 Stay-knot, 281 Stenosis of cardia, 637 of pylorus, 638 Stercoraceous abscess, 99 Sterilized gauze, 46 Sternal symptom in carcinoma of breast, 867 Sternberg's theory of phagocytosis, 34 Sternum, fracture of, 353 Stings of bees and wasps, 176 of insects, 176 Stitch-abscess in surgical fever, 8g Stomach, cancer of, 634 -orifices, cicatricial stenosis of, 637 peptic ulcer of, 636 -reefing, 681 rupture of, without external wound, 628 Stone in bladder, 790. See Vesical calculus. operation for, in women, 807 Strain-fracture, 322 of a muscle, 507 Strangulated hernia, 707. See Hernia. Strangulation of intestine, 639 Streptobacilli, 21 Streptococci, 20 Streptococcus articulorum, 39 of erysipelas, 38, 140 antagonistic to anthrax, 179 pyogenes, 38 as a cause of osteomyelitis, 317 septicus, 38 Stretching of sciatic nerve, 532 Stricture of esophagus, 620 cancerous, 623 cicatricial or fibrous, 620 treatment of, 622 of rectum, 719 of urethra, S23 symptoms and results of, 824 treatment of, 825 organic, catheterization in, 785 spasmodic, catheterization in, 786 Stromeyer's anterior angular splint, 421 Strongylus armatus as a cause of aneurysm in horses, 248 Strumous abscess, 98 joint, 408 Struve's test for blood in urine, 764 Stupe, 70 turpentine, 70 Styptics in hemorrhage, 262 Subastragaloid dislocation, 473 Subclavian artery, anatomy of, 288 ligation of, 288, 289 triangle, 293 Subcutaneous drilling and scraping for de- layed union of fractures, 341 ligature lor varicocele, 225 tubercle, painful, 216 Subcuticidar suture, Halsted's, 42 Subdural abscess, 560 hemorrhage, 548, 549 Subluxation of head of radius, 457 of knee-joint, 470 of shoulder-joint, 450 Submaxillary triangle, 292 Submental triangle, 292 Subphrenic abscess, 100, 657 Suggillation, 160 Sunburn, treatment of, 737 Superficial abscess, 99 Superior longitudinal sinus, location of, 539 maxillary bone, fracture of, 344 Supernumerary digits, 521 Suppuration, 93 phlegmonous, 96 symptoms of, 95 Suppurative fever, 89 thecitis, loi Surgery of the respiratory organs, 596 of the spine, 577 Surgical fevers, 87, 88 kidney, 777 scarlet fever, go Suture a distance, 531 continuous, 46 of dura, 575 Cushing's right-angled, 673 Czerny-Lembert, 673 Dupuytren's, 673 Gussenbauer's, 673 Halsted's, 42 mattress or quilt, 673 interrupted, of scalp, 575 Jobert's, 673 Lembert's, 672 of intestine, 671 Wolfler's, 674 Suturing of annular ligament of wrist, 519 Swedish leech, 63 Sweet's apparatus for locating foreign bodies by Jf-rays, 876 Swelling in inflammation, 60 Sylvius' fissure, location of, 537 Syme's amputation at ankle-joint, 853 for ankle-joint disease, 420 incision for excision of scapula, 499 method of amputating leg, 855 operation of external urethrotomy, 830 staff. 830 Symmetrical gangrene. 126 Sympathetic abscess, 99 fever, 61 Symptomatic fever, 61 Syncope, local, 126 Syndactylism, 521 Synovitis, 406 acute, simple, 406 symptoms of, 406 treatment of, 407 chronic, 407 9o8 INDEX. Synovitis, chronic, symptoms of, 408 treatment of, 408 in hereditary syphilis, 207 in syphilis, 195 pannous, 409 traumatic, 407 Syphilide, diagnosis between secondary and tertiary, 194 macular, 192 maculopapular, 192 tubercular, 194 Syphilides, 191 papular, 193 papulosquamous, 193 pustular, 193 Syphilis, 184-209 acquired, 185 affections of bones in, 195 of brain in, 199 of ear in, 195 of eye in, 196 of hair in, 195 of joints in, 195 of mucous membranes in, 194 of nails in, 195 of testes in, 196 albuminuria in, 199 alopecia in, 195 amyloid degeneration from, 198 arteritis in, 196 ataxia in, 19S bacilius of, 41 baldness in, 195 bubo of, 190 calomel fumigation in, 201 choroiditis in, 196 condylomata of, 194 congestion of viscera in, 197 definition of, 184 diagnosis between secondary and tertiary lesions of, 194 endarteritis in, 196 epididymitis in, 196 epilepsy in, 199 general, 190 hereditary, 185, 205 dactylitis in, 207 diagnosis of, 207 evidences of, 207 Hutchinson teeth in, 208 interstitial keratitis in, 207 intertrigo in, 207 snuffles in, 207 treatment of, 208 Virchow's sign in, 207 immunity from, 185 infection in utero, 206 initial lesions, 187 insomnia in, 199 intermediary period of, 196 iritis in, 196 Meniere's disease in, 195 mixed infection of chancer and chancroid, 1 38 mucous patches in, 194 natiform skull in, 207 nervous, 199 neuritis in, 199 obliterative endarteritis in, 196, 199 onychia in, 195 ophthalmoplegia in, 198 osteophytes in, 207 palmar psoriasis in, 196 paronychia in, 195 periostitis in, 195 phthisis in, 198 primary, 186 ptosis in, 199 Syphilis, reminders, 185, ig6 retinitis in, 196 rules of inheritance of, 206 salivation from mercurial treatment of, 220 secondary, 191 skin lesions in, 191 treatment of, 204 stages of, 186 synovitis in, 19s tertiary, 197 gumma in, 197 rupia in, 197 serpiginous ulcers in, 197 skin eruptions in, 197 various lesions of, 198 thrombosis in, 196 transmitted congenital, 205 transmission of, 185 treatment of, in primary stage, 199 in secondary stage, 200 of complications in the secondary stage 202 in tertiary stage, 205 visceral, 198 warts of, 194 Syphilitic abscess, 99 bubo, 190 eruptions, 191 forms of, igi-194 fever, 191 erythema, 192 maculae, 192 roseala, 192 sarcocele, 196 ulcers, 197 warts, 194 Syphilodermata, 191 Syringomyelia as a cause of brittleness of bones, 327 Syringomyelocele, 577 Swain, method of treating ankylosis, 436 Szumann's solution for intravenous injection, 277 Tabatiere anatomique, 282 ^ ligation of radial artery in, 282 Tabetic arthropathy, 429 Tache cerebrale, 560 Taenia echinococcus, 238 Tagliacotian method of rhinoplasty, 763 Talipes, 523 calcaneo-valgus, 524 calcaneo-varus, 524 calcaneus, 523 equino-valgus, 524 equino-varus, 524 osteotomy for, 479 equinus, 523 osteotomy for, 580 treatment of, 524 valgus, 523, 524 varus. 523, 524 Tapping in edema, 91 of the heart-cavity, 274 of pericardial sac, 274 Tarantula, bite of, 176 T-bandage of perineum, 758 Teale's amputation through forearm, 848 flap in amputation of thigh, S56 method of amputating the arm, 849 of amputating the leg, 854 Telangiectasis, 225 Telangiectatic carcinoma, 236 Telephonic probe, Girdner's, 173 Temperature after wounds as a danger-signal, 167 in shock, 162 Temporal artery, ligation of, 297 INDEX. 909 Tendon, healing of, 86 -lengthening, 518 suture, 518 Tendons, dislocation of, 509 rupture of, 510 wounds of, 510 Tenosynovitis, 510 Tenotomy, 516 of tendo Achillis, 516 of tendons of peroneus longus and brevis, 517 of tendon of tibialis amicus, 517 of tibialis posticus, 517 Terminations of inflammation, 90 Terrier's treatment of hammer-toe, 526 Tertiary syphilis, 197. See Syphilis. syphilitic eruptions, 197 Testicle excision of, 839 malplaced, 838 retained, 838 syphilitic affections of, 196 Tetanus, 144 antitoxin, 148 cephalic, 145 chronic, 145 diagnosis of, 145 head, 145 hydrophobic, 145 symptoms of, 144 table of differential diagnosis for, 146 treatment oT, 147 Tetracocci, 20 T-fracture of humerus, 371 Thecal abscess, 99 Thecitis, 510 acute, 510 symptoms of, 510 treatment of, 510 chronic, 511 treatment of, 511 suppurative, loi Thiersch's method of skin-grafting, 361 Thigh, amputation of, 216 Third intention, healing by, 85 Thomas's splint, 416 Thompson's diagnostic questions in diseases of urinary organs, 767 divulsor, 826 evacuator, 805 lithotrite, 804 vesical forceps, 8og Thoracoplasty. 610 Thoracotomy, 609 Thrombo-arteritis, 133 Thrombophlebitis, 133, 241 treatment of, 241 Thrombiisis. 133 in syphilis, 197 symptoms of, 133 treatment of, 133 Thrombus, antemortem, 133 causes of, 132 red, 133 white, 133 Thrush, 18 Thumb, amputation of. 848 Thymol, 29 Thyroid artery, inferior, ligation of, 290 extract in treatment of fibromata, 217 in treatment of goiter, 744 gland, atrophy of, 743 congestion of, 743 diseases and injuries of, 743 inflammation of, 743 wounds of. 743 Thyrotomy. 601 Tibia, fracture of, 400 Tibial artery, anterior, ligation of, 299-301 Tibial artery, posterior, ligation of, 301 Tinnitus aurium.6i in hemorrhage, 259 Toe-nail, ingrown, 742 Toes, amputation of, 850 Tongue, complete removal of, 619 partial removal of, 618 -lie, operation for, 618 Torpid shock, 162 Torsion in hemorrhage, 261 Torsoclusion, 262 Torticollis, 519 congenital, 520 rheumatic, 504 symptoms of, 520 spasmodic, 520 treatment of, 520 Tourniquet, 843 Toxalbumins, 32 Toxins, 51 Trachea, foreign bodies in, 600 operations on, 601 wounds and injuries of, 598 Tracheotomy, 601 for fracture of hyoid bone, 348 for fracture of laryngeal cartilages, 349 high, 602 Transfixion. 262 amputation by, 846 Transfusion, arterial, 278 of blood, 276 of saline fluid, 277 Transthoracic hepatotomy, 103 Traumatic carditis, 240 dislocations, 438. See Dislocations. fever, 85. hysteria, 589 inflammation of brain and its membranes 557 neurastlienia, 589 pericarditis, 240 Traumatism, psychical, 590 Trendelenberg on method of treating varix of the leg, 274 position, 667 Trephining, 571 in extradural hemorrhage, 266 of bone for abscess, 212 the frontal sinus, 573 Treves's " dangerous area," 540 method of amputating penis, 833 of excision of scapula, 499 operation, 483 Triangle, inferior carotid, 292 occipital, 293 of election, 292 ligation in, 294 of necessity, 292 ligation in, 294 of the neck, 291 anterior, 291 posterior, 292 Scarpa's, 303 subclavian, 293 submaxillary, 292 submental, 292 superior carotid, 292 Triangular sling, 375 Trichiniasis, 506 Trichinosis, 506 Trichlorid of iodin, 29 Trigger-finger, 521 trentinent of, 522 Tripper, 815. See Gonorrhea . Trismus, 145 nascentium or neonatorum, 143 Trophic ulcer, 117 Tropical abscess, 99 9IO INDEX. Truss for reducible hernia, 701 Tubercle, 140 anatomical, 152 bacillus of, 149 caseation of, 149 of bone, 309 Tubercular abscess, 98, 99, 105 adenitis, 154 arthritis, 408 disease of bone, 154 of joints, 154 gummata, 152 meningitis, 559 osteitis, 154 pleurisy, 154 syphilides, 194 Tuberculin, Koch's, 157 Tuberculosis, 148 bacillus of, 149 diagnosis of, 155 intestinal, 153 of alimentary canal, 153 of bone, detection of, by A'-rays, 877 of hip-joint, 411 complications of, 414 diagnosis of, 412 differentiation of, from sacro-iliac dis- ease, 413 from spinal caries, 413 prognosis of, 414 symptoms of, 411 treatment of, 415 of kidney, 778 treatment of 779 of lymphatic glands, 154 of mammary gland, 108 of sacro-iliac joint, 410 of skin, 151 of special joints, 410 of subcutaneous tissue, 152 peritoneal, 153 prognosis of, 155 pulmonary, 153 treatment of, 155 Tuffier method of exploring for abscess of lung, 612 Tuffnell's plan for treating aneurysm, 250 tourniquet in aneurysm, 251 Tumors, 209-239 causes of, 210 classes of, 209 classification of, 213 connective-tissue, innocent, 214 fibro-fatty, 214 hereditation as a cause of, 210 heterologous, 210 innocent epithelial, 231 intracranial, 565 malignant and benign, 213 connective-tissue, 227 epithelial, 233 of the bladder, 798 of bone, 309 of brain, 565-569 treatment of, 567 of cerebellum, 567 of corpus striatum, 566 of intestine, malignant, 647 of kidney, 768 of mammary gland, 863 malignant, 865 of the medulla, 567 of muscles, 506 of nipple, 863 of occipital lobe, 566 of parieto-occipital lobe, 506 of pons, 567 of prefrontal region, 566 Tumors of spine, 578 of the temporosphenoidal lobe, 566 parasitic, origin of, 211 Turpentine stupe, 70 Tympanitic abscess, 98 Typhoid arthritis, 422, 423 bacillus as a cause of arthritis, 422 fever, bacillus of, 41 Ulcer, iiq callous, 117 classification of, iii exuberant, 116 fungous, 116 gummatous, in tertiary syphilis, 198 healing of, 87 healthy, 116 hemorrhagic, 117 Jacobs', 117, 235 neuroparalytic, 117 of bowel, 646 of leg, 112 acute, n2 chronic, 113 complications of, 115 of rectum, 718 of stomach, peptic, 636 perforating, 117 phagedenic, 112, 117 rodent, 117, 235 scorbutic, 118 serpiginous, in tertiary syphilis, 197 syphilitic, 197 varicose, 116 varieties of, 116 Ulceration, no Ulna, fracture of, 373. See Fracture . Ulnar artery, anatomy of, 283 ligation of, 283, 284 incision, 492 Umbilical hernia, 713. See Hernia. Union, delayed, treatment of, 341 fibrous, 333 immediate, 83 of fractures, delayed, 334 membranous, 334 vicious, treatment of, 341 primary, 82 Unity theory of syphilitic infection, 187 Uranoplasty, 616 Ureter, diseases and injuries of, 768 operations on, 779 wounds of, 172 Uretero-ureterostomy, 783 Urethra, foreign bodies in, 813 inflammation of, 814 stricture of, 823 wounds of. Bid Urethral catarrh, chronic, 817 discharges, chronic, treatment of, 822 fever, 829 Urethritis, 814 eczeraatous, 815 gouty, 815 simple, 814 specific, 815. See Gonorrhea. traumatic, 814 tubercular, 815 Ureterolithotomy, 783 Urethrotome, Gross's, 826 Maisonneuve's, 826 Urethrotomy, external, 830 internal, 826 Urinary abscess, 99 Urine, retention of, 784 symptoms of, 785 treatment of, 785 Uterine fibroid, 216, 222 INDEX. 911 Vagina, cleansing of, 44 Valentine's method of irrigation for gonorrhea, 819 Valleix's points douloureux, 58 Valsalva, treatment of aneurysm, 250 Van Hacker's method of gastrostomy, 679 Van Hook's method of treating wounds of ureter, 772 operation, 783 Varicocele, 242, 841 open operation for, 274 subcutaneous ligature for, 275 Varicose aneurysm, 255 lymphatics, 747 ulcer, 116 veins, 241 Varix, 241 aneurysmal, 255 of leg, operation for, 274 treatment of, 243 Vascular system, operations on, 274 Veins, inflammation of, 240 wounds of, 258 Velpeau's bandage, 755 in forward dislocation of clavicle, 446 in fracture of clavicle, 359 rule, 533 Vense comites, 2S0 Venereal catarrh, 815. See Gonorrhea. Venesection, 275 in inflammation, 73 Ventral hernia, 713 Verminous abscess, 99 Verruca necrogenica, 152 Vertebral artery, anatomy of, 289 ligation of, 289 Vesical calculus, 790 composition of, 791 crushing of, 803 symptoms of, 792 treatment of, 793 Vicious union, treatment of, 341 Virchow's disease, 320 law, 210 sign, 207 Viscera, congestion of, in syphilis, 197 Visceral syphilis, 198 Volkmann's limit, 868 membrane, 106 operation, 840 Vnlvulu'^, 639 Vomiting in shock, 163 Von Graefe's sign, 745 Von Zeissl, formula for treatment of acute cystitis, 795 Wagner's osteoplastic resection of skull, 572 Wandering abscess, 98 kidney, 768 spleen, 665 Wardrop's operation for aneurysm, 254 Warts, 231 in syphilis, 194 lymphatic, 747 Wasps, stings of, 176 Water-bath in inflammation, 71 on the brain, 559 Watson's plaster-of-Paris swing splint, 496 Weavers' bottom, 515 Webbed fingers, 521 Weir, method of disinfecting operator's hands, 43 Wens, 238 Wet cold in inflammation, 65 cups, 65 Wheelhouse's operation of perineal urethrot- omy, 830 White swelling, 154, 408, 418 thrombus, 133 White's division of syphilitic periods, 186 operation of bilateral orchidectomy, 838 for myoma of prostate, 223 rule for treating tertiary syphilis, 205 Whitehead's operation, 717 for removal of tongue, 620 Whitlow, 512. See Felon. Wiring of bones for ununited fracture, 483 of fractured patella, 397 of fractures, 336 of ununited fracture of patella, 483 Witzel's method of gastrostomy, 678 Wladimiroff-Mikulicz operation, 420 Wolfler's method of gastro-enterostomy, 680 suture, 674 Wool-sac cocci, 20 -sorters' disease, 178. See Charhon. Wounds, 161 by cannon-balls, 171 by small shot, 171 cleansing of, 165 closure of, 166 complications of, 167 constitutional treatment of, 166 contused, 167 of arteries, 257 dissection of, 175 drainage of, 166 dressing of, 166 gunshot-, 168 amputation for, 174 dressing of, 174 of arteries, 258 incised, 167 of arteries, 257 irrigation of, 165 lacerated, 167 of arteries, 258 local, phenomena of, 162 of abdominal wall, 632 of arteries, 257 of brain, 554 of chest, 606 of heart, 240 of kidney, 770 of larynx, 598 of liver, 658 of mucous membranes, 184 of rectum, 721 of spleen, 665 I of thyroid gland, 743 of ureter, 772 of veins, 258 poisoned, 174 punctured, 167 of arteries, 258 septic, 175 treatment of, 165 Wrist, dislocation of, 458 -joint disease, 421 excision of, 491 Wry-neck, 519. See Torticollis. Wyeth's apparatus for hip-disease, 416 bloodless amputation at hip-joint, 857 A'-RAY apparatus in diagnosticating fractures, 330. 331 " burn," 874 employment of, 871 for discovery of foreign bodies in esophagus, 625 value of, in surgery, 874 Yeasts, i8 Zooglea, 20 CATALOGUE OF THE MEDICAL PUBLICATIONS OF W. B. SAUNDERS, No. 925 WALNUT STREET, PHILADELPHIA. Arranged Alphabetically and Classified under Subjects. ' I ■'tiE books advertised in this Catalogue as being sold by subscription are usually to be obtained from traveling solicitors, but they will be sent direct from the office of pub- lication (charges of shipment prepaid) upon receipt of the prices given. All the other books advertised are commonly for sale by booksellers in all parts of the United States ; but any book will be sent by the publisher to any address, carriage prepaid, on receipt of the published price. 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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 offer 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 b5' 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, $3.00 net. ' Atlas of Legal Medicine. 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- ures on 56 plates, and 193 beautiful half-tone illustrations. Cloth, fo.50 net. 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; Physician-in-Charge, Throat and Nose Department, Hospital of the University of Pennsylvania. With 107 colored figures on 44 plates, and 25 text-illustrations. Cloth, $2.50 net. Atlas of Operative Surgery. By Dr. O. Zuckkrkandl, of Vienna. Edited by J. Chalmers DaCosta, M.D., Clinical Professor of Surgery, Jeft'erson Medical College, Philadelphia; Surgeon to the Philadelphia Hospital. With 24 colored plates, and 217 text illustrations. Cloth, |3.oojiet. 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, I3.50 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, Jefferson 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 Qenerai 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. So/d by Subscription. " As a work either for study or reference it will be of great value to the practitioner, as it is virtually an exposition of such clinical therapeutics as experience has taught to be of the most value. Taking it all in all, no recent publication on therapeutics can be compared with this one in practical value to the working physician." — Chicago Clinical 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 di 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 11 90 pages, profusely illustrated. Cloth, $7.00 net; Sheep or Half Morocco, |8.oo net. Sold by Subscription. " 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 every student and practitioner. " — American 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. Heady soon. Illustrated Catalogue of the ** American Text-Books" sent free upon application. 4 Medical Publications of W. B. Saunders. AN AMERICAN TEXT=BOOK OF QENITO=URINARY AND SKIN DISEASES. By 47 Eminent Specialists and Teachers. Edited by L. Bolton Bangs, 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 the Diseases of the Genito-Urinary Organs, of the Venereal Diseases, and of the Affections of the Skin. Having secured the collaboration of well-known authorities in the branches represented in the Mndertaking, the Editors have not restricted the Contributors in regard to the particular views set forth, but have offered every facility for the free expression of their individual opinions. The work will therefore be found to be original, yet homogeneous and fully representative of the several depart- ments of medical science with which it is 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 70Q pages, with 360 illustrations in the text, and 37 colored and half-tone plates. Cloth, ;g6.oo net; Sheep or Half Morocco, $7.00 net. Sold dy Sicbscription. " It is practical from beginning 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 Morocco, ^8.00 net. Sold by Subscription. " Permit me to say that your American Text-Book of Obstetrics is the most magnificent medical work that I have ever seen. I congratulate you and thank you for this superb work, which alone is sufficient to place you first in the ranks of medical publishers. " — Alexander 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." — American Journal of the- Medical Sciences. IlltJstf ated 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 Prepa7-atiofi. AN AMERICAN TEXT-BOOK OF PHYSIOLOGY. By lo 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." — Amen'can Journal of the Aledical 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 Examiners of the Royal College of Surgeotts, 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, $6.00 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 Practice 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 of its kind it has ever been our fortune to see. " — New York Medical Jonrnal. Illustrated 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 Authoritative Opinion in all branches of Medicine and Surgery, drawn from journals, monographs, and text-books of the leading American and Foreign authors and investigators. Collected and arranged, with critical editorial com- ments, by eminent American specialists and teachers, under the general editorial charge of George M. Gould, M.D. 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. Sold by Subscription. " It is difficult to know which to admire most — the research and industry of the distin- guished band of experts whom Dr. Gould has enhsted 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 Germany." — Londott 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, $5.50 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 tJie 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 the Illijtois 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. Crown octavo, 252 pages; 75 illustrations. Cloth, $1.00; interleaved for notes, ^1.25. [See Saunders^ Question- Compends, page 21.] «' Embodies the whole subject in a nut-shell. We cordially recommend it to our read- ers." — Chicago Medical Tivies. 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 l)ook as an important event in the history of pharmaceutical te.iching in this country, and predict for it an unquali- fied success." — Aliontii Report to the Philadelphia College of Pharmacy. "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." — Birmingham (Eng. ) Medical Keviexv. "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." — British 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." — Yale 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 Saimders' Question- Compe?ids, 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." — New 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 j Visiting Physician to St. Joseph's Hospital, etc. I71 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 F. Butler, Ph.G., M.D., Professor of Materia Medica and of Clinical Medicine in the College of Physicians and Surgeons, Chicago ; Professor of Materia Medica and Therapeutics, Northwestern University, Woman's Medical School, etc. Octavo, 858 pages, illustrated. Cloth, ;g4.oo 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," — Jottmal 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 be found a valuable work of reference for the practitioner." — Ai7ierica7i Aledico-Stirgical Bidletiti. 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. Jti Preparatioji. 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 very useful to practitioners who takg an interest in the many newer remedies of the present day." — Ediiiburgh Medical Journal. " The appearance of this new edition of Dr. Cerna's very valuable work shows that it is properly appreciated. The book ought to be in the possession of every practising physi- cian." — New York Medical 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." — New 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. /;/ Preparatioti. CLARKSON'S HISTOLOGY. A Text=Book of Histology, Descriptive and Practical. By Arthur Clarkson, M.B., CM. 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^eiu 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 M. Corwin, A.M., 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 memor>' 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 N'e)~vous and Mental Diseases. 10 Medical Publications of W. B. Saunders. CRAQIN'S GYNECOLOGY, Fourth Edition, Revised. Essentials of Gynaecology. By Edwin B. Cragin, M.D., Attend- ing Gynaecologist, Roosevelt Hospital, Out-Patients' Department, New York, etc. Crown octavo, 200 pages; 62 fine illustrations. Cloth, ^i.oo; interleaved for notes, $1.25. [See Saunders^ Question- Co7nJ>ends, page 21.] " A handy volume, and a distinct improvement on students' compends in general. No author who 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- ology, or who wishes an accurate account of the various methods of research, the book may be recommended with confidence that he will find there what he requires." — London Lancets 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 Jourtial, 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 writtenj 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, University 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 FROTHINGHAM'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 School, 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 Aledico- Surgical Bulletin. 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 Subscnptio/i. " 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." — Brooklyti 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 homfy its readers." — American Medico- Surgical Bulletin. 12 Medical Publications of W. B. Saunders. GRIFFIN'S MATERIA MEDICA AND THERAPEUTICS. Manual of Materia Medica and Therapeutics. By Henry A. Griffin, A.B., M.D., Assistant Physician to the Roosevelt Hospital, Out-Patient Department, New York City. In 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 plates. 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 through with advan- tage." — Ay-chives 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." — Ameri- can 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 Adams 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. Medical Publications of W. B. Saunders. 13 HARE'S PHYSIOLOGY. Third Edition, Revised. Essentials of Physiology. By H. A. Harr, 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, ^i.oo net; interleaved for notes, $1.25 net. [See Saunders^ Question- Compends, page 21.] " The best condensation of physiological knowledge we have yet seen." — Aledical 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." — New 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 instructor — 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. /« 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- Chirurgical 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 QLEASON'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 Gleason, M.D., Surgeon-in-Charge of the Nose, Throat, and Ear Department of the Northern Dispensary of Philadelphia. Two volumes in one. Crown octavo, 290 pages; 124 illustrations. Cloth, $1.00; interleaved for notes, $1.25. [See Saunders' Question-Cojjipends, 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 Psediatric 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, Leucomaines, 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, $6.00 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 Principles mid Practice of Medicine, Rush 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 Feser. It will prove to be of importance and interest not only to the general surgeon and physician, but also to many specialists — laryn- gologists, gy^necologists, 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. /// Freparatmi. LAINE'S TEMPERATURE CHART. Temperature Chart. Prepared by D. T. Laine, M.D. Size 8 x v^y^ 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, M.D., Professor of Diseases of Women and Children, Medical College of Virginia, etc. Cloth, interleaved, $1.00 net. " The book is certainly an admirable resume 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, I5.00 net; Half Morocco, ^6.00 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." — The Medical Nezvs, 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, fohns 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, ^i.oo ; 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 style is interesting, and its illustrations are admirable." — Medical and Surgical Reporter. 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 AIcFarland, 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 lias 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- teriologv. 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, $1.00; 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 News. 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 Appendix 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 News. 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 Abbreviations ; of the Instruments, Drugs, Diseases, Acci- dents, Treatments, Operations, Foods, Appliances, 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, ^i.oo. " A 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." — Chicago 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, ^i.oo; interleaved for notes, ^1.25. [See Saunders' Question- Compe7ids , 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." — A^nerican 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 of 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 wlio 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 Thysician 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 Saunders' Question- Comp ends , page 21.] "Contains the gist of all the best works in the department to which it relates." — American Practitioner and Neivs. PRINQLE'S SKIN DISEASES AND SYPHILITIC AFFECTIONS. Pictorial Atlas of Skin Diseases and Syphilitic Affections (American Edition). Translation from the French. Edited by J. 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 been seen better in point of correctness, beauty, and general merit." — New 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 Joui-nal. 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 Medicine and Surgery. Price per Part, ^i.oo. Now ready: Vol. I., Parts I. to IV.; Vol. II., Parts I., II. SaTINDFRS^ ^^^^^^^ ^^ Question and ^^ Answer Form> V^ U Ho 1 IwiN np^HE MOST COMPLETE AND BEST C^nii^nTynKTTiQ illustrated series of v^L/lVlJrjIllNJU^ coMPENDs ever issued. Now the Standard Authorities in Medical Literature ♦ ♦ . . with Students and Practitionars in every City of the United States and Canada, •<3 ^ ^ OVER X 65,000 COPIES SOLD, ^ THE REASON WHY, They are the advance guard of "Student's Helps" — that DO help. They are the leaders in their special line, well and authoritatively written by able men, who, as teachers in the large colleges, know exactly what is wanted by a student preparing for his examinations. The judgment exercised in the selection of authors is fully demonstrated by their professional standing. Chosen from the ranks of Demonstrators, Quiz-masters, and Assistants, most of them have become Professors and Lecturers in their respective colleges. Each book is of convenient size (5x7 inches) , containing on an average 250 pages, profusely illustrated, and elegantly printed in clear, readable type, on fine paper. The entire series, numbering twenty-three volumes, has been kept thoroughly revised and enlarged when necessary, many of the books being in their fifth and sixth editions. TO SUM UP, Although there are numerous other Quizzes, Manuals, Aids, etc. in the market, none of them approach the "Blue Series of Question Compends;" and the claim is made for the following points of excellence : 1. Professional distinction and reputation of authors. 2. Conciseness, clearness, and soundness of treatment. 3. Quality of illustrations, paper, printing, and binding. Any of these Compends will be mailed on receipt of price (see next page for List). Oaunders^ \)uestion-Compend Series* Price, Cloth, $1.00 per copy, except when otherwise noted. " Where the work of preparing students' manuals is to end we cannot say, but the Saunders Series, in our opinion, bears oft' the palm at present." —JVew York 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, M.D. Sixth edition, revised, with an Appendix 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 L.wvrence ^VoL^F, M.D. P'ourtli 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. Armand 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, M.D. An Appendix on Urine Examination. By Lawrence Wolff, M.D. Third edition, enlarged by some 300 Essential Formulce, selected from eminent authorities, by Wm. M. Powell, M.D. (Double number, ^2.00.) 10. ESSENTIALS OF GYN/ECOLOGY. By Edwin B. Cragin, M.D. Fourth edition, revised. 11. ESSENTIALS OF DISEASES OF THE SKIN. By Henry W. Stelwagon, M.D. Third edition, revised and enlarged. ($1.00 net.) 12. ESSENTIALS OF MINOR SURGERY, BANDAGING, AND VENEREAL DISEASES. By Edward Martin, M.D. Second ed., revised and enlarged. 13. ESSENTIALS OF LEGAL MEDICINE, TOXICOLOGY, AND HYGIENE. By C. E. Armand Semple, M.D. 14. ESSENTIALS OF DISEASES OF THE EYE, NOSE, AND THROAT. By Edward Jackson, M.D., and E. B. Gle.ason, M.D. Second ed., revised. 15. ESSENTIALS OF DISEASES OF CHILDREN. By William M. Powell, M.D. Second edition. 16. ESSENTIALS OF EXAMINATION OF URINE. By Lawrence Wolff, ALD. Colored "Vogel Scale." (75 cents.) 17. ESSENTIALS OF DIAGNOSIS. By S. Solis Cohen, M.D., and A. A. Eshner, M.D. (Si. 50 net.) 18. ESSENTIALS OF PRACTICE OF PHARMACY. By Lucius E. Sayre. Second edition, revised and enlarged. 20. ESSENTIALS OF BACTERIOLOGY. By INL V. Ball, M.D. Third edition, revised. 21. ESSENTIALS OF NERVOUS DISEASES AND INSANITY. By John C. Shaw, jNLD. Third edition, revised. 22. ESSENTIALS OF MEDICAL PHYSICS. By Fred J. Brockway, M.D. Second edition, revised. (Sl.oo net I 23. ESSENTIALS OF MEDICAL ELECTRICITY. By David D. Stewart, M.D., and Edward S. L.awrance, ALD. 24. ESSENTIALS OF DISEASES OF THE EAR. By E. B. Gleason, M.D. Second edition, revised and greatly enlarged. Pamphlet containing specimen pages, etc sent free upon application. Saunders' x c. j . lof Jtudents New Series and of Manuals P»-actitioners. 'T'HAT there exists a need for thoroughly reliable hand-books on the leading branches of Medicine and Surgery is a fact amply demonstrated by the favor with which the SAUNDERS NE^ SERIES OF MANUALS have been received by medical students and practitioners and by the Medical Press. These manuals are not merely condensations from present literature, but are ably written by well-known authors and practitioners, most of them being teachers in representative American colleges. Each volume is concisely and authoritatively written and exhaustive in detail, without being encumbered w^ith the introduction of **cases,*^ which so largely expand the ordinary text-book. These manuals will therefore form an admirable collection of advanced lectures, useful alike to the medical student and the practitioner: to the latter, too busy to search through page after page of elaborate treatises for w^hat he w^ants to know, they will prove of inestimable value ; to the former they will afford safe guides to the essential points of study. The SAUNDERS NEW SERIES OF MANUALS are conceded to be superior to any similar books now^ on the market. No other manuals afford so much infor- mation in such a concise and available form. A liberal expenditure has enabled the publisher to render the mechanical portion of the work w^orthy of the high literary standard attained by these books. Any of these Manuals will be mailed on receipt of price (see next page for List). >au nders^ 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. Octavo, 900 pages, profusely illustrated. Cloth, $4.00 net ; Half Morocco, $5.00 net. DOSE=BOOK AND MANUAL OF PRESCRIPTI0N=WR1TINQ. 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, $1.50 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 Medical 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- pensary, 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 Infirmary for Nervous Diseases, etc. 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 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 Saundbv, M.D. Edin., 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 Foetal Head, Obstetrical Table, Diet List for Various Diseases, Materials and Drugs used in Antiseptic Surgery, Treatment of Asphyxia from Drowning, Surgical Remembrancer, Tables of Incompatibles, Eruptive Fevers, Weights and Measures, etc. Hand- somely bound in 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 ^neid into English Verse;" Co-Author of the "New Pronouncing Dictionary of Medicine." 32mo, 280 pages. Cloth, 75 cents; Leather Tucks, $1.00. " Remarkably accurate in terminology, accentuation, and definition." — Jourtial 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 Saundei's' Question- Co7npends, 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 SeiMPLe, B. A., ALB. Cantab., M. R. C. P. Lend., Physician to the Northeastern Hospital for Children, Hackney, etc. Crown octavo, 212 pages; 130 illustrations. Cloth, $1.00; interleaved for notes, 51-25. [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. , ]\I.B. Cantab., IM.R. C.P. Lond., Physician to the Northeastern Hospital for Children, Hackney, etc. Crown octavo, 174 pages; illustrated. Cloth, 31.00; interleaved for notes, $1.25. [See Saunders' Question- Compends, page 21.] " Should take its place among the standard volumes on the bookshelf of both student and practitioner." — London Hospital Gazette. SENN'S QENITO=URINARY TUBERCULOSIS. Tuberculosis of the Qenito=Urinary Organs, Male and Female. By Nicholas Senx, 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 Reportei-. " A work which adds another to the many obligations the profession owes the talented author." — Chicago Medical 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 Sexx, 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-M 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, S7.00 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 vears. 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, ^i.oo; interleaved for notes, $1.25. [See Saunders' Question- Compefids, page 21.] "Clearly and intelligently written.'' — Boston Medical and Surgical Journal. "There is a mass of valuable material crowded into this small compass." — American- Medico- Su7-gical Bulletin. I 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. I1.25 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, $x.2e^ net. [See Saunders^ Question- Compends, 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 Woman'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 modem 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 Magazine. 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. S{)ecially 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 bespeaks its popularity. It is an excellent condensation of the essentials of medical practice for the student, and may be found also an excellent reminder for the busy physician." — Buffalo Medical 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 Jourtial. 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^ Question- Comp ends, page 21.] " Throughout the whole brief space at their command the authors show a discrininating 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." — T/ierapeutic Gazette. " This is a well-WTitten, eminently practical volume, which covers the entire range of private nursing as distinguished from hospital nursing, and instructs the nurse how best to meet the various emergencies which may arise, and how to prepare everything ordinarily needed in the illness of her patient." — American Journal of Obstetrics and Diseases of Women and Children. " It is a work that the physician can place in the hands of his private nurses with the assurance of benefit." — Ohio Medical Joternal. 28 3Iedical Publications 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 American Medical Association. THOMAS'S DIET LISTS AND SICK=ROOM DIETARY. Diet Lists and Sick=Room Dietary. By Jerome B. Thomas, M.D., Visiting Physician to the Home for Friendless Women and Children and to the Newsboys' Home ; Assistant Visiting Physician to the Kings County Hospital. 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=WRITINQ. 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 text, 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 circulatory 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 Medical Magazine. Medical Publications 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, in the Harvard Graduate Magazine. " The handsomest specimen of bookmaking that has ever been issued from the American medical press." — American Journal of the Medical Scietices. " 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 Sau7iders'' 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; inter- leaved for notes, $1.25. [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." — Pharmaceutical Era. CLASSIFIED LIST Medical Publications W. B. SAUNDERS, 925 "Walnut Street, Philadelphia. ANATOMY, EMBRYOLOQY, HISTOLOGY. Clarkson — A Text-Book of Histology, 9 Haynes — A Manual of Anatomy, . . . 13 Heisler — A Text-Book 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, . . II 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 Starr — 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, . . 14 Morten — -Nurse's Dictionary, .... 18 Saunders' Pocket Medical Lexicon, . 24 EYE, EAR, NOSE, AND THROAT. An American Text- Book of Diseases of the Eye, Ear, Nose, and Throat, . 3 Casselberry — Dis. of Nose and Throat, 8 De Schweinitz — Diseases of the Eye, . 10 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 Genito- urinary and Skin Diseases, 4 Hyde and Montgomery — Syphilis and the Venereal 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, ... II 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, 17 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 Warren — 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, I3 Meigs — Feeding in Early Infancy, , . 17 Morten — Nurse's Dictionary, .... 18 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 Dorland — Manual of Obstetrics, . . . lo Hirst — Text-Book of Obstetrics, ... 13 Norris — Syllabus of Obstetrics, .... 18 PATHOLOGY. An American Text-Book of Pathology, 5 Mallory and Wright — Pathological Technique, 16 Semple — Essentials of Patholog)' 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- or}' and Practice of Medicine, .... 5 An American Year-Book of Medicine and Surger}', 6 Anders — Text-Book of the Practice of Medicine, 6 Lockwood — Manual of the Practice of Medicine, 15 Morris — Essentials of the Practice of Medicine, 1 7 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 Venereal Diseases, 13 Martin — Essentials of Minor Surgery, 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 Surgeiy, 17 Pye — Elementary Bandaging and Surgi- cal Dressing, 19 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 Exercises in Bot- any, 7 Gould and Pyle — Anomalies and Curi- osities of IMedicine, n Keating — How to Examine for Life Insurance, I4 Keen — Surgical Complications and Se- quels of Typhoid 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-Conipends, . . 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. de Schweinitz, M.D., Professor of Ophthalmology in the Jeffer- son Medical College, Philadelphia; 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 Guiteras, 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, Nevir 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,, Illinois. STENGEL'S PATHOLOGY. A Manual of Pathology. By Alfred Stengel, INI. 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 A-rchibald 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., Professor 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 Laryngologist, 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 rules of the Library or by special arrange- ment with the Librarian in charge. DATE BORROWED DATE DUE DATE BORROWED DATE DUE jm 4 1945 . ■ ; 1 C28(|I4i)m100 COLUMBIA UNIVERSITY LIBRARIES ihsi stxi RD31D11 1898 C.1 A manual of modern surgery 2002063778 4 RD31 Da Co£5ta 18?8