CONTRIBUTORS TO VOLUME I. 
BELFIELD, WILLIAM T., M.D.; 
BURRELL, HERBERT L., M. D.; 
EVE, DUNCAN, M.D.; 
FORDYCE, JOHN A., M. D.; 
GERRISH, FREDERIC H., M. D.; 
HARDAWAY, WILLIAM A., M.D.; 
HARE, HOBART AMORY, M.D.; 
HOLLOWAY, JAMES M., M. D.; 
MUDD, HENRY H., M. D.; 
NANCREDE, CHARLES B., M. D.; 
PARK, ROSWELL, M.D.; 
PARMENTER, JOHN, M.D.; 
RANSOHOFF, JOSEPH, M. D.; 
SMITH, CHAUNCEY P., M. D.; 
SOUCHON, EDMOND, M. D. A 
Treatise on Surgery 
BY 
AMERICAN AUTHORS. 
FOR STUDENTS AND PRACTITIONERS OF SURGERY 
AND MEDICINE. 
EDITED BY 
ROSWELL PARK, A.M., M.D, 
Professor of the Principles and Practice of Surgery and of Clinical Surgery in the 
Medical Department of the University of Buffalo, Buffalo, New York; Member 
of the Congress of German Surgeons; Fellow of the American Surgical 
Association; Ex-President Medical Society of the State of New 
York ; Surgeon to the Buffalo General Hospital, etc. 
VOLUME I. 
GENERAL SURGERY. 
WITH 350 ENGRAVINGS AND 21 FULL-PAGE PLATES 
IN COLORS AND MONOCHROME. 
LEA BROTHERS & CO., 
PHILADELPHIA AND NEW YORK. 
1896. Entered according to Act of Congress in the year 1896, by 
LEA BROTHERS & CO., 
in the Office of the Librarian of Congress, at Washington. All rights reserved. 
WESTCOTT & THOMSON, 
ELEOTROTYPERS, PHILADA, 
PRESS OF 
WILLIAM J. OOrtNAN, PHILADA. PREFACE. 
In preparing a new treatise on Surgery it was evident that the surest 
method of achieving success was to invoke the collaboration of those 
who unite the qualifications of teachers in our leading colleges with 
abundant experience in private practice and in hospital clinics. It has 
been the agreeable duty of the Editor to secure this co-operation, and 
the distinguished names which adorn the several chapters of the work 
not only show how zealously this assistance has been rendered by the 
most eminent members of the profession, but offer the best guarantee of 
the value of the teachings embodied in the following pages. 
The wonderful advance in both the science and art of Surgery dur- 
ing recent years has rendered advisable a departure from tradition, and 
the treatment bestowed on certain topics is therefore essentially new. 
This is the case, for instance, with the distinction everywhere maintained 
between hypersemia and inflammation (i. e. infection). Chapters have 
been inserted on subjects not hitherto discussed in general treatises on 
Surgery—notably that on the Surgical Pathology of the Blood, intro- 
duced partly because of a decided conviction that the exact methods of 
clinical study so useful to the modern physician should not be denied to 
his surgical confrere. The chapters on Auto-intoxications and on the 
Surgical Sequelse of Acute Non-surgical Diseases are also practically 
new. The importance of Bacteriology is everywhere recognized, and 
its teachings are impressed upon almost every page. In thus present- 
ing the most recent results of research and experience, however, care 
has been taken not to neglect the vast amount of accumulated knowledge 
which is our heritage from the past, and unremitting effort has been 
devoted to afford under each topic a complete and condensed account of 
theory and practice representing the science and art of Surgery in the 
advanced position of to-day. Recent years have witnessed correspond- 
ing progress in medical education toward the highest standards, and this 
tendency to a beneficent uniformity renders practicable the preparation of 
a text-book answering the requirements of the continually increasing 
proportion of students who seek the advantages of our best institutions. 
Their needs cannot be sharply differentiated from those of the student 
after graduation; hence it is believed that the present volumes will be 
found serviceable in affording full practical information to the surgeon, 8 
PREFACE. 
and to the general physician whose duties frequently call for surgical 
knowledge. 
The first volume will be found to contain the more general subjects 
of Surgical Pathology, the General Principles and Theory of Surgery, 
and the Surgery of the Tissues and Tissue-systems, the particular 
applications of general surgery to the Surgery of Regions and Organs 
being reserved for the second volume. As each volume may be pro- 
cured separately, the needs of all classes of readers will thus be met. 
Especial care has been devoted to the very complete series of illustra- 
tions, of which by far the greater part have been prepared expressly for 
the work, and colored plates have been introduced wherever they would 
best serve to elucidate the text. 
In conclusion, the Editor desires to express his warmest thanks to 
the eminent contributors, whose zealous association in the production of 
the work will remain one of the most cherished recollections of a busy 
life. He would also express his indebtedness to Charles E. Smith, Esq., 
of Philadelphia for the careful supervision of the proof, and to Dr. 
Chauncey P. Smith of Buffalo for invaluable assistance throughout the 
preparation of the work. 
ROSWELL PARK. 
Buffalo, August, 1896. CONTRIBUTORS TO VOLUME I. 
WILLIAM T. BELFIELD, M. D., 
Professor of Bacteriology and Lecturer on Surgery, Kush Medical College, Chicago; 
Professor of Genito-urinary and Venereal Diseases, Chicago Policlinic. 
HERBERT L. BURRELL, M. I)., 
Assistant Professor of Clinical Surgery, Medical School of Harvard University, 
Boston; Surgeon to the Boston City Hospital and to the Children’s Hospital, 
Boston. 
DUNCAN EVE, A. M., M. D., 
Professor of Surgery and Clinical Surgery, Medical Department of Vanderbilt 
University, Nashville, Tennessee. 
JOHN A. FORDYCE, A. M., M. D., 
Professor of Dermatology and Syphilology, Bellevue Hospital Medical College, 
New York ; Visiting Dermatologist to the City (Charity) Hospital, New York. 
FREDERIC H. GERRISH, A.M., M. D., 
Professor of Anatomy, Bowdoin College; Consulting Surgeon, Maine General 
Hospital, Portland, Maine. , 
y 
WILLIAM A. HARDAWAY, A. M., M. D., 
Professor of Diseases of the Skin and Syphilis in the Missouri Medical College, 
St. Louis; Ex-President of the American Dermatological Association. 
HOBART AMORY HARE, M. D., B. Sc., 
Professor of Therapeutics and Materia Medica in the Jefferson Medical College, 
Philadelphia ; Physician to the Jefferson Hospital, Philadelphia. 
JAMES M. HOLLOWAY, A. M., M. D., 
Professor of Surgery and Clinical Surgery, Kentucky School of Medicine ; Profes- 
sor of Clinical and Operative Surgery, Louisville Medical College, Louisville, 
Kentucky. 
HENRY H. MUDD, M.D., 
Professor of Clinical Surgery and Special Fractures and Dislocations, St. Louis 
Medical College ; Consulting Surgeon, St. Louis City Hospital. 10 
CHARLES B. NANCREDE, A. M., M. D., 
Professor of Surgery and of Clinical Surgery, Department of Medicine and Sur- 
gery, University of Michigan; Emeritus Professor of General and Orthopaedic 
Surgery in the Philadelphia Polyclinic. 
ROSWELL PARK, A. M., M. D., 
Professor of Principles and Practice of Surgery and Clinical Surgery in the Medi- 
cal Department of the University of Buffalo; Surgeon to the Buffalo General 
Hospital, etc., Buffalo, N. Y. 
JOHN PARMENTER, M. D., 
Professor of Anatomy and Adjunct Professor of Clinical Surgery, Medical De- 
partment of the University of Buffalo; Surgeon to the Erie County, Fitch 
Accident, and Children’s Hospitals, Buffalo, N. Y. 
JOSEPH RANSOHOFF, M. D., F. R. C. S., 
Professor of Anatomy and Clinical Surgery, Medical College of Ohio, Cincinnati; 
Surgeon to the Good Samaritan, Cincinnati, and Jewish Hospitals. 
CHAUNCEY P. SMITH, M. D., 
Assistant Attending Surgeon, Fitch Accident Hospital ; Instructor in Surgery, 
Medical Department, University of Buffalo, Buffalo, N. Y. 
EDMOND SOUCHON, M. D., 
Professor of Anatomy and Clinical Surgery, Medical Department, Tulane Univer- 
sity of Louisiana; Visiting Surgeon, Charity Hospital, New Orleans. 
CONTRIBUTORS. CONTENTS OF VOLUME I. 
PART I. 
SURGICAL PATHOLOGY. 
CHAPTER I. 
PAGE 
HYPEREMIA: ITS CONSEQUENCES AND TREATMENT 17 
By Roswell Park, M. D. 
CHAPTER II. 
SURGICAL PATHOLOGY OF THE BLOOD 32 
By Roswell Park, M. D. 
CHAPTER III. 
INFLAMMATION 53 
By Roswell Park, M. D. 
CHAPTER IV. 
ULCER AND ULCERATION 89 
By Roswell Park, M. D. 
CHAPTER V. 
GANGRENE 102 
By Roswell Park, M. D. 
PART II. 
SURGICAL DISEASES. 
CHAPTER VI. 
ON AUTO-INFECTION, ESPECIALLY IN SURGICAL PATIENTS ... 109 
By Roswell Park, M. D. 12 
CONTENTS. 
CHAPTER VII. 
PAGE 
THE SURGICAL FEVERS AND SEPTIC INFECTIONS 117 
By Roswell Park, M. I). 
CHAPTER VIII. 
SURGICAL DISEASES COMMON TO MAN AND THE DOMESTIC 
ANIMALS 138 
By Roswell Park, M.D. 
CHAPTER IX. 
SURGICAL DISEASES COMMON TO MAN AND THE DOMESTIC 
ANIMALS (Continued) 160 
By Roswell Park, M.D. 
CHAPTER X. 
SYPHILIS 182 
By John A. Fordyce, M. D. 
CHAPTER XI. 
GONORRIICEA AND ITS SEQUELAE 214 
By William T. Belfield, M. D. 
CHAPTER XII. 
SHOCK AND COLLAPSE 230 
By Roswell Park, M.D. 
CHAPTER XIII. 
SCURVY AND RICKETS 234 
By Roswell Park, M. D. 
CHAPTER XIV. 
SURGICAL ASPECTS AND SEQUELS OF OTHER INFECTIONS AND 
DISEASES 239 
By Roswell Park, M. D. 
CHAPTER XV. 
POISONING BY ANIMALS AND PLANTS 247 
By Roswell Park, M.D. 
CHAPTER XVI. 
ACUTE INTOXICATIONS, INCLUDING DELIRIUM TREMENS .... 251 
By Roswell Park, M.D. CONTENTS. 
13 
PART III. 
SURGICAL PRINCIPLES AND METHODS AND MINOR 
PROCEDURES. 
CHAPTER XVII. 
PAGE 
CONTROL OF HEMORRHAGE; ABSTRACTION OF BLOOD; PARA- 
CENTESIS; COUNTER-IRRITATION 257 
By John Parmenter, M. D. 
CHAPTER XVIII. 
MINOR SURGERY AND BANDAGING 268 
By John Parmenter, M. D. 
CHAPTER XIX. 
ANAESTHESIA AND ANAESTHETICS 285 
By Hobart Amory Hare, M.D. 
CHAPTER XX. 
SURGICAL DIAGNOSIS 304 
By Chauncey P. Smith, M. D. 
CHAPTER XXI. 
THE METHODICAL REPORT OF A SURGICAL CASE 316 
By Edmond Souchon, M.D. 
PART IV. 
INJURY AND REPAIR. 
CHAPTER XXII. 
WOUNDS 319 
By Charles B. Nancrede, M. D. 
CHAPTER XXIII. 
GUNSHOT WOUNDS 327 
By Charles B. Nancrede, M.D. 14 
CONTENTS. 
CHAPTER XXIV. PAGF 
PROCESSES OF REPAIR 350 
By Charles B. Nancrede, M. D. 
CHAPTER XXV. 
TREATMENT OF WOUNDS: ANTISEPSIS AND ASEPSIS 362 
By Charles B. Nancrede, M. D. 
PART Y. 
SURGICAL AFFECTIONS OF THE TISSUES AND 
TISSUE-SYSTEMS. 
CHAPTER XXVI. 
CYSTS AND TUMORS 385 
By Roswell Park, M. D. 
CHAPTER XXVII. 
SURGICAL DISEASES OF THE SKIN 444 
By William A. Hardaway, M. D. 
CHAPTER XXVIII. 
BURNS, SCALDS, AND FROST-BITES, AND THEIR TREATMENT ... 479 
By John Parmenter, M. D. 
CHAPTER XXIX. 
THE MUSCLES, TENDONS, AND TENDON-SHEATHS, BURSAS, AND 
FASCLE • 487 
By Herbert L. Burrell, M. D. 
CHAPTER XXX. 
INJURIES AND DISEASES OF THE LYMPHATIC VESSELS AND 
NODES . . • • . 518 
By Frederic Henry Gerrish, M. D. 
CHAPTER XXXI. 
SURGICAL INJURIES AND DISEASES OF THE VEINS 536 
By James M. Holloway, M. D. CONTENTS. 
15 
CHAPTER XXXII. 
PAGE 
SURGICAL INJURIES AND DISEASES OF THE ARTERIES, IN- 
CLUDING ANEURISM 547 
By Duncan Eve, M. D. 
CHAPTER XXXIII. 
INJURIES AND DISEASES OF THE JOINTS AND JOINT-STRUC- 
TURES 584 
By Joseph Ransohoff, M. D. 
CHAPTER XXXIV. 
OPERATIONS ON JOINTS 629 
By Joseph Ransohoff, M. D. 
CHAPTER XXXV. 
SURGICAL DISEASES OF THE OSSEOUS SYSTEM .647 
By Rosweee Park, M. D. 
CHAPTER XXXVI. 
FRACTURES 690 
By Henry H. Mudd, M. D. 
CHAPTER XXXVII. 
DISLOCATIONS 750 
By Henry H. Mudd, M. D. GENERAL SURGERY. 
PART I. 
SURGICAL PATHOLOGY. 
CHAPTER I. 
HYPEREMIA: ITS CONSEQUENCES AND TREATMENT. 
By Roswell Park, M. D. 
The reactionary results of injury to various tissues and the first 
local appearances clue to the surgical infectious diseases are indicated 
by certain appearances which, for a few hours at least, are in large 
measure common to both. Their beginnings being pathologically 
similar, their results depend not alone on the violence or intensity of 
the process, but in predominating measure upon the primary influ- 
ences at work. The consequences of mere mechanical injury—such 
as strain, laceration, etc.—are in healthy individuals promptly repaired 
by processes which will be taken into consideration in the ensuing 
chapters. They are throughout conservative and reparative, and are 
directed toward restoring, so far as possible, the original condition. 
The consequences, on the other hand, of the surgical infections are 
more or less disastrous from the outset, although the extent of the 
disaster may be localized within a very small area, as after a trifling 
furuncle, or they may be so widespread as to disable a limb or an 
organ, or they may even be fatal. It is of the greatest importance, 
not alone for scientific reasons, but because treatment must in large 
measure depend upon the underlying conditions, to differentiate 
between these two general classes of disturbance, which we speak of 
as— 
A. Those produced by external or extrinsic disturbances — i. e. 
traumatisms, sprains, lacerations, etc.; and 
B. Those produced by internal and, intrinsic causes, which, for the 
most part, are the now well-known micro-organisms, such as produce 
the various surgical diseases. 
These latter disturbances may be imitated or simulated in the 
presence of certain irritants within the tissues, such as the poisons of 
various insects and plants; the irritation produced by foreign bodies, 18 
SURGICAL PATHOLOGY. 
minute or large; and possibly the presence within the system of cer- 
tain poisons whose nature is not yet known, such as that of syphilis 
or certain others whose chemistry is fairly well understood, but whose 
presence cannot be easily explained, as uric acid, etc. 
Clinically, all these disturbances are manifested by certain phe- 
nomena common to each which may present themselves at one time 
more prominently, at another time less so. These significant appear- 
ances have been recognized from time immemorial as the color, rubor, 
dolor, tumor, et functio Icesa of our ancestors, or as the heat, redness, 
pain, swelling, and loss of function of our common experience. When 
one or more of these are present, the surgeon cannot afford to disre- 
gard the fact, while he should, moreover, be able to account for each 
on general principles which should to him be well known. 
To their more exact study we must, however, make some preface 
in the way of general remarks concerning a phenomenon everywhere 
easily recognized, but as yet incompletely understood. This phenom- 
enon has reference to an undue supply of blood to a part, and is com- 
monly known under two terms which are practically synonymous— 
namely, congestion and hypercemia. To begin with these, then, we 
must note, first of all, that congestion and hyperaemia may be— 
A. Active; and 
B. Passive. 
They may also be spoken of as— 
1. Acute; and 
2. Chronic. 
Considering first the two latter distinctions, it will be found that 
the acute hyperaemias are met with most often in consequence of sharp 
mechanical disturbances. The chronic hyperaemias, on the contrary, 
are conditions which in many individuals are more or less permanent. 
Note accurately here the proper significance of certain terms. Hyper- 
aemia means, in effect, an over-supply of blood to the given part: the 
term should have only a local significance. When the entire body 
seems to be too well supplied with blood, the condition is known as 
plethora, the counterpart of which term is usually anaemia. The direct 
counterpart of the term hypercemia should perhaps be ischaemia, mean- 
ing a perverted blood-supply in reduced amount. With plethora and 
anaemia as terms implying general conditions, with hype Hernia and 
ischaemia implying local conditions, there should be little room for 
confusion in phraseology. 
The active form of hyperaemia used to be called “ fluxion,” a term 
now rarely used. Active hypercemia means an increased supply of 
arterial blood. In passive hypercemia the over-supply is rather of 
venous blood. In the former case the condition seems due to over- 
activity of the heart, with such local tissue-changes as permit it to 
occur. In passive hyperaemia the blood-current is slower—there is a 
tendency toward, and sometimes there is actual, stagnation ; all of 
which is usually due to obstruction to the return of blood to the 
heart. The conditions permitting these two results may be widely 
variant. 
Active hyperaemia may be produced by purely nervous influences, 
even those of emotional origin. The flushing of the face which is HYPERSEMIA: ITS CONSEQUENCES AND TREATMENT. 
19 
known as “ blushing ” is, perhaps, the most common illustration of 
this fact. It is well known also that this is, in some degree at least, 
the result of division of certain nerves which have to do with the 
regulation of the blood-supply. The cervical sympathetic is the best 
known and most often studied of these, and the consequences of 
division of this nerve in the neck are stated in all the text-books on 
physiology. So also by electrical stimulation of certain nerves the 
parts supplied bv them can be made to show a very active hypersemia, 
which will subside shortly after discontinuance of stimulation, provid- 
ing this has not been kept up too long. In active hypersemia there 
is absolute increase of intra-arterial tension, and under these circum- 
stances pulsation may be noted in those small vessels where commonly 
it is not seen nor felt. This is the explanation of the throbbing pain 
complained of under many actively hypersemic conditions. This 
hypersemia atfords the explanation of the clinical signs to which 
attention has already been called. The increased heat of the part is 
the result of greater access of blood, which prevents cooling by 
radiation and evaporation : the peculiar redness is due to the greater 
filling of the capillaries with the blood, which gives the peculiar hue 
to the skin and visible textures; while to the increased pressure upon 
sensory nerves is also due the pain. The minuter changes occurring 
within the congested part call for more accurate description. Whether 
or not there be actual dilatation of capillaries under these circumstances 
is a matter still under dispute, but of the dilatation of the larger vessels 
there can be no possible question. 
The phenomena attending the circulation of the blood through the 
involved part can be now succinctly stated, because they are observ- 
able in the mesentery of a frog, for instance, under the microscope. 
What is observed under these circumstances can be summarized as 
follows : An enlargement in the calibre of the vessels and a temporary 
increase in the amount of blood present, as well as in the rapidity 
of its flow—i. e. an increase in the blood-pressure with more or less 
stretching of the blood-vessels. Under these circumstances the vessel- 
walls easily leak, and the fluid portions of the blood ooze out between 
the cells of the vessel-walls, as water may leak through cracks in a 
hose, especially if the pressure be increased. When the blood-plasma 
escapes or virtually leaks out in this way, it produces a condition of 
watery infiltration of tissues which is known generally as oedema. When 
this fluid escapes into a previously existing cavity, it constitutes a 
dropsy of that cavity, to which in various parts of the body various 
particulate names are assigned. 
As hypersemia is to such a great extent brought about by action of 
the nervous system, it is well to divide it more accurately into the 
hypersemia of paralysis, or neuroparalytic congestion, which is the result 
of a paralysis of the constrictor fibres of the vasomotor system, and 
into the hypersemia of irritation, or neurotonic congestion, which is due 
to the irritation of the dilators (Recklinghausen). Physiologists are 
are fairly well agreed that as between the dilating and constricting 
apparatus of the vasomotor system there is ordinarily preserved a cer- 
tain degree of equilibrium; to which fact it is probably due that a 
normal condition of affairs is brought about after temporary disturb- 20 
SURGICAL PATHOLOGY. 
ance, since, too, over-action in one direction succeeds reaction in the 
other. As Warren lias illustrated this, our common treatment of frost- 
bite by cold applications is a concession to this fact, since by the cold 
application we endeavor to limit the reaction which would otherwise 
follow after thawing out the frozen part. 
The best examples of the hypereemia of paralysis are perhaps to be 
met with after certain injuries to nerves, as, for instance, flushing of 
the face and hypersecretion of nasal mucus, tears, etc. after injury to 
the cervical sympathetic. Such too, in its essentials, is that form of 
shock known as brain-concussion, which is often followed by nutri- 
tive disturbances among the brain-cells, with consequent perversion 
of brain-function. 
Waller’s experiment of placing a freezing mixture over the ulnar nerve at 
the back of the elbow is also significant, the result being congestion and ele- 
vation of surface temperature of the fingers supplied by this nerve. Congestion 
and swelling have also been observed after fracture of the internal condyle of 
the humerus, by which this nerve was pressed upon; and similar phenomena 
may be noted in fingers or toes as the result of injuries of other nerves. 
Hypereemia due to paralysis of the perivascular ganglia is observed 
sometimes in transplanted flaps, in the suffusion of a limb after re- 
moval of the Esmarch bandage, in the congestions of certain sac- 
walls after tapping, in the hypenemia, perhaps even hemorrhage, from 
the bladder-wall after too quickly relieving its over-distention, in 
the swelling of the extremities when they begin to be first used after 
having been put at rest because of injury, etc. 
The hypercemias of dilatation are more acute in course and mani- 
festation. Along with them go sharp pain, hypersecretion of glands, 
oedema, and sometimes desquamation of superficial parts. The facial 
blush due to effusion; the temporary flushing due to indulgence in 
alcohol; the suffusion of the conjunctiva, perhaps the face, with 
hyperlachrymation, accompanying facial neuralgia or hemicrania; and 
the hypereemia consequent upon herpes zoster, urticaria, etc., are 
illustrative examples of this form. The erythema due to nerve irri- 
tation or injury, the swelling of the joints which appears after similar 
lesions, and that condition described by Mitchell as erythromelalgia, 
probably also belong here. In fact, almost all the reflex hyper- 
eemias are hypereemias of dilatation. 
In those instances which are numerically more common, where the 
cause of the hypenemia is temporary or evanescent, the appearances 
above described vanish perhaps almost as quickly as they appear. 
If the congestion be both intense and last a few hours, or even less, 
we get a temporary oedema, such as most writers call collateral, which 
is particularly noticeable in soft tissues. Even such separations of 
vascular walls as shall permit escape of blood—i. e. hemorrhage— 
may be the result of simple hypercemia without changes which neces- 
sitate elaborate further description. Hemorrhagic exudates, seen 
especially in certain skin diseases and on mucous surfaces, are the best 
examples of this condition. A more or less continuous hypercemia 
means an increased amount of nutritive material, the result of whose 
presence is increase of tissue-elements by that form of overgrowth 
which will be later dealt with as hypertrophy and hyperplasia. HYPEREMIA: ITS CONSEQUENCES AND TREATMENT. 
21 
The forms of hypersemia considered above belong mainly to the 
designation of active. Passive hypereemia is most often a mechani- 
cal consequence of obstruction to return of blood which can be imitated 
at will, and which is not infrequently the result of sheer carelessness, 
as when an injured limb is bandaged too tightly. Experiment shows 
that when such mechanical obstruction has taken place there is tempo- 
rary increase of intravenous pressure, which soon returns to the nor- 
mal standard, such readjustment meaning that blood has found its way 
back by collateral circulation. Only when such rearrangement is pos- 
sible do we have anything like permanent passive hypersemia. In 
organs with a single vein, such as the kidneys, the question of obstruc- 
tion may assume a very important aspect. Under these circumstances 
the appearance of the involved part, when visible, is spoken of as 
cyanotic, while its surface instead of being abnormally warm is the 
reverse, due to impeded access of warm blood and more rapid surface- 
cooling. The blood under such conditions is often darker than natural, 
because, remaining longer in the part, it absorbs more carbonic dioxide 
or at least gives up more of its oxygen. So long as actual gangrene 
is not threatened, the blood-column has a communicated pulsation, at 
least in the large veins. Escape of corpuscular elements may occur 
after the phenomena above noted have been present for some time; 
but the corpuscles rarely, if ever, escape until there has been more or 
less copious transudation of the fluid portion of the blood—i. e. the 
serum. When anatomical changes can be grossly yet carefully observed, 
as in the fundus of the eye, it is seen that under these circumstances 
the arteries become smaller, although whether this be a primary or 
secondary change is not to be made out. Discoloration of the integu- 
ment is the frequent result of leakage of blood-corpuscles and their 
pigmentary substance into the tissues, and is consequently a frequent 
accompaniment of chronic passive oedema. It is seen very often in 
connection with varicose veins of the legs. 
Another form of passive congestion or hypenemia is that due to 
enfeeblement of the heart’s action by serious injury or wasting disease. 
When under these circumstances the lung has become more or less 
infiltrated with fluid, with hemorrhagic extravasation, the condition is 
known as hypostatic pneumonia—a misnomer, nevertheless indicating 
a condition which is only too frequent in the aged and feeble. 
Results of Hyperemia and Congestion. 
These may be— 
1. Speedy Subsidence of all Hypersemic Phenomena—Resolution. 
2. Acute Swelling. 
3. Chronic Enlargement. 
4. Gangrene. 
5. Nutritional Changes—Atrophy and Hypertrophy. 
1. The speedy subsidence of hypersemic phenomena is often 
known as resolution—a term which has also been applied to the retro- 
grade phenomena after a genuine inflammation. For present purposes 
it implies, first, the subsidence into inactivity of the exciting cause or 
its complete removal. This may include the passing of an emotion, 
the removal of an irritant, the loosening of a bandage, the resort to 22 
SURGICAL PATHOLOGY. 
certain applications or to constringing or astringing measures by which 
the effect is counteracted. A particle of dust in the conjunctiva may 
within a very few moments produce a very active congestion of the 
conjunctival vessels, which, ordinarily scarcely visible, become now 
prominent and easily noted. The removal of the offending substance 
permits a prompt return to their original size, and all this may be a 
matter of perhaps half an hour. This is an example of the speedy 
subsidence of the hyperamiia of dilatation after removal of the cause. 
Should the hypersemia not subside at once, it is well known what aid 
maybe gathered from cold applications, or in this instance from some 
gentle astringent collyrium, or from some agent whose physiological 
effect it is to produce contraction of vessels, such as cocaine. 
2. Acute Swelling.—When the effusion above referred to takes 
place into loose connective tissues the condition is spoken of techni- 
cally as oedema, while when it occurs into a previously existing cav- 
ity, such as that of a joint, it is known as an effusion. The amount 
of blood thus effused will be in large degree influenced by the anatom- 
ical and mechanical conditions obtaining about the part. It may be 
laid down as a general rule that when the extravascular pressure 
equals the intravascular pressure little or no more fluid may escape. 
As a matter of fact, it is seldom that the former even rises to the 
degree of the latter. Conversely, one method of treating such 
oedemas and effusions is by some device which shall make the ex- 
travascular pressure exceed the intravascular, when the fluid is, as 
it were, forced back into the vessels, and is made to resume its 
proper place within the same. This is often done by taking advan- 
tage of elastic compression, as when a rubber bandage is applied 
about the part. In certain parts of the body it may be done by 
pressure brought about bv some other device. Pressure may be 
used practically for two purposes: 
A. To so increase extravascular pressure as to limit the possible 
amount of an effusion, as when it is put on early after an injury; or, 
B. When it is used as a later resort for the purpose of reducing 
swelling which has already occurred. 
An ideal illustration of an acute swelling is that afforded by a sprain of a 
joint. As the result of the mechanical injury, and probably of activity of special 
nerves supplying the part, there is brought about an active hvpersemia of dila- 
tation whose consequence is a prompt effusion. How easy it may be to limit 
this by pressure, made early, is as well known as that swelling may be speedily 
reduced in size by resort to the same method later. 
3. Chronic Swelling.—This is something more than the swelling 
alluded to under Acute Swelling. Chronic swelling implies either a 
continuous passive hypersemia, or, what is much more common, a 
positive increase in tissue-elements as the result of an over-supply of 
nutrition brought by the blood, which itself was furnished to the part 
in a degree far in excess of its needs. The result is a more rapid 
reproduction of cell-elements, with result in the shape of tissue-thick- 
enings or tissue-enlargements, which are to the laity known as “over- 
growth,” or to us as hypertrophy, or, more properly speaking, hyper- 
plasia, of a part. This chronic swelling or chronic enlargement is in HYPEREMIA: ITS CONSEQUENCES AND TREATMENT. 
23 
some degree also connected with the phenomena of escape of white 
corpuscles from the blood-vessels and mitotic division of certain tis- 
sue-cells, which have up to this time been usually regarded as so dis- 
tinctive a feature of the true inflammatory process. This will be 
taken up in greater detail a little farther on; but, nevertheless, it is 
necessary to emphasize just here that hyperplasia or chronic enlarge- 
ment of the part may be the result of hypersemia alone, without neces- 
sarily invoking the presence of elements which have escaped from 
within the blood-vessels as the result of excess of nutritive supply. 
4. Gangrene.—This may be the result of sheer hypersemia—for 
the most part the passive forms—though most instances of gangrene 
due to intrinsic causes are inseparable from the presence of infectious 
micro-organisms. The gangrene which is spoken of here would 
include that due to the pressure of tumors, tight dressings, or any 
natural or intrinsic agency, and that due to pressure from without 
when not so pronounced as to produce immediate and total loss of 
circulation in a part. It includes the formation of many bed-sores 
and so-called pressure-sores, which may be due to an enfeebled heart, 
to an obstructed pulmonary circulation, or to external pressure in con- 
junction with cardiac debility. While insisting, then, that gangrene 
be recognized in this place as a possible result of hypersemia, it should 
be added that gangrene is in effect a tissue-death, and that dead tissue 
is always and everywhere practically the same thing, no matter by 
what causes brought about. Consequently, the subject of gangrene 
will be considered under a heading by itself. 
There should also be included here the possible evil consequences of too active 
interference in the presence of threatened harm as the result of passive hyper- 
semia due to pressure. When external pressure is removed, but little possible 
harm may come, probably only benefit; but when internal pressure is too 
speedily removed, disaster sometimes occurs, and from various causes. It is 
often necessary also to provide some external pressure which shall in some 
measure compensate for the changed conditions brought about by relief of 
internal. To illustrate: After aspirating a joint distended by an acute effu- 
sion it is always well to equalize pressure by a suitably graduated (preferably 
elastic) compression from without, by which a repetition of effusion shall be 
avoided. Indirectly also caution should always be exerted in aspirating a full 
chest for the relief of a pleural effusion which is the result of passive hyper- 
semia, since not infrequently the heart is materially displaced by the accumulated 
fluid, and such rapid readjustment of its position as might be brought about 
by a too sudden removal of fluid might entail upon it more strain than it 
could bear without syncope or complete cessation of activity Or a greater 
source of danger is that of oedema of the lung or possible dislodgement of 
thrombi or emboli from relaxation of pressure. So, too, after tapping certain 
spinse bifidae, more particularly after incision and evacuation of their contents, 
the sudden removal of intraspinal pressure might produce disastrous effects in 
the brain and cord, did one not take the precaution to have the patient with the 
head down, so that the intracranial hydrostatic pressure might be disturbed as 
little as possible. 
5. Nutritional changes will be considered by themselves a little 
later. 
The consequence of persistent hypercemia is exudation—i. e. escape 
of blood-plasma from the vessels into body-cavities and tissue-interspaces. 
This leads to consideration under a distinct heading of 24 
SURGICAL PATHOLOGY. 
Exudates. 
Exudation may occur alike in vascular and non-vascular, in firm 
and soft tissues, in, under, and upon membranes. AVitli respect to 
location, exudates are described as free when found upon free surfaces 
or within natural cavities; interstitial when found between the tissues 
or parts of tissues; and parenchymatous when they are situated with- 
in the tissues themselves, particularly in epithelial and glandular cells 
of any kind. 
As concerns quality, exudates are serous, mucous, fibrinous, or 
mixed, the mixed forms including the so-called sero-purulent, the 
muco-purulent, the croupous, and the diphtheritic, as they used to be 
mentioned by the older writers. When any exudate contains red 
globules in sufficient quantity to stain it, it is called hemorrhagic. 
Serous exudates from free surfaces are sometimes spoken of as 
serous catarrhs ; when into cavities, as dropsies ; when into tissues, as 
oedema; when occurring beneath the epidermis they form serous vesi- 
cles or blebs or bulhe. 
The best example of catarrhal exudate perhaps is furnished by the vopious 
secretion from the nose in cases of acute coryza. Serous exudates are in all 
probability regulated, to at least some degree, by nerve-action. This is particu- 
larly evident after ligation of the submaxillary duct with irritation of the chorda 
tympani. After secretion is exhausted there sets in a speedy oedema of the 
gland itself. 
Mucous exudate differs little from normal mucus, save that it is sometimes 
thicker or usually thinner. Occurring from mucous membranes, it forms the 
ordinary mucous catarrh. 
Fibrinous exudation refers to the fluid which coagulates soon after 
its exit from the vessels within those spaces into which it has oozed. 
When flocculi of coagula float in serous fluid it is known as a sero- 
fibrinous exudate. Pure fibrinous exudate occurs relatively rarely, 
save in and upon mucous membranes* The extent to which exposure 
to the air is responsible for the firm coagulation of the fibrin pre- 
viously held in solution is uncertain. The most potent factors in pro- 
ducing such coagulation are bacteria, but it is not yet disproven that 
coagulation may occur without their aid. When such coagulation 
occurs upon the surface of a mucous membrane it has been spoken of 
as croupous. When the epithelial covering as well as the basement 
membrane, and often the submucous tissues, are involved so that now 
the membrane cannot be stripped off without tearing across minute 
blood-vessels, the exudate has been known as diphtheritic. These 
terms may possibly be still retained in an adjective sense as implying 
the exact location of a surface exudate, but are scarcely to be used in 
any other significance. 
It is probable that the factor which mainly has to do With solidification of 
such fluid exudate as comes to the surface in fresh abrasions or in larger super- 
ficial wounds, by whose desiccation is produced the so-called scab or crust, is 
simple exposure to the air. It is, at all events, a conservative process in most 
instances, since by drying a thin but sufficient protection is afforded for the deli- 
cate reparative processes which go on beneath, these including proliferation of 
epithelium from the periphery of the lesion and formation of delicate granula- 
tions from the mesoblastic tissues. Fibrinous exudates may also undergo fatty 
degeneration or fatty metamorphosis, and sometimes calcification, the latter being 
simply a deposition of the calcium salts which are held in solution in the sur- H YPER MM I A : ITS CONSEQUENCES AND TREATMENT. 
25 
rounding fluids. Resorption of fibrinous exudate also occurs, probably by 
means of a liquefaction brought about by agencies whose minute chemistry is not 
yet known. 
So soon as an exudate becomes exposed to contact with air or with many of 
the body-secretions, there is danger of its prompt infection by means of micro- 
organisms. These may enter from within or from without, as is shown in the 
next chapter. The prompt effect of such exposure is the conversion of a non- 
purulent exudate into pus, which means that the gross lesion is now altered 
from one of simple hypersernia with its natural sequence into one of true in- 
flammation with suppuration. This conversion of fluid or solid exudate, whether 
active or passive, into pus is seen very often, as, for instance, in joints, in the 
pleural cavity, etc. Along with the concealed microscopic and chemical changes 
going on within the tissues, there are also phenomena which are usually easy 
of recognition, and which more or less completely alter the clinical type of the 
case in hand. 
The following table illustrates significant differences whose full 
importance cannot be impressed before a study of inflammation has 
been carefully entered upon : 
HyperyEmic Exudates. 
Poor in albumen. 
Rarely coagulate in the tissues. 
Contain few cells. 
Low specific gravity. 
Contain no peptone. 
Inflammatory Exudates. 
Rich in albumen. 
Usually coagulate in the tissues. 
Contain numerous cells. 
High specific gravity. 
Contain peptone (product of 
cell-disintegration). 
Symptoms and Treatment of Congestion and Hyperjemia. 
The principal clinical characteristics of these conditions have been 
already mentioned. They may be summarized as redness, which is 
due to increased amount of blood in the part, the color varying in 
intensity according as arterial or venous blood predominates in the 
part, and the tint deepening as the blood-current slackens. It is 
under these circumstances, with excess of tension and overcrowded 
capillaries, that a sufficient number of red corpuscles escape into the 
exudate to produce the so-called hemorrhagic form of exudate and 
the punctate ecchymosis characteristic of certain eruptions. Ordi- 
narily in the presence of abundant exudation redness is diminished. 
Naturally, mucous membranes show these colors better than the skin. 
The most perfect visible type of disturbance of this kind may be seen 
in the conjunctiva, when vessels become easily visible which ordi- 
narily are not perceived. 
Swelling has already been explained as due to distention of blood- 
vessels and escape of their contents in the shape of exudation. Not 
infrecpiently it occurs that an innocent exudation into the superficial 
parts accompanies unmistakable and more serious affection of the 
deeper. This is known as collateral oedema. The condition known as 
hepatization is simply infiltration of more soft and distensible organs 
or tissue with exudates which partially or completely solidify. 
The pain is simply an expression of pressure upon terminal sensory 
nerves, and differs within the widest possible degrees. Loose and dis- 
tensible tissues will easily expand to accommodate the increasing exu- 26 
SURGICAL PATHOLOGY. 
elation, and there will be but a minimum of pain. Tissues covered 
with firm, resisting membranes, like bone, prostate, testicle, fundus 
oculi, etc., will cause intense, even agonizing, pain upon a minimum 
of distention. The throbbing pain so often complained of is due to 
the added heart-pressure of systole upon sensitive nerves. Throbbing 
pain is seldom complained of in mere congestion or hypersemia; it is 
usually rather a sign of infection and threatening suppuration. It is 
a law of neuro-physiology that irritation along the course of a nerve 
is or may be referred to its terminal distribution, and this fact is often 
demonstrated in studying the complaints made by the patient. Pain 
may also radiate upward and involve parts above the level of the 
lesion. 
Heat—i. e. increase of local surface temperature—is the fourth 
external symptom of congestion. This is usually easily recognized by 
the palpating hand. It is due to local hypersemia, and still more to 
local infections—i. e. inflammations. The temperature of the affected 
part is in the main proportionate to the degree of hypersemia. 
Along with these manifestations of local disturban&e, which if they attain 
any degree are recognizable at once, there is the fifth symptom of disturbed func- 
tion of the part with which older writers used to deal so much; the congested 
part is temporarily disabled in partial or complete degree. Its sensitiveness is 
augmented : that gives extreme pain or cannot be tolerated which under other 
circumstances would cause no sensation whatever. The disturbance of function 
is in the main proportionate also to the degree of the lesion, and in non-hyster- 
ical or non-neurotic subjects a fair estimate can be made by noting the functional 
disturbance. 
Treatment.—These disturbances are to be combated, first of all, 
by insisting upon physiological rest. This, perhaps, is the most im- 
portant measure of all. The profession is greatly indebted to Hilton 
for the decided advance which he made in the treatment of congestive 
and inflammatory affections by insisting upon this principle in his 
celebrated work on Rest and Pain, which every young practitioner 
should read. Aside from this first and underlying principle, the treat- 
ment must, in some measure at least, be based upon the time at which 
we are called upon to treat the case. If seen at once, before exu- 
dation has been excessive or the other disturbances marked, we may 
carry out a certain line of treatment for the purpose of limiting all 
these unpleasant features. On the other hand, if seen late, when 
exudation has been copious and when pain and other disturbances are 
due to its presence, a distinctly different course will be adopted. 
Toward the end first mentioned—namely, the limitation of hypersemia—we 
may adopt local and general measures. Local measures include graduated pres- 
sure, providing this be not intolerable to the patient, endeavoring to so equalize 
pressure that outside of the vessels it shall equal that inside. This may be done 
by careful bandaging, extreme care being taken that the pressure be applied 
from the very extremity of the limb; otherwise, passive exudation might be 
augmented and gangrene be precipitated. Elevation of a limb will often accom- 
plish much the same purpose. Cold, which is in effect an astringent and which 
tends to contract blood-vessels, is another measure in the same direction, and if 
applied early will do much to limit the degree of the attack. This may be 
applied as dry or moist cold, and should be gradually mitigated as the congestion 
subsides. It acts through the vasomotor system, and is a measure to be resorted 
to with some caution. An efficient way of applying dry cold can be extempor- 
ized by a few yards of rubber tubing, held in place by wire or sewed in place HYPEREMIA: ITS CONSEQUENCES AND TREATMENT. 
27 
to a piece of cloth, through which a stream of cold water is permitted to gently 
pass. 
Heat is another efficient means, acting, however, in a rather different way. 
Heat is a measure to be employed to hasten the disappearance of exudation— 
in other words, to quicken resorption, which it does by equalizing blood-pres- 
sure, dilating the capillaries, stimulating the lymphatic current, and in every 
way helping to clear the tissues of that which has left the blood-vessels. 
It is necessary also, at least in extreme cases, to employ some deter- 
gent or derivative measures, which include blood-letting as one not 
sufficiently resorted to. When done for this purpose, depletion should 
be carried out at the area involved if possible. This may be done 
either as venesection, by leeching either with the natural or the arti- 
ficial leech, or by a series of minute punctures or incisions, which give 
relief to tension, permit the rapid escape of fluid exudate, and often 
save tissues from the disastrous effects of strangulation. In some 
cases of deep-seated congestions these measures are inapplicable, and 
venesection at the point of election—say the cephalic vein in the arm 
—may be followed by great benefit. Another method of depletion is 
by administration of cathartics, such intestinal activity being stimu- 
lated as shall lead to copious watery evacuations. The salines rank 
high as measures directed toward this end, but in emergency much 
stronger and more drastic drugs may be administered, such as jalap, 
calomel, elaterium, etc. Diaphoretics and diuretics help to reduce 
temperature, and in some degree to deplete, but their action is usually 
slow. When exudation is considerable in amount and confined to some 
one of the body-cavities, it is often best combated, if at all obstinate, 
by the method of aspiration. This includes any suitable suction ap- 
paratus by which the fluid may bq withdrawn through a small needle 
or cannula, the operation being trifling in difficulty, but one to be per- 
formed under strictest aseptic precautions, lest infection of an exudate 
already at hand be permitted. 
Certain individuals, especially the neurotic, will need more or less anodyne, 
particularly Avhen local applications fail to give relief. Sometimes a small dose 
of morphia administered hypodermically will act like magic in making efficient 
those measures which would otherwise be inefficient. In little children also 
some anodyne.or hypnotic will be of great service. Under all circumstances it 
is well to keep the lower bowel empty, and certain elderly individuals with weak 
and enfeebled hearts will need the stimulation to be afforded by digitalis, quinine, 
and alcohol, or preferably by strychnia administered subcutaneously. 
In cases of chronic hypersemia and its consequent hyperplasias 
(induration, thickening, etc.) there is no one measure so generally 
applicable and effective as the continued use of cold-water dress- 
ings. These are generally spoken of as “ cold wet packs,” and may 
be continued—constantly or intermittently—for many days. 
On Atrophy and Hypertrophy, and the Consequences of 
Altered, Diminished, and Perverted Nutrition. 
As a consequence of increase of nutrition we have produced a con- 
dition known commonly as hypertrophy, more accurately as hyperpla- 
sia. Hypertrophy literally means overgrowth, whereas hyperplasia 
more accurately describes that which constitutes hypertrophy— 
namely, numerical increase of constituent cells. Common usage 
has made the more inaccurate name “ hypertrophy ” cover nearly 28 
SURGICAL PATHOLOGY. 
all these conditions. Hypertrophy or hyperplasia means enlargement 
of a part or of an organ beyond its usual limits, and as the result 
of increased function or increased nutrition. It is to be distin- 
guished from gigantism, which means inordinate enlargement as 
the result of a congenital tendency or condition. Hypertrophy is— 
A. Physiological 
1. Compensatory; 
2. From deficient use. 
3. Local; 
4. General; 
5. Senile ; 
6. Congenital. 
B. Pathological 
A. Physiological Hypertrophy.—1. This includes many of the 
compensatory enlargements of an organ or a part when extra work is 
put upon it owing to deficiency of some other organ or part. This is 
spoken of as compensatory enlargement. Illustrative examples may 
be seen in the heart, which becomes 
larger and stronger when the blood- 
vessel walls are diseased and their 
lumen narrowed or when other ob- 
structions to circulation are brought 
about; again, in enlargement of one 
kidney after extirpation of the other, 
or of the wall of the stomach when 
the pylorus is constricted or ob- 
structed ; again, of the fibula after 
Fig. 2. 
Fig. 1. 
Congenital hypertrophy : gigantism of both 
lower extremities (case of Dr. Graefe [San- 
dusky] ). 
Congenital hypertrophy: gigantism of one ex- 
tremity (Fischer). 
weakening or more or less destruction of the tibia, or of the shaft 
of any bone when it has been weakened at some point by not too 
acute disease ; or, again, of the walls of bursa; after constant friction. HYPEREMIA: ITS CONSEQUENCES AND TREATMENT. 
29 
2. The best examples of physiological hypertrophy owing to defi- 
cient use are perhaps seen in some of the lower animals; as, for 
instance, in the teeth of such rodents as beavers when kept in cap- 
tivity and prevented from natural use. 
Fig. 3. 
Congenital hypertrophy: gigantism of both lower extremities (case of Dr. Graefe [Sandusky]). 
B. Pathological Hypertrophy.—3,4. Instances of this are every- 
where and every day to be met in the resnlts of so-called chronic 
inflammation, a term which is a complete misnomer and should be 
expunged from text-book use. So-called chronic inflammation simply 
means increase of nutrition owing to a certain degree of hypersemia, 
which may have been produced in the first place as the result of trau- 
matism, which may come from chemical irritants circulating in the 
fluids of the part—as, for example, uric acid, etc.—or which are 
brought about as the result of perverted trophic-nerve influence. 
Instances of local pathological hypertrophy may be seen in the 
thickened periosteum after injury, in the enlargement of a phalanx 
known as the “ baseball finger,” and in numerous other places; or 
they may be general, in which case they are brought about mainly 
by some irritating material in the general circulation. The unknown 
poison of syphilis notoriously provokes such nutritive disturbances. 
5. Senile hypertrophy is connected with nutritional disturbances 
characteristic of old age, as to whose remote causes we are still in the 
dark. Instances of senile hypertrophy, however, are common, par- 
ticularly in the prostates of elderly men, which are quite prone to 
undergo vexatious, and even vicious, enlargement. 30 
SURGICAL PATHOLOGY. 
6. Of congenital hypertrophy and that of unknown origin we see, 
for instance, examples in certain rare cases of hypertrophy of the 
breast, in leontiasis, perhaps even in acromegaly, etc.; and these are 
to be distinguished from gigantism, because in most instances of the 
former type the hypertrophic tendency is not manifested until youth 
or adult life, whereas gigantism is a condition in which the tendency 
was apparently manifested even before the birth of the individual. 
Atrophy. 
Atrophy implies impaired nutrition, and means diminution in the size 
of an organ or part, and is the converse of hypertrophy. It is neces- 
sary to make plain that in atrophy nutrition is only impaired and not 
arrested, since complete arrest of nutrition means necrosis—i. e. gan- 
grene. It may be— 
A. Physiological 
[ 1. From Disuse without Disease ; 
2. Biological or Developmental; 
[ 3. Senile. 
B. Pathological 
4. Result of Acute Tissue-losses; 
5. Result of Phagocytic Activity; 
6. Result of Continuous Pressure; 
7. Specific. 
A. Physiological Atrophy.—1. This is always the result of 
disuse or impaired function from any cause. Its evidences are most 
quickly seen in the fatty structures and muscles—i. e. in the soft 
parts. It is true, however, even of the bones, or, of greater inter- 
est, even in the brain-cells. We see evidences of it also in minute 
organs; as, for example, in the digestive glands in certain cases 
where diet is restricted. Again, we see it in the diminution of the 
size of the heart after hip-amputation, less being required of that 
organ. Again, in the entire structure of the rectum after colostomy. 
2. Examples of the developmental type are best seen in the natural 
disappearance of the hypogastric arteries, the ductus arteriosus, the 
vitelline duct, the Wolffian bodies, and in the various generative ducts 
(Gartner’s, etc.) shortly after birth of the human individual. We see 
it also in the prostate after double orchidectomy. Equally illustrative 
is the disappearance of the tail and gills of the tadpole, the eyes of 
animals living in caverns, and, in a general way, of organs which 
become useless owing to a different environment. 
3. Senile atrophy is seen equally well in the hair-follicles, the teeth, 
the bones, and the sexual organs of elderly people—in fact, in all their 
tissues, even in the brain. 
B. Pathological Atrophy.—4. Very acute atrophy of surrounding 
tissues is the necessary accompaniment of destruction by suppurative 
or other disturbances; that is, parts disappear by absorption which 
have not been interfered with by pyogenic organisms. So complete 
may atrophy be under these circumstances as to cause disablement of 
an organ or part. This kind of senile disappearance is merely an 
expression of phagocytic activity, although not now a question of 
bacteria. 
5. The same is true of that variety spoken of above as biological HYPEREMIA: ITS CONSEQUENCES AND TREATMENT. 
31 
or developmental, since phagocytes are the active agents in producing 
the disappearance of the tadpole’s tail. 
6. A more slow form of pathological atrophy is seen in the gradual 
disappearance of tissues in the neighborhood of advancing tumors, 
enlarging cysts, etc. This is perhaps but another expression of atro- 
phy from continuous pressure. But a still better illustration is the 
atrophy which comes from immobilization of a part without pressure. 
This is notorious when splints or orthopedic apparatus have to be long 
kept in place. Other examples of slow atrophy from these condi- 
tions can be seen as the result of tight bandages or ill-fitting splints; 
again, in the distortion of the skull produced among the Flathead 
Indians by pressure, in the Chinese woman’s foot, in the atrophy of 
the cord and testicle, as well as of other soft parts, which may be 
produced by the pad of a truss ; in certain posture-deformities ; in the 
paralysis of the arm known as “ crutch paralysis ” even after inter- 
mittent pressure upon crutches; in the deltoid paralyzed by inj ury to 
the circumflex nerve by the dislocated head of the humerus; and in 
the distant atrophy of limbs which is produced by pressure on main 
trunks of vessels or nerves from any of the above causes. These 
forms of atrophy are closely allied to or are identical with that which 
is often spoken of as absorption, but these are to be abruptly distin- 
guished from the condition known as ulceration, implying such lower- 
ing of vital resistance as to permit of infection. Atrophy and absorp- 
tion contravene the possibility of infection ; ulceration always implies it. 
7. Specific forms of pathological atrophy are largely connected with 
disturbances in the central nervous system. They are often spoken 
of as trophoneurotic. Their exact mechanism is not yet understood, 
and cases may be confused under this head whose remote causes are 
widely different. Here should be included, for instance, the atrophy 
of a deep bone which occurs after extensive burn of the surface; also 
that peculiar form of atrophy of tissues in the stump which produces 
the so-called conical stump. These cases are indeed of a more com- 
plicated character, since if pressure be removed from the bone-end, 
especially in young people, the bone tends to grow faster than it 
should, while the soft parts disappear, partly as the result of mere 
disuse or loss of function. In this way conicity is produced, which 
sometimes calls for subsequent reamputation. Under this head might 
also be included the so-called “ trophic inflammation ” (misnomer) of 
some writers, such, for example, as ulceration of the cornea after 
division of the trigeminus. The general subject of atrophic elonga- 
tion also belongs here, referring to the fact that as a result of disuse, 
or sometimes of active disease, the bones, while showing atrophic 
changes in other respects, actually increase in length. Should such 
increase occur in one bone of those portions of the limbs which are 
supplied with two, the result would be posture-deformity and displace- 
ment of the terminal portion. 
Treatment.—Hypertrophy may sometimes call for reduction by 
operative measures. Atrophy, on the other hand, calls for stimula- 
tion of nutrition in the affected parts by massage, electricity, cold 
douching, exercise, deep injections of strychnia, etc., after removal of 
the cause when possible. CHAPTER II. 
SURGICAL PATHOLOGY OF THE BLOOD. 
By Roswell Park, M. D. 
The part played by the constituent elements of the blood in 
inflammation, suppuration, and other still more disastrous conditions 
is so great and so important that, before proceeding to discussion of 
these lesions, it seems necessary to set forth a resume of facts illus- 
trating the importance of accurate knowledge concerning this most 
important fluid. 
Thrombosis. 
Thrombosis is a term applied to the formation of a thrombus—i. e. 
a clot within the cavity of the heart or one of the blood-vessels—the 
term being limited to coagulation of blood within these natural cavi- 
ties, and without specifying the exciting cause of the same. A clot 
so formed is called a thrombus. To be accurate, a distinction should 
be made between a thrombus, which is always caused before death—or, 
rather, during life—and the clot, which is essentially a post-mortem 
affair. Our application, then, of the terms “ thrombosis ” and 
“ thrombus ” refers solely to that which takes place during life. In 
order to appreciate the conditions which lead to thrombosis it is neces- 
sary to fully appreciate the reciprocal conditions which must normally 
be maintained between the circulating blood and the walls of the ves- 
sels in which it flows. Fluidity of blood depends always upon integ- 
rity of the vessel-wall. So long as its lining membrane be absolutely 
undisturbed and normal, blood will never coagulate within it, and the 
only thrombi that may be met within it are those which are propa- 
gated from a distance. Coagulation of blood is for the most part 
associated with the peculiar properties of fibrin. Fibrin, it is now 
well established, is produced by the union of two substances, known 
as fibrinogen and paraglobulin, which union takes place as the result 
of the activity of the so-called fibrin-ferment. The fibrinogen is 
ordinarily kept in solution in the blood-serum ; all of the fibrin-fer- 
ment, and at least the greater part of the paraglobulin, are contained 
within the colorless blood-corpuscles, bv whose disintegration they 
are released. Consequently, so long as nothing happens to the leu- 
cocytes, coagulation cannot occur. It seems to be one of the peculiar 
activities of the endothelial lining of vessels to restrain this very dis- 
integration. Even when small quantities of fibrin-ferment are intro- 
duced from without, this membrane seems to have the power of ren- 
dering it inefficient, and large quantities introduced at once are 
necessary to artificially produce coagulation in this way. Physiolog- 
ical integrity of vascular walls, therefore, is inimical to thrombosis. 
Causes.—The underlying cause of all thrombi is, then, alteration SURGICAL PATHOLOGY OF THE BLOOD. 
33 
of the endothelium. In consequence, when it is desirable to produce 
coagulation artificially advantage may be taken of this fact, and me- 
chanical injury to the vessel-walls may be quickly followed by the 
desired results. Advantage is also taken of this fact in surgery, espe- 
cially in certain methods of treating aneurism, by rude handling, by 
needling, by the introduction of horse-hairs, fine wires, etc. 
While such endothelial lesions are essential, there are, neverthe- 
less, numerous other accessory causes which must here be mentioned. 
These comprise— 
A. The presence of foreign bodies, as, for example, needles, booklets 
of echinococci, parasites, particles of tumors, fragments from the 
heart-valves, and, most of all, that which is essentially a foreign body, 
a clot which has come from some other point. Around such foreign 
particles, by the way, will quickly group themselves a relatively large 
number of other leucocytes, affording thus another example of phago- 
cytosis, soon to be described. Mere slowing of blood-stream without 
some such mechanical irritation is not sufficient to produce coagulation. 
If, for instance, a section of vein be isolated between two ligatures, 
the ligation being aseptically done and the surroundings of the vein- 
wall disturbed as little as possible, the blood thus shut up within the 
vein remains fluid indefinitely. If, however, the vessel-wall be sepa- 
rated from its surroundings, so that its nourishment is compromised, 
the contained fluid quickly coagulates. 
B. Necrosis, gangrene, etc. lead to quick involvement of the endo- 
thelium of the vessels contained within the involved part, and conse- 
quently quickly to coagulation of the blood which they contain. 
C. Temperature has also an influence in the same direction, and 
extremes in either direction, or drying of vessels which may happen 
to be exposed to the air for some time, leads to the same results. 
1). Inflammatory and degenerative processes occurring in and about 
the vessel-walls tend always to produce coagulation. This is well 
seen in the influence exerted by the so-called atheromatous ulcers—i. e. 
the degeneration of certain areas in the walls of large vessels. 
E. Micro-organisms and their products are perhaps the most fre- 
quently effective of all the accessory causes of thrombosis. In other 
words, in all the surgical infectious diseases we may expect to find 
more or less, sometimes extensive, thrombosis in the vessels of the 
affected part. This may so far shut off circulation as to lead to gan- 
grene, which may be local or may terminate the life of the patient. 
Also, in some of the infectious diseases not ordinarily considered surgical 
we see similar conditions, and thrombosis is not an infrequent sequel of the puer- 
peral condition, typhoid fever, etc. The condition is also well marked in certain 
cases of infectious endocarditis, which is very often followed by thrombosis and 
pyaemia as a complication, the latter being due to the septic character of the 
micro-organisms at fault. 
Thrombi are classified as— 
1. Primary; and 
2. Propagated. 
The primary thrombus is one which has originated at the spot 
where it has been first produced, and is usually coextensive with its 
cause. The propagated thrombus may be one which has been carried to 34 
SURGICAL PATHOLOGY. 
a considerable distance, and is met with at a point widely different from 
that where it originated, or one which lias extended along the vascular 
channel in which it was first formed, but far beyond the limits of its 
prime cause. When a thrombus attaches itself to a part of the vessel- 
wall it is called parietal or valvular, because it does not completely 
occlude the vessel; when it involves the entire circumference of the 
vessel, but does not completely occlude it, it is spoken of as annular. 
The obstructive thrombus is that which completely fills a given vessel 
and shuts off all circulation through it. 
The propagated thrombus extends usually in both directions, and 
always much farther in veins than in arteries. Thus, thrombi may be met 
with extending from the ankles even into the inferior vena cava. The 
venous valves, which, on the.one hand, may excite coagulation, on the 
other hand tend to fix the coagula more firmly in their place. In arte- 
ries thrombi usually extend finally to the first collateral channel on 
the cardiac side, but occasionally they extend farther. The cause of 
a primary thrombus is to be sought for at the site of its lodgement ; the 
cause of propagated thrombi is often to be met with at wide distance 
from the effect. 
Thrombosis is, again, to be spoken of as— 
a. Marasmic; 
b. Mechanical or traumatic ; 
c. Infective. 
a. The marasmic forms are due to essential alterations in the constituents of 
the blood, which for the most part are due to starvation or wasting disease. 
Marasmic thrombi seldom give rise to serious disturbance during life until the 
condition is so complex and serious that the patient is at death’s door. Post- 
mortem evidences of marasmic thrombi, hoAvever, are often found, and yet have 
but little surgical significance. They are seen perhaps as often in the cranial 
sinuses as anywhere. 
b. Thrombi of mechanical or traumatic origin are those, for instance, which 
are due to the presence of foreign bodies, to stagnation of blood as the result of 
ischaemia or local anaemia, to compression by tumors, etc. 
c. Infective thrombi are those distinctly due to the injurious effects of micro- 
organisms, and are those mainly concerned in the various manifestations of 
sepsis which are of such interest to surgeons. ( Vide Plate II. Fig. 2.) 
While the ordinary evidences of thrombosis are most often looked 
for in the veins of the extremities, in the lungs, and in the cranial 
’sinuses, it must not be forgotten that thrombosis may occur equally 
easily in the portal system of vessels; in which case we find the most 
marked expressions in this system and in the liver. In cases also of 
pyaemia proceeding from lesions in the rectum or in the bowels we get 
our first evidences of infection, abscess, etc., in the liver, and not in 
the lungs, to which point infective thrombi from other sources are 
promptly carried. 
Thrombi, as such, are classified and spoken of as— 
A. Fibrinous thrombi, composed principally of fibrin with its 
marked cohesive properties, and attaching themselves firmly to vas- 
cular walls. 
B. Hcematoblastic or globulin thrombi. By many recent investiga- 
tors these are supposed to be in some obscure way connected with the 
activities of the third corpuscular element of the blood. 
C. White or leucocytic thrombi. These are composed for the most SURGICAL PATHOLOGY OF THE BLOOD. 
35 
part of the white corpuscles, which have attached themselves to the 
surface, of the vessel-wall, especially where circumstances favor, as at 
the point of division of a vessel, or where a sudden curve leads to 
stagnation of the current. This form is relatively rare; is most com- 
mon in cases of leucaemia, in which the capillaries of the mucous mem- 
brane, especially of the intestines and nose, are filled with them and 
made to resemble white streaks. They occur also in the rear of cer- 
tain emboli when the section of the occluded vessel behind them is very 
short; also behind venous valves, in the spaces between the columns 
of the heart, and in the sheltered cavities which form in connection 
with aneurisms and varices. It is said that they also form in slowly- 
circulating blood as free thrombi. 
D. Red blood-corpuscle or hcematostatic thrombi. This is a genuine 
stagnation form, to which removal of blood-serum from the area in- 
volved is a contributing factor. It takes place also when pressure is 
exercised on the red corpuscles. White corpuscles which are entangled 
with the red usually lose their identity. The best examples of this 
form are seen in those regions where a good-sized vascular area is 
shut off, as, for example, at the ligature of a vein of some size. Under 
these circumstances the arteries are dilated, and the collateral circula- 
tion usually takes away the overflow. All the so-called ischaemic 
conditions depending upon arterial contraction can cause stagnation 
thrombi if they occur in a region whose veins are enlarged and well 
filled. Lessening of venous flow is always accompanied by increase 
of vascular pressure, and this determines increase of exudation, and 
usually oedema. Very typical forms are met with in senile gangrene, 
also after contusions and various injuries. Propagation of such 
thrombi along the arteries is often noted. Small thrombi also be- 
long here, resulting from venous stasis combined with hemorrhage, 
and such occur about the constriction in certain cases of strangulated 
hernia, and lead to the so-called hemorrhagic gangrene. This disas- 
ter, however, is by no means the necessary result of these thrombi. 
E. The mixed thrombi, or thrombi in layers. These layers are 
formed by deposition at different times of the solid material of the 
blood, which layers are not necessarily duplicates of one another. 
Moreover, if considerable intervals of time elapse between layer-forma- 
tions, the older will have time to undergo marked changes, usually in 
the direction of condensation and organization. This kind of lamina- 
tion of thrombi is seen most often in dealing with aneurisms and hsema- 
tomata, concentric deposits having taken place at various intervals. 
Of all the thrombi met with in the body, the mixed and the white 
forms are the most common. All of these are to be carefully distin- 
guished from post-mortem clots. These latter are moist, glistening, 
elastic, with smooth surface and showing no evidence of other change. 
Thrombi, on the contrary, are dryer and more compact, and, if they 
have attained any age, are more or less laminated or at least stratified. 
If from a thrombus which has attained some age a piece be torn off, 
it terminates in an almost stair-like extremity (Cohnheim), due to its 
stratification. 
Thrombi also pass through certain metamorphoses which must be 
mentioned : 36 
SURGICAL PATHOLOGY. 
A. Decolonization.—This is noted particularly in the red thrombi, 
and is due to disintegration of the red corpuscles, their coloring mat- 
ter being diffused and resorbed or transformed into hsematoidin. It 
would be a mistake, however, to suppose that all light-colored thrombi 
are those which, originally red, have been decolorized. The possi- 
bility of white thrombi must be always remembered. 
B. Organization.—This is the result of time, and means a meta- 
morphosis into solid vascular connective tissue. Newly-formed 
minute vascular loops project from the vasa vasorum into the throm- 
bus, and it becomes thus vascularized, while the completion of the 
organization is due, for the most part, to spindle-celled connective 
tissue, which is formed by wandering cells that penetrate into the 
Fig. 4. 
Organization of thrombus (Letulle): vv, vasa vasorum still open; m, media rich in muscle- 
cells; l, intima;/, fibro-vascular tissue; nc, new capillaries; nv, new arterioles. 
thrombus from without. This gives the organized thrombus a certain 
resemblance to a sponge, and makes the original vein resemble a 
cranial sinus, since its interior is spanned by bands of connective 
tissue. Typical illustrations of this kind are seen, for instance, where 
the iliac veins join to form the inferior cava, by which a certain 
amount of obstruction to venous return is produced without its being 
total. The length of time required for these changes is indefinite. 
They begin, however, within a short time after ligature of a vein, and 
proceed with a rapidity varying according to circumstances. 
C. Calcification.—Calcium salts are occasionally deposited in 
thrombi, usually not until they have undergone considerable contrac- 
tion and alteration ; as the result of which we have formation of 
small masses, essentially minute calculi, to which the name of plilebo- 
liths has been given. These phleboliths are not infrequently found in 
more or less occluded and much distended varicose veins of the ex- 
tremities. Their formation is favorable in this regard, that they pro- 
hibit the occurrence of softening. SURGICAL PATHOLOGY OF THE BLOOD. 
37 
D. Softening.—This is the most serious termination of the throm- 
botie accident, and is, for the most part, due to the agency of infecting 
organisms. A non-infectious form is, however, recognized, by which 
there is a metamorphosis of original clot into an oily or pulpy fluid, 
usually dark colored, but in the white thrombi often yellowish-white, 
reminding one crudely of pus. The discovery of such material under 
these circumstances has led in time past to the supposition that pus, 
as such, was found floating in the blood—a condition that does not 
exist under any except most extraordinary circumstances. It is with 
infection of thrombi and consequent softening, however, that surgeons 
have most to deal, and the paramount importance to them of such 
disturbances is emphasized in those pages dealing with pysemia. 
A closely-allied topic to that above considered is the subject of 
thrombo-phlebitis. This means, in effect, inflammation of one or 
more veins, which is directly due to the presence therein of thrombi. 
Such a condition is, in its strict sense, an inflammation, since it is 
always an infectious process. If in the veins of a non-infected region 
simple thrombi form, they may be occluded by organization of the 
included masses, but such a process never extends beyond the imme- 
diate area involved. On the other hand, if the process be essentially 
an infectious one, either from without or from within, then both ves- 
sel and its contained thrombi succumb completely to the infectious 
process, which is also essentially a spreading one; and this is limited 
only by mechanical barriers, by conservative suppuration, or often 
only by the life of the individual. Excellent examples of thrombo- 
phlebitis are seen in the involved uterine sinuses in cases of puerperal 
septicaemia, and in the cranial sinuses after infected compound frac- 
tures, or particularly after disease originating in the middle ear has 
extended to them. 
Thrombo-phlebitis is essentially a surgical condition, terminating 
favorably occasionally by suppuration and spontaneous evacuation, 
but calling loudly for surgical intervention whenever it can be recog- 
nized and the parts are accessible. The principles of treatment of 
these conditions are positive and unmistakable. They comprise 
evacuation of the infective material and disinfection of the involved 
cavities and tissues. Thus, in sinus-phlebitis—i. e. thrombo-phlebitis 
of the cavernous sinus—it has been made practicable not only to open 
the sinus in the mastoid region, but to expose the jugular vein in the 
neck, to ligate it, and to wash through from one opening to the other, 
effectually getting rid in this way of a long mass of infected throm- 
bus. By such bold and radical measures only may life be saved in 
many of these instances. 
Embolism. 
Embolism means the transportation of any material by ivhich a 
blood-vessel can be occluded or plugged from some one point in the 
vascular system to some other point. The underlying idea is that of 
transportation or carriage. An embolus is anything so transported, 
without implying its exact character. The name is even applied to 
so insubstantial an affair as a minute bubble of air, which, however, 38 
SUBGIGAL PA TJIOLOG Y. 
in a tube containing a circulating fluid is a possible source of consid- 
erable disturbance. A single bubble thus carried would, by itself, be a 
trifling affair, but when numerous bubbles are thus transported the 
result is such local disturbance as may lead to loss of function. 
Thus, air-embolism, so called, may provoke profound, even fatal, 
disturbances, as, when with the returning blood-stream through the 
cranial sinuses or one of the large veins in the neck when opened bv 
accident or operation, air is sucked in, it is carried to the right side of 
the heart, whose action is perhaps completely perverted because of the 
new and strange substance which thus enters it, so different from that 
for which its lining membrane is prepared and to which it reacts. The 
entrance of air into veins, which constitutes in effect air-embolism, has 
been in time past a bugbear to surgeons, but nevertheless is a source 
of probable danger when large venous trunks in proximity to the heart 
are thus exposed. Air-embolism is certainly a rarity. On the other 
hand, those substances which figure most often as emboli are vegeta- 
tions from the valves of the heart; drops of fat; fragments of tumors ; 
pieces of softened and disintegrated thrombi; foreign bodies, as booklets 
of echinococcus cysts; and, perhaps most often of all, the micro-or- 
ganisms clinging to some minute fragment of thrombus which has 
been dislodged. Embolism is also produced experimentally by the 
artificial introduction into the circulating blood of cinnabar or small 
particles of pith or other material. Emboli differ in size, from the 
smallest appreciable up to the largest, which may be met with in the 
larger venous trunks. They are dislodged from their primary site 
sometimes by accident, as by rude manipulation, injury, etc.; some- 
times by undue cardiac activity, as when detached from a valve-wall; 
sometimes by the process of softening of thrombus and a subsequent 
introduction into the blood-stream as a result of some trifling motion ; 
or even by spontaneous processes. Emboli also differ in numbers ac- 
cording to the nature of the primary lesion. In cases of so-called 
fat-embolism fluidified fat is taken into the returning blood-stream, 
carried to the heart, churned up with the contained blood, and distrib- 
uted to the lungs in such a way that myriads of minute fat-masses 
are distributed throughout the capillaries of the lungs, and free circu- 
lation of blood through them thereby impeded. 
Whatever may be the character of the embolus in a given case, given its 
origin, its direction and course can be predicated up to at least a certain point. 
The embolus which springs from the left side of the heart will always be swept 
into the aorta, but, so far as known, it is accident alone which determines 
whether it shall be diverted into one of the main arterial trunks which spring 
from the aortic arch, or whether it shall be carried down to be sent out through 
one of the lower aortic branches. On the other hand, the embolus which is 
produced as the result of a thrombus in the portal system is surely first lodged 
in the liver, while that coming from any one of the general systemic veins is 
first carried to the right side of the heart, and then to some branch of the pul- 
monary artery, and embolism of the lung is the consequence. Whether, now, 
from the lung there shall emanate further disturbance of the same character 
will depend upon the source and nature of the embolus in question. If it have 
come from an infected thrombus, it will be sure to set up within the lung dis- 
turbance similar to that where it originated; the consequence of which will be 
coagulation-necrosis and thrombosis in the area involved, with repetition of the 
original condition and likelihood of repetition of the original accident. Let, 
now, a thrombus come from this secondary focus in the lung: it returns with SURGICAL PATHOLOGY OF THE BLOOD. 
39 
blood by the pulmonary vein to the left side of the heart, whence it may be 
distributed to any point in the entire arterial system, this point, again, being 
determined apparently by accident. Septic thrombi, if they occur at all, are 
practically multiple and usually exceedingly numerous; and so, if the embolism 
partake of this septic character, we may be sure that a crop of septic emboli has 
been distributed, rather than one embolus. In each instance, however, there will 
again be a repetition of the original condition; and it is by these means that 
so-called metastatic foci, either of cancer or of septic infection, are produced. 
The term metastasis, therefore, is indistinguishable from a consideration of em- 
bolism, and its fundamental significance in surgical terminology is that of trans- 
portation of some injurious material. It will be readily appreciated that after 
entrance into the arterial current a given embolus will be checked only when 
it has entered an artery whose lumen is too small to permit its passage without 
greater pressure than that at the time existing in the blood-vessel. 
It will thus be seen that the relations between thrombosis and 
embolism are most intimate, but that either one may occur without 
the occurrence of the other. 
As the result of the combined or single condition we may have— 
1. Temporary occlusive effects, which are later atoned for by the 
collateral circulation. This is possible in any given case, except 
when the artery involved is one of those known as terminal. In 
this instance the condition of the parts supplied by said vessels is 
hopelessly compromised. The best examples of this are seen proba- 
bly in the brain, where the arrangement of vessels is peculiar, and 
where an area which is thus shut off remains condemned to a mini- 
mum of blood-supply which shall be insufficient for perfection of 
function, and often so slight as to be followed by degeneration, etc. 
In other words, the question always is whether there is beyond the 
plug and between it and the capillaries a sufficient arterial anastomo- 
sis with the obstructed vessel. If not, aside from the enforced ane- 
mia of the affected region, the occluded vessel becomes tilled with 
thrombus, while, if the individual live long enough, there will arise 
in advance of it either uncomplicated necrosis or a necrosis associated 
with engorgement, leading to that described below as hemorrhagic in- 
farction. 
2. Infarct, which refers to the area of tissue, usually conical in 
outline, representing so much as is shut off from blood-supply by the 
occlusion of the artery supplying that region. In this case the apex 
of the cone corresponds to the location of the embolus, the base of 
the same to the surface supplied by the terminal ramifications of the 
obstructed vessel. Infarcts are divided into the anaemic—which is 
practically the condition already described—and the hemorrhagic, 
which is the usual sequel of coagulation-necrosis in front of the 
arterial plug. Such infarcts are often visible to the naked eye, 
and occasionally involve areas of considerable size. The so-called 
hemorrhagic character is given to them by the reflux of blood 
which takes place from the contiguous capillaries or arterioles, in- 
sufficient for continuance of function, but with sufficient vis a tergo 
to escape from vessel-walls already weakened by coagnlation-necro- 
sis, and to constitute in effect a truly hemorrhagic lesion. The 
most pronouncedly hemorrhagic infarcts are met with in the lungs. 
In lesser degree they are seen in the spleen and kidneys, though 
most of the infarcts met with here are of the anaemic variety. 40 
SURGICAL PATHOLOGY. 
Coagulation-necrosis is, however, not the most serious sequel to 
infarct; but when embolism involves the popliteal artery, for instance, 
it may be followed by gangrene of the foot and leg. Gangrene of the 
lung or of other tissues may also occur even if the original embolus 
be not septic, since large areas thus shut off' receive a blood-supply 
insufficient for the barest needs of nourishment, and, tissue-resistance 
thus lowered, infection becomes easy, so that moist, septic gangrene 
may be the result of an original non-septic lesion. 
Embolism, then, is ordinarily a most undesirable condition. Yet 
in rare instances we take advantage of its possibilities and endeavor 
deliberately to provoke it, practically for the same purposes that we 
endeavor to provoke thrombosis—i. e. for the cure of aneurism 
mainly. 
Inasmuch as an aneurism is always lined by laminated thrombi, it has been 
suggested to cause the detachment of some particle of this material by forcible 
manipulation, hoping that it will thus form an embolus as it is swept into the 
blood-stream, and that it may plug the vessel below in such a way as to pro- 
duce the same effect as would a ligature applied from without. Although the 
method is so simple in theory, and though surgeons have availed themselves of 
it in the past, it is essentially unscientific and clumsy, mainly for the reason 
that the consequences of such manipulation cannot be controlled, and more 
harm than good may be done, even to the extent of producing gangrene or of 
rupturing the sac. 
Among the viscera, with the exception possibly of the brain, no- 
where are the disastrous consequences of such processes as those just 
described more apparent and indicative than in thrombosis and embol- 
ism of the mesenteric blood-vessels—a condition not so rare as journal 
articles would imply, yet nevertheless one seldom recognized either 
during life or after death. Its principal symptoms consist of intense 
abdominal pain, bloody diarrhoea, subnormal temperature, sometimes 
with vomiting, perhaps in the latter stages vomiting of blood. Shock 
is usually also extremely marked. The consequence of this condition 
is almost inevitably gangrene of the intestine supplied by that particu- 
lar portion of the mesenteric vessels. The pain comes on within a 
short time after the occurrence, and under the peculiar circumstances 
gangrene may be practically determined within fifteen hours. More 
than fifty cases of this kind are now on record in surgical literature, 
and the condition is one well worthy the prompt attention of the sur- 
geon, because only by surgical intervention—i. e. by resection of the 
necrotic mass of intestine—can life possibly be saved. Thus, Elliot1 
successfully resected 1|- metres of intestine for this purpose. 
Fat-embolism. 
Fat-embolism as a distinct, sometimes fatal, surgical condition 
has received of late so much study as to be now entitled to considera- 
tion by itself. By this term is meant g, plugging of small arteries by 
minute drops of fat, which, having been set free somewhere about the 
periphery, are carried into the venous circulation and thence dis- 
tributed to various parts of the system. Inasmuch as the capillaries 
of the lungs are often the first lodging-place, fat-embolism here is 
most often met with, and consequently recognized and studied. But 
1 Annals of Surgery, Jan., 1895, p. 9. SURGICAL PATHOLOGY OF THE BLOOD. 
41 
it may obtain in the brain, the choroid, the kidneys, or other parts, 
provided only that there has been sufficient vis a tergo on the part of 
the heart to force the fat-globnles through the pulmonary capillaries 
and into the systemic circulation. 
Fat-embolism occurs relatively quite often, and to a slight extent 
in nearly every case of fracture and laceration. So common is it, and 
so closely allied are some of its most prominent symptoms to those of 
shock, that as a matter of fact many cases heretofore considered shock 
are really to be regarded as instances of this condition. Indeed, even 
in a miscellaneous series of 260 dead bodies fat-embolism was found in 
10 per cent. The injuries most likely to be followed by it are simple, 
and particularly compound fractures of bones; laceration of soft 
parts, especially of adipose tissues; certain surgical operations; acute 
infections of bone and periosteum ; rupture of fatty liver; and certain 
pathological conditions where the phenomena are not so easily 
explained—e. g. icterus gravis, diabetes, etc. 
Drops of fat may be seen floating on fluid or semi-fluid blood after many 
operations and compound injuries, and the possibility of escape of fat—or, 
more accurately, its suction into the vessels from which this blood has escaped 
—is easily appreciable. But it has also been shown that absorption of fat is 
possible even from serous surfaces, and that fat-embolism may occur when fluid 
fat has been passed into the heart through the thoracic duct, although more 
slowly. Oil-drops are also found in the interior of the tissues, while in a piece 
of lung spread out in water in the visible vessels highly refracting fatty mate- 
rial may be noted. Fatty infarction, particularly in the lower lobes, is some- 
times plainly visible to the naked eye. Under a low objective, especially with 
osmic-acid staining, the presence of fat is easily and beautifully demonstrated. 
Fig. 5. 
Pulmonary capillaries filled with fat in fat-embolism. 
The essential danger in case of fat-embolism is of so clogging the 
pulmonary capillaries that oxygenation shall become so imperfect as 
to lead to absolute asphyxiation from carbonic-dioxide poisoning. 
When this fact is understood, the cyanosis, the rapid breathing, the 
over-action of the heart, etc. are easily and correctly interpreted. 42 
S URGIGAL PA TIIOL OGY. 
Fat-embolism by itself cannot cause inflammation nor infection 
nor sepsis in any sense. It may, however, lead to ecchymoses in con- 
junction with fatty infarcts in the organs most affected. The minute 
hemorrhages are easily explained by bursting of the capillaries in the 
attempt to force blood through them. Fatty emboli, however, take 
the same course as do septic—are carried first to the right side of the 
heart and distributed over the lungs; are, if the patient live, forced 
through the lungs into the systemic circulation, and are then carried 
to the brain, kidneys, etc. The first symptoms are referable to the 
plugging of the pulmonary capillaries; the secondary symptoms to 
the systemic disturbance. 
Symptoms.—Pallor of countenance with facial expression of anx- 
iety and distress, followed by cyanosis and contracted pupils, are seen. 
Patients are usually first excited, sometimes more or less disturbed, 
then become somnolent, and, finally, comatose in the fatal cases. The 
respiration-rate increases from normal up to 50 or 60, and breathing 
is sometimes stertorous. Dyspnoea, increasing in intensity until it 
becomes agonizing, sometimes marks these cases. Occasionally foam, 
possibly blood, proceeds from the mouth, as in oedema of the lungs. 
Occasionally, too, haemoptysis occurs. The pulse becomes weak, fre- 
quent and irregular, while toward the close it is fluttering. Tempera- 
ture is not notably disturbed, at least not typically. 
These symptoms set in usually within thirty-six to seventy-two 
hours after the lesion which has caused them. I have, however, 
known death to occur in one or more cases within eighteen hours after 
reception of injury. 
After fat has been forced through the lungs and carried to the 
kidneys it will be eliminated with the urine, and may be found float- 
ing upon it in the shape of oil-like drops. Discovery of this condi- 
tion is positive evidence of fat-embolism. It is to be distinguished 
from shock in that by the time the symptoms of embolic disturbance 
are at their height, all or nearly all symptoms of pure shock should 
have subsided. Furthermore, cyanosis and embarrassment of respi- 
ration are not indicative of shock; and, finally, the discovery of fat 
in the urine will be corroborative. 
A mild degree of fat-embolism may be noted, if looked for, after almost all 
serious fractures. It will give rise to slight embarrassment of respiration and 
cyanosis and to the elimination of fat by the kidneys. 
Prognosis.—Prognosis is somewhat in proportion to the extent 
of the injury and the proximity of the lesion to the heart and lungs; 
also to the possibility of continuous entrance of fat—i. e. from its 
continual absorption. Prognosis really depends upon whether the 
heart can be given sufficient vigor and endurance to continue pump- 
ing blood with its burden of fat through the pulmonary circulation. 
A secondary danger may come from the circulation of this fat-ladened 
blood through the capillaries of the brain. Should the source of 
motive power thus become paralyzed along with general enfeeble- 
ment, death may ensue. When well-marked evidences of fat-embolism 
are present, but are followed by recovery, the worst of the trouble is 
usually over within forty-eight hours after it begins. 
Treatment.—Obviously, treatment is mainly directed toward the SURGICAL PATHOLOGY OF THE BLOOD. 
43 
heart that it may stimulate it to carry its load of fat through from 
the venous into the arterial system. If it can do this, the fat is dis- 
posed of by oxidation or is saponified by the alkalies in the blood. 
Physiological rest of the injured part is the first indication, however, 
and if this occur in a patient, say with delirium tremens, powerful 
mechanical restraint may be necessary. The most powerful cardiac 
stimulants are called for—alcohol, digitalis, strychnia. In other 
respects treatment is largely symptomatic. Next to giving the heart 
vigor in this way, inhalations of oxygen give the most promise, 
because of the crying need of the system during this ordeal for this 
life-giving gas.1 
The Corpuscular Elements of the Blood. 
Within the past few years has come into a considerable importance 
the so-called third corpuscle or blood-plaque, minutely described by 
Osier and others. It is composed of colorless protoplasm, averaging 
[). (mikrons) in diameter, and is present in proportion of about one 
to twenty of the red blood-corpuscles. While circulating in the blood 
these plaques do not ordinarily cohere, but immediately on their with- 
drawal they form aggregations; to which fact is due the lack of their 
earlier recognition. They are most numerous in the infant and in the 
aged. Their presence is not yet fully accounted for, and their rela- 
tion to the formation of other corpuscles not yet distinctly determined. 
In acute infectious diseases and in certain chronic wasting forms they 
exceed their normal proportion. During crises of fevers and during 
convalescence from acute and extensive suppuration they are most 
often seen in large numbers. 
The blood-plaques are not the only corpuscles of the blood which 
undergo rapid increase or diminution in number, since this is true 
also of the leucocytes, which during acute inflammations rapidly aug- 
ment in number. Whether this is to furnish more which may escape 
from the blood-vessels and act as phagocytes, or whether destined to 
some other purpose, is not yet settled, though the former is probable. 
Under many of the circumstances connected with phlegmon and 
active corpuscular escape it is found that the spleen and lymph-nodes 
are materially enlarged. Temporary increase in the proportion of 
leucocytes is known as leucocytosis, which is a usual accompaniment 
of suppuration, even though the focus of activity be small. Diminu- 
tion in number of white cells is known as oligocythaemia, and its 
significance will be alluded to below. The relation of the leucocytes, 
which contain most of the paraglobulin and peculiar ferment which 
are such important factors in the coagulation of blood, to thrombosis 
is most important; and it must naturally follow that breaking-down 
of these cells—i. e. release of such materials—will have very much to 
do with coagulation, and that, therefore, thrombosis may be a frequent 
accompaniment of leucocytosis in inflammation. The colorless cor- 
puscles contained in the blood and lymph present several varieties 
more or less distinct from each other, and are classified as follows: 
Lymphocytes.—Small leucocytes with large, round nuclei and a 
relatively small amount of protoplasm, occurring conspicuously in the 
1 See paper by the writer, N. Y. Med. Journ., Aug. 16, 1884. 44 
SURGICAL PATHOLOGY. 
lymph-nodes. They stain readily, especially with aniline dyes, which 
color the nucleus deeply and the protoplasm faintly. These lympho- 
cytes grow until they become large-sized leucocytes, and it is charac- 
teristic that the larger they grow the more easily their protoplasm 
stains and the less so their nucleus. As they attain larger size their 
nuclei sometimes change in shape, and it is not always easy to distin- 
guish a large mononuclear leucocyte from certain fixed connective- 
tissue cells or endothelial cells. 
The eosinophile leucocytes contain in their protoplasm granules 
which do not stain with basic aniline dyes, like fuchsin, methyl vio- 
let, etc., but which readily take up the acid aniline colors, especially 
eosin ; whence their name. In this variety the nucleus is variable in 
shape and form, and is often lobed. 
Another form is represented by cells in which the nucleus is either 
lobed or composed of portions united by delicate filaments, giving the 
impression of a multinuclear cell—in fact, the nuclei often are really 
multiple. Hence this form is known as the polynuclear form. 
These leucocytes also contain a small central body of chromatin and 
polar filaments of achromatin. Their nuclei are deeply stained by 
aniline dyes, while their protoplasm remains for the most part unaf- 
fected. This latter is granular, and can only be stained by a mixture 
of acid and basic dyes, so that these polynuclear forms are often 
spoken of as neutrophile. This form comprises about three-fourths of 
the total number of leucocytes in the blood. The term formerly used, 
myelocyte—i. e. a cell supposed to be found in the bone-marrow and 
distinct from the other leucocytes—has been nearly abandoned. Ehr- 
lich, who has been the leader in this study of blood-cells, has shown 
that the eosinophile cells form in the blood at the expense of smaller 
ones which have been produced in various organs. Consequently, an 
undue proportion of eosinophile cells indicates pathological activity 
of bone-marrow and betokens one form of leucocythsemia. 
The entire modern study of leucocytes of the blood is based upon 
their reaction to certain staining agents, for the most part the aniline 
dyes. According to these reactions in connection with peculiarities 
of size, shape, etc., we speak, then, to-day of the following varieties 
of white corpuscles: 
1. Lymphocytes, derived from lymphoid tissues of the body; in 
number from 20 to 30 per cent, in the leucocytes of the blood. Their 
nucleus is large, and their non-granular protoplasm appears only as a 
narrow rim. 
2. Large mononuclear forms, with large, oval, feebly-staining 
nuclei and a fair quantity of non-granular protoplasm; 2 to 3 per 
cent. 
3. So-called polynuclear leucocytes, those with polymorphous nuclei. 
These represent two-thirds of the whole number of leucocytes. They 
are smaller than No. 2, and have irregular nuclei. Their protoplasm 
contains numerous neutrophilic granules, and they are often called 
polynuclear neutrophiles. 
4. Transitional forms, similar to No. 2, with irregular nuclei, in 
transitional stage from mono- to polynuclear form, constituting about 
3 per cent, of the entire number. PLATE I 
Appearances of .he Blood Corpu.ele. in Various Condition.. (Rieder.l PLATE I. 
Appearances of the Blood Corpuscles in Various 
Conditions. (Rieder.) 
1. Mixed Leucxmia or Myeiaemia. Four red corpuscles without and 
two with nuclei; two large eosinophile (marrow) cells; one leucocyte, show- 
ing mitotic division of its nucleus, x 1600. Fosin-hsematoxylin. 
2. Acute Leucaemia. Leucocytes mostly mononuclear, small; reds regu- 
lar in outline, x 300. Fosin-heematoxylin. 
3. Lymphatic Leucaemia. On the right, x 300. Red corpuscles rosy pink, 
mono- and polynuclear white corpuscles blue. On the left, x 1100; red cor- 
puscles neutral tint, white corpuscles blue. Fosin and hematoxylin stains. 
4. Anemia Qravis with Leukocytosis. On the right, x 300. Red cor- 
puscles very pale ; leucocytes polynuclear. On the left, x 1100. Reds irregular 
in outline ; one large polynuclear leucocyte, one small mononuclear; mass of 
blood-plaques. (From case of carcinoma) Fosin-hematoxylin. 
5. Inflammatory Leukocytosis. On the right, x 300. Polynuclear leuco- 
cytes (neutrophile) greenish blue. On the left, x 1100. Same, showing nuclei 
among numerous granules contained within the cell. (From case of crou- 
pous pneumonia) Aronson’s stain. 
6. Anaemia Qravis. Poikilocytosis of reds, with macro- and microcytes ; 
one mononuclear leucocyte with blue-stained nucleus, x 300. Fosin-methy! 
blue. SURGICAL PATHOLOGY OF TIIE BLOOD. 
45 
5. Eosinophile cells, same size as No. 3 ; nuclei variable, protoplasm 
largely made up of refractive eosinophile granules. They constitute 
from 2 to 4 per cent, of the total of leucocytes, and originate in bone- 
marrow. Nos. 2, 3, and 4 are regarded as formed in both spleen and 
bone-marrow. 
These proportions are fairly constant in a state of health; in the 
presence of certain diseases they vary widely. Hence the value of 
proper estimation and recognition of their relative proportion. It is 
also generally accepted that in certain diseases cells not met with in 
health may be found in the blood. These have not yet been suffi- 
ciently studied, but their recognition is a matter of growing import- 
ance. Their various appearances are indicated in Plate I. 
Leucocytosis as an Element in Diagnosis.—Leucocytosis dif- 
fers from leucaemia in that while both refer to the increase of the actual 
number of white corpuscles in a given volume of blood, and while in 
both instances these belong to the classes found normally present, in 
the former instance the condition is a temporary and evanescent one, 
while in the latter it is a permanent one and constitutes a marked fea- 
ture of the disease. It is perhaps incorrect to say that in leucaemia 
only the normal types of cells are present. All of the normals are 
present, but there are also present those which are not found under 
normal conditions. In leucocytosis the increase is mainly in the poly- 
nuclear cells. 
The normal standard implies that in a cubic millimetre of blood there should 
be present about 7,500 leucocytes to from 5,000,000 to 5,500,000 red blood-cells; 
but the relative proportion of whites varies even from hour to hour within cer- 
tain limits, and a relative leucocytosis is normal during digestion of a hearty 
meal, during pregnancy, and in newly-born children. But, as an index of ab- 
normal conditions, one may say in a general way that leucocytosis as a diseased 
condition is nearly always associated with the inflammatory process, with cer- 
tain malignant tumors, and in other rare conditions which may be mentioned 
below. Any variation of more than 1,500 above or below the above standard 
of 7,500 should be considered abnormal. 
Some writers have stated that leucocytosis exists during typhoid 
fever. This is, however, distinctly a mistake, since it is never present 
except when some such complication as thrombosis, abscess, pneumonia, 
etc. complicates the case. It is even possible to make a diagnosis as 
between relapse and other complication by counting the leucocytes. 
This is particularly true in cases of appendicitis, since it is difficult 
sometimes to diagnose as between typhoid and appendical disease. 
Should leucocytosis be present, diagnosis may be positively made in 
favor of the latter. So, also, in general septic conditions, which may 
be differentiated from typhoid in the same fashion. Again, in case of 
threatening surgical complications, so long as the leucocytes are normal 
in number one may pin his faith to typhoid alone. 
It is not so, however, in pneumonia. In this disease there is a marked in- 
crease in the white corpuscles. Moreover, prognosis is bad in pneumonia when 
this condition does not obtain, as Cabot has shown. In cases of acute obstruc- 
tion of the bowel, so long as no leucocytosis is present the case is not one of 
appendicitis nor of suppurative peritonitis. 
In malignant disease, especially in the soft and rapidly-growing 
tumors, and particularly in sarcoma of bone, there is marked leucocy- 46 
S UR GIG A L PA THOL OGY. 
tosis, by which in doubtful cases a distinction may be made before 
operation between malignant conditions and tuberculosis, chronic 
arthritis, etc. It is furthermore stated that in malignant disease, 
even when no leucocytosis is present, a differential count of stained 
specimens will show marked increase in the percentage of polynuclear 
cells. In all forms of suppuration, deep or superficial, circumscribed 
or diffuse, and in all types of septic invasion and infection, leucocy- 
tosis is present. Cabot has shown how the test may be applied in 
cases of deep wounds, compound fractures, etc., where one is dis- 
turbed by rise of temperature, etc. and hesitates whether or not to 
re-dress the wound. If there be no leucocytosis present, there need 
be no fear of retained or accumulating pus.1 Furthermore, in such 
a case—for instance, as one of uncertain diagnosis between typhoid 
and purulent meningitis—an increase of leucocytes will point surely 
to the latter; and diagnosis has been corroborated by the discovery 
of middle-ear disease, from which the meningeal complications pro- 
ceeded. 
It will be seen, then, that the relative and numerical estimate 
of the richness of the blood in its white corpuscular elements may 
be of the greatest service to the surgeon by furnishing indications 
of importance for the subsequent management of the case or for 
diagnosis. 
Red Corpuscles.—With care in examination certain differences 
can be detected in the behavior and size of the red corpuscles, which 
may also furnish important information. This brings up mainly in 
this connection the question of the anaemias, which are relative and 
positive. After an acute loss of blood, as after operation or accident, 
there is, of course, a deficiency in the amount of blood in the system, 
which, however, does not materially influence the proportion of reds 
to whites nor the number of reds present in a given volume. Oligocy- 
thcemia is a term applied to a deficiency of red corpuscles, or to a con- 
dition by which their relative proportion is recognizably lowered. If 
we accept from five to five and a half million of red cells in a cubic 
millimetre as the normal standard, it will be seen that we may have 
various degrees of oligocythiemia, which, however, is rarely reduced 
below a proportion of two million. Poikilocytosis is a term applied 
to that condition in which the red corpuscles are irregular in shape 
and in size, these irregularities varying from the slightest crena- 
tion of their borders up to a very marked alteration in all their 
proportions. 
It is possible, then, without long special training, to estimate both the 
number of the red cells present, their thickness, shape, general appear- 
ance, whether they are very biconcave or not, and how they react to 
ordinary stains; from all of which considerable valuable information, 
sometimes of the greatest importance, can be gained. Stains partic- 
ularly readily illustrate alterations in shape and nucleation. In all 
acute anaemias and in many of the chronic and secondary forms nucle- 
ated corpuscles may be determined : the nuclei have peculiar refrac- 
tion, and perhaps are even seen in the act of escaping from their parent 
corpuscles. In certain grave forms of anaemia, particularly in the per- 
1 Boston Med. and Surg. Journ., March 22, 1894. SURGICAL PATHOLOGY OF THE BLOOD. 
47 
nicious form, and in the leucaemias, one finds corpuscles larger than 
usual with pale-staining nuclei, in which a network of karyokinetic 
figures can often be made out. This has led to the fanciful distinc- 
tion between normoblasts—i. e. red corpuscles of normal tissue—and 
megaloblasts, meaning thereby the form just described. 
Inasmuch as I have spoken of the source of the various forms of leucocytes, 
I should state here that it is now generally held that the red corpuscles are 
formed almost solely from the nucleated red cells which may be seen in the red 
marrow of bone, the transformation taking place by the process of extrusion of 
the nucleus. Inasmuch as the nucleated cells increase in bone-marrow very 
rapidly after great loss of blood, this view is in large degree corroborated thereby. 
The marrow-cells divide also by mitosis in order to produce the red blood-cells. 
It will thus be seen that bone-marrow is most important in the formation both 
of the red and the white corpuscles, and that to it we must look for the source 
of most of them, rather than to the spleen, in which, after all, little if any such 
activity can be proven. How rapid may be regeneration after hemorrhage, etc. 
is shown by their manufacture at the rate of over fifty thousand per cubic 
millimetre a day (Osier). 
Methods of Examination. 
These can be referred to here only in the briefest possible manner. 
The student who desires to take up this matter carefully should refer 
to works on physical diagnosis, such as those of Von Jaksch, etc. 
The principal examinations called for in pursuing the methods of diagnosis 
above outlined are the estimation of the red corpuscles, the numerical and differen- 
tial estimation of the leucocytes, and the estimation of hcemoglobin. The apparatus 
Fig. 6. 
Thoma’s hsemocytometer. 
generally in use for counting the red corpuscles is that of Thoma, made by 
Zeiss, in which the blood is diluted in a mixer from one to two hundred times, 
a saline fluid being used whose specific gravity corresponds with that of the 
blood. It is an advantage to slightly tinge this with methyl violet, because the 
leucocytes take up this stain and are as easy to count as are the reds. Using 
this instrument, the error will probably not exceed 2 to 3 per cent. 
A very convenient and for many purposes sufficiently accurate method of 
estimating the solids of the blood is by centrifugating machines or hamiatobates. 
For this purpose the blood is mixed with an equal volume of Muller’s fluid or 
of a 21 per cent, solution of potassium bichromate, with which the capillary 
tube is filled; after centrifugation for several minutes the red blood-corpuscles 
will be found to have separated themselves to the farther end of the tube, since 
their specific gravity is greater than that of the whites. Their relative propor- 48 
SURGICAL PATHOLOGY. 
tion may be read oft’ upon a graduated scale. The same may be done with the 
whites. In the average of healthy individuals the red blood-corpuscles will 
occupy about one-half of the length of the full tube. This corresponds to a 
little over 5,000,000 corpuscles to the cubic millimetre. About one-fiftieth of the 
length of the tube will be occupied by the white corpuscles, whereas in advanced 
cases of leucaemia the leucocytes may occupy ten or twelve times as much space. 
This method of centrifugation cer- 
tainly offers an easy and for many 
purposes a sufficiently accurate esti- 
mation. By making repeated ex- 
aminations in the same case it af- 
fords a very accurate method of 
judging of progress or the reverse. 
Daland’s admirable instrument is 
shown in Fig. 7. 
Up to the present it has been found 
of no practical value to count the 
number of blood-plaques or third 
corpuscles present, these varying 
within wide limits—according to 
Osier, from 200,000 to 500,000 to 
the cubic millimetre. 
The leucocytes may be counted at the 
same time as the reds, and practically 
always should be. By this means their 
relative proportion to each other is 
determined, and the general fact of 
leucocytosis or leucaemia must be es- 
tablished. But this is now not enough 
for accurate diagnosis, and we must 
resort to dried specimens of the 
blood, stained with various aniline 
dyes, before a complete estimation 
can be arrived at. In securing a 
drop of blood for examination it is 
best taken from the lobe of the ear, 
which should be thoroughly washed, 
pricked, and the minute drop of blood 
collected upon a cover-glass which 
has been cleansed and prepared with 
minute care. These cover-glasses are 
then kept for an hour or two at a tem- 
perature of 120° C., in order that the 
haemoglobin of the red cells may be 
so fixed as not to be removed by the 
staining fluid. Various stains may be 
used, the aniline dyes being largely 
resorted to for this purpose. The 
cells are differentiated largely by 
their reaction or behavior with the 
two groups of aniline colors known as acid or basic, the former being those in 
which the staining agent is the acid portion ; the latter, those in which it is 
the basic portion of the combination that forms the dye, while the union of a 
staining acid and a staining base makes what is known as a neutral dye. Not 
to go into the refinements of the subject too far, we will simply mention that 
the triple stain of Ehrlich, containing methyl green, acid fuchsin, and orange 
G., is the most serviceable for all-round purposes, since by its use the nuclei of 
the white cells are stained green, those of the nucleated red cells nearly black, 
the red corpuscles orange, tbe eosinophilic granules red, and the neutrophilic 
granules dark violet, I have already called attention to the significance of a 
preponderance of one of these forms over the other. Let it suffice, then, to say 
that this is a serviceable method of determining such preponderance. 
The amount of haemoglobin is easily determined, either by arbitrary color 
scales or by the spectroscopic test, and gives information of considerable value 
Fig. 7. 
Daland’s haematokrit. 
Upper view of Daland’s instrument. 49 
SURGICAL PATHOLOGY OF TILL BLOOD. 
both in diagnosis and prognosis. For its estimation Fleischl’s instrument is 
now generally resorted to. This consists of a wedge of glass of the same tint 
Fleischl’s hsemometer. 
as haemoglobin, which is moved under a cell containing a watery solution of 
the blood until the tints correspond, when the amount of haemoglobin present is 
read off on a scale. Inasmuch as the 
normal amount in healthy blood is 14 per 
cent., the number 100 on this scale corre- 
sponds to this limit. It is a purely arbi- 
trary method, but one which is very easy 
of execution, and which gives results suf- 
ficiently accurate and indicative to make 
it of great value. Fleischl’s instrument 
(Figs. 8 and 9) is the one in general use 
for this purpose. 
Finally, th e specific gravity of the blood 
may be determined by different methods, 
a very simple one being to have at hand 
a mixture of chloroform and benzole of 
known specific gravity, into which the 
blood is dropped, while enough of one 
or the other is added until the blood-clot 
manifests no tendency to rise or fall. The specific gravity of this mixture 
is now taken, and equals, of course, that of the blood. 
Physical Properties of the Leucocytes. 
Phagocytosis.—All leucocytes have the power of shifting their 
location. The lymphocytes, so called, being the youngest of the 
white corpuscles, show it less than do even the older forms. Also 
the eosinophile cells are less able to manifest the peculiar activities 
of the other forms. It is particularly the mono- and polynuclear 
corpuscles which are endowed with most pronounced activity. These 
have the power, like the amoebae among the lowest forms of life, to 
not only spread themselves around inert bodies, like granules of car- 
mine or other particles used for experiment, or the particles of coal- 
dust found in certain conditions in the human body, but they have 
also the power to englobe many living organisms, for the most part 50 
SURGICAL PA TIIOL OGY. 
vegetable (bacteria). Under the microscope it is possible to see liv- 
ing bacilli performing active movements although enclosed in the 
nutritive vacuoles of the leucocytes in some of the lower animals. 
This amoeboid power possessed by 
these cells of thus attacking and 
disposing of foreign bodies or ir- 
ritants has been demonstrated and 
proven, especially by Metchnikoff, 
and has been called by him phago- 
cytosis. His views were for a long 
time disputed, and are perhaps not 
yet absolutely and generally ac- 
cepted. Nevertheless, they fulfil 
every demand made upon them for 
explanation, and are susceptible of 
such demonstration under the mi- 
croscope that we now have practi- 
cally a new and apparently a cor- 
rect theory of the inflammatory 
process. (See next chapter.) Anv 
cell which has this property is 
known as a phagocyte. It is 
shared by certain of the leuco- 
cytes with certain other cells to 
be spoken of later (wandering tis- 
sue-cells). Cells which possess 
this power do not attract all mi- 
crobes indiscriminately, and it is 
often the case that the leucocytes of an animal peculiarly susceptible 
to a certain kind of bacteria do not attract them at all, even 
though they be directly in contact. It is plausible that an expla- 
nation of the peculiar susceptibility of certain animals to certain 
diseases is furnished by this fact. (See Fig. 10.) 
On the other hand, leucocytes may and do englobe virulent mi- 
crobes. In man the mononuclear forms do not take up either the 
streptococcus of erysipelas or the gonococcus; whereas these two 
organisms are readily attracted by the polynuclear neutrophile cells. 
The bacillus of leprosy, on the other hand, is never attacked by the 
polynuclear forms, but is speedily devoured by the mononuclear cells. 
This shows that the various leucocytes may exercise a marked selec- 
tive ability. This inclusion of minute bodies within amoeboid cells 
seems to be an evidence of a peculiar tactile sensibility upon the part 
of the latter. In fact, this is clearly established, and seems to be 
inseparable from the peculiar attraction between leucocyte and bac- 
terium to which the name chemotaxis has been given, and which is 
described in the ensuing chapter. If the included organism be, as is 
usually the case, killed, it is disposed of by a true process of intracel- 
lular digestion in a neutral or alkaline protoplasmic medium, and its 
inert portions are again extruded. On the other hand, if the leuco- 
cyte be poisoned or die in this phagocytic attempt, it presents usually 
as a so-called pas-cell or corpuscle, and the solid part of pus is made 
Fig. 10. 
Active phagocytosis. Endothelial cells en- 
closing the bacilli of swine septicaemia, 
from an hepatic vein of a pigeon: a, endo- 
thelial cells; b, leucocytes (MetchnikofF). SURGICAL PATHOLOGY OF THE BLOOD. 
51 
up in large measure of cells which have perished in this way. (See 
next chapter.) 
To regard phagocytosis as an affair mostly of certain tissue-cells and 
invading bacteria would be altogether too narrow a view to take of it. 
It is really a process of the greatest importance and of constant per- 
formance in our systems. By virtue of it disintegrated muscle-fibres 
and other tissue-cells are disposed of, sloughs are separated, certain 
absorbable foreign bodies (catgut, etc.) taken away—i. e. absorbed— 
cellular tissue reduced in numerical strength (progressive atrophy); 
and a great variety of changes, either normal, as those pertaining to 
health and advancing years, or abnormal, like those incident to many 
diseases, are actually the product of this kind of phagocytic activity. 
The protective power, then, which the phagocytes exert as against 
bacteria is only one part of their normal functions, by virtue of 
which they become, in effect, perhaps the most important cells within 
our bodies. Their powers are limited, however, as will be seen when 
describing pus, for the so-called pus-corpuscle is nothing but a phago- 
cyte which has perished in its self-assumed task. It is known also 
that in certain instances phagocytes, which are incapable of defence 
as against the mature bacterial organism, are nevertheless capable of 
englobing its spores and preventing their development. This is true, 
for instance, in case of anthrax in animals ordinarily immune, as, for 
instance, the frog and fowl. If, however, in these very animals the 
vitality of the phagocytes be affected—as by cooling in fowls or heat- 
ing in frogs—phagocytosis is so far interfered with that the spores 
germinate within the enfeebled leucocytes and the entire organism is 
infected. ( Vide also Plate II. Fig. 1, illustrating diapedesis.) 
Hemoglobin. 
The principal interest of the red blood-corpuscles for the surgeon, 
aside from their relative number and shape, inheres in their relation 
to haemoglobin, and haemoglobin is of particular interest here because 
much can be learned by estimating the proportion in which it be 
present. That the amount contained in the blood varies within wide 
limits under different conditions has long been known. The ideal 
normal standard is present in but a small proportion of cases, even in 
strong young men in the third decade of life. The average is con- 
siderably lower and can scarcely be placed above 90 per cent. Fe- 
males show a smaller amount than males—3 or 4 per cent. less. 
After haemoglobin loss, as after surgical operations, much can be 
gained in the matter of prognosis by estimating the speed of its re- 
generation. With regard to how much actual haemoglobin loss a 
patient can bear, it seems to be more important to determine how 
much still remains in the body. The minimum is apparently 20 per 
cent. In three cases dying of collapse after operation Mikulicz found 
only 15 per cent, remaining. The rapidity of regeneration is a fairly 
accurate indication of improvement in every other respect. Regener- 
ation is interfered with by constitutional syphilis, and, on the other 
hand, is often apparently favored in cases of tuberculosis. In malig- 
nant tumors the average of haemoglobin is reduced to about 60 per 52 
SURGICAL PATHOLOGY. 
cent., and in these cases also complete regeneration is materially re- 
tarded. Incomplete removal or recurrence of cancer prevents typical 
regeneration or restoration, while after successful or radical removal 
complete restoration to the previous standard, often with positive 
gain, is obtained. Thus, a woman who had gained thirty pounds 
after resection of a cancerous pylorus showed after three months 
haemoglobin repair to the amount of 65 per cent. A prognostic sig- 
nificance often attaches to the accurate estimation of haemoglobin at 
intervals after removal of malignant tumoxs.1 
1 See my Lectures on Surgical Pathology, p. 13. CHAPTER III. 
INFLAMMATION. 
Roswell Park, M. D. 
Inflammation is an expression of the effort made by a given organism to rid itself 
of or render inert noxious irritants arising from within or introduced from without 
(Sutton, modified). 
After having duly considered hypersemia as a phenomenon having 
an identity and termination of its own, we are prepared to study the 
more complex processes implied under the term inflammation, the 
first of which is the hypersemia already considered. The characteris- 
tic of the truly inflammatory process is that it does not stop with 
mere congestion nor with any of its above-mentioned terminations, 
but goes on to something more complex, now to be described. It 
must be understood, therefore, in this consideration that hypersemia 
here is the first act of the vessels, resulting from peculiar stimuli 
which must shortly be considered. Even the hypersemia seems to be 
now more distinct than under other circumstances, and along with 
the dilatation of vessels and the stagnation of blood-current the capil- 
lary vessels now seem crowded with blood-corpuscles to an abnormal 
degree, the rapidity of their motion is checked, and there is accumu- 
lation of blood-cells along the walls of the small veins, to which they 
seem to adhere as if by some new cohesive property. The result is 
that before long the vessel-wall appears to have received a new coat- 
ing of white corpuscles, this being more marked in the veins than in 
the arterioles, while in the latter the red are more numerously min- 
gled with the white than in the veins, in which the distinction be- 
tween the two classes of cells is better maintained. 
Next comes the phenomenon whose clear recognition and descrip- 
tion is inseparably connected with Cohnheim’s name. This is known 
under different names as migration or diapedesis of the leucocytes. 
The programme is about as follows : A little protrusion of the vascular 
wall, a marked alteration in the shape of a leucocyte, which yet ad- 
heres to this point of its lumen, and then the curious fact so often seen 
under the microscope—the gradual passage of this cell through the 
vascular wall, from its inner to its outer side, by what is generally 
known as its amoeboid movement. This migration of the leucocyte is 
not confined to its mere escape from the restriction of the vessel-lumen, 
but goes on to an indeterminate extent after it has detached itself from 
the outer surface of the vessel. This seems to occur by virtue of the 
same amoeboid characteristic which it exhibited in passing through 
between the cells of the vessel itself. If this occur at one point, it 
occurs at innumerable points, in consequence of which a large number 54 
SURGICAL PATHOLOGY. 
of leucocytes escape into the tissues of the part involved. This diape- 
desis occurs most markedly from the smaller veins, to a less extent 
from the capillaries. The cells which escape from the latter are usually 
accompanied by more or less red cells, the consequence being that the 
exudate which necessarily occurs at the same time is more' or less 
tinged with the coloring matter of the blood, and is known as a hem- 
orrhagic exudate. (See Plate II., Fig. 1.) 
The above phenomenon, described in so few words, is in its minutiae 
a really complex one, depending on a variety of causes not easily ap- 
preciated ; but it is at least positive and well known, because it can be 
observed at will in the mesentery or web or tongue of certain animals 
which can be confined upon the stage of the microscope. The phe- 
nomena of inflammation, therefore, comprise, first, hypercemia, and then 
escape from the blood-vessels of the corpuscular and fluid elements of 
the blood. The former may be due, as already seen, to various irri- 
tations of a non-specific character; while, as we shall learn, the latter 
practically never take place save when the irritation has been, as 
pathologists like to say, specific or infectious. 
It would, perhaps, be too much to say that no corpuscles may escape from 
the blood in a condition of true hypersemia, but it is speaking accurately and 
yet comprehensively to say that such congestion is not characterized by corpus- 
cular emigration, whereas the essential phenomena of true inflammation are 
never met with save in connection with such escape. Experimental pathologists 
have long sought the explanation for this difference, and some have thought to 
explain it on the theory of changes in the vessel-walls; others by loss of tonus 
in the vessels—i. e. their inability to resist dilatation; others yet on the hypoth- 
esis of a peculiar attraction between the vessel-walls and the corpuscles circu- 
lating within them, or by a concentration of blood-plasma, or by vital attraction 
between the various elements of the blood ; while still other hypotheses, even 
less tenable than these, have been advanced in no small numbers. Certain it is 
that the condition of vascular tonus is more marked than in simple hyperemia, 
and that the character of the fluid as well as of the solid exudate is more dis- 
tinctive. There is greater relaxation of tissues, while the intensity of passive 
congestion, as well as of active, is often so much heightened that rapid gan- 
grene ensues unless this tension be relieved. The freedom of transudation also 
interferes with the facility with which the lymph-channels may carry away fluid, 
and gangrene is thereby the more easily produced. In proportion to the cor- 
puscular elements would be the richness of the albumen strength of the fluid 
exudate. It is characteristic of active inflammatory exudates that they contain 
so much albumen as to easily coagulate, while this is much less true of passive 
exudates, which are for the most part very fluid. 
The phenomena of true inflammation comprise practically the role 
played by the three elements which conspire to produce those changes 
—namely, the tissues, the blood, and the specific irritants which are the 
primary causes of the entire lesion. Each of these must be considered 
separately. 
All observers agree that in actively inflamed tissues the number of 
cells is very greatly increased. A certain increase may be accounted 
for by that which has been already described—namely, the escape into 
the tissues of the wandering cells from the blood-vessels. But neither 
this alone nor the products of their rapid proliferation are sufficient to 
account for all the cells found in the truly inflammatory condition. 
The older view, for which Virchow long contended without accurate 
contradiction, was that these cells were due to multiplication of those 
peculiar or proper to the part, since he showed how much their activity PLATE II. 
FIG. 1 
Small Vein showing Diapedesis of Leucocytes ; a, Leucocyte escaping between Endothelial Cells ; 
b% c, Leucocytes escaped ;f, Leucocytes migrating toward centre of attraction. (Eugelmanu.) 
FIG. 2. 
Septic Thrombosis of Pulmonary Capillaries, after Puerperal Septicaemia. Showing rapidly 
increasing colonies of Streptococci. (Klebs.) INF LA MM A TION. 
55 
might be increased by what was then spoken of vaguely as “ the in- 
flammatory irritant.” After Cohnheim had made plain the matter of 
diapedesis, his followers were prone to account for all the abnormally 
present cells by multiplication of those which had escaped from the 
vessels. In this way great contention arose between the followers of 
Virchow and of Cohnheim. We have since learned that the true 
explanation is afforded by the combination of both views. It is now 
well established that in connective tissue there are two varieties of 
cells—the fixed and the wandering—the former concealed in the tra- 
beculae of the intercellular substance, while the latter are small, ordi- 
narily round in shape, much resembling the white corpuscles, possessed 
of amoeboid characteristics, and having the power of changing position. 
These are known as the wandering cells, which meander through the 
lymph-spaces of the tissues or back and forth into and out of the 
blood-vascular system, their migration being regulated by causes not 
yet known to us. Under natural conditions their number is relatively 
small. Once given a true inflammatory disturbance, and they are 
reproduced with amazing rapidity; and their numbers, added to those 
produced by diapedesis of leucocytes, with the combined proliferative 
activity of both forms, serve to account for the new cells whose pres- 
ence characterizes phlegmonous 
and other similar disturbances. 
That these wandering connec- 
tive-tissue cells have much to 
do with these changes is shown 
by the recently pointed-out but 
unmistakable evidences of ex- 
cessive activity known as kar- 
yokinesis (i. e. nuclear activity). 
Karyokinesis is a term in- 
troduced during the past few 
years, implying a very compli- 
cated series of changes with 
nuclear cell-division, with 
radiate arrangement of pro- 
toplasm around a polar cen- 
tre, a division of the globule 
into two hemispheres of ap- 
parently clear protoplasm, 
with a granular arrangement 
of the chromatin which it con- 
tains, into peculiar surface- 
markings, while the achro- 
matin is metamorphosed into 
threads, forming a more or less spindle-shaped arrangement stretching 
between the two poles. A synonym for karyokinesis is Jcaryomitosis, 
frequently spoken of as mitosis for short. When a cell is about to 
undergo these changes the chromatin—that is, the part of the nucleus 
which stains easily—is increased and the nucleus disappears. Shortly 
after formation of the threads, which gather themselves in a series 
of loops pointing from the equator to the poles, a new membrane 
Fig. 11. 
Karyokinesis ; section from border of an inflamed 
gum: ep, karyokinetic division of deep epi- 
thelium ; v, vessel divided transversely, show- 
ing proliferating endothelium; e, chromatin 
threads in endothelium cell; /, fixed cell under- 
going nuclear division (Letulie). 56 
SURGICAL PATHOLOGY. 
is formed around this coil, and two nuclei are thus formed out of 
one. During this division the protoplasm undergoes also certain 
rotary changes of position, accompanied by segmentation of the pro- 
toplasm contained in the cell outside of the nucleus, so that two cells 
are thus formed. While nuclear division is usually bipolar, it may 
be multipolar; and in all probability multipolar division gives rise 
to those polynucleate cells often spoken of as giant cells. Kar- 
yokinesis is common not only in inflammatory disturbances, but in new 
growths of rapid formation, especially sarcomata, which are formed 
from mesoblastic cells, the same which have to do with connective 
tissue. Endothelial cells also undergo the same changes. 
The wandering tissue-cells, or those which have been produced in 
the natural order of events, or those which seem to be the product of 
rapid breaking down of other tissue-cells (Ziegler), are not easy to 
distinguish from leucocytes. It is claimed, however, that they do 
not produce pus-corpuscles, but have more to do with repair. This 
claim, however, is not yet fully substantiated and needs to be corrob- 
orated. 
It has been claimed also that many of the cells concerned in a vivid inflam- 
matory disturbance are produced from intercellular substance whose component 
parts retain a power of conversion into more distinctly cellular elements in the 
presence of certain stimuli. At all events, when new cells appear their nuclei 
are first small and apparently destructive of protoplasm. They are so snugly 
fitted in between the bundles of fibres proper to the part that it would seem 
difficult to account for their presence by mere emigration. They are often seen 
where there is no sign of karyokinesis, which would appear to prove that they 
are of independent origin. 
The peculiar characteristics of the leucocytes have been already 
described at considerable length in the preceding chapter. It must 
suffice, then, here to say that during the inflammatory attack the leu- 
cocytes are increased in number—i. e. there is a temporary leucocyto- 
sis which is the usual accompaniment of suppuration. (According to 
Cabot, this is regularly present in purulent, but not in catarrhal forms 
of appendicitis.) The recognition of this fact may be of great value 
in diagnosis. For instance, leucocytosis is rarely present in tubercular 
disease unless suppuration complicate the case. It is met with in 
suppurative osteomyelitis and in all cases of pocketing of pus. More- 
over, when leucocytosis is present coagulability of the blood is 
increased. Of the various leucocytes, it is the mononuclear and poly- 
nuclear forms which are endowed with the most pronounced activity 
and which play the principal role among the blood-cells or phagocytes. 
That phagocytosis plays a most important part in the inflammatory 
process is a matter to be emphasized in more than one way and more 
than one place. The account of the process already given must suffice 
for descriptive purposes; the importance of the act, however, must 
be made most prominent in considering inflammation and suppuration. 
That the phagocytic properties of these cells are limited will be 
remembered when we recall that in certain instances phagocytes, 
which are incapable of defence as against the mature bacterial organ- 
ism, are yet capable of englobing the spores and preventing their 
development. Nevertheless, the activities of even the most lively 
phagocytes are capable of being influenced and repressed by extremes INF LAMM A TION. 
57 
of heat and cold to which patients may be exposed, either locally or 
generally. 
The Phagocytic Role of Certain Tissue-cells. 
It must be definitely understood that phagocytes are not made up 
of leucocytes alone, but that particular cells belonging to certain tis- 
sues participate in this protective work. Next most important to the 
leucocytes are probably the endothelial cells of the vessels, which, as 
embryology teaches us, have retained some portion of their original 
mobile activity. Endothelial cells are certainly endowed with con- 
tractility, because it is by virtue of this that stomata are left in the 
vessel-wall through which the leucocytes escape. Numerous observers 
have proven that the endothelial cells often become overloaded with 
bacteria, this being perhaps particularly true in the liver. After 
death from malaria the endothelial cells of the liver are found filled 
with the plasmodium. When pigeons die with the septicaemia of 
swine almost all the endothelial cells of the blood-vessels of the body 
may be seen choked with microbes. Inasmuch as these organisms are 
non-mobile, their presence within the endothelial protoplasm can only 
be regarded as due to activity on the part of the tissue-cells. The 
lymphatic endothelial cells also are extremely active, while the ordi- 
nary connective-tissue cells are much less so. So, too, the basophile 
cells or Mastzellen of Ehrlich seem to be active in this direction. 
Chemotaxis. 
Haying considered briefly the cells which take prominent part in 
the inflammatory process, and the escape along with them of the fluid 
portions of the blood, whether these coagulate or not, it is necessary 
before speaking of specific factors to discuss for a moment that which 
induces the above cells to act in this way. That there is a peculiar, 
even a mysterious, attraction which brings specific irritant and phago- 
cyte together has been for some time recognized, but it remained for 
Pfeffer to study it carefully and to give it the name by which it now 
passes—i. e. chemotaxis—while others have widened our knowledge 
of it. 
Chemotaxis is a term implying a peculiar property of attraction 
and repulsion between cells, both animal and vegetable. It mainly per- 
tains to vegetable cells alone, and has been offered as the explanation 
of the sporulation of ferns, for example; but as it interests us most 
in this place, it is manifested between the animal cells of the human 
body and the bacteria, which are vegetable cells. As the result the 
former—i. e. the phagocytes—having power of migration, are drawn 
toward the latter. To be more accurate, this mutual or peculiar 
attraction is known as positive chemotaxis, it being also known that 
exactly the reverse obtains under certain circumstances, and that 
mobile cells will move away as rapidly as possible from certain 
organisms or substances for which they seem to have a repugnance, 
this being known as negative chemotaxis. 
This chemotactic phenomenon is not confined to phagocytic cells alone, but 
is manifested as well among the bacteria and in many other unicellular vege- 58 
SURGICAL PAT1IOLOG Y. 
table and animal organisms. Our best manifestations of it, however, probably 
occur in the poly- and mononuclear leucocytes. Just as mobile bacteria move 
toward nutritive material, so the phagocytes seem ordinarily to move toward 
that which, in the interest of the parent organism, they are to attack and 
destroy. It is chemotaxis apparently which impels phagocytes to take up and 
dispose of certain cells, as during atrophy or during the process of sloughing 
and separation of dead or inert tissue. It is a combination, apparently, of 
chemotaxis and phagocytosis by which the tadpole’s tail is separated when the 
animal becomes the mature frog. It is this combination, in fact, which leads 
the phagocytes to act everywhere as scavengers for our systems and makes them 
our best friends. It is apparently the albuminoid material of bacterial cells 
which exerts a positive chemotaxis and attracts the phagocytes, which are 
brought to the infected area, as it were, by an irresistible magnetism. The 
chemotactic activity of bacteria may be exerted by them either living or dead. 
The explanation of giant cells in tubercle is probably the transformation of 
mononuclear leucocytes which have been drawn toward the bacilli in their r61e 
as phagocytes, and which, having performed their duty or having migrated in 
unnecessary numbers, undergo well-known transformation into the epithelioid 
and giant cells characteristic of the pathological tubercle. One may quote here 
to advantage Metclinikotf’s statement that tubercle is composed of a collection 
of phagocytes, mesodermic in origin, which move toward the spot where the 
bacilli are situated and englobe them. The polynuclear cells which englobe 
the bacilli quickly perish, and then with the microbes which they contain are 
disposed of by the mononuclear phagocytes, which on account of their relative 
size have been classed under the name macrophages. This has to do, however, 
rather with chronic inflammation, miscalled, which will be considered later. 
Specific Irritants. 
These are essentially living organisms, grouped for the most part 
among the bacteria, fungi, and the protozoa, the first named being by 
far the most frequent. Before a lesion can assume the type of inflam- 
mation as here understood some one or more of these organisms must 
have secured an entrance into the tissues, the circumstances determin- 
ing such invasion being considered a little farther on. It is these 
living organisms which, having once invaded the tissues, determine 
that most active congregation and proliferation of certain cells which 
we have just described under the head of Phagocytosis. When once 
the irritants are present, there begins that very active conflict which 
Virchow has so graphically alluded to as the battle of the cells. Now 
the mysterious chemotactic properties of the component substances 
manifest themselves, and now phagocyte is drawn toward bacterium, 
or the reverse, while the tiny war goes on with sometimes varying 
results, it being a question which can prove victor in the conquest. 
This is no fiction of the imagination, but is again a contest which may 
be seen under the microscope in certain of the lower animals, while 
its results may be seen in the examination of pus from any human 
source. In another place I have likened also this conflict to that in 
which certain of the enemy resort to poisoned weapons, because 
modern biological chemistry has now shown very evidently that it is 
a part of the life-history of many of these micro-organisms to produce, 
probably as excretory products, albuminoid or other substanceshaving 
sometimes extremely toxic properties. And so it comes about that in 
many of the surgical infections, while the local destruction is produced 
bv tlie actual death of tissues which have been invaded by micro- 
organisms, the general or systemic symptoms, ordinarily spoken of as 
the toxic symptoms, are literally due to poisons generated in the 59 
INFLAMMA TION. 
infected area, dispersed throughout the system, and often proving 
fatal. 
The local effect of these specific irritants when they are not promptly 
attacked, devoured, and removed by phagocytes is pus, which means 
cellular death, or gangrene, which is death of. masses of cells which 
have not had time to separate from each other. Pus, then, is the 
ordinary consequence of the contest above alluded to, and each pus-cell 
represents the dead body of a phagocyte which has perished in the at- 
tempt to protect the parent organism from harm. That it has died 
valiantly can almost invariably be determined, because within its dead 
body may be seen the body of one or more of the minute invaders 
which it has attacked. This, then, is the light in which inflammation 
and infection should be viewed. 
In other words, we may have escape of fluid portions of the blood, 
which may or may not coagulate ; we may even have some escape of 
corpuscular elements with some activity in the extravascular cells, 
which shall lead to temporary or even permanent enlargement of a 
part; all of which may be provoked by injury or by the presence of 
certain chemical irritants within the blood or tissues; for example, 
alcohol, uric acid, etc. But the factors which provoke the greatest 
activity on the part of intra- and extravascular cells, and which deter- 
mine the richness in albumin of fluid exudates, or their prompt coagu- 
lation so soon as blood-serum has escaped from the vessels, and which 
particularly determine the furious rush of phagocytes and that kind 
of intercellular conflict which leads many of the contestants on both 
sides to death, is produced solely by living organisms introduced from 
without, whose presence at the point of inflammation is abnormal and 
injurious, which are offending substances in every respect, while the 
whole phenomenon of inflammation is an expression of an effort to 
rid the system thereof. Taking this view of the subject, there is a 
most important distinction between hypersemia and its consequences, 
which is absolutely a non-infectious condition, and inflammation and 
its consequences, which is always an infection and is always followed 
by more or less death of cells, the same being often extruded in a 
semifluid mass known as pus. 
Next must be studied the— 
Circumstances which Favor Infection. 
1. The Virulence of the Infecting Organisms and the Amount 
Introduced.—There is the widest difference between various forms 
of micro-organisms in the matter of virulence; and it is true that 
there are very great differences between the same species under dif- 
ferent circumstances, these differences depending on conditions as yet 
absolutely unknown. With certain organisms it is enough to infect 
an animal with one alone in order to bring about a fatal result, this 
meaning that the organism itself is extremely virulent and the animal 
extremely susceptible. 
In a guinea-pig, for instance, a single virulent anthrax bacillus will produce 
death, whereas in a more resistant animal many are required, and in yet others 
there is absolute immunity against the disease. Man is much more susceptible 
to the pyogenic organisms than most of the lower animals, which is one reason 60 
SURGICAL PATHOLOGY. 
why wrong deductions have been drawn from many experiments, and why 
veterinary surgeons, who are so careless of all antiseptic precautions, yet, as a 
rule, have good results in work which, done after the same fashion on the 
human being, would be inevitably fatal. It is one reason also why one may 
draw false inferences from experimental work done, for instance, upon dogs, 
which survive many an operation which can scarcely be successfully repeated 
upon a human being. The influences which affect the vitality and virulence 
of micro-organisms are most numerous and widespread. Temperature, sunlight, 
moisture or dryness, association with other bacteria, source, are but a few of the 
conditions known to be more or less operative. Inoculation of a small number 
of certain bacteria may be harmless: up to a certain number it may produce 
only a local disturbance, like abscess, while a still larger dosage may produce 
fatal results. This is not the case with all, however, but only with some organ- 
isms. Bacteria which have been repeatedly passed through the animal body 
become more virulent than those cultivated for many generations in test-tubes 
in the laboratory. This variable virulence is especially characteristic of the 
colon bacillus, the anthrax bacillus, and the micrococcus of erysipelas. Nor 
does it always follow that the most virulent organism is necessarily cultivated 
from the most toxic or serious manifestation of its activity. 
2. Association.—Bacteria are seldom found in pure cultures 
under natural conditions. By mutual association remarkable changes 
are produced, sometimes in the direction of enhanced virulence, some- 
times in the direction of attenuation of effect. Certain organisms, 
extremely dangerous alone, lose their power when combined with 
others, while still others have their virulence increased to a rapidly 
fatal degree. In fact, these effects are so strange and so contradictory 
that no law governing them has yet been formulated, it being neces- 
sary to establish each case by experimental investigation. The viru- 
lence of the anthrax bacillus under ordinary circumstances is well 
known, as is also that of the streptococcus of erysipelas in man. Yet 
when these two organisms are introduced simultaneously the mixture 
is apparently wellnigh harmless. On the other hand, the simulta- 
neous inoculation of certain other species greatly increases the danger 
from either alone. The diplococcus pneumoniae when combined with 
the anthrax bacillus seems to have a greatly augmented power. 
3. Hereditary Influences.—The fact that immunity against cer- 
tain infections and susceptibility to other conditions are transmitted 
from parent to offspring is one which admits of no dispute. The 
explanation, however, is almost as remote from us to-day as it ever 
was. But the recognition of the fact is of the greatest importance to 
all practising surgeons. That bacteria frequently enter through wounds 
and bruises is self-evident, but we all know that such wounds are more 
likely to suppurate in some than in others, and the causes of infection 
in some are, to a certain extent, connected with hereditary habit of 
tissues. The same causes influence not merely liability to infection, 
but its severity and character. There are undoubtedly also local as 
well as general variations, and it is very certain that among these the 
results of bruising or contusion are by far the most prominent. There 
is also undoubted experimental evidence that under certain circum- 
stances bacteria produce only local lesions, whereas under others they 
produce general and even fatal infection. 
This brings up, in fact, the whole subject of immunity, which 
must be divided into the (a) natural or hereditary, and the (b) acquired. 
Natural immunity is, to some extent, of racial origin. Ordinary TNFLA MM A TION. 
61 
sheep are, for instance, extraordinarily susceptible to anthrax, but the 
Algerian sheep, which differ less from the others than do certain races 
of mankind from each other, are practically immune against anthrax. 
There are the same differences between the common house-rat and the 
white rat. Morphological differences, however, do not explain this, 
for the negro is relatively exempt from yellow fever, and it is said 
that the Japanese do not have scarlatina. Acquired immunity, on the 
other hand, is the result of accidental circumstances. It may be con- 
ferred by one attack of certain diseases, as yellow fever, scarlatina, 
etc. It is, however, less complete and not so permanent as the natural 
form. That acquired immunity may be produced experimentally in 
numerous ways is of very great interest, but is a subject which can 
hardly be discussed here at length. Two facts, however, which we 
have learned experimentally, afford not a little light upon certain 
infections in the human being. One is that extreme fatigue will so re- 
duce natural immunity that infection may occur. This is shown, for 
instance, by making a rat, which is ordinarily immune against 
anthrax, tire itself out by working in a wheel cage, after which it can 
be infected. So, also, certain animals can be infected with disease to 
which ordinarily they are immune after plunging them in a cold bath 
or elevating their temperature considerably above the normal. 
If we are permitted to draw any inferences from such laboratory 
investigations, they shed not a little light upon the favoring influences 
of fatigue and exposure as concerns the human individual. So, 
also, by producing artificial diabetes in animals which are ordinarily 
immune, or by altering their diet, or by injecting certain substances, 
such as phloridzin, curare, and others, their immunity may be re- 
duced or practically abolished; so, also, by starvation, or by removal 
of the spleen, or combining different bacteria as in an artificial mixed 
infection. These facts all have an important bearing on the etiology 
of disease in the human being, because they are all capable of being 
paralleled in our daily experience. 
4. Local predisposition is a factor of almost equal importance. 
Once given a distinct infection, and hypersemia is sometimes a con- 
tributing cause of inflammation. Per contra, anaemia of tissues seems 
to be again a favoring condition. In parts involved in chronic con- 
gestion the blood flows more slowly, while the vessels are dilated and 
apparently susceptibility is increased. Infection here produces a type 
of disease ordinarily spoken of as hypostatic inflammation. General 
anaemia, again, is a predisposing cause, while toxaemias, including 
diabetes, etc., are still more so. The liability of diabetic patients 
to suppurative and even gangrenous infections is proverbial. The 
presence of foreign bodies has much to do also, and, infection once 
having occurred along with its introduction, the presence of a for- 
eign body will nearly always excite suppuration; otherwise, it will 
ordinarily remain inert. The withdrawal of trophic nerve-influences 
also apparently permits infection, as is instanced by the ease with 
which bed-sores form in paralytic patients. Obstruction to the cir- 
culation or to escape of secretions more easily permits infection : for 
example, in the appendix, in the kidney, in the gall-bladder, the sali- 
vary glands, etc. Furthermore, one may formulate a quite comprehen- 62 
SURGICAL PATHOLOGY. 
sive statement and say that all such lesions as solutions of continuity, 
hemorrhages, degenerations, vascular stasis produced by strangula- 
tion, etc., and all perforations, increase more or less the liability to 
infection. 
The ease, for instance, with which the colon bacillus passes through the 
coats of intestine which have been in the slightest degree disturbed or abraded 
is remarkable. It often happens that in the fluid contained within the sac of a 
strangulated hernia these bacilli, and sometimes other organisms, are found in 
great numbers. (In consequence the sac should be carefully disinfected before 
reduction is effected.) Therefore, without the existence of recognizable lesions 
these bacteria sometimes migrate in this way, and thus perhaps enter the cir- 
culation. 
It has been held in time past that the presence of blood within a 
wound was most undesirable, and haemostasis has been a strenuous 
insistence of all recent surgical writers, it being held that blood-clot 
offers a most favorable nidus for the development of bacteria. It has 
been more recently shown that virulent organisms injected into blood- 
clots occasion no suppuration, and our views are of late somewhat 
modified with regard to the danger of retained clot. In fact, it has 
been recently utilized in the healing of a certain class of wounds. 
Retained blood which produces undue tension is a source of danger, 
but that which is unirritating by its presence and uncontaminated by 
bacteria is capable of speedy organization. 
5. Pre-existing- Disease.—Here are reckoned—first, previous and 
long-existent toxaemias—e. g. syphilis, diabetes, scurvy, etc. Other 
conditions, like lithsemia, cholsemia, acetonaemia, and the various con- 
ditions represented by oxaluria or in which acetone, peptone, and ex- 
cess of uric acid are found in the urine, come also under this head. 
One need never be surprised to find suppuration occurring in those 
cases in spite of due observance of all ordinary precautions, since by 
their existence immunity is destroyed and vulnerability increased. 
(Vide also chapter on Auto-infections.) 
Recent toxaemias also have important bearing in this same respect. 
For instance, after typhoid fever and other acute wasting disease, in- 
cluding the exanthemata, surgical operations are sometimes followed 
by failure, and should always be postponed until complete recovery, 
except in cases of emergency. The condition to be hereafter described 
as enterosepsis, and which in time past has been spoken of under many 
different names, as fecal anaemia, stercoraemia, etc., is one which posi- 
tively makes dangerous the performance of all operations, and which 
certainly predisposes to septic disturbances of all kinds. The post- 
puerperal state is also one in which operations are to be avoided if 
possible. 
Certain anatomical changes peculiar to the various ages also belong 
in this category. Old age with its accompanying arterial sclerosis, 
its cardiac debility, and other well-known tissue-alterations, favors 
sluggishness of wound-repair and leads not infrequently to sloughing 
or to bed-sores. Amyloid changes betoken impaired vitality. Chil- 
dren are much more liable to acute osteomyelitis than adults. Nurs- 
ing infants are apparently exempt from many of the infectious 
diseases, but possess relatively small power of vital resistance to 
surgical operations. General anaemia and impaired nutrition of INF LAMM A TION. 
63 
the body predispose to most infections, acute starvation notori- 
ously so. 
6. Personal Habits and Environment.—Diet has much to do 
with tissue-resistance. Rats fed on bread are more susceptible to 
anthrax than those fed on meat. Hunger makes pigeons highly sus- 
ceptible to the same disease, and artificial immunity induced in various 
animals is quickly destroyed by starvation. Prolonged thirst seems 
to have the same result. Prolonged fatigue notoriously reduces im- 
munity, as already mentioned. The various drugs which destroy red 
corpuscles impair immunity, and even by injection of water into the 
circulation the bactericidal power of the blood is reduced. White 
mice fed with phloridzin, which produces artificial diabetes, become 
highly susceptible to glanders, from which they are ordinarily exempt. 
In this connection may also be mentioned the various toxaemias alluded 
to under the previous heading, which may proceed from the intestine, 
from the genito-urinary tract, and probably also from other sources. 
Climate has more or less to do, as also extremes of weather, with 
power to resist infection or to survive serious operations. Dark habi- 
tations, poorly ventilated, constitute surroundings which notoriously 
predispose to infection of all kinds. Rabbits inoculated with tuber- 
culosis and confined within a dark cell, badly ventilated, become rap- 
idly diseased, while others similarly inoculated, but allowed to roam 
at large, present but slight evidences of the affection. Certain occu- 
pations predispose to certain diseases. This is pre-eminently the 
case, for example, with workers in mother-of-pearl, who are exceed- 
ingly liable to a particular form of osteomyelitis; and with those who 
make phosphorus matches, who are prone to suffer from a peculiar 
necrosis of the lower jaw: that prolonged suppuration may produce such 
changes in the blood and tissues that vital processes of repair, cell- 
resistance, and chemotaxis may be so far interfered with as to facili- 
tate subsequent infection, is a matter upon which I have elsewhere in- 
sisted. So, too, with regard to those agents usually considered most 
desirable—i. e. antiseptics—which sometimes set up toxic disturbances 
of minor or serious degree, especially when injudiciously used, by which 
the very effect we desire to gain is negatived or destroyed. It occa- 
sionally happens that in the use of these remedies in too great strength 
chemical reaction between vital fluid and antiseptic leads to decom- 
position of one or both; the latter being decomposed, its previous 
properties are lost, and the exposed tissues unfavorably acted upon. 
Finally, the influence of local injury to tissues, particularly of con- 
tusions which cause tissues to lose their vitality, is strenuously insisted 
upon by all, and is spoken of repeatedly in other places in this 
work. Many tissues will succumb to inoculation after bruising, liga- 
ture en masse, etc. which before such injury are not in the least dis- 
turbed. 
7. Foetal Infection.—It is only in a very limited class of cases 
that infection can be transmitted from mother to foetus, but there are 
instances of this kind in which the surgeon is deeply concerned. As 
Welch has stated, syphilis is the only infection capable of direct 
transmission through the ovum or spermatozoon; but intra-uterine 
infection may occur in many ways, and many diseases may be thus 64 
SURGICAL PATHOLOGY. 
transmitted. The placenta is usually regarded as a perfect filter; 
nevertheless, it is occasionally passable by micro-organisms. These 
may be caused by pre-existing lesions in the placenta or by the viru- 
lence and activity of bacteria. It is known that in animals the bacilli 
of chicken cholera (inoculated into the mammalia), of symptomatic 
anthrax, and the pyogenic cocci frequently traverse this barrier. In 
mankind infection in utero has been observed in small-pox, measles, 
scarlatina, relapsing fever, syphilis, tuberculosis, croupous pneumonia, 
typhoid fever, anthrax, and surgical sepsis. 
Sources of Infection. 
That the effects of bacterial invasion may be anticipated and 
guarded against most effectually it is necessary that the practitioner 
be thoroughly familiar with the sources from which they come, and 
the localities in and about the body which they most commonly inhabit 
or where they are met with in largest numbers. 
Skin and Mucous Membranes.—Of all possible sources of infection, 
the skin itself is probably the most fertile. It is exposed to contam- 
ination by air and by everything which may come in contact with the 
body, and there is perhaps no organism ever met with in disease which 
may not be found upon its surface or within its recesses. In fact, 
these recesses, such as the crevices beneath the nails, the spaces between 
the toes, and the various pockets like the tonsils, the axillae, etc., are 
those most commonly inhabited by micro-organisms. 
Welch has described a special form of staphylococcus, which he calls the 
S. epidermidis albus, which he considers a regular inhabitant of the normal skin, 
just as the colon bacillus is of the intestinal canal. He deems it a variety of 
the S. pyogenes albus, possessed ordinarily, however, of but feeble pyogenic 
power, and frequently present in layers of epidermis lining the hair-shafts—i. e. 
extending deeper into the skin than can any means of cutaneous disinfection. 
While it would be impossible, then, to dislodge these by most careful scrubbing, 
it is quite possible in passing sutures through the skin to carry this organism with 
them ; and this undoubtedly is a common explanation of stitch-hole abscesses 
or much deeper and more serious infections. It is an argument, therefore, in favor 
of passing all sutures through the skin from within outward, which is particu- 
larly true in abdominal work. Like all other organisms, it varies in virulence, 
but this very fact makes the skin one of the greatest sources of danger. 
Bacteria may penetrate the skin by means of three different routes—namely, 
the sweat-glands, the hair-follicles, and the sebaceous glands by means of 
their regular openings. The hairy appendages of the skin are even greater 
sources of danger than the skin itself, since a direct path of infection into the 
depths of the skin is afforded by their follicles. Experimentally it has been 
shown that when bacteria are rubbed into the skin where there are no follicles, 
there is absolute freedom from infection, whereas the reverse is equally true, and 
it is clinically generally recognized that furuncles and carbuncles form almost 
exclusively in those parts provided with hair and sebaceous glands. 
Contamination with the soil is always a source of danger, since ordinary 
black earth especially contains two organisms of ordinarily greatest virulence 
and danger—namely, the bacillus of tetanus and of malignant oedema. Smegma 
also contains saprophytic and sometimes other organisms in great abundance. 
Particularly often it contains bacilli known as the smegma bacilli, which are 
not infrequently mistaken for the tubercle bacillus, having certain properties 
common with it. Cerumen, too, is loaded with bacteria, although it seems to be 
a less prominent source of danger than most of the other secretions. 
The mucous membranes are in constant contact with micro-organisms, and 
furnish conditions in many respects favorable for their rapid development. PLATE III. 
FIG. 2. 
FIG. 1. 
Artificial Dental Caries—in cross section ; tubules 
filled with bacteria. (Miller.) 
Putrid Tooth Pulp. Infection of Dental Tissue. 
(i-iooo.) (Miller.) 
FIG. 3 
FIG. 4. 
Dental Caries ; disappearance of dental tissues as 
result of presence of bacteria. (Miller.) 
Dental Caries; tubules filled with cocci. (Miller.) 
FIG. 5. 
FIG. 6. 
Dental Caries. (1-500.) (Miller.) 
Dental Caries; tubules plugged with cocci. 
(1-500.) (Miller.) INF LAMM A TION. 
65 
Nevertheless, the latter is interfered with, and often inhibited, by certain me- 
chanical and chemical influences which afford us protection. The conjunctiva 
is an extremely exposed membrane, which harbors, however, but a relatively 
small number of bacteria under ordinary circumstances. The tears before 
escaping from the conjunctival sac are sterile, and are probably saline enough 
to act as an antiseptic bath for the cornea. Moreover, by free escape of secre- 
tion through the nasal duct the conjunctival sac is kept constantly irrigated, to 
which is mainly due, in all probability, its ordinary healthy condition, since we 
know how commonly lesions follow obstruction to the lachrymal duct. The hor- 
rible results of Egyptian ophthalmia—i. e. the pyogenic form of conjunctivitis— 
are familiar to all travellers in Egypt. This disturbance has by Howe and 
others been clearly shown to be in the main due to the flies which are attracted 
toward the eyes of the infants, and which are most pronounced carriers of infec- 
tion, while the superstitious notions of the parents restrain these children from 
instinctive protection of the eyes when thus irritated. There is probably no 
greater common carrier of pyogenic infection than the common house-fly, and 
nowhere is this agency more abundantly demonstrated than in the hot climates 
of the Orient. 
Upper Respiratory Tract.—The oral cavity and pharynx are never 
free from bacteria. Miller has studied over one hundred species that 
he lias found under various circumstances in the human mouth. Some 
of these are pathogenic; others are apparently absolutely innocent. 
Many of the forms which grow in saliva will not grow in ordinary 
media. (Vide Plate III., illustrating infection of the teeth.) Miller 
has also shown that all forms of dental caries are but expressions 
of bacterial invasion even of those apparently most solid structures, 
the teeth; and of late we have been taught more fully that such 
invasion may extend far beyond the confines of the teeth alone, and 
may spread to various, even to distant parts, and produce possibly 
fatal mischief. Abscesses in the brain and extensive septic infections 
have been clearly traced to invasion along the line of the dental 
tubules. One of the most virulent of all the common inhabitants of 
the mouth is the pneumococcus of Friinkel, known also as the micro- 
coccus lanceolatus of Sternberg. In virulence it is a most variable 
organism, but it is present in a virulent state in only 12 or 15 per cent, 
of cases of infection due to it. This is the organism which is the 
cause of lobar pneumonia, and frequently of broncho-pneumonia, as 
well as of numerous phlegmons and other inflammations of the throat, 
and which, getting into the general circulation through the tonsils or 
other possible ports of entry about the mouth, causes serious septic 
and inflammatory disturbances in widely distant regions. Aside from 
dental caries, a widely-opened port of entry is often afforded by those 
ulcerations around the margins of the gums which are produced by 
accumulations of tartar. Disease in the antrum of Highmore, for 
instance, and many other local destructions, are frequently caused in 
this way. ( Vide Fig. 12 for example.) 
The next most common port of entry is the tonsil, which contains 
a variety of crypts which are often filled with secretions or retentions 
loaded with bacteria. And one of the most common sources of an 
infection which leads to involvement of the cervical lymph-nodes in 
tubercular disease is an infection springing first from the tonsil or 
the teeth. 
In spite of the fact that myriads of bacteria are swept into the 
nasal cavities with the air we breathe, relatively few are met in the nose. 66 
SURGICAL PATHOLOGY. 
A peculiar capsule bacillus, closely allied to that described by Fried- 
lander, lias been found in a number of cases of ozaena, while the pneu- 
mococcus of Frankel is also often found there, and is known to produce 
abscesses of the brain. One specific organism—namely, that of rhino- 
scleroma—concerns the nose almost 
solely, its first ravages at least 
being met with in this location. 
Immunity from infection in the nose 
is largely produced by the bactericidal 
properties of nasal mucus, which have 
been definitely established. It is cer- 
tain, however, that from the nasopha- 
rynx pathogenic bacteria work their 
way along the Eustachian tube and 
produce serious disturbance in the 
middle ear, from which it may spread 
farther. The question of the permea- 
bility of unbroken mucous surfaces to 
organisms, particularly to tubercle 
bacilli, is one of very great importance. 
There is much reason to hold to the 
possibility of such migration, although 
experimental experience is wanting. 
Clinical evidence, however, is very 
strong. It would appear that tubercle 
bacilli may, and occasionally do, enter 
the lymphatic circulation without causing recognizable lesion at the point of 
entry. Nevertheless, a careful search will often reveal that which a casual 
investigation may not show. 
Fig. 12. 
Invasion of tongue by pneumococci after sub- 
cutaneous infection (Miller). 
Alimentary Canal.—Probably more micro-organisms enter the ali- 
mentary canal than gain access in any other way, these coming both 
from food and drink as well as air. Once within its confines, rela- 
tively very few of them are capable of prolonged existence. Welch 
states that the meconium of new-born infants is sterile, but that within 
twenty-four hours it usually contains abundant bacteria. That bac- 
terial infection through this passage-way is a very fertile source of non- 
surgical lesions is well known. The possibility of surgical infections 
being produced in the same way is both more remote and less demon- 
strable. Naturally, anaerobic organisms find here more favorable 
conditions, and even extremely acid or extremely alkaline conditions 
do not serve to destroy all such life. Pyogenic cocci are often present, 
and are frequently found, in peritoneal exudates. In the intestines of 
herbivorous animals the tetanus bacilli and those of malignant oedema 
are regularly found. The fungus of actinomycosis also easily finds its 
way into the bowel along with ingested food. Under ordinary con- 
ditions the bile in its natural reservoirs is free from bacteria, but the 
colon bacilli and pyogenic cocci often invade these precincts. 
Genito-urinary Tract.—Even the healthy urethra always contains 
bacteria. While these may wander upward to an indefinite extent, 
there is every reason to think that the urine contained within the bladder 
in a condition of perfect health is free from bacteria, and t|iat if such 
gain entrance they do not long remain. The same is true of the female 
bladder and urethra. The vagina contains organisms of many species, 
some of which do not grow on ordinary culture-media, but are to be INFLAMMATION. 
67 
recognized by the microscope. While it is quite generally acknow- 
ledged that the vaginal secretion is, as a rule, possessed of bacteri- 
cidal properties, there is as yet no satisfactory nor comprehensive 
explanation of this fact, its normal acidity not being sufficent in 
this direction. 
The Milk in the Lacteal Ducts.—In a condition of perfect health 
milk secreted from the ideal mammary gland is sterile, but may easily 
become contaminated upon its exit from the nipple. Conversely, 
under many favoring conditions these organisms may travel into the 
lacteal ducts from the skin without, and thus contaminate the milk. 
In all probability, the breast corresponds in behavior to other glands 
whose ducts open upon the surface, and, while such openings invite 
entrance of bacteria, their migrations do not extend far from the sur- 
face unless some of the other conditions already mentioned predispose 
to further infection or extension. 
In summarizing the general topic of possible sources and paths 
of infection we may say that bacteria may enter and exert deleterious 
action— 
A. From within the system ; and 
B. From without. 
A. From within they may get into the tissues either through the 
inspired air, through food and drink—i. e. ingesta—or by means of 
more direct inoculation, as, e. g., by foreign bodies or by venereal con- 
tact. The danger through infection by inspired air is relatively very 
small, and concerns most probably a limited number of organisms, of 
which the tubercle bacillus is the most important. Foul air and air 
which emanates from sewers, cess-pools, etc., while most unpleasant 
to breathe and deleterious in many other ways, does not necessarily 
contain any micro-organisms which can be injurious. This fact, in 
opposition to generally-received notions, is, nevertheless, proven by 
recent investigations. The ingesta furnish the most fertile source of 
contagion from within, but the diseases thereby produced fall for the 
most part into the domain of medicine rather than that of surgery. 
B. Infection from without the body may come by actual contact 
with previous skin or mucous lesions, and particularly from noxious 
insects and certain parasites. Among surgeons the principal sources 
of contact-infection to be enumerated and guarded against are— 
1. Skin and hair; 
2. Instruments; 
3. Sponges or their substitutes ; 
4. Suture materials; 
5. The hands of the surgeon and his assistants; 
6. Drainage materials; 
7. Dressing materials ; and 
8. From miscellaneous sources—e. g. drops of perspiration, unclean 
irrigator nozzle, a contaminated nail-brush, the clothing of the op- 
erator, etc. 
While insisting here upon the recognition of these sources of dan- 
ger, the precautions to be taken against them are to be considered 
under another heading, to which the reader must at present be re- 
ferred. 68 
S URGICA L FA TIIOL OGY. 
Highly virulent pyogenic organisms of various kinds are frequently, if not 
always, present upon the exposed skin-surfaces of the body, where they remain 
inert, but where they are most favorably placed for such deeper implantation as 
may bring about septic disturbances. So, too, the viscera and normal fluids of 
the healthy body are free from bacteria, while, in fact, they seem to be inti- 
mately concerned with the vital processes of digestion, etc. Here, too, disturb- 
ance of normal conditions permits speedy entrance into the circulation with all 
its attendant possibilities for harm. It is probably harder to take the ideal pre- 
cautions when dealing with mucous membranes than in any other part of the 
body. While wounds and deliberate surgical lesions of mucous surfaces or 
deeper parts covered by them, for the most part, heal satisfactorily, we never 
expect such ideal wound-repair as in external wounds which can be closed com- 
pletely by suture. Nevertheless, we have here abundant demonstration that the 
mere presence of bacteria is not necessarily sufficient to interfere with healing. 
One of the greatest sources of possible infection has of late been shown to 
be the presence of flies and other noxious insects, which act as carriers of infec- 
tion. The Egyptian ophthalmia, which ruins the sight of 30 per cent, of the 
inhabitants of Egypt, has been shown by Howe and others to be due to infection 
by this mechanism ; and a very simple bacteriological experiment will suffice 
to show that the foot-tracks of a single fly across a wound furnish abundant 
opportunities for infection with organisms which are presumably virulent. In 
fact, the danger of carriage of infection by this means is greater than from 
almost all other sources, except the use of improper materials during surgical 
operations. 
Infectious micro-organisms, like the non-pathogenic forms, are 
often effectually dealt with after gaining entrance into the body by 
virtue of protective powers possessed by the organism and manifested 
in more than one way. Thus they are removed bv excretion through 
certain emunctories, they are destroyed by certain living cells and 
normal fluids (blood-serum especially), or they die from lack of a 
pabulum upon which they can exist. The pyogenic bacteria are not 
infrequently eliminated through the urine, in which case they may 
cause temporary disturbance within the kidneys, or, if the dosage be 
continuous, the lesion may become not only permanent, but progres- 
sive. Thus, in pneumonia, in typhoid, in erysipelas, and in other acute 
infections these specific organisms are frequently found within the 
urine. Here is also often found the colon bacillus. Tubercle bacilli 
are present in the milk of cows which have extensive tubercular dis- 
ease. Pyogenic cocci may even be excreted through the mammary 
gland after puerperal fever. Pneumococci are found in the milk of 
nursing-women with lobar pneumonia. Anthrax bacilli have been 
found in the sweat from the paw of an infected rat, and pyogenic 
organisms have been detected in the perspiration of patients suffering 
from septicaemia and pyaemia. 
The Elimination and Destruction of Bacteria. 
It is necessary to at least summarize the conditions which, in oppo- 
sition to the many lesions described as favoring infection, serve now 
to produce immunity, or at least to increase vital resistance and de- 
crease vulnerability. A summary of this will not long detain us. 
The ideal condition is that which is summed up in the generally rec- 
ognized expression of “perfect health,” under which condition the 
various secretions and fluids, possessing their normal acidity or alka- 
CONDITIONS WHICH AFFORD PROTECTION OR IMMUNITY. IN FLA MM A TION. 
69 
linity, are sufficient to destroy or render inert harmful organisms 
which enter their precincts; where the skin is cared for by the habits 
of the individual in such a way as to prevent its being overloaded 
with harmful microbes, and where there is such perfect equilibrium of 
ingestion and excretion as to permit no extravascular excitement, no 
congestion, no exudate which may become infected—in other words, 
where the natural functions are performed in an ideal manner. 
Under such conditions almost any accident is survived and repaired 
without perceptible struggle, the tissues and fluids in their healthy 
state being abundantly able to dispose of such bacteria as may acci- 
dentally enter. Under these conditions the traumatic exudate is 
speedily absorbed, the hypersemia of irritation promptly compensated 
for, and here we find those general conditions which surgeons every- 
where rejoice to see, and under which they feel warranted in making 
any necessary interference. These, too, are the conditions where if, 
by accident, infection have positively occurred, as by introduction of a 
foreign body, phagocytosis is so prompt and the lymphatic filtration 
through the lymphatic nodes is so thorough that the worst that may 
happen is local suppuration. This general condition is met with in its 
most complete expressions where no hereditary influences have con- 
spired to dwarf organs or impair their activity ; where no poison, like 
that of syphilis or uric acid or alcohol, interferes with perfect nutrition 
and cell-activity; where exposure has not lowered tissue-vitality; 
where over-exertion and mental worry have not lent their aid in con- 
tributing to impair natural processes. These are the conditions which 
afford protection and under which the surgeon loves to work. 
Classification of Infections. 
We speak of infections in another way as primary, secondary, and 
mixed; and it is necessary, for purposes of accuracy at least, to make 
a reasonably clear distinction between them. By primary infection 
is meant infection with a single form of organism whose effects are 
prompt and speedy. Of this erysipelas or syphilis may serve as a good 
illustration, although in the latter instance the character of the con- 
tagium vivum is not yet definitely known. Most of the acute infec- 
tions, in fact, belong to the primary type. 
Secondary infection means that after certain disturbances due to 
a primary infection—i. e. one of a given type—there occurs at some 
later period and from a distinct source another infection whose results 
maybe more or less disastrous, and cause the case, at least for the time 
being, to assume a different aspect. We may have an illustration of 
this in the case, for example, of primary tuberculosis with distinct 
infection of a number of lymph-nodes, which, acting as filters, have 
caught in their tissue-net a large number of tubercle bacilli that, 
lodging there, have produced the usual well-known results and have 
practically converted the infected nodes into granulomata. In these 
infected masses well-known changes, such as those which follow tuber- 
cular infection—atrophy, caseation, calcification, etc.—may be occur- 
ring, when suddenly there comes infection of a pyogenic type and 
from another source, and suppuration of the granuloma is the result. 70 
SURGICAL PATHOLOGY. 
It is possible even to have a tertiary infection, of which the follow- 
ing may be a hypothetical instance : Primary infection with scarlatina 
or measles, by which vital susceptibility is in some instances notori- 
ously lowered; as the result of this, secondary tubercular infection in 
an individual previously resistant; and, third, a suppurative infection, 
as above described. 
In contradistinction to these distinct events, separated by an ap- 
preciable, sometimes a considerable, length of time, we recognize a 
mixed infection, where two or more organisms are implanted at or 
about the same time. A very common illustration of this is met with 
in most cases of gonorrhcea, in which there is a synchronous attack 
made by the gonococcus, which is a specific micro-organism, accom- 
panied by staphylococci or streptococci, whose effect will complicate the 
case and make it assume a less particulate type of infection. Mixed 
infections may often occur in other ways, as syphilis and chancroid, 
chancroid and gonorrhoea, etc. Most cases of mixed infection belong 
rather to surgery than to general medicine, and constitute an apparent 
violation of the rule to which physicians often point—that two distinct 
infectious diseases are seldom communicated or acquired at the same 
time. Nevertheless, the facts remain as above. 
Bacteria which act as agents in the formation of pus are collec- 
tively known as pyogenic organisms. These are divided into two 
groups: 
A. The Obligate; and 
B. The Facultative. 
Obligate pyogenic organisms are those whose activity is always 
manifested in the direction of pus-formation, which seem to produce 
it if they produce any unpleasant action whatever. On the other 
hand, the facultative organisms are those which are known occasionally 
to be active in this direction, and yet which are not always nor neces- 
sarily so. The members of the group A are fairly well known and 
catalogued, and are not very numerous. On the other hand, there is 
reason to think that many organisms may have the occasional effect 
of producing pus, as it were by accident or at least in a way not abso- 
lutely natural nor peculiar to themselves, but are yet frequently found 
when there is no pus present. A suitable list of the facultative organ- 
isms, therefore, can hardly be made, and will not be here attempted, 
the effort being only to mention the more common organisms which 
play this facultative role. It must be mentioned also that even the 
adjectives “ obligate ” and “ facultative ” are to be accepted with some 
mental reservation, since staphylococci, for instance, may be met with 
even in the absence of pus, although nearly all that we know about 
these organisms implies that pus would be the result of their presence 
if one wait. Furthermore, there are certain other organisms, not, 
strictly speaking, bacteria, which also have the power of producing 
either pus or pyoid material. These will also be mentioned in their 
place. Some of them belong not only to the vegetable, but to the 
animal kingdom. 
Bacteria of Pus-formation, INFLAMMA TION. 
71 
Obligate Pyogenic Organisms.—A. The staphylococcus pyogenes 
aureus, albus, dtreus, etc.—These are minute spheroids, averaging 
eight-tenths of a micron in diameter, occurring usually in groups, 
sometimes showing a diplococcus appearance, found inside and out- 
side the pus-cells, growing at ordinary temperatures on all media with 
and without oxygen, liquefying gelatin, coagulating milk, staining 
readily with all aniline dyes, surviving for a long time in dry pus, 
dying easier in comparatively high temperatures when moist rather 
than dry, of very variable virulence—the most commonly met with of 
all the so-called pus-organisms. 
The S. p. aureus produces pigment as it grows, from which its name is taken. 
So, too, the dtreus; the albus grows without pigment-formation. The staphylo- 
coccus epidermidis albus, more recently discovered, is probably a sub-variety, 
which grows and liquefies gelatin more slowly. Other forms of staphylococci— 
namely, the cereus albus and cereus flavus—have been described, but are seldom 
met with. They are of lesser degree of virulence. 
One of the marked characteristics of the staphylococci as a group is the 
powerful peptonizing action which they exert. Moreover, the chemical prod- 
ucts of their life-changes seem to be more potent both in a local and general 
way, leading to greater destruction of tissue in their immediate vicinity, with 
greater inhibition of the chemotactic powers of the leucocytes; that is, with 
more interference with phagocytosis, by which their progress would be inter- 
fered with. Their presence is often to be recognized by a peculiar odor, as of 
sour paste, which when detected should always lead to a prompt change of 
dressings and disinfection of the wound (by irrigation, spraying with hydrogen 
dioxide, etc.). 
B. Streptococcus pyogenes and Streptococcus erysipelatis.—These two 
organisms do not differ in morphology or characteristics, and, while 
for some time considered as distinct from each other, are now by 
most observers regarded as identical. The streptococci grow in 
chains of variable length, and individual cocci vary in size. They 
Fig. 13. 
Fig. 14. 
Staphylococci in pus; X 1000 (Frankel and 
Pfeiffer). 
Streptococci in pus; X 1000 (Frankel and 
Pfeiffer). 
grow with and without oxygen, in all media, at ordinary temperatures, 
do not liquefy gelatin, stain readily, sometimes but not invariably 
coagulate milk, and vary very much in longevity. They differ extra- 
ordinarily in virulence as obtained from different sources. 72 
SURGICAL PATHOLOG Y. 
There are many streptococci not included under the above head which are 
indistinguishable morphologically and in other respects, and yet which are in 
a measure or entirely free from all pathogenic activity in man. A careful bio- 
logical study reveals remarkable and unexplainable transformation in effect as 
between the different members of this species, a part of which may be referable 
to conditions pertaining to the organism infected, but part of which appar- 
ently pertains to the bacteria themselves. It is held by some that scarlatina is 
an invasion by certain organisms of this class; this, however, is not yet defi- 
nitely established. When found in the stools of children with summer diar- 
rhoeas they are regarded as indicating actual ulceration of the intestinal mucosa. 
In contradistinction to the staphylococci, the streptococci manifest 
a strong predilection for lymph-vessels and lymph-spaces, along which 
they extend themselves with great rapidity. They have much less 
peptonizing power than the staphylococci (except in the absence of 
oxygen); hence streptococcus infection assumes usually the type of 
widespread infiltration rather than of circumscribed and distinct 
oedema. One sees remarkable in- 
stances of this in cases of phleg- 
monous erysipelas. It is suggested 
also that the peculiar manner of 
growth of the streptococci, in long 
chains which may coil up and en- 
tangle blood-corpuscles, has much 
to do with the formation of fat- 
emboli and with general pyaemic 
disturbances. 
Both these bacterial forms have the 
power of producing lactic fermentation 
in milk; and it is quite sure that lactic- 
acid formation sometimes takes place 
along with suppuration in the human 
tissues, causing acidity of discharge, 
sour odor, and watery pus. It would 
appear also that these two pyogenic 
forms have less power of ptomaine or 
toxine formation than many others, and, 
consequently, that the pyrexia attend- 
ing suppuration or purulent infiltration is not always to be ascribed to this 
cause alone, for fever may in some measure be due to tissue-metabolism attend- 
ing their growth, the metabolic products being pyretic. This is in a measure 
substantiated by the fever attending trichinosis, where the question of ptomaine- 
poisoning has not yet been raised. 
C. Micrococcus lanceolatus, known also as the diplococcus pneu- 
monitis or the pneumococcus of Frankel and Weichselbaum, and as 
the micrococcus of sputum septiccemia of Pasteur and of Sternberg. 
This is a capsulated, lance-shaped coccus, occurring usually in pairs, 
sometimes in chains ; it grows at ordinary body-temperature, does not 
liquefy gelatin, loses virulence and dies quickly in cultures, but may 
long survive in dried sputum or blood. In virulence and other prop- 
erties it is extremely variable. It is of interest to surgeons because 
it causes many localized inflammations and is a frequent factor in 
causing septicaemia; it is very often present in the mouths of healthy 
individuals. It may produce all the various forms of exudates as the 
result of congestion set up by its presence. It may produce otitis 
media, meningitis, osteomyelitis, and serious suppurative disturbance 
Fig. 15. 
Staphylococcus infiltration of perirenal tissue, 
from a case of pyaemia; X 1000 (Frankel and 
Pfeiffer). INFLAMMA TION. 
73 
in the periosteum, the salivary glands, the thyroid, the kidney, the 
endocardium, etc. 
D. The micrococcus tetragonus grows in groups of four, enclosed 
in gelatinous capsules, at ordinary room-temperature, with or without 
oxygen ; is ordinarily pathogenic for the smaller animals, and is found 
frequently in tubercular cavities in the lungs, less often, in connection 
with other cocci, in abscesses about the jaws and neck, into which it 
Fig. 16. 
Fig. 17. 
Diplococci pneumoniae (microe. lanceolati) in 
pus from peritoneal cavity; X 1000 (Friinkel 
and Pfeiffer). 
Micrococcus tetragonus in splenic pulp; 
X 1000 (Frankei and Pfeiffer). 
seems to have gained entrance through the mouth. Suppurations pro- 
duced by these organisms alone are prolonged, mild in character, not 
painful, but accompanied by much brawny induration of tissues. 
E. The micrococcus gonorrhoeas or gonococcus is found constantly in 
the pus of true gonorrhoea, in many cases the pus being a pure culture 
of this organism. These cocci are always met with in pairs (biscuit- 
shaped), while their inclusion within the leucocytes or their attachment 
in or to epithelial cells is characteristic. 
Unlike all other pyogenic cocci, these do not stain by Gram’s method, being 
decolorized by iodine, by which fact they may be distinguished. They are cul- 
tivated with difficulty, and are known rather by their clinical effects than by 
their laboratory characteristics ; are a strict human parasite, other animals, so 
far as known, being practically immune. The gonococcus may also produce 
abscesses, and may be carried to distant parts of the body, where its effects are 
most commonly noted as pyartlirosis, although endocarditis, pericarditis, pleu- 
risy, etc. are known to be due to it, and fatal pyaemia has been produced in con- 
sequence. In some way, not always clear, it is probably the explanation of the 
post-gonorrhoeal arthritis so often wrongly spoken of as gonorrhoeal rheumatism. 
F. The Bacillus coli communis or Colon bacillus.—This is an ordi- 
nary inhabitant of the intestinal canal; varies extremely in virulence 
and somewhat in morphological appearances ; coagulates milk ; is often 
associated with other organisms; migrates easily both along the ali- 
mentary canal and from it into the surrounding tissues or channels. 
It is a frequent disturbing element in the production of kidney and 
hepatic disease, as also in the production of appendicitis and perito- 74 
SURGICAL PATHOLOGY. 
nitis. Ordinarily its pyogenic properties are not virulent; occasion- 
ally, however, it becomes extremely virulent. 
The colon bacillus is found at points widely separated from its natural home, 
and has been known, for instance, to produce abscess in the brain. The pus due 
to the presence of these organisms, either in pure culture or mixed, is usually 
characterized by an offensive fecal odor, which led to the attempt to separate 
the bacillus fcetidus as a distinct form. 
The bacillus pyogenes fcetidus and the bacillus lactis aerogenes, as well as certain 
other forms occasionally met with in connection with disease, are now regarded 
as identical with the colon bacillus. 
G. The bacillus pyocyaneus, a widely-distributed organism, often 
met with in the skin and outside of the body; a motile, liquefying 
bacillus, growing at ordinary temperatures, seldom met with alone, 
but occasionally producing pus without association with other organ- 
isms ; it stains the discharges and dressings a characteristic bluish- 
green and imparts sometimes an offensive odor. 
Suppuration caused by this bacillus is usually prolonged, but characterized 
by little constitutional disturbance. Is often found in enteric discharges. When, 
as it may, it produces general infection, it may cause hemorrhagic or gangren- 
ous enteritis. The bacillus pyocyaneus is an organism quite tenacious of life, 
and one which it is sometimes difficult to completely get rid of. I have known 
patients to follow, one after another, in the same bed or the same corner of a 
room, in each of whose cases blue pus was a marked feature. It seemed very 
much as if infection hung around this particular locality, and as if the organ- 
isms were not disposed of by the ordinary process of disinfection. 
Among other organisms which have been more or less identified 
with the obligate pyogenic bacteria, and yet which have scarcely found 
a prominent enough place to deserve more than mere mention here, 
are the staphylococcus salivarius pyogenes, the micrococcus salivarius 
septicus, the micrococcus gingivae pyogenes, which have been found in 
saliva in the human mouth; the streptococcus septicus liquefaciens, 
found in the same cavity; and the streptococcus coryzce contagiosce 
equorum, met with in that disease in the horse known as strangles, 
where it is found in the pus. 
Facultative Pyogenic Organisms—i. e. those which have the 
power of provoking suppuration, but which have other and more dis- 
tinct pathogenic activities as well. 
A. Bacillus typhi abdominalis.—This is found in many pus-foci, developing 
during or after typhoid fever. It is occasionally met with alone, though most 
of these abscesses are really mixed infections. It is most commonly met with 
in the bone or beneath the periosteum. Such abscesses are frequently met with 
in the ribs, and may not be noticed until months after the convalescence from 
the fever. The pus contained within them is not always typical in appearance, 
but may be unduly thin or unduly thick. 
B. Bacillus proteus — Under this name are included three distinct forms 
which were originally described by Hauser as distinct species, but which are 
now regarded as pleomorphic forms of the same organism. It is a motile bacil- 
lus, met with in decomposing animal and vegetable material, and occasionally 
found in the alimentary canal. It has been found to produce pus, especially in 
the peritoneal cavity and about the appendix. It may even cause general infec- 
tion and peritonitis. 
C. Bacillus diphtheria.—A non-motile bacillus, varying considerably in size 
and shape, changing the reaction in sweet bouillon from acid to alkaline; pro- 
duces a most dangerous infective inflammation of exposed surfaces, with tena- 
cious exudate amounting to a distinct membrane. As a part of its life-history 
it also produces a powerful toxalbumen, which is one of the most profound cell- INF LAMM A TION. 
75 
poisons known, the disintegration of the cell-constituents due to its action being 
rapid and pronounced. This will account for the sudden heart-failures which 
are so often reported in connection with the disease. The distinctive mem- 
branes maybe produced on any abraded surface in any part of the body. Diph- 
theria of wounds is much more common on the European continent than at 
home. It is connected always with at least superficial necrosis, and sometimes 
with very extensive gangrene, even of the so-called hospital type. Most of the 
abscesses met with in diphtheritic cases are instances of mixed infection, 
although it is said that occasionally the pus may be almost a pure culture of the 
diphtheria bacilli. All the symptoms and disturbances of diphtheria can be 
produced by the toxalbumen except the membranes, which apparently require 
the presence of the bacilli to provoke the coagulation. 
D. Bacillus tetani.—More will be said about this organism when consider- 
ing Tetanus, and to that subject the reader is referred. The tetanus bacillus is 
occasionally found in pus which comes from the area through which the orig- 
inal infection was produced. But these bacilli do not travel to any distance in 
the human body, and are practically never found away from the area primarily 
involved. Under most of these circumstances the pus is the product of a mixed 
infection. 
E. Bacillus cedematis maligni.—This, too, will be more fully considered 
under a different heading. (See Malignant (Edema.) It is a long, anaerobic 
bacillus, widely distributed in the soil and the faeces of animals. There is rea- 
son to think that this, like the tetanus bacillus, may occasionally lead to forma- 
tion of pus. 
F. Bacillus tuberculosis.—This organism likewise will receive fuller descrip- 
tion in an ensuing chapter. (See Tuberculosis.) The pus of old cold abscesses, 
in which the more obligate pyogenic organisms have long since died out, usually 
still contains this organism in mildly virulent form. On the other hand, fresh 
suppurations occurring in connection with tubercular disease are mixed infec- 
tions. There is reason to hold, however, that this organism is capable of pro- 
ducing pus even when none of these are present. For example, in that form of 
acute miliary tuberculosis which is occasionally met with as bone-abscess it may 
be found, for whose origin we naturally look to this organism. 
G. Bacillus anthracis. (See Anthrax.)—This is one of the most malignant 
and resistant organisms known, being in the highest degree poisonous for the 
smaller animals, man being less susceptible. One of its characteristic lesions in 
the human body is a form of pustule commonly known as malignant pustule, the 
pus in which is usually a pure culture of this organism. 
H. Bacillus mallei.—This is the organism which produces glanders in the 
lower animals and in man. That form 
of the disease which is commonly known 
as farcy, in which the infected nodules 
rapidly break down, is most likely to 
contain pus which shall be more or less 
g pure culture of this organism. 
I. Bacillus leprce.—This is the micro- 
organism which produces leprosy and 
which closely resembles the tubercle 
bacillus. It is constantly and exclu- 
sively present in the lesions in leprosy, 
which are often of the suppurative type, 
the bacilli being enclosed within pus- 
cells, as well as found in the fluid sur- 
rounding them. Although suppuration 
in these cases may be in a large measure 
due to secondary infection, it is positive 
that the leprous bacilli deserve to be 
grouped in this place. 
J. The bacillus pneumoniae of Fried- 
lander was at one time regarded as the 
cause of croupous pneumonia, which is 
now known to be due to the micro- 
coccus lanceolatus. The Friedlander bacillus, however, is capable of pro- 
ducing broncho-pneumonia, and is occasionally met with in empyema, suppu- 
Fig. 18. 76 
SURGICAL PATHOLOGY. 
rative meningitis, and inflammations about the naso-pharyngeal cavity, of which 
it is known to be an occasional inhabitant. 
K. The bacillus of influenza, perhaps the smallest bacterium yet described, 
has been found in the purulent discharges from patients suffering from grippe. 
While the etiological relations of this bacillus to the surgical sequelae of grippe 
(quite numerous, by the way) are not yet finally established, the organism is, 
nevertheless, of interest and importance to the surgeon. 
L. The Bacillus of Rhinoscleroma.—A distinctive organism has been described 
for this disease and given this name. It has such wide morphological differ- 
ences, however, that it is possible that it is only the bacillus of Friedliinder 
above mentioned. At all events, an organism of this general character is con- 
stantly found in the thickened tissues from the nose in this disease. ( Vide Fig. 20.) 
Fig. 19. 
Fig. 20. 
Rhinoscleroma: infiltration of tissues about the 
nose (case reported by Dr. Wende, Buffalo). 
Bacilli of rhinoscleroma; X 1000 (Frankel and 
Pfeiffer). 
M. Bacillus septiccemice hcemorrhagicce.—This is known also as the bacillus of 
chicken cholera, of rabbit septicaemia, of swine-plague, and of deer-plague. It 
is probably also the same as the bacillus described by Davaine in 1872. It is 
found in the blood and oedematous fluids of affected animals, produces indol 
when grown in peptone solution, and retains vitality for a long time when not 
dried. Its most characteristic pathogenic activities are to cause swelling of the 
spleen and lymph-nodes, ecchymoses in mucous membranes, acute oedema at the 
point of inoculation, hemorrhages and degenerations in muscles, and pus in cer- 
tain animals. 
N. The Bacillus of Bubonic Plague.—This was recently discovered by Kita- 
sato, and, in view of the recent ravages of the disease in the Orient, has as- 
sumed considerable importance. It grows upon most media, and is found in the 
blood, in the buboes, and in all the internal organs of patients suffering from 
this disease. The smaller animals are susceptible upon inoculation. Animals 
fed with inoculated foods die also, showing the possibility of infection through 
the intestine. When exposed to direct sunlight for a few hours the bacillus 
dies. The general expressions of the disease are those of hemorrhagic septicaemia 
and its consequences. 
O. The Bacillus of Rauschbrand.—This is seldom, if ever, seen in this country. 
It is known in England as “ the black-leg” or “ quarter-evil.” It is an anaerobic 
organism, frequently met witli in cattle, which causes a peculiar emphysema of 
subcutaneous tissue, which spreads more deeply, and is followed by a copious 
exudate of dark serum with gas-formation. The smaller animals are not ordi- 
narily inoculable; but, if to the culture-material used be added 20 per cent, of 
lactic acid, their insusceptibility is overcome and they succumb quickly to the 
disease. So also, as in the case of the tetanus bacillus, by addition of the bacil- 
lus prodigiosus or of proteus vulgaris the disease may be induced in otherwise 
insusceptible animals. INFLAMMA TION. 
77 
Besides the micro-organisms everywhere grouped as bacteria, there are other 
minute organisms which have also the power of engendering pus. One of these 
is the ray-fungus, known as the actinomycis, which causes the disease known as 
lumpy jaw or actinomycosis. Suppuration is always a concomitant of the ad- 
vanced lesions of this disease, and, while it may be in many instances a mixed 
infection, it is not necessarily so. Moreover, the pus produced under these cir- 
cumstances contains minute calcareous particles which are pathognomonic, and 
by which a diagnosis can sometimes be made off-hand. 
Besides these fungi, others, belonging rather to the class of vegetable moulds, 
which are yet pathogenic for human beings, may be occasionally met with under 
these circumstances—for example, the fungus of Madura-foot, the leptothrix, and 
other moulds from the mouth, while the different varieties of aspergillus may be 
found in pus about the ear, or even in that from the brain. 
Fungi. 
Protozoa. 
The protozoa also have the power occasionally of producing, if not absolute 
ideal pus, something so strongly resembling it that we may include them among 
the facultative pyogenic organisms. The best known of these protozoa are the 
amoebae which are so often met with in the intestinal canal in certain countries, 
and which are occasionally met with in the United States, especially as the 
exciting causes of a peculiar type of dysentery often accompanied by abscess of 
the liver. In these abscesses the amoebae are usually found, and no .other organ- 
isms. Another group of the protozoa, known to biologists as the coccidia, are 
also capable of causing pus-formation, more particularly in some of the lower 
animals. Numerous other parasites, belonging higher in the animal kingdom, 
are undoubted exciters of pus-formation, though it is not necessary to lengthen 
the list beyond those already mentioned. 
Clinical Characteristics of Pus from Different Agencies. 
Staphylococcus.—Dirty white, moderately thick, with sour-paste 
odor. 
Streptococcus.—Thin, white, often with shreds of tissue. 
Colon Bacillus.—Thick, brownish, with fetid odor, or thin, dirty 
white, with thicker masses. 
Micrococcus Lanceolatus.—Thin, watery, greenish, often copious. 
Bacillus Pyocyaneus.—Distinctly green or blue in tint. 
Bacillus Tuberculosis.—Thick, curdy, white paste, or thin, green- 
ish, with small cheesy lumps or even with bone-spiculse. 
Actinomycis.—Thick, brownish white, with small firm nodules of 
yellow color. 
Amoeba Coli.—Thick brownish-red. 
Bacterial Determination as an Indication in Treatment. 
There ie a practical side of great importance pertaining to the 
recognition of the nature of the infectious organism in many cases of 
suppuration and abscess. For instance, pus which is Sue to strepto- 
coccus invasion indicates a collection which should be freely evacu- 
ated and carefully drained. This is also true in essential respects of 
staphylococcus pus, particularly that due to the S. aureus. Putrid 
pus from any source calls for disinfection and free drainage, the 
former preferably perhaps by hydrogen dioxide. Pus which is due 
to the colon bacillus is not often extremely virulent, which accounts 
for so many cases of appendicitis recovering with or without opera- 
tion. A collection of this pus calls for little more than mere drain- 78 
SURGICAL PATIJOLOGY. 
age and opportunity for escape. Pus from a recognizable tubercular 
source may still contain living tubercle bacilli. This means either 
that the cavity whence it came should be completely destroyed and 
eradicated, or else that the margins of the incision or opening through 
which it has escaped should be so cauterized that infection of a fresh 
surface is impossible. The same is true of abscesses due to glanders 
bacilli and to certain cases of suppurating bubo following chancroid, 
where the whole course of events shows the virulent character of the 
organisms at fault. 
Suppuration. 
Although it may be possible to produce in certain laboratory ex- 
periments metamorphosed material which very closely simulates pus, 
or, in fact, by injection of chemical irritants, to sometimes quite faith- 
fully imitate the suppurative processes, nevertheless, the student 
must be promptly brought face to face with the statement, to which 
for surgical purposes there is no practical exception, that suppura- 
tion—i. e. formation of pus—is due to the presence in the tissues 
of the specific irritants already catalogued and described, and of 
the peculiar peptonizing or other biochemical changes which bacteria 
exert upon living animal cells. Coagulation-necrosis is the term 
applied to the characteristic changes occurring in the tissue-cells 
when thus attacked, which may be summarized as a fading away of 
cell-outlines, diminution in reaction to reagents, and a sort of merg- 
ing together of cells and intercellular substance. Coagulation- 
necrosis is not the sole result of bacterial activity, but may be brought 
about from other causes. Nevertheless, pyogenic bacteria do not 
exert their deleterious action upon the tissues without bringing about 
changes included under this term. In an area thus infected, as 
already described, leucocytes—i. e. phagocytes—are present in largely 
increased numbers for purposes already distinctly described. As we 
get nearer to the centre of activity phagocytes are more numerous 
than are cells, and intercellular barriers completely break down. 
Where bacteria are found in greatest numbers, there also occurs the 
greatest phagocytic activity, and there too will be found the charac- 
teristic evidence of suppuration—i. e. pus. As already indicated, the 
polynuclear leucocytes are most active of all in the process of defence. 
Where coagulation-necrosis is most marked there has been the 
greatest activity of conflict 'with the greatest death of cells. Around 
these areas bacteria and cells are found in indiscriminate arrange- 
ment. Tissue-vitality is impaired by intoxication of the cells by the 
excretory products of the bacteria—i. c. the so-called ptomaines, 
toxines, etc.—and their power of resistance is thus weakened. From 
the mechanical results of pressure tension around the centre of 
activity is increased; by which tension vitality is still more impaired 
and more rapid tissue-death occurs. Thus there occurs migration or 
burrowing of pus; or, to put it more clearly, the tissues break down 
in front of the advancing destruction, and always in the direction of 
least resistance. This is known as the pointing of pus, and this it is 
which brings it many times to the surface, and often in other and 
less desirable directions. PLATE IV. 
Abscess in Kidney of Rabbit after Intravenous Injection into an Ear-vein of Culture of Pyogenic Cocci. 
Dense mass of cocci surrounded by area of coagulation necrosis due to their toxic activity. 
Outside this a zone of phagocytes INF LAMM A TION. 
79 
Abscess. 
An abscess is a circumscribed collection of pus. The term is 
used in contradistinction to purulent infiltration, in which the collec- 
tion is by no means circumscribed, but is exceedingly diffuse and 
extends itself in various directions, the amount at any particular 
spot being almost inappreciable. Purulent infiltration is commonly 
regarded as much the more serious of the two conditions, since it is 
much harder for pus to safely escape under these circumstances than 
when it can all be evacuated through a single opening. The term 
phlegmon is one which is now generally used, both at home and 
abroad, to indicate a suppurative process usually of the general cha- 
racter of purulent infiltration rather than of abrupt abscess, but some- 
what generally employed to cover both conditions. The adjective 
phlegmonous is coupled with the name of any of the other surgical 
infectious diseases to indicate that it is complicated by suppuration— 
e. g. phlegmonous erysipelas. Pus is a product of bacterial activity 
which is usually formed rapidly rather than slowly, and abscess- 
formation or phlegmonous activity of any kind is ordinarily a matter 
of but a few days. 
In connection with this I would like to summarize the story of 
inflammation and suppuration, to paraphrase Sutton, and read it 
zoologically, as though it were the story of a battle. The leucocytes 
(phagocytes) are the defending army, the vessels its lines of communi- 
cation, the leucocytes being, in effect, the standing army maintained 
by every composite organism. When this body is invaded by bacteria 
or other irritants, information of the invasion is telegraphed by means 
of the vasomotor nerves, and leucocytes are pushed to the front, rein- 
forcements being rapidly furnished, so that the standing army of 
white corpuscles may be increased to thirty or forty times the normal 
standard. In this conflict cells die, and often are eaten by their 
companions. Frequently the slaughter is so great that the tissues 
become burdened by the dead bodies of the soldiers in the form of 
pus, the activity of the cells being proven by the fact that their proto- 
plasm often contains bacilli in various stages of destruction. These 
dead cells, like the corpses of soldiers who fall in battle, later become 
hurtful to the organism which, during their lives, it was their duty to 
protect, for they are fertile sources of septicaemia and pyaemia. This 
illustration may seem a little romantic, but is warranted by the facts. 
. Around the margin of the site of an acute abscess is formed a 
barrier, by condensation and cell-infiltration of the surrounding tissues. 
This is not a distinct wall nor membrane, yet, nevertheless, serves as a 
sanitary cordon to confine the mimic conflict within reasonable bounds. 
This is the zone of real inflammation; within it there are tissue- 
destruction and coagulation-necrosis. (Vide Plate IV.) By virtue 
of the peptonizing power of the pyogenic organisms the parts involved 
in this necrosis gradually liquefy, the intercellular substance dissolv- 
ing first. It is this which in the main forms the fluid portion of the 
pus. Various tissues show widely differing resistance to this soften- 
ing process. In true glands the interlobular septa seem to break 
down first, and in this way suppuration extends around the acini or 80 
SURGICAL PATHOLOGY. 
gland-lobules, and thus pus may contain masses of easily recognizable 
size. These masses are ordinarily known as sloughs. 
It is by virtue of the so-called lymphoid cells, which are those 
principally involved in producing the barrier or boundary of the acute 
abscess as above described, that granulation-tissue is formed, which 
promptly takes up the effort of repair so soon as pus is evacuated. 
This boundary has no sharp limit, but shades off* into healthy sur- 
rounding tissues. 
Under the term “abscess” is ordinarily meant that which is more minutely 
described as acute abscess. Under certain circumstances, especially where they 
are produced by the facultative pyogenic organisms rather than the obligate, 
abscesses form much more slowly, and may be spoken of as subacute. These are 
terms used in contradistinction to the so-called cold abscess, which, although clin- 
ically bearing a certain resemblance to the acute, is in almost every pathological 
respect widely different from it. Cold abscesses will be considered at length 
under the head of Tuberculosis. It is possible to have an acute pyogenic infec- 
tion of a cold abscess ; in such case we have acute manifestations. Gravitation- 
abscesses are those where pus forming in one part tends to migrate, usually in the 
direction in which gravity would take it, extending into portions deeper or lower 
down. Perhaps the best illustration of this is the pointing of a psoas abscess 
below Poupart’s ligament. Metastatic abscesses are those which are formed as 
the result of embolic processes, each one being in miniature a repetition of a 
lesion which has already occurred at some other part of the body. The under- 
lying fact concerning metastatic abscesses is that the primary process has 
occurred in some other portion of the body, whence it has been distributed 
as above. These will be more fully considered in the chapter dealing with 
Pyaemia. 
The characteristic product of all acute suppurative lesions is pus. 
This is an opaque fluid of creamy consistence and whitish or grayish 
appearance, varying somewhat in density, met with in amounts from 
a minute drop to collections of half a gallon or even more. Under 
ordinary circumstances it is odorless, and its reaction, either acid or 
alkaline, very faint. It is, like the blood, composed of a fluid and a 
solid portion. The solid portion consists of so-called pus-corpuscles 
and other debris of tissue, which will vary with the site of the disease 
and the parts involved. The source of the pus-corpuscles has already 
been cited at length, and the statement already several times made 
that they are in effect the bodies of phagocytes which have perished 
in the biochemical fight for existence of the parent organism. In 
them may frequently—almost always, in fact—be seen cocci or bacilli, 
which are also found in large quantities in the surrounding fluid. It is 
characteristic of certain micro-organisms to sustain peculiar relations to 
the pus-cells, which will be considered more at length in their appropri- 
ate place. Aside from these, there will be granular debris, the result of 
breaking-down leucocytes and other normal cells. When treated with 
acetic acid and various staining reagents, the pus-corpuscles are found 
to be multi nucleated, which is a sign rather of degeneration than of 
proper cell-activity. Under the microscope, with fresh pus from an 
acute abscess, certain pus-cells will be seen to show amoeboid move- 
ments. The characteristic pus-corpuscle is in reality an original poly- 
nuclear leucocyte. 
Pus should be ordinarily without odor, but under certain circumstances it 
possesses an odor which will vary in character according to the source of the pus 
or the nature of its principal bacterial excitant. Pus from the upper end of the INF LAMM A TION. 
81 
alimentary canal frequently has the sour smell so characteristic of gastric con- 
tents ; that from the neighborhood of the lower end, the characteristic fetid odor 
which is for the most part due to the action of the colon bacillus. Inasmuch as 
this colon bacillus is found in widely distant parts of the body, it may also give 
unpleasant odor to pus even from a brain-abscess. When the pus has become 
contaminated by any reason with the ordinary saprophytic organisms, it may 
smell like any other decomposing material. The older writers used to speak of 
this as ichorous pus, while sanious pus was supposed to be that more or less mixed 
with blood, undergoing ammoniacal decomposition or else strongly acid. Pus 
sometimes has a well-marked blue or bluish-green tint. This is due to the pres- 
ence of the bacillus pyocyaneus, already described. An orange tint is sometimes 
given by the presence of liEematoidin crystals, due to the original hemorrhagic 
character of the infected exudate. The former appearance indicates usually a 
discouragingly slow course to the suppurative lesion, while the latter has been 
regarded by some as affording an unfavorable prognosis. Distinctly red pus, 
whose tint is due to the presence of a bacillus giving bright-red cultures on 
blood-serum, has been noted in other instances. This can readily be distin- 
guished from blood, because upon dressings it does not change color. 
Surgeons of ordinary experience are accustomed to allow a certain 
rather indefinite length of time between the first sign of impending 
suppuration and the formation of pus, in those parts of the body where 
the course of events can be reasonably well distinguished. This is 
measured ordinarily by an interval of from sixty to one hundred 
hours. Under certain circumstances, however, suppuration takes 
place with almost fulminating rapidity, and this is particularly true 
in appendicitis, meningitis, and in the disease known as malignant 
oedema. Extensive coagulation-necrosis occurs very early, and the 
patient may even die before pus has time to form. 
Pus may form quite superficially, when we speak of it as a sub- 
cutaneous suppuration, in which case there is a minimum of pain, 
because tension is not great and because the distance to the surface is 
short. Collections which form beneath the fasciae, especially the deeper 
fasciae of the limbs and trunk, give rise to much more extensive dis- 
turbance, both locally and generally, and frequently do not point for 
many days, or, instead of pointing, burrow deeply and find their out- 
let at some undesirable point. These are known as subfascial collec- 
tions. Subperiosteal abscesses give rise to still more pain, because of 
the unyielding character of their limiting structures, and the symp- 
toms caused by them are often very acute and very distressing. 
An illustration of the pain and disaster which may follow deep suppuration 
may also be seen in the ordinary panaritium or bone-felon, where the path of 
infection is from without, but the destructive lesion is confined within absolutely 
unyielding tissues, at least at first. Along certain tissues infection spreads with 
amazing rapidity. This is particularly true of the delicate areolar tissue met 
with between tendons and tendon-sheaths, and the infectious process may follow 
this tissue wherever it shall lead, even along complex courses. 
The question is often raised, Can pus be resorbed f There is no 
question but what under many circumstances small amounts of pus 
are disposed of by phagocytic activity, and the disappearance of puru- 
lent infiltration under the influence of favoring remedies, or even 
when left alone, is not infrequently noted. True pus-resorption is 
entirely a question of phagocytic possibilities, and can only occur in 
very limited degree as a result upon which it is not safe to count, and 
which is capable of encouragement only up to a certain point. 
One inevitable law seems to govern collections of pus, and that is, 82 
SURGICAL PATHOLOGY. 
that when they advance or migrate in any direction it is always in that 
of least resistance. This causes it to take peculiar and sometimes dis- 
astrous courses, but it is a law which is virtually never violated. It 
leads, for instance, to the bursting of abscesses into the brain, into the 
pleural cavity, into the peritoneal cavity, the bowel, and elsewhere ; it 
leads to a condition where pus may travel slowly along a path even a 
foot or more in length, rather than come directly to the surface, a dis- 
tance of perhaps an inch, and affords one of the best reasons for early 
operative interference in order that the disastrous effects of burrowing 
may be obviated. When the collection of pus is limited to a drop or 
a fraction thereof, the little abscess is usually spoken of as a furuncle, 
especially when in the skin. The average “ boil ” of the layman is a 
subcutaneous or subfascial abscess near the surface. When the infil- 
tration is pronounced, and when there has been more or less extensive 
destruction of tissue, with perhaps formation of numerous outlets for 
the desired escape of pus and detritus, we have what is known as a 
carbuncle; all of which will be of treated in Chapter XXVIII. In 
certain peculiar conditions small superficial furuncles or boils form, 
sometimes in great numbers and almost synchronously, or, as it 
were, in crops. This condition is spoken of as general furunculosis. 
Signs and Symptoms of Abscesses.—The appearances by which 
the presence of pus may be suspected or detected are those of conges- 
tion and hypersemia, more or less abruptly circumscribed and markedly 
accentuated. Along with these there is more or less oedema or oedem- 
atous infiltration of the skin and overlying tissue, which permits of 
that peculiar appearance known as “ pitting on pressure.” Often, too, 
there is a distinctly oedematous swelling of the parts, especially around 
the margin, with brawny infiltration of the centre of the infected area. 
Xumerous vesicles occasionally are noted upon the skin, which maybe 
filled with reddish serum. As softening and actual pus-formation 
occur, we get a condition which to the palpating fingers gives the cha- 
racteristic sensation known as fluctuation. Fluctuation ordinarily 
simply points out the presence of fluid beneath ; but when in an area 
marked as thus described fluctuation is noted, it practically always 
means the presence of pus beneath. It is best detected by manipulat- 
ing in a direction parallel to and concentric with the axis of the limb 
or part. The pain is also significant in most instances : patients speak 
of it, ordinarily, as having an intense and throbbing character. Along 
with these local signs occur often more or less reliable symptoms indi- 
cating some degree of septic intoxication—i. e. pyrexia, chills, malaise, 
sweats, etc.—which are always corroborative indications, their inten- 
sity being a reasonably correct index of the severity and gravity of the 
local infection. 
It is but seldom that a superficial collection of pus can ever be mistaken for 
anything else. In small and superficial abscesses (boils, furuncles) as pus ap- 
proaches the superficial layer (epidermis) of the skin it may often be discovered 
through its thin covering. In deeper lesions there is often room for honest 
doubt, even on the part of the most experienced. The measure now usually 
resorted to for purposes of diagnosis and exact recognition is the exploring or 
aspirating needle. The old exploring needle was one of good size, having a 
groove along which, after introduction, pus might pass. Since the common and 
every-day use of the hypodermic syringe, a small aspirating needle attached to JNFL A 3131 A TION. 
83 
the ordinary syringe is now the measure commonly adopted. Such a needle may 
be introduced into the brain, into the liver, or into almost any and every soft 
tissue without danger, and if properly manipulated is almost sure to facilitate 
detection of pus. Exploration done with either of these means and for this pur- 
pose should always be conducted as an aseptic, even if a minor operation, in order 
that no extra infection may be added from without. The skin should be care- 
fully washed, the needle sterilized, etc. 
It is well known by observations of writers, although to-day too often for- 
gotten, that repeated punctures of this kind, either with the needle or with the 
fine-bladed knife, not only give information as above described, but have an 
antiphlogistic effect; that is, in some indirect way they seem to check the pro- 
cess and bring about a more rapid resorption or disposition of inflammatory 
products than would otherwise take place. The antiphlogistic touch of the knife, 
then, is a measure which Pancoast and other eminent surgeons of the previous 
generation have taught us, and constitutes a remedial measure never to be de- 
spised. The same may be said for antiseptic exploration of deep lesions, as in 
the liver and elsewhere. 
It is often good surgery to resort to the knife either for the above 
purpose or in order that by a longer incision or by the opening of the 
cavity deep exploration may be made. Such explorations are usually 
of benefit even though one fail to find a circumscribed collection of 
pus, since by relief of tension and local abstraction of blood they act 
in a revulsive way and do much good. Acting upon the same prin- 
ciple, one may use the trephine or the bone-chisel for the purpose of 
opening the cranium and exploring for deep collections of pus, or of 
opening into the medullary canal of the long bones and hunting there 
for that which we have reason, from external appearances, to suspect. 
Treatment.—So soon as suppuration threatens, one should adopt 
speedy measures, either for the purpose of bringing about resorption, 
if possible, or of favoring and hastening suppuration. In theory anti- 
septic applications are demanded; in practice they are sometimes of 
benefit. These may consist of mere soothing applications, like the 
lead-and-opium wash of our forefathers, or some other wet or dry 
astringent applied upon the surface, or they may consist of cold appli- 
cations, which by their astringent action shall limit the amount of 
exudate and possibly prevent its further infection. Or, as is the cus- 
tomary practice everywhere, one may take advantage of the well-known 
properties of moist heat, and by the application of hot poultices or 
fomentations may encourage exudation, but particularly hasten super- 
ficial breaking down, and thus hurry that desirable time when the 
abscess shall point, or at least shall come near enough to the surface 
to plainly show that its contents are pus, and to permit of easy evacu- 
ation. Such local applications, therefore, give relief from pain and 
hasten favorably the suppurative process. In cases of phlegmonous 
infiltration I favor, above all other measures, the application of an 
ointment composed of resorcin 5, ichthyol 10, mercurial ointment 35, 
and lanolin 50 parts. Under the influence of this antiseptic and sor- 
befacient preparation, and of moist heat, one may see many phleg- 
monous infiltrations assume a kindlier type, and may even perhaps 
secure the actual resorption of pus. 
Finally, in almost every case the time comes when pus must be 
evacuated. Here, again, the universal rule may be laid down to 
which there are practically no exceptions. This needs to be deeply 
stamped on the mind of every student and young practitioner. It 84 
S UR GICA L PA THOL OGY. 
is—that pus left to itself will do more harm than will the knife of the sur- 
geon if judiciously used for its evacuation. All action take in accord- 
ance with this rule may be considered wise and timely. The operation 
of evacuation may at one time be a mere puncture, or possibly the 
aspirator needle alone will be enough ; at other times it requires ex- 
tensive and careful dissection and entails no little responsibility. 
This is particularly true in such deep-seated suppurations as those 
around the appendix and in the brain, while in deep-seated bone- 
lesions of this character the extensive use of the bone-chisel or the 
cutting forceps will be called for. But the rule holds good, no mat- 
ter where the pus may be, and so long as good judgment be shown in 
the operative procedure nothing but good can come from recognition 
of this law. After the evacuation of pus the cavity should be cleansed 
so far as circumstances permit, and disinfected with hydrogen dioxide, 
perhaps even with caustic pyrozone, or, if these be not at hand, with 
other suitable antiseptic solutions. 
Ordinary judgment should be manifested in evacuating every 
abscess, in order that opening be made at that point which in the 
common position of the body shall be most favorable to drainage by 
mere gravity alone. If circumstances compel opening where advan- 
tage cannot be taken of gravity, then one or more counter-openings 
must needs also be made, these at points to be selected where drainage 
may be best effected, and at the same time where anatomical conditions 
do not make it injudicious to incise. Drainage must, furthermore, be 
favored by the introduction of drainage tubing or of other aids, 
such as gauze, strands of catgut, bundles of horse-hair, etc. Finally, 
a dressing must be applied which shall be both protective and absorb- 
ent, and in quantity sufficient to make compression of the walls of 
the abscess-cavity—not sufficient to obstruct drainage, but enough 
to favor prompt adhesion of surfaces, which by speedy granulation 
shall ensure prompt healing. 
Abscesses in peculiar locations call sometimes for distinctive methods of 
attack. Thus, a suppurating cyst in the abdominal cavity is often first sewn to 
the margin of the abdominal incision before it be evacuated—this when com- 
plete extirpation of the same without opening is impracticable. This is known 
as Yolkmann’s method—is applicable generally to abscesses in the liver whose 
walls have not become adherent to the abdominal parietes, and to gangrenous 
abscesses in the lung where, again, the adhesions have not yet shut off possible 
access to the pleural cavity. Or gauze is packed in and left in situ for twenty- 
four to forty-eight hours, until adhesions by exudates have formed. 
Occasionally an abscess is so located as to make it quite impossible to open 
it at its lowest portion or drain it. In these cases it is possible sometimes to take 
advantage of the physical properties of glycerin, which has higher specific gravity 
than pus. By keeping such a cavity reasonably well filled with boroglyceride, 
for instance, pus as it may form will be floated to the surface and more easily 
gotten rid of, while at the same time the cavity itself will be kept much more 
clean and in a much more desirable condition. 
Certain abscesses are so located in proximity to large vessels or dangerous 
anatomical regions that the greatest care must needs be exercised in opening 
them. Here much better than the bold incision is the careful dissection made 
under an anaesthetic. This may be true of abscesses in the neck; it certainly 
is true of those around the appendix; for example, where the general peritoneal 
cavity is only shut off by more or less delicate adhesions, and where one must 
literally feel his way with great precaution lest adhesions be torn and the pre- 
viously protected cavity be infected. At other times, especially in abdominal INFLAMMA TION. 
85 
abscesses, it is necessary to pack sponges or absorbent gauze in and about the 
parts in such a way that any fluid which may inadvertently or necessarily escape 
shall be caught by these dressings and thus kept out of harm’s way. 
Accompanying- Disturbances.—The disturbance of function 
which accompanies all congestion and exudation, whether provoked 
by specific irritants or not, has already been alluded to; but in cases 
of surgical infections, especially those which produce local suppura- 
tion, disturbance of function is much greater, while there are other 
more, widespread disturbances which sometimes constitute the worst 
feature of these cases. The presence of pus is often indicated, espe- 
cially when deeply seated, by one or more chills, and the occurrence 
of a chill is always marked by pyrexia to varying degree. It is 
correct to say that the chill is an expression of a general septic dis- 
turbance ; but it is necessary also not to forget that general septic 
disturbance is a frequent accompaniment of pus which is not promptly 
evacuated so soon as formed. Moreover, in certain cases suppuration 
and septic infection seem to occur synchronously, one being local, the 
other general. 
Of the exact causes which lead to elevation of temperature this is hardly 
the place to speak—for one reason, because the theories of fever are so numer- 
ous, and because investigators are yet far from being united in their opinions. 
The conditions underlying heat-regulation are as yet not well understood. It 
is characteristic of fever, however, that the respiration-rate is increased as well 
as temperature elevated. It is characteristic also of the contradictions afforded 
in disease that, in spite of the intense chilly sensations, body-temperature may 
be much elevated. The probable explanation of pyrexia is the presence of 
pyrogenic substances within the circulation; but an expression of this kind 
must necessarily be too vague to be corroborated by any very exact statements 
without going, even in detail, into a large amount of experimental study, for 
which this is not the place. At all events, pyrexia is not purely nor necessarily 
a disastrous condition, but may be in no small degree conservative, since dele- 
terious substances may thus be burned up or temperature raised too high for 
pathogenic micro-organisms to flourish. When dealing with sepsis the ques- 
tion of temperature and its characteristic alterations will be more fully dis- 
cussed. 
The other general disturbance, or perhaps the most widespread 
general disturbance with which suppuration is so often complicated, 
is septic infection. In fact, it may be questioned whether pyrexia is 
not really an expression of this condition. With the general state- 
ment that any collection of pus, no matter how small, may cause 
recognizable signs of septic infection, and that, on the other hand, 
large collections may be formed without serious septic symptoms— 
in other words, with the statement that suppuration and expressions 
of septic infection may be blended in almost every conceivable way— 
the further consideration of sepsis as a distinct condition will be 
relegated to another chapter. 
It is important to summarize what may become of pus when once it has 
formed and is not promptly evacuated. Without going freely into the subject, 
pus may when long present be— 
A. Absorbed. 
B. Encapsulated. 
C. Undergo various degenerations or chemical alterations. 
A. The possibility of the absorption of pus, or, what is equivalent to it, its 
spontaneous disappearance, has already been mentioned. While it does not 
usually take this course, it may thus disappear, as, for instance, in the anterior 86 
SURGICAL PATHOLOGY. 
chamber of the eye in cases of hypopyon, or in various other localities, particu- 
larly when present only in small amounts. The absorption of pus is purely a 
matter, so far as we know, of phagocytic activity plus the power of the tissues 
to take up various fluids. 
B. Encapsulation.—This only occurs when pus has been present for some 
time and when the virulence of the pyogenic organisms is not intense. We 
may get encapsulation of pus in any part of the body, the most typical illustra- 
tion naturally being within the bones. Around the purulent focus, as around 
any other irritating foreign body, the capsule is formed by condensation of sur- 
rounding tissue. This is, in fact, the way in which most cold abscesses with 
their limiting membranes are produced, those produced by tubercle bacilli 
having ordinarily relatively slight irritating properties. Inasmuch, then, as 
the biological activity in such a focus is small, there is time for such encapsula- 
tion ; while by the membrane thus formed, or the sanitary cordon as I have 
already spoken of it, protection is afforded to the surrounding tissues. In such 
a collection fresh infection may incite acute disturbances again, and many 
abscesses which thus lie latent for considerable lengths of time are fanned, as it 
were, into a conflagration, when a new and acute inflammation is produced. 
C. Of the various metamorphoses and chemical changes that occur in that 
which was originally pus, the caseous and the calcific are the most common. 
These also are connected largely with the tubercular process, although calcare- 
ous particles are met with in the pus of actinomycosis. Under their respective 
heads these degenerations will be more particularly described. 
Certain particular names have been given to collections of pus in 
particular localities or under peculiar circumstances. A collection of 
pus in the anterior chamber of the eye is known as hypopyon; when 
in any pre-existing cavity, it is known as empyema of that cavity, the 
distinction between empyema and abscess being that “ abscess ” means a 
circumscribed collection where previously there was no cavity, while 
“ empyema ” implies a normal cavity, without respect to size or loca- 
tion, filled with this abnormal fluid. By common consent, without 
other authority than common usage, the term empyema, when not 
used in connection with some particular cavity, is understood to refer 
to a collection of pus in the pleural cavity. Other names are also 
used which are particulate and distinctive; in these the prefix pyo- is 
used, while the suffix indicates the part involved: thus we have 
pyothorax, pyopericardium, pyarthrosis, etc. 
Sinus and Fistula. 
These are terms applied to more or less tubular channels abnorm- 
ally connecting various parts of the body, or connecting some cavity with 
the surface of the body in a way anatomically quite abnormal. Or they 
may be regarded as tubular ulcers, or ulcerated tunnels, connecting as 
above. A more exact distinction between the two terms would imply 
that a sinus connects the surface with some deeper portion where 
a cavity is not normally present—i. e. with a focus of disease ; whereas 
a fistula properly refers to a tubular passage connecting natural or 
pre-existing cavities in an abnormal manner. Thus, we speak of 
buccal, rectal, vesico-vaginal fistulse, etc., whereas a passage leading 
down to an old abscess or to a focus of disease in bone, for instance, 
is properly spoken of as a sinus. It is possible for the margins of a 
fistula to become more or less cicatrized and to cease to be ulcerous; 
whereas the entire track of a sinus is practically a continuous ulcer, 
only tubular in arrangement. INF LA MM A TION. 
87 
Causes.—A. Congenital.—There are numerous points about the 
body where, as the result of arrest of development or failure to grow, 
fistulous passages which are comprised within the normal foetal 
arrangements, but which should close later, either before or at birth, 
fail to do so. In this way we get, for example, congenital fistuhe of 
the neck, persistent urachus, persistent omphalo-mesenteric duct, 
etc. These are in no sense primarily connected with diseased condi- 
tions, but may become so secondarily. 
B. Pre-existing abscess with unhealed channel of escape—e. g. 
rectal, fecal, and other fistuhe and sinuses which connect with tuber- 
cular foci in any part of the body. 
C. Previous traumatic or other destruction of normal tissues, as, e. g., 
vesico-vaginal fistula? due to tissue-death from pressure, buccal fistuhe 
from gangrene of the cheek, as in noma. 
D. Foreign bodies—bullets, ligatures, etc.—which prove irritating 
or infectious enough to prevent absolute healing. More or less tortuous 
sinuses will almost always be found leading down to the irritating 
material. 
E. The presence of necrosed or necrotic material, as, for example, a 
sequestrum in bone, which is usually evidenced by the presence of one 
or more sinuses. 
Sinuses and fistulse may be single or multiple ; may be direct or very sinuous 
or tortuous in their course; may be short or long, even, in rare cases, up to 
twenty-four inches or more. The appearance of the opening of a sinus will 
often be an indication as to the character of the diseased condition down to 
which it leads. In nearly all forms of deep tubercular trouble, especially of 
bone, the mouth of the sinus is surrounded by a little crown of fungous, often 
cedematous granulations, which are frequently arranged in an almost valve-like 
way, not preventing escape of fluid from within, but often making it difficult to 
introduce a sound or irrigator nozzle from without. The discharge from these 
openings will depend entirely upon circumstances. Accordingly, it may be 
saliva, gastric juice, fecal matter, urine, pus, pyoid material, etc., the character 
of the same depending upon its location and cause. 
Treatment.—If the determining cause be still acting, the treat- 
ment is practically summed up in the advice to remove the cause. 
Consequently, when the sinus leads down to diseased bone or other 
dead or dying tissue, the complete evacuation of the cavity is neces- 
sary before the sinus may heal. If the cause be a foreign body, its 
removal shoidd be at once insisted upon. 
Fistulse of congenital origin and those which connect two normal 
cavities of the human body are usually due to a cause which has ceased 
to act. Consequently, one here endeavors solely to atone for the re- 
sult. One may acquaint himself with the direction and, in a general 
way, with the course of a sinus by the use of a probe curved to suit 
the case and manipulated by a gentle hand, force never being required. 
Or sometimes, when the silver instrument fails to pass, a flexible 
bougie or catheter may be introduced. Information is thus gained as 
to the direction and extent. This information, however, is of less 
value than is ordinarily esteemed, since the character of the passage 
can be for the most part judged by the appearance of the discharges. 
With sinuses of recent origin leading down to recent suppurative foci 
it may be enough to enlarge the opening and to wash out thoroughly 88 
SUE arc A L PA TJfOLOG Y. 
the cavity as whose exit it serves. If, as sometimes happens, a par- 
ticle of gauze, tube, or sponge have been left therein, its removal is 
probably all that is necessary to secure prompt healing. In cases of 
longer standing it is good practice often to inject antiseptic and stimu- 
lating substances, or even to cauterize the interior by means of strong 
solutions or by means of zinc chloride or silver nitrate melted upon 
the end of a probe. The chronic sinus, as well as the chronic rectal 
fistula, is almost invariably an expression of local tubercular disease. 
Accordingly, these passages will be found lined with the same dense 
fungating membrane which lines a cold abscess-cavity—the membrane, 
protective in its purpose, to which I have given the name pyophylactic. 
Whenever such tissue and such membrane are met with, they should 
both be extirpated as thoroughly as possible, since in this way only 
can absolute eradication of the tubercular infection be relied upon. 
After such complete excision—which means usually laying open the 
entire sinus—the parts may perhaps be brought together with sutures 
(this, at least, is usually possible about the rectum) in such a way as 
to secure primary union ; otherwise, the whole sinus, as well as the 
cavity to which it has led, must heal by the granulating process, both 
being kept packed with gauze or some other desirable foreign body 
which shall act as an irritant, thereby provoking more rapid forma- 
tion of granulation-tissue. When it is necessary thus to pack a 
cavity, or when it is desired to keep its upper exit open lest it heal 
before the lower part, ordinary white beeswax, as suggested by Gunn, 
makes a very serviceable material. This can be moulded in hot water 
to fit the cavity, can be tunnelled or bored for drainage, can be dimin- 
ished in size as the cavity heals, and is absolutely non-absorbent. 
Finally, there are numerous plastic methods which have been re- 
sorted to in various parts of the body, most of which are made to 
comprise, first, the absolute eradication of the diseased tract, and, 
later, the closure of the wound, thus made, by transplantation or slid- 
ing of flaps or any other plastic expedient which may be considered 
best. These, as well as the special treatment made necessary for par- 
ticular forms of sinus and fistula, will be dealt with more at length 
under the proper headings in Volume II. CHAPTER IV. 
ULCER AND ULCERATION. 
Roswell Park, M. D. 
The term ulcer pertains to surfaces, and should be defined as a sur- 
face which is or ought to be granulating—i. e. healing. 
While an ulcer may be the result of what is known as ulceration, it 
is by no means necessarily so, the term ulceration being one of very loose 
significance and applied to many different processes. For our present 
purposes the idea underlying ulceration is infection, and, when limited 
to its proper significance, the term should never be used for a process in 
which infection and consequent breaking-down of tissue do not virtually 
comprise the whole process. In this regard, therefore, it is to be abruptly 
distinguished from certain disappearances of tissue already alluded to 
under the head of Atrophy or Interstitial Absorption. It is therefore 
not correct to say that the sternum ulcerates away, making room for a 
growing aortic aneurism, the question of infection not here being raised. 
These distinctions should be accurately maintained and constantly borne 
in mind. 
The causes of ulcers may be— 
A. Traumatic; 
B. Local; or, 
C. Constitutional. 
A. Traumatic.—This would include all those surfaces which are 
Ulcers. 
Fig. 21. 
Recent traumatic ulcer of arm. 
granulating and healing more or less rapidly, or are displaying, in other 
words, a kindly disposition toward healing, and which may have been 
originally produced by wounds, burns, frost-bites, etc. These include 
also those ulcers which are due to pressure, as from splints, bandages, 90 
SURGICAL PATHOLOGY. 
various orthopaedic apparatus, or from external friction. Ulcers which 
form around foreign bodies may also be included under this head, their 
essential cause being traumatic. 
This should include also destruction of the surface by various chem- 
ical agencies, such as strong caustics; also the consequences of intense 
heat or cold, including particularly burns and frost-bites. 
B. Local.—1. Among local causes may be mentioned local infections 
with tissue-death in consequence, such as occur in tuberculous, leprous, 
syphilitic, and other specific manifestations where surfaces are involved. 
2. Tumors, either benign or malignant, whose blood-supply is cut off 
and whose surface is thereby predisposed to infection. 
3. Perverted surface-nutrition, such as is most commonly met with, for 
example, in connection with varicose veins of the extremities, where, 
Fig. 22. 
Chronic ulcer ol leg. 
aside from any perverted trophoneurotic influence, there is stagnation of 
blood, saturation of tissues with serum, and final leakage of the same, 
even to the surface. In other words, a passive hypersemia leads here 
to oedema, perversion of nutrition, failure to repair trilling surface-injury, 
and a commencing ulcer is the consequence. 
4. So-called pressure-sores or bed-sores, which in some cases may be 
regarded as having a traumatic origin, but which, nevertheless, would 
not occur from purely traumatic influences without predisposing tissue- 
changes. The bed-sore is probably the best illustration of this. Simple 
ulcer is known as bed-sore, while a sloughing ulcer of this kind is fre- 
quently alluded to as decubitus. Such ulcers are usually found over those 
regions of the body made most prominent by bony projections, upon 
which undue pressure is made when debilitated patients have lain for 
a long time in bed. 
5. Ulcer is the frequent result of numerous skin diseases, into whose 
etiology as yet bacteria have not been introduced—e. g. pemphigus, 
eczema, etc. 
6. Ulcer is the occasional result of embolic or other disturbance of the 
principal artery of the part, by which nutrition is cut off and tissue- 
death results. 
7. Bites of insects or other parasites or of noxious animals frequently 
lead to ulceration. ULCER AND ULCERATION. 
91 
8. Certain more specific forms of ulcer are described by some 
writers, apparently with more or less reason, among them being chan- 
croid, perforating ulcer of the foot, etc. Chancroid will be found de- 
scribed in Volume II. Perforating ulcer of the foot is a circumscribed 
circular ulcer with thickened edges, often nearly concealed by overhanging 
skin. It may be found in any part of the sole of the foot, but is most 
common near the first joint of the great toe. The borders of the ulcer 
are usually anaesthetic. By some it is closely associated with trophic 
nerve-disturbance ; bv others it is regarded as having a specific etiology 
of its own. The probability, however, is that it is simply a subvariety 
of pressure-sore. 
C. Constitutional.—1. Ulcers are frequently met with in certain con- 
stitutional conditions which are characterized by tendency to local man- 
ifestation at points of least resistance. Among these should be mentioned 
scurvy. 
2. There are ulcers of apparently distinctive trophoneurotic origin, 
of which that mentioned above as B, 8—perforating ulcer of the foot— 
may possibly be one. These notoriously accompany certain nervous dis- 
orders of central origin, prominent among which are locomotor ataxia 
and tabetic disease of all forms. 
3. Ulcers are produced sometimes as the result of specific or selective 
action of certain drugs, among them mercury and phosphorus being the 
most prominent. These manifestations are met with in the mouth most 
commonly, and may perhaps be regarded as infections at points of least 
resistance. Nevertheless, they are commonly associated with the tend- 
ency of these drugs. 
4. There are many constitutional conditions in which vitality is so 
lowered that a special liability to ulcer—i. e. infection and production of 
ulcer at many points—is noted. It is well, however, to mention that 
the common diseases in which this tendency is most often noted are 
typhoid, diphtheria, diabetes, and syphilis. 
With this summary of the common causes of ulcer it should be again insisted 
upon that ulcers may be due to direct consequence of traumatic loss of substance 
or to the process of ulceration—i. e. as a consequence of previous infection, or as 
permitted by trophoneurotic disturbance and ischaemia. In this connection also 
ulceration should be spoken of as a process of molecular death, in which cells die 
successively and more slowly, as distinguished from gangrene, in which there is 
simultaneous death of large aggregations of cells, by which a slough or its equiv- 
alent is produced. 
Ulcers are spoken of as healthy when the process of granulation is 
proceeding with average rapidity ; indolent, when the reverse obtains; 
sloughing, when there is actual visible tissue-death in connection with 
the ulcerative process; phagedenic, when the gangrenous tendency is 
well marked and the process exceedingly rapid; irritable or erethistic, 
when the surface is exquisitely sensitive; hemorrhagic, when bleeding 
easily; fungous or fungoid, when the granulations have risen above the 
surface and are being manufactured at altogether too rapid a rate. 
The best examples of the indolent ulcer are seen in connection with varicose 
veins of the extremities; of the phagedenic ulcer, in certain cases of chancroid ; 
of the irritable ulcer, in ulceration of the cornea, where the pain and photophobia 
are intense; or in fissured ulcer of the anus, where the pain and sphincter spasm 
are sometimes agonizing. 92 
SURGICAL PATHOLOGY. 
Ulcers are described according to their shape as regular or irregular ; 
ns fissured, when they extend more or less deeply and abruptly into the 
Fro. 23. 
Varicose ulcer of leg, with lymphcedema (Dr. Holloway). 
surface involved ; as fistulous, when they have a tubular arrangement; 
as rodent, when they spare nothing in their course. 
The borders of ulcers are described as healthy, indurated, tumid, cedem- 
atous, undermined, livid, inflamed, etc., these adjectives explaining them- 
selves. 
The surfaces of ulcers are described as healthy when they have normal 
color and appearance, inflamed, excavated, covered with sloughs, callous, 
etc. The ccdlous ulcer is one which exhibits little change from month to 
month ; its surface is dirty, and its secretion thin and muco-purulent. 
It is usually sunk considerably below the surrounding level, while its 
border is firm and nodular. The best examples of this form are those 
accompanying varicose veins. 
In size or area ulcers may vary from the slightest local destruction 
of tissue to an area covering an entire limb or a large part of the trunk 
of the body. In depth also they vary within lesser limits, while an 
external ulcer may connect with some deep lesion by means of a tubular 
passage or sinus. It thus appears that the term ulcer may be applied to 
the result of a natural effort to repair loss of substance without intro- ULCER AND ULCERATION. 
93 
ducing the element of disease, or that it may be the consequence of local 
infection with local tissue-disaster. 
The character of the material discharged from an ulcer will vary 
much according to the category in which it belongs. The healthy, 
healing or granulating surface, often spoken of as ulcer, discharges a 
material in gross appearances much resembling pus from an acute 
abscess. In consistency it is the same, and in color and other appear- 
ances. Nevertheless, its origin is essentially distinct. This material 
represents simply the waste of reparative material sent up to the surface 
for the purpose of hurrying the process. Its fluid, like that of pus, 
conies from the serum of the .blood ; its corpuscular elements, like those 
of pus, are leucocytes or wandering tissue-cells, which have been fur- 
nished in great numbers—in fact, in excess. As it comes to the surface 
—or as, rather, it is rejected from the surface, being superfluous in 
amount—it is quite likely to become contaminated with bacteria by 
contact infection, and consequently may be seen under the microscope 
to contain various micro-organisms. This contamination has been final, 
however accidental and irrelevant. This material is not pus ; has no 
infectious properties, except those which may accidentally be conveyed 
to it; represents no warfare of cells, only excess of supply or over- 
demand ; and should be spoken of as pyoid or puruloid material, and 
never confused with pus. In amount it will vary according to the 
activity of the reparative endeavor, and somewhat according to the 
amount of irritation of the surface by dressings which may be applied. 
If a granulating surface be absolutely protected from possibility of con- 
tact-infection, it will never contain micro-organisms; while this pyoid, 
if allowed to remain too long, especially when infection is permitted, 
may decompose and become irritating, and is a material to be gently 
dislodged by a spray or an irrigating stream with each dressing, which 
dressing should be made once in twenty-four to sixty hours. 
Material similar to this is met with often in drainage-tubes after the second or 
third day in instances where an absolutely aseptic course has been maintained. 
It is material of exactly the same character, due to essentially the same causes, 
will usually be found free from micro-organisms, will be gelatinous or coagulable 
to a degree permitting partial or complete occlusion of the drainage-tube, but has 
absolutely no infectious properties. This also, originating under parallel circum- 
stances, may be spoken of as pyoid or puruloid material. 
From ulcers having local infections as their primary causes discharges may 
come containing in themselves the specific irritants which may prove infectious 
to other points—which, in other words, may be auto-inoculable or hetero-inocu- 
lable. Such discharges, for instance, come from tuberculous, leprous, and syphil- 
itic ulcers, and those of glanders and some other rarer diseases. Again, from 
sloughing and gangrenous ulcers will come yet other kinds of material containing 
bacteria of putrefaction in large numbers, having unpleasant odor, being blood- 
stained, or marked by other characteristics according to circumstances. 
Processes of Repair. 
An ulcer having been defined as a surface which is or ought to be 
granulating, it becomes necessary to define the granulation process and 
to show how healing is thereby achieved. Granulation-tissue is a 
name applied to a new and temporary tissue of embryonic type, which 
acts as a scaffolding or temporary structure, permitting the construction 
of more permanent tissue. It is produced entirely by the activity of 94 
S URGICA L PA THOLOGY. 
cells, which are the single and polvnucleated leucocytes and the wander- 
ing cells already so often mentioned. They are frequently known as 
embryonal cells when performing this function; sometimes as formative 
cells. They have a distinct nucleus, which stains readily, and, having 
this resemblance to epithelial cells, they are often spoken of as epithe- 
lioid cells—sometimes as fibroblasts, because they may later assume the 
dignity of connective-tissue cells. They assume a multitude of shapes. 
In a way not yet sufficiently described, between these cells as they are 
drawn toward the point at which they are most needed, perhaps by 
chemotactic activity, there appears an intercellular substance, which later 
becomes fibrillated. As these fibres develop the remaining cells become 
entangled between them, and we have in this way a new connective 
tissue formed of cells of originally mesoblastic origin. Of such tissue 
the solid part of granulation-tissue is built. It is necessary to empha- 
size that this tissue is essentially different from the epithelium which 
it is expected will subsequently cover it. If a normal granulating sur- 
face be scanned with a magnifying glass of small magnifying power, it 
will be seen to consist of numerous minute projections, each of which is 
known as a granulation, and which consists of the tissue above described 
formed as a minute eminence around a budding capillary blood-vessel, 
from which a little projection has occurred upon the exposed surface. 
This capillary bud is the result of karyokinetic activity on the part of 
the endothelium—namely, the hypoblastic cells of which it is essentially 
composed. In each of these cells, under certain circumstances, the 
karyokinetic threads already spoken of develop and become loosely 
coiled, while the chromatin in the nucleus increases in amount and the 
nucleolus disappears. The chromatin threads become thicker, arrange 
themselves equatorially around the poles of the nucleus, and gradually 
turn so as to point toward it, while a new membrane forms around each 
separate coil, and two nuclei are thus made out of one. While this is 
going on within the nucleus the cell-protoplasm undergoes active rotary 
motion, is finally segmentated, and by the time the nucleus is divided 
is nearly ready for complete division of the cell. While nuclear division 
is usually bipolar, it may be multipolar : if a rearrangement of the pro- 
toplasm is delayed, the result becomes a multinuelear cell, known as a 
giant cell. 
The consequence of this endothelial activity is new cell-formation and the 
construction of a projection from the capillary which soon attains the dignity of 
its parent vessel, and, as connective-tissue cells form around it, soon becomes a 
granulation by itself, each granulation, being marked by a capillary loop of its 
own. Healing by granulation or the granulation process, no matter how set up 
or caused, is essentially the formation of hundreds or thousands of these tiny 
structures, a new one being formed on top of those which precede it, while those 
first formed and deeper down undergo condensation and metamorphosis of tissues, 
by which they are converted into something higher in the tissue scale. Under 
ideal conditions true granulation-building proceeds pari passu with epithelial 
reproduction around the margin of the granulating surface, so that by the time 
granulation-tissue has completely filled the defect, no matter how caused, epi- 
thelial covering has been completely constructed and the healing process thus 
completed. These two processes, however, do not necessarily keep pace with each 
other; and, should surface-repair take place relatively early, we may have a 
depressed scar; while, on the other hand, should it not proceed rapidly enough, 
or, to put it in another way, should the granulating process be too rapid, we have 
such excess of granulations as shall rise considerably above the surrounding level, ULCER AND ULCERATION. 
95 
and may, under certain circumstances, become so exuberant that nutritive ma- 
terial cannot be formed rapidly enough, and those granulations farthest away 
from the centre of supply may die. Such exuberant granulation is often spoken 
of as fungoid, and constitutes that great bugbear in the eyes of the laity which is 
termed by them proud flesh. It has no further significance than that the supply 
has exceeded the demand and that the granulating process has been overdone. 
Such exuberant granulations may be cut away with scissors or knife, may be 
burned away with caustic agents or the actual cautery, or may be disposed of in 
any other manner without harm and only with benefit; in fact, it is often neces- 
sary to suppress this exuberant tendency by caustics and pressure, in order that 
the desired epithelial covering may be properly formed. 
Epithelium, being an epiblastic structure and capable of no other 
origin save from its like, can only be supplied from those regions where 
it has pre-existed. Consequently, ulcers involving the external surface 
of the body demand a lively epithelial reproduction in order that they 
may have a normal covering. Epithelial activity sometimes becomes 
retarded, and is much slower toward the termination of the healing 
process than at the beginning. The epithelial covering of a healing 
ulcer is always marked by a delicate whitish or pinkish film, which pro- 
ceeds from the periphery as well as from any little island of original 
epithelial structure left. It is notorious that after a certain amount of 
this repair the process sometimes conies to a complete halt, and the vari- 
ous expedients for stimulating and promoting it, as sponge-grafting and 
the different methods of skin-grafting, have been devised solely to atone 
for such sluggishness or inability. 
Ulcers of small size which are more or less exposed to the air in healthy indi- 
viduals, while also exposed to possibility of infection, nevertheless seem to escape 
it, owing to the defensive power of the blood-serum and the active cells. Such 
discharge as naturally comes from them, when not excessive, undergoes evapo- 
ration until a point is reached where a dry crust or scab is formed. Under this scab 
granulation proceeds up to a point where the pressure of the scab itself, presum- 
ably on the level of the surrounding parts, checks its activity, while at the same 
time epithelial reproduction goes on until it has been completed. Then the scab, 
being no longer of use, drops off or is detached by slight friction. 
Such is granulation-tissue: at first a mere trellis-work of temporary 
and delicate cell-structure, traced in a certain amount of intercellular 
homogeneous substance, into which the budding vessels project, the whole 
mounting nearer and nearer to the surface, day by day with variable 
rapidity, diminishing in this regard as the days go by, so that frequently 
the granulation process comes to an apparent halt before enough new 
tissue has been formed. While the superficial granulations preserve the 
characteristics above noted, those deeper down undergo firmer and more 
complete organization, and the delicate embryonic structures show the 
same tendency which they do in the growing embryo, by virtue of what 
Virchow has called metaplasia, to become converted into something 
higher and more dignified in the tissue scale. It is not given to these 
cells to specialize themselves to the extent permitting complete repair of 
organs of special sense. Thus, while a wound in the cornea or retina 
may be completely healed, it heals by cicatricial tissue, and not by repair 
of the special structures involved. On the other hand, tissues of more 
common connective type—fibrous, bone, cartilage, etc.—are capable of 
regeneration; and it seems to be a part of the privilege of these new 
granulations to merge themselves into that kind of tissue necessary for 
filling the gap. Nevertheless, the most common result of granulation is 96 
SURGICAL PAT 110LOG Y. 
its metablastie conversion into fibrous tissue which lias the special charac- 
teristic of contractility without elasticity. As the result scars contract; 
in consequence of which most 
disfiguring results are some- 
times the almost inevitable 
consequence of healing of 
extensive losses of substance. 
In certain instances it is pos- 
sible by constant effort to 
overcome the unpleasant ef- 
fect of this cicatricial con- 
traction. For example, after 
extensive burn of the anterior 
part of the arm, the forearm 
will be gradually and perma- 
nently flexed upon the arm by 
virtue of contraction of the scar 
in front of the elbow, unless 
some forcible means be prac- 
tised for maintaining exten- 
sion of the arm for at least a 
part of the time. So with many other injuries and the various mechanical 
or other expedients required 
to prevent the untoward re- 
sult. Nowhere are the con- 
sequences more disfiguring or 
serious than about the face, 
where eyelids are drawn out 
of shape, the contour of the 
mouth altered, or where some- 
times one may see extensive 
manifestations of this same 
most undesirable consequence 
(See Figs. 24 and 25.) 
As the result of healing of 
the granulating surface, we 
have what is known as a 
cicatrix or scar. This is 
composed of fibrous tissue, 
probably more or less dis- 
torted by virtue of its con- 
tractility, and of epithelial 
covering furnished from the 
margin of the original nicer, 
constituting a thin, glistening 
membrane, applied closely to 
the scar-tissue beneath, with- 
out intervening fat or tissue 
which permits of the play of 
the one upon the other. When 
this epithelial surface is abraded, it is repaired with difficulty, and a raw' 
Fig. 24. 
4ig. 25. ULCER AND ULCERATION. 
97 
or ulcerating scar is usually a difficult thing to heal. Manifestation of 
perverted epithelial outgrowth is frequently provoked at these points by 
the action of continuous irritation. In consequence we have what is 
generally recognized as the transformation of a chronic ulcer, or the 
site of one, into an epithelioma, or possibly, by similar irritation of the 
connective-tissue elements, into a sar- 
coma. This is the so-called cancerous 
degeneration of previous ulcers, and is 
noted occasionally. The lesion is one 
which often requires disfiguring, or 
even mutilating operations in order to 
get rid of the malignant disease. 
The surface of a superficial scar while thus 
covered with epithelium shows a complete lack 
of all the other skin-elements. No hair grows 
upon such a surface, because the original hair- 
follicles are destroyed ; neither is it moistened 
by perspiration nor anointed by sebaceous ma- 
terial, because the secretory glands have also 
disappeared. It is a surface which often needs 
more or less protection, especially when in ex- 
posed situations. 
Treatment.—Here, as in all other 
instances, the first effort of the surgeon 
should be to remove the cause, be it what 
it may. This may be done by local, or 
may require constitutional, measures. If 
a definite local cause can be made out, its 
removal may be a slight, or may entail a 
more or less serious, surgical operation. 
Aside from this disposal of the exciting 
agent, treatment must be divided into the 
geneial and the local. General tleatment Epitheliomatous degeneration of chronic 
is scarcely called for when dealing wi th Ulcer, necessitating amputation (original). 
healthy ulcers; but in all those instances where the constitutional condi- 
tion of the patient is below par or where there is a general poisoning or 
infection underlying the ulcer itself, prompt and energetic constitutional 
treatment should be at once instituted. In scurvy, for instance, the diet 
and hvgienic surroundings of the patient should be rectified immediately. 
In syphilis no lasting nor deep impression can be made on local manifes- 
tations without general constitutional treatment. In tuberculosis and the 
other surgical infections much will be accomplished by internal medica- 
tion, by proper hygiene, as well as by local applications or operation. 
The importance of these general measures is likely to be under-esti- 
mated, and many fail to realize the advantage of combining suitable 
internal and external therapeutic measures. 
Local Treatment.—First of all should be mentioned the complete 
insistance upon repose which brings about that which we best know as 
physiological rest. The ulcer which may never heal so long as the parts 
are constantly moved may show a prompt and kindly tendency so to do 
as soon as the part is put absolutely at rest. This may mean wearing a 
splint or restraining apparatus, or it may mean confinement in bed, 
Fig. 26. 98 
SURGICAL PATHOLOGY. 
depending upon the location of the nicer. Physiological rest will be 
enforced sometimes by such measures as stretching a sphincter in order 
to temporarily paralyze it in cases of irritable rectal ulcer, where the 
principal pain is produced by the reflex spasm of its fibres. Again, the 
eye with irritable ulcer of the cornea is some- 
times kept so tightly closed by the same kind 
of spasm there that it is necessary at times 
to divide the lids, or the orbicularis muscle at 
the angle of the lids, in order to make access 
to the part. This is in a measure carrying out 
the principle of physiological rest, because it 
permits proper exposure and treatment. 
The absolutely healthy and kindly-healing 
ulcer needs no treatment except protection. 
Epithelial covering will probably keep pace 
with filling of the depression by granulations, 
and all that it is necessary to do is to prevent 
external irritation. Should there be excess of 
discharge, the simplest possible absorbent dress- 
ing, with enough of some antiseptic material to. 
prevent putrefaction by contamination with 
the ordinary bacteria of the surrounding air, 
should be employed. The ulcer which is be- 
coming tardy in its repair may be stimulated 
by silver nitrate, zinc chloride, or other more 
or less caustic applications, which act as a spur to the sluggish granula- 
tions, destroying those with which it comes in contact, but stimulating 
those below to do their duty more promptly. 
The conventional applications to ulcers fall usually under two cate- 
gories—the watery solutions and the unguents. 
Fig. 27. 
Cicatricial deformity following 
specific ulcer (original). 
Among the former which give the most satisfactory results are diluted alcohol; 
carbolic lotion ; solutions of some of the astringents and antiseptics, such as zinc 
sulphate or chloride, quite weak; potassium chlorate, saturated ; potassium per- 
manganate ; alum, etc. Of these the potassium chlorate is usually the most satis- 
factory. Among the various ointments have been suggested nearly all possible 
combinations imaginable of the soluble and insoluble antiseptic drugs, in connec- 
tion with various excipients like vaseline, lard, lanolin, etc. Among those sub- 
stances most commonly used are perhaps zinc oxide, bismuth subnitrate, boric acid, 
salicylic acid, iodoform, aristol, etc. The latter preparations have the advantage that 
surface evaporation does not lead to drying and formation of crusts whose detach- 
ment gives pain. Aqueous solutions permit of more easy and comfortable washing 
of the parts without need for friction to remove ointment. Each class of preparations, 
therefore, has its advantages, and circumstances would best decide which would be 
the better for a given case. Balsamic preparations have also been largely used in 
time past, among them especially balsam of Peru. This, mixed with 10 per-cent, 
of guaiacol and 5 per cent, of iodoform, makes a combination which I am very fond 
of applying to tubercular and all specific forms of ulcer. 
Of late the investigations of the laboratory have led to the employ- 
ment of numerous peptonized preparations, among which may be men- 
tioned peptonized cod-liver oil and some of the partially or predigested 
foods, such as bovinine, etc. These appear to have the power of digest- 
ing sloughs and of causing a speedy separation or disposal of everything 
which one wants to get rid of in the endeavor to secure a healthy con- ULCER AND ULCERATION. 
99 
dition of the ulcerating surface, and give in many instances most sat- 
isfactory results. Glycerin solutions have also been used (especially 
boroglvceride), which act by abstracting water, and which are particu- 
larly useful in certain conditions where the granulations are quite oedem- 
atous. When sloughs are present it is frequently an advantage to dust 
over them some of the preparations, like papoid, pepsin, etc., which have 
the power of catalytic disposition of decomposing material without ref- 
erence to action of bacteria. Under their use there seems to be a sort 
of solution and disposition of these dead products. When one has to do 
with a torpid or callous ulcer whose surface is covered with a thick, 
immovable film, where the tissues apparently are not dead, yet not 
alive, the addition of some digestive agent, coupled with the favoring 
action of heat and moisture, such as are to be secured bv the application 
of a poultice, will, if properly enforced, lead to the speedy separation of 
a slough. While an ulcer should never be continuously poulticed, nor a 
healthy ulcer under any circumstances, poultices are yet a valuable means 
of first treating a limited class of cases. With a foul ulcer—one from 
which the discharge is more or less offensive, due usually to decompo- 
sition of sloughing masses not yet separated the method of continuous 
immersion in hot water—when it can be carried out, is always preferable 
to all others. 
Various expedients may be practised to effect this purpose, from a domestic 
pan or pail up to the porcelain bath in which the patient’s whole body is kept con- 
tinuously immersed. The water should be as hot as can be comfortably borne, and 
may be impregnated with a very small percentage of some antiseptic, like mer- 
curic chloride, zinc chloride, or something of that kind. This is, for instance, an 
admirable method of treating those ulcers caused by extensive burn, from which 
much tissue has always to separate by sloughing, and on whose surface there are 
always patches which hover between tissue-life and death for some hours or days, 
which possibly maybe redeemed under the favoring influence of hot water. For 
the treatment of phagedenic ulceration also, hot water offers perhaps the best 
method, although there is no reason for not combining this with previous treatment 
with bromine, caustics, or other measures. 
Another method of stimulating is by resort to compression, either by rubber 
bandages, straps, or other means. The old method of strapping used to be much 
favored. Of late all of these methods have rather fallen into disuse, because of the 
preference of modern surgeons for the speedy conversion of a chronic ulcer into a 
fresh sore and its treatment by skin-grafting or other methods. A method more 
in vogue than strapping, and in some respects easier of performance, is that by use 
of the elastic rubber bandage. The treatment by compression is based upon sup- 
porting the surrounding parts, equalizing the pressure, and overcoming the collat- 
eral oedema which is one reason for sluggishness of repair. 
Many ulcers are surrounded with such firm, indurated borders that it 
seems impossible that any active regenerative process can arise from 
such source. Hence incisions have been practised for centuries. These 
have been made radially from the centre or have been made parallel to 
the margin of the ulcer, or sometimes the firm, dense tissues have been 
minced or chopped by a series of cross-cut stabs or incisions ; as the result 
of which renewed activity has been set up, and an impetus, oftentimes 
sufficient, has been given to the healing process. These methods, however, 
have now yielded to that just above alluded to. The comparatively 
recent ulcer in which granulation has come to a stand-still is often 
treated with the sharp spoon or curette. The result of this has been to 
provoke again a speedy renewal of granulation efforts, and treatment by 100 
SURGICAL PATHOLOGY. 
curetting is standard and often useful. Actual cauterization of the ulcer 
with a view to such complete destruction of its covering and border as 
shall lead to their separation by the sloughing process is occasionally 
practised. This is perhaps best performed with the actual cautery. It 
lacks, however, the valuable features of the operative method to be 
described below. Modern methods have made it plain that it is often 
an absolute waste of valuable time to resort to the older expedients of 
stimulation, incising the edges, etc., and that one can accomplish by an 
operation in perhaps three weeks what ten times that length of time 
would fail to do by older methods. The most effective method, therefore, 
in dealing with old and chronic ulcers is to anaesthetize the patient, to 
excise the entire affected area—i. e. the surface which ought to be granu- 
lating and the firm border and tissue in its neighborhood—and then to 
cover this surface either with shin-grafts, pared off with a razor according 
to the Thiersch method, or with a strip of skin whose full thickness is 
raised, which is taken from surrounding parts by some auto- or hetero- 
plastic method. This line of treatment is so far preferable to all others 
that, except in case of refusal of the patient to submit to it, it is the 
one which must hereafter universally commend itself. It may afford 
opportunity for extensive plastic operations or for the exercise of the 
best discretion and knowledge of experienced men ; yet cases are rare in 
which it cannot be successfully carried out. These methods of skin- 
grafting have so far supplanted the older method of sponge-grafting 
that the latter is now scarcely ever practised. It may possibly 
have a sphere of usefulness in certain ulcerated cavities, but under all 
other circumstances it must take a position far below the plastic methods 
in practical value. 
Finally, ulcers of specific type — syphilitic, tubercular, leprous, 
glanderous, etc.—all need methods in which the first effort shall be not 
so much to arrange for healing as to dispose of infectious material. 
The knife, the scissors, the sharp spoon, come first into play here, the 
surgeon bearing in mind that almost all this material is more or less 
infectious, and that inoculation of his own hands is possible as the result 
of carelessness. After taking away with instruments all the granula- 
tion-tissue with its surroundings which seems to expose to danger, it 
would be well to thoroughly cauterize the part with the actual cautery, 
nitric acid, bromine, zinc chloride, or something of the kind as a pat- 
ter of insurance of the desired purpose. 
As the result of the caustic there will be superficial separation of the cauter- 
ized tissue, beneath which, however, should spring up healthy granulations. 
Such an ulcerated surface, having by this means been converted into what we 
may call a healthy ulcer, becomes then amenable to the treatment already men- 
tioned. The ulcer covered with fungous or exuberant granulations—i. e. the proud 
flesh of the laity—should be rapidly scraped or burned down at least to the level 
of the surrounding parts, the quickest method being that by which the knife or 
scissors is used, compression for a few moments always sufficing to check hemor- 
rhage. Common attention after this will be all that such a surface needs. 
The markedly hemorrhagic ulcer, whose surface bleeds on the slight- 
est contact or disturbance, is often a cancerous ulcer, though not neces- 
sarily so. This ready bleeding is usually the cause of the extreme 
fragility of the tender walls of the rapidly new-formed blood-vessels. 
In many instances it is enough to thoroughly scrape until one comes ULCER AND ULCERATION. 
101 
down upon harder or more resisting tissue. Hemorrhage may be pro- 
fuse for the moment, but it is almost invariably easily controlled. 
Caustics may then be applied or not, according to the judgment of the 
surgeon. 
Another method is to treat such a surface with the actual cautery. Another 
is to operate, even in the presence of really incurable disease, simply in order to 
check tendency to fatal hemorrhage before the natural tendency of the disease 
has expended itself. In a general way, with regard to all small ulcerating can- 
cerous surfaces, one may say that if they bleed excessively or are unduly irritable, 
it is perfectly legitimate to attack them by operative measures in spite of the im- 
possibility of effecting a cure. 
Numerous other methods of treating ulcers may be found in the older text- 
books, but they have, in whole or in part, been abandoned for the comparatively 
few already mentioned. CHAPTER Y. 
GANGRENE. 
By Roswell Park, M. D. 
This is known also as necrosis, although by general consent this 
term is usually limited to gangrene of bone. It is known also to the 
laity as mortification, and to the older writers, especially when soft parts 
die and separate in sloughs, as sphacelus. Gangrene means death of 
tissue in visible and more or less circumscribed masses. It is to be dis- 
tinguished from ulceration because now we have to deal not with a pro- 
cess of molecular disintegration, particle by particle, but with death in 
toto and synchronously of a large perhaps innumerable number of cells. 
Gangrene is described as due to causes which may be— 
A. Traumatic, including the so-called thermal causes as essentially 
mechanical injuries. Under this head would come all cases where 
injury is the primary cause, whether this injury be the crushing of a 
limb, the separation or occlusion of its main blood-vessels, the division 
of its main nerves, the crushing or pulpefving of its entire structure bv 
machinery or accident, and also those so-called thermal cases which are 
due to intense heat or intense cold. To these might be added the 
chemical causes, comprising injuries by powerful caustics, alkalies, or 
acids, which are known to cause speedy death of every living tissue 
with which they come in contact. 
B. Local Causes.—These are largely connected with ischaemia, pro- 
duced in one way or another. Gangrene from oedema—itself the result 
of passive hypersemia and exudation—is not infrequent, the most com- 
mon expression of this condition being seen, perhaps, in the external 
genitals of the male. Embolism due to valvular heart disease, thrombosis 
due usually to a preceding phlebitis, but possibly to marasmic origin, 
especially met with after confinement, with disturbance in the uterine 
sinuses, shutting otf the circulation by endarteritis, which thus assumes 
the form obliterans, are some of the local causes which concern the blood- 
vessels alone. In fact, the majority of cases of spontaneous gangrene 
are probably due to changes in the vessels, endarteritis being the cause 
of a condition known as atheroma of vessels, in which fungoid out- 
growths or, rather, ingrowths into the vessel-lumen, are common. Any 
one of these, if detached, may serve as an embolus. The degenerative 
excavations in the thickened walls of the blood-vessels which discharge 
more or less cholesterin and other debris, and which have in time past 
been known as atheromatous abscesses (misnomer), are frequently the 103 
GANGRENE. 
precursors of the disease under consideration. As the result of these 
changes alone, without reference to formation of emboli, vessels may 
become completely occluded, especially when slightly injured. 
Extravasation of blood is another cause connected with the blood- 
vessels, this coming usually from traumatic rupture, possibly from 
idiopathic causes. At any rate, the tension in the part may threaten 
its life because of the pressure which overcomes the circulation of blood. 
Ligation of the main trunk of an artery is sometimes followed by gan- 
grene, no matter how carefully done, collateral circulation being insuf- 
ficient to sustain the nourishment of the part. In certain fractures, 
simple as well as compound, the blood-supply of a part is rudely broken 
off by injury to a blood-vessel in such a way as to cause local or general 
death, either of a bone or of the entire limb. Flaps made for plastic 
purposes, arranged without sufficient regard to their proper blood-sup- 
ply, or so dressed after operation as to sustain undue pressure, are often 
so shut off from the heart as to die for want of blood. Finally, gan- 
grene may be the result of pressure either from splints, bandages, etc., 
or from tumors increasing in size, or possibly, as in certain pressure- 
sores, etc., from the mere weight of the body. Here, too, chemical 
agents must be mentioned, referring now to the peculiar action of certain 
foods or drugs, particularly ergot. Thus, antiseptic solutions, partic- 
ularly carbolic acid, may be made strong enough to destroy the vitality 
of certain tissues. Carbolic gangrene (Warren) is a possibility not to be 
forgotten. 
C. Constitutional Causes.—Among these are to be mentioned partic- 
ularly that symptom-complex ordinarily known as diabetes or glycosuria. 
It is notorious that this means a depraved 
condition of the system in which gangrene 
is threatened or permitted under circum- 
stances which otherwise would have little or 
no disastrous effect. Thus diabetic gangrene 
has come to be one of the recognized mani- 
festations of the general subject. That the 
trophic nerves have a more or less pro- 
nounced effect in determining gangrene in 
certain cases seems to be now quite well es- 
tablished. It is well known how quickly 
bed-sores form after injuries to the spine, 
while in certain nervous affections a mini- 
mum of friction of the skin may determine 
its death, particularly about the labia or 
scrotum. It is said that the insane, when 
made to sleep by chloral, may develop 
decubitus from pressure in a single night. 
There is also a well-known form of symmetrical gangrene, known some- 
times as Raynaud’s disease, which is characterized by symmetry of 
lesions and absence of definite pathological changes. The so-called 
digiti mortui, or dead fingers, are expressions of trouble of this same 
character; so is also that condition described by neurologists as erythro- 
melalgia. A condition almost leading up to gangrene, but perhaps not 
absolutely terminating in such a way, has been known as local asphyxia, 
Fig. 28. 
Raynaud’s disease; symmetrical gan- 
grene ; digiti mortui (Lanceraux). 104 
SURGICAL PATHOLOGY. 
which seems to be a condition of arterial spasm with venous congestion 
and slight cedema. 
As constitutional causes also must be included the deleterious effects 
of certain drugs, particularly ergot and phosphorus. A hundred years 
ago and more ergotism, or gangrene produced by eating diseased rye, 
made great devastation among the peasants of Central Europe, whole 
hands and limbs being involved in the gangrenous process. This is a 
condition now perhaps never noted, at least in this country. The selec- 
tive affinity of phosphorus for the osseous structure of the lower jaw is 
also well known, and gangrene of the bone—i. e. necrosis—used to be a 
frequent lesion among the workers in match-factories where phospho- 
rus was used. This condition has been almost abolished by wise legal 
enactments. Mercury, too, when given to excess or for an injudicious 
length of time, produces a gangrenous condition of the gums and alve- 
olar process, by which the teeth are loosened ; along with which gangren- 
ous ulcers appear also about the mouth and sometimes elsewhere. 
D. Infectious Causes of Gangrene.—In the instances already men- 
tioned I have avoided reference to the infectious micro-organisms. There 
remain to be considered special types of gangrene due to the activity of 
certain micro-organisms—among these that variety of gangrene known 
to our fathers as hospital gangrene, as well as phlegmonous erysipelas, 
malignant cedema, gangrenous emphysema, noma, ainhum, etc. 
Gangrene as the result of infectious processes is met with, for instance, in 
severe cases of phlegmonous erysipelas, where death of tissue seems to he due to 
the combined influence of the invading organisms and of mechanical agencies— 
i. e. tension produced by stasis and exudation, with such stretching of tissues or 
overcrowding them with inflammatory products as to virtually strangle them, in 
consequence of all of which they die. Gangrene of an entire hand may thus 
result, or, more commonly, the gangrene is limited in extent to the more super- 
ficial parts, so that sloughs separate. A peculiar and specific form of gangrenous 
inflammation is that also known as malignant cedema, which is due to a peculiar 
anaerobic bacillus, and which will be treated of separately under a distinct head- 
ing. Quite like it in several respects is the gangrenous emphysema of certain 
writers, known also as the fulminating form, or, as the French call it, the “ gangrene 
foudroyante” More or less emphysematous condition may accompany malignant 
oedema; yet that we do get gaseous forms of gangrene without the specific bacillus 
of malignant cedema is established. 
Hospital gangrene, so called, has been in years past the terror of mili- 
tary surgeons and camp hospitals. As a type it has almost completely 
disappeared from observation, and, in its old manifestations at least, is 
now practically never seen. During the days when it was most common 
there was no application of knowledge of bacteriology, and we are to-day 
practically in the dark as to whether it was due to a specific organism, 
or was not, on the other hand, due to causes already described acting 
upon constitutions vitiated by exposure and upon tissues made vulner- 
able by fatigue and injury. The latter is the more probable. Clinically, 
it assumed the aspect of gangrene which spread with terrific rapidity, so 
that within a few hours the death of an entire limb might be determined, 
almost without power to check it. After terrible experience with it in 
numerous camps, military surgeons found that the most effective agent 
with which to combat its destructive power was bromine, which was 
applied dilute or in full strength, as appeared best. 
Noma, known also as gangrenous stomatitis, cancrum oris, and gan- GANGRENE. 
105 
grcena oris, is a term applied to a form of tissue-necrosis affecting the 
cheeks or parts about the face of young children, occurring frequently 
as a complication of the exanthemata. A similar condition occasionally 
involves the external genitals. 
From the fact that it seldom 
passes across the middle line, it 
lias been regarded by some as of 
neurotic origin. Naturally, bac- 
teria are always found in the 
decomposing tissues, but whether 
there as cause or as result is not 
eet absolutely established. The 
probability is, however, that we 
have to deal with a specific form 
of infection. The loss of sub- 
stance is usually so great as to 
determine complete perforation 
of the cheek, so that the jaw- 
bones may be laid bare. The 
gums and alveolar processes also 
frequently share in the process, 
and the teeth accordingly drop 
out. Death of tissue is rapid, 
and septic infection may accompany it to such extent as to cause death 
of the little patient within two or three days. While theoretically most 
vigorous measures are necessary for combating it, these patients are 
often so reduced as to preclude the 
possibility of doing much, and death 
is the common termination of noma. 
Should patients recover, there is 
extensive deformity as the result of 
cicatricial contraction. 
Along the coast of Africa and in 
the West Indies there occurs among 
the negroes a peculiar gangrenous 
affection of the toes known as 
ainhum. This may assume either 
the moist or the dry type of gan- 
grene, but the result is gradual 
separation of the part, usually by 
the dry process, as if it had been 
strangulated by a ligature. The 
disease is very slow and may ex- 
tend over ten years. The minute 
cause is as yet unknown. 
Finally, gangrene is the termi- 
nation of the infectious process in several other zymotic diseases, among 
the best illustrations being that afforded by diphtheria. The formation 
of diphtheritic ulcers in the mouth and the vulva, about the eyes and 
elsewhere, as the result of separation of sloughs, is too frequent to pass 
unnoticed, yet at the same time does not essentially differ from the sepa- 
Fig. 29. 
Noma (Neisser). 
Fig. 30. 
Section of noma cheek; showing tissue of ne- 
crosis from bacterial infection (Miller). 106 
SURGICAL PATHOLOGY. 
ration of sloughs due to any other specific cause. All these acute zymotic 
diseases, therefore, need to be regarded as among the possible causes of 
gangrene by infection of tissues. 
The symmetrical gangrene, often paroxysmal, affecting the fingers and 
toes, described by Raynaud and often called by his name, is due to vaso- 
motor spasm, and is accompanied by neuralgia and sensory disturbances, 
with coldness of the part and discoloration suggestive of impending 
gangrene. (I Tide above.) 
Billroth and others have also described a spontaneous or angio-neurotic 
gangrene of the extremities, occurring during youth, in abrupt distinc- 
tion to senile gangrene, whose course is tedious and painful, and which 
will usually necessitate amputation. The cause of this condition has 
been found to be a well-marked 
arterio-sclerosis and thrombosis, 
both in the arteries and veins. 
This form of gangrene occurs 
most often in the frigid zone— 
e. g. in Northern Russia. 
Gross Appearances.—In a 
general way, tissue-death, known 
as gangrene, assumes two quite 
opposite types—the moist and 
the dry. In moist gangrene, 
aside from those general appear- 
ances which plainly indicate com- 
mencing putrefaction of tissues, 
and the loss of heat due to shut- 
ting off of the blood-supply, one 
of the most characteristic features 
is the formation of a so-called line 
of demarcation—i. e. border which 
separates the dead from the liv- 
ing tissues. While this is usually 
plainly indicated by a red line 
which more or less abruptly sepa- 
rates the discolored, usually dark, 
dead portion from the bright-red, 
congested appearance of the living tissues, we note that this area of 
redness shades out into a more and more natural appearance as we pass 
upward, while below the line we note a surface, usually covered with 
blisters, from which exudes a foul-smelling altered serum, while the 
gangrenous portion usually assumes a dark, finally an almost black, 
appearance, retaining only the crude outlines of its original shape. 
Along with this the objective evidences of putrefaction are unmistak- 
able, appearances and odor being characteristic. With all there is more 
or less constitutional disturbance, and a recognizable, often a profound, 
condition of septic infection, due to the fact that along the line of demar- 
cation absorbents are still active, and that the poisonous products of 
putrefaction are being absorbed into the general system. Consequently, 
collapse, profuse perspiration, septic diarrhoea, etc. are commonly noted. 
In gangrene from frost-bite the process is usually somewhat more slow 
Fig. 31. 
Moist gangrene of foot (original). GANGRENE. 
107 
than in the more distinctly traumatic forms. In gangrene from extra- 
vasation of urine the separation of sloughs is often extensive, and com- 
plete sloughing of the scrotum with exposure of the testicles is a not 
infrequent result. In decubitus or bed-sore the process is still more 
slow, but always of the moist type. After a variable length of time 
there is separation of slough and a resulting large, often foul, ulcer. 
Dry—or, as it is usually known, senile—gangrene presents a very 
distinct contrast to the moist type. It is met with almost invariably in 
patients over fifty, and occurs often as the result of causes which are 
slow of action. As the result of the shrinking and corrugation of the 
tissues, along with the dryness of the same by evaporation, we have a 
peculiar appearance known as mummification, the foot, for instance—for 
the feet are usually first involved—very much resembling the foot of a 
person who has been embalmed, except that it is discolored. It is pos- 
sible sometimes to have a combination of moist and senile gangrene, 
especially when there has been infection by which putrefaction is per- 
mitted. When from the outset putrefactive processes are absolutely 
prevented, the gangrene of this type is almost invariably dry. In prac- 
tically all of the cases of this character there will be found evidences 
of vascular disease, usually in the femoral artery and its branches. 
Gangrene of the foot alone is most commonly due to endarteritis, 
while gangrene of the foot and leg together are usually due to embolism 
or thrombosis. 
Signs and Symptoms.—Aside from those already mentioned, which 
are recognizable at a glance, there is but little more to say. The ap- 
pearance and the odor of a part will quickly indicate impending or actual 
traumatic gangrene. The pallor, the coldness, and the dryness of senile 
gangrene are also characteristic. In the latter form, at least up to a 
certain point, constitutional symptoms are not indicative nor essentially 
of septic type. Just so soon, however, as a process of spontaneous sepa- 
ration begins putrefaction is inevitable and sepsis unavoidable. In moist 
gangrene there is seldom acute pain. This is one of the predominating 
subjective features of the senile forms, at least in many instances. Hem- 
orrhages occur, sometimes terminating fatally, in the moist forms when 
large vessels are eroded. This is particularly true of the phagedenic or 
hospital form. A recognition of their possibility may enable us to avoid 
sudden death from this source. 
Treatment.—We shall speak first of treatment of threatening gan- 
grene, which, so far as it may be possible, should impel us to attack and 
remove the cause. Threatening bed-sores may be avoided by equalizing 
surface pressure, and this best with the water-bed; by protecting the 
skin or by stimulating and toughening it with alcoholic and astringent 
lotions; by frequent changes of position; by attention to the heart, 
which should be stimulated to a point that may make it capable of for- 
cing or distributing blood equably over the entire body. So, too, with 
limbs which are enveloped in dressings or splints : it is always well to 
leave exposed the tips of the toes or fingers, at least when practicable, 
in order that discoloration of the same may be quickly recognized 
and the threatening disasters averted. Local gangrene as the result 
of pressure by tumors, aneurisms, etc. cannot always be averted, 
though one realize its imminence. These are cases where one needs 108 
SURGICAL PATHOLOGY. 
must sit hopelessly and helplessly by and see that occur which he can- 
not obviate. 
For gangrene which has actually occurred there is but one relief, and 
that is the removal of the dead and dying tissue. The method and loca- 
tion of the operation must be determined somewhat, however, by the 
general character of the cause. For a case of acute traumatic gangrene 
amputation at the nearest point of election above the injury will often 
suffice. In case of gangrene from frost-bite the tissues in the neighbor- 
hood of the line of demarcation are often so affected or their vitality so 
compromised that to simply separate the tissues along the lines at which 
nature is endeavoring to remove them is not enough, and to go an inch 
or so above this line is simply to operate in tissues which bleed readily 
and heal badly. Consequently, here it is often good judgment to select 
a suitable point at some distance above. But it is especially in the forms 
of diabetic and senile gangrene that surgeons have now laid down the 
rule that if amputation be done at all, it must be high. If one have senile 
gangrene of the toe, for instance, as the result of disease of the vessels, 
he maybe sure that it will be wise to amputate at least above the ankle; 
whereas if any greater portion of the foot be threatened, it will be emi- 
nently judicious to amputate above the knee, if at all. I have repeatedly 
under these circumstances found the tibial arteries so brittle as to snap 
under a ligature, and even the femorals so disorganized as to require 
handling and ligating with the greatest caution. These high amputations 
are therefore necessitated by the condition of the vessel-walls ; all of 
which must needs be explained to many patients before they can appre- 
ciate the reasons for such high operations or consent to them. While 
amputation for traumatic and acute cases is, in the majority of instances, 
if not too long delayed, successful in saving life, in the senile, and par- 
ticularly in the diabetic forms, it is in the majority of cases a disappoint- 
ment ; and my advice to all, especially to young men who are chary 
about assuming responsibility, is to have these matters definitely under- 
stood and the situation thoroughly canvassed before consenting even to 
make such an operation, urgently as it may seem indicated. PART II. 
SURGICAL DISEASES. 
CHAPTER VI. 
ON AUTO-INFECTION, ESPECIALLY IN SURGICAL PATIENTS. 
Roswell Park, M. D. 
Oxe of the greatest advances made in recent pathology has been the 
establishment of the fact that a great many of the morbid conditions 
from which the human race suffer are those due to causes arising 
entirely from within their own systems and in consequence of deficien- 
cies of elimination or of perverted physiological processes which, in 
large degree, are themselves the result of errors and indiscretions in diet, 
in manner of life, in habits, etc. That these general facts have been 
recognized for centuries is perhaps a credit to the powers of observation 
of practitioners of past generations. Exact knowledge, however, has 
come only with exact laboratory methods of research and most pains- 
taking study of the secretions and excretions, both under normal and 
morbid conditions. The subject of auto-intoxication has been too com- 
monly relegated to the domain of internal medicine, and has been sup- 
posed to be one in which the surgeon, as such, need take only passing 
interest. 
This is a most sad and egregious error, however, and that surgeon will prove 
himself the best master of the situation who is thoroughly conversant with all 
that the general topic of auto-infection comprises and implies, for he will find 
that his surgical patients do well or badly just in proportion as he maintains 
equilibrium between ingestion and egestion, or as he realizes that retained excre- 
mentitious products are among the most active predisposing causes of what may 
a little later appear as distinct surgical sepsis. For this purpose, therefore, the 
present chapter is included in a distinctly surgical text-book. It includes not 
only the interesting topics of the ptomaines and leucoma'ines, but comprises much 
more, as shall be seen. 
It pertains in large degree to the intimate secrets of the chance meeting of 
man and microbes, which are so constant, yet so often without result. In the 
consideration of auto-intoxication is to be found much of the explanation why 
infection, which apparently occurs so easily, is yet relatively so uncommon. It 
brings up the statement so emphasized by Bouchard, that physicians ought not to 
permit themselves to be occupied alone with the research after microbes, but that 
they ought to busy themselves as well with investigating the circumstances which 
disarm the organism against microbic invasion. 
The alkaloids are by no means the only poisonous products which 
the human body may produce and retain. The most important excre- 
mentitious material of all—i. e. carbonic dioxide—could not be retained 110 
SURGICAL DISEASES. 
in the organism for more than a few moments without death as the in- 
evitable consequence. The various soluble ferments elaborated by certain 
glands may exert deleterious influence, botli local and general; and in 
the saliva are also found products which are not ferments. The biliary 
acids also, if they do not find free escape, may produce fatal poisoning. 
So also leucin, tyrosin, and all of the excrementitious products which 
arise from insufficient liver-activity, are capable of producing forms of 
intoxication—such, for example, as eclampsia, etc. By no means all of 
the alkaloids produced within the body are poisonous. Some of them 
are met with in the normal tissues, and they are, perhaps, only one of 
the many results of the disassimilation of animal cells. Nor are all 
these poisions of bacterial origin, although many are only formed in the 
presence of microbes. 
Throughout his life man is inhabited for nearly the whole length of his digest- 
ive tube by inferior and parasitic vegetable organisms. When some of their prod- 
ucts are absorbed more or less poisoning is sure to ensue, while, again, abnormal 
conditions not primarily due to them may, nevertheless, prevent their elimination, 
and intoxication thus ensue. 
From these constantly-menacing sources of intoxication man escapes 
by virtue of his intestinal, cutaneous, pulmonary, and renal emunctories. 
For instance, the usefulness of the perspiration is shown by the odor 
which it assumes under the influence of certain disorders. Amongst 
hypochondriacs and the inactive, fatty acids are eliminated abundantly 
by the skin. Hence the odors of hospital wards, asylums, prisons, etc. 
So, too, in the case of many who suffer from deep-seated, indolent 
ulcers, the odor of the skin is suggestive of the presence of pus. During 
twenty-four hours there are eliminated from the lungs 1100 grams of 
carbonic dioxide, water, etc., which sometimes contain ammonia and 
various volatile fatty acids; all of which will explain foetor of breath 
when it is the result of incomplete nutrition and destruction of food. 
Of all the organs of elimination, the most important is the kidney, which 
can never be charged with reabsorbing a part of its own products, as 
does the intestine. The kidneys eliminate fluids and solids, not gases. 
The most important of the toxic principles contained in the urine are— 
1. XJrea, which ordinarily plays a most important and useful role in 
the economy, since it possesses the property of forcing the renal barrier 
and removing along with itself both the water in which it is dissolved 
and other toxic matters. Urea is toxic, but only in the sense that any 
other substance, even water, may be so—i. e. it is toxic only in relatively 
enormous doses, much less so than sugar, and no more so than the most 
inoffensive salts. This is contrary to generally received views, but is 
experimentally clearly established by the researches of Bouchard. 
2. A narcotic substance, and 
3. A sialogogue substance, whose composition is unknown. 
4. 5. Two substances having the property of causing convulsions, one 
having the power of contracting the pupils. Composition of both un- 
known. 
6. A substance which produces heat by diminishing heat-production 
—possibly a coloring matter. 
7. Potassium salts, which are really convulsing agencies, and are the 
most toxic perhaps of any of the poisons contained in the urine. The ON AUTO-INFECTION, ESPECIALLY IN SURGICAL PATIENTS. 
111 
chloride of potassium, for instance, is toxic at 18 grains for every kilo 
of animal. 
Salivation and myosis, as well as diarrhoea, are often noticed in so-called 
urcemia. In that form known as hepatic uraemia, when the liver no longer forms 
urea, the kidneys scarcely act. In other words, if urea be no longer present in 
the body, the kidneys are deprived of their principal stimulation to physiological 
activity. Consequently, urea, for so long a time the bugbear of physicians, is 
shown to be most dangerous when absent. When urea is deficient it is most wise 
to resort to withdrawal of large quantities of blood-serum or of water in which the 
other toxic substances are dissolved. This is best done by venesection, whose value 
in so-called ursemia past experience amply corroborates. When kidney activity 
ceases intoxication is most likely to be produced by potassium salts. 
Correct performance of hepatic function is also most necessary in 
order that surgical cases may progress without disturbance. Bile 
escapes direct absorption by the blood, but not all contact with it, since 
in the intestine it is in contact with mesenteric capillaries, but must 
pass again through the liver, which shall take it up anew and pour it 
once more into the intestine. 
Bile in the blood is always dangerous, although its toxicity is relatively much 
smaller than has been generally supposed. Of all the bile thrown out into the 
duodenum, we are only able to account for about one-half. Its coloring matter 
and biliary salts are metamorphosed. Yet in certain morbid conditions bile, as 
such, may be reabsorbed in the liver along the margin of the hepatic cells. In 
these cases, if the kidneys remain permeable, auto-intoxication is simply threat- 
ened ; if they have ceased to be permeable, actual auto-intoxication is the result. 
Putrefaction of intestinal contents affords another source of auto- 
intoxication. This comes both from imperfect metamorphosis of food 
and from bacterial infection. Here the conditions are most favorable. 
Nitrogenous substances become peptonized, and peptones form the best 
culture-media for microbes. Water is present in sufficient quantities, 
and a constant temperature of 37° C. is maintained. The digestive tube 
is always open, and invaded at frequent intervals. By such mechanism are 
formed those products whose effects are revealed in the so-called putrid 
fever of Gaspard. Brieger has shown that alkaloids are developed 
during the act of peptonization. Fecal matter contains also excretin, 
whose toxicity has been amply proven, and several other alkaloidal sub- 
stances, soluble in various media, varying in toxicity. The potassium 
and ammonium salts contribute largely to the toxicity of faeces ; bile also, 
but in lesser degree. It has been shown that the aqueous extract of 
putrid matter is very toxic, but that of fecal matter is much more so. 
From the tissues, the secreting organs, the ingesta, and the various putrefac- 
tions going on within the body come the principal toxic products introduced into 
the blood, and which it is possible to estimate. The elimination of these is thrown 
almost entirely upon the kidneys; but it does not follow, because the urine is 
strongly toxic, that the blood is habitually so. If the urine were not toxic, the 
blood would rapidly become so. Auto-intoxication practically does not happen to 
those whose kidneys work perfectly naturally. 
A normal kidney secretes ordinarily from 1200 to 1500 c.c. of urine, but it may 
secrete as much as 25 litres. Instead of 20 to 25 grams, the average elimination 
of urea, it may eliminate 120 grams, as in cases of diabetes insipidus. Instead of 
the 1 gram of uric acid which is ordinarily eliminated in twenty-four hours, it may 
in cirrhosis and leukaemia eliminate 8 grams or even more. Even 140 grams of 
sugar per litre may be passed off in this way; and so fat, peptones, albumen, and 
other substances, which it ought not to permit to pass, may escape through its 
channels. The few grams of albumin which the patient with Bright’s disease 112 
SURGICAL DISEASES. 
eliminates each day are made too much of. Such a slight spoliation is not capable 
of causing deterioration by itself, for a nursing woman loses ten times as much by 
her milk, and her system*is not thereby weakened. It is only when albuminuria 
is accompanied by fever or by impaired nutrition, or when it is intense—in other 
words, it is only when albuminoid loss is serious, as in cases of abundant leucor- 
rhcea, dysentery, suppuration, and ascites—that it becomes really serious. 
The most serious features of the various conditions grouped in time 
past under the heading Bright's disease are their so-called uraemic fea- 
tures. These happen at the period when retention of toxic products is 
peculiarly harmful. So long as the urine be ample in amount and of 
high enough density—i. e. containing enough toxic materials in solution 
—there is no danger of intoxication. But when it no longer eliminates 
in twenty-four hours what it ought to, then we see the chronic and par- 
oxysmal nervous accidents, the oedemas, fluctuations of temperature, etc., 
which are properly considered so serious. Oliguria with urine of increas- 
ing density and general oedema of the tissues may be noticed, although 
the other secretions continue natural and the tongue be moist. So long 
as the normal amount of solids is eliminated, this form of u uraemia” may 
be due to mere accumulation of water, and may not be serious. Ordi- 
narily, uraemic patients are those whose urine has lost its toxicity. Usually 
on the day in which so-called uraemic accidents happen the urine quite 
ceases to be toxic and is scarcely more so than distilled water. Urea 
alone is not to be held guilty for this condition. In order to kill a man 
with urea it would require the quantity which he makes in sixteen days. 
Nevertheless, it may become harmful after undergoing transformation 
into ammonium carbonate or other substances. 
Among the most poisonous substances in the urine are the extractive 
and coloring materials. Normal urine loses one-half of its toxicity by 
decoloration ; bile acts in the same way. Urea alone represents about 
one-eighth of the total toxicity of urine. Ammonia is toxic, but present 
in small amounts. The coloring matters of the urine cause two-thirds of 
its toxicity, the remainder of which is to be ascribed to its mineral salts, 
which it contains in the following proportion : A litre of urine ordinarily 
contains 44 grams of solid matter, of which 32 are organic, 12 mineral. 
Of the latter, potassium salts constitute 3 grams, sodium salts 7.50, and 
other earthy salts constitute the remainder. 
In these conditions physicians have, in time past, relied largely upon purga- 
tives, hoping thereby to remove urea from the blood. But intestinal elimination 
has no elective affinity for it, and removes it only in its normal proportion with the 
balance of the blood. Purgatives, however, help, first, by dehydrating the tissues 
—i. e. removing water with toxic material in solution. But they should be followed 
by restoring to the tissues pure water. By bleeding more extractives are removed 
than by any other channel, except by the kidneys. A bleeding of 32 grams removes 
from the body as much toxic matter as would 280 grams of a liquid diarrhoea or 
100 litres of perspiration. This much may be removed by two leeches. It is espe- 
cially in the subacute nephritis of scarlatina, etc. that bleeding finds its greatest indi- 
cation. If the kidneys be chronically diseased, the utility of bleeding is doubtful, 
for we cannot continue it incessantly. Between the arterial capillaries of the bowels, 
however, and the liver is found a mass of blood accumulated in the portal vessels. 
This may now be regarded as a reserve which can be thrown into the general cir- 
culation when needed, in order that thereby we may augment arterial tension and 
so increase kidney function. Gold injections into the bowels will often accomplish 
this, and serious anuria often disappears after their use. It is reasonable now, also, 
to make deliberate use of urea by subcutaneous administration as the most power- 
ful diuretic known, surface friction, caffeine, digitalis, etc. being far behind it in ON AUTO-INFECTION, ESPECIALLY IN SURGICAL PATIENTS. 
113 
efficiency. In that particular form of intoxication noted in the eclampsia of puer- 
peral patients inhalations of chloroform are most valuable. Potassium salts should, 
under these circumstances, never be employed. We may also take advantage of 
the fact that an exposure of urine in compressed air will diminish its toxicity, on 
account of contact with the oxygen, as well as of the fact that the most toxic bac- 
teria are those which grow without oxgyen. Consequently, by causing these 
patients to inhale this gas we may in large measure overcome this kind of auto- 
intoxication. 
The value of a thoroughly active liver is also not appreciated to the 
full extent by most surgeons. The blood of the portal vein is so much 
more toxic than that of the hepatic vein that it is most evident that the 
function of the liver is, in large measure, to purify and remove from 
the blood that comes from the intestines no small amount of highly 
toxic material. This has been called by Flint and others the depura- 
tive action of the liver. In order that it may functionate properly it is 
well to limit the food to the minimum of putrescible substances; for 
which purpose a milk diet, when well tolerated, comes the nearest to 
the ideal. The intestinal canal should also be cleared of putrefactive 
material so far as possible, and, in addition to purgatives, drugs like pow- 
dered charcoal, bismuth salicylate, iodoform, naphthaline, salol, etc. 
should be administered. Many uraemic accidents supervening after 
surgical operations may be atoned for, and the condition made to pass 
away, by internal administration of naphthaline and charcoal. 
Man forms by his liver in eight hours enough poison to kill himself. Of 
these liver-poisons the urine does not eliminate half. In fact, it would 
take the urine of two days and four hours to get rid of the quantity of 
poison of hepatic origin necessary to kill. Bile is nine times as poison- 
ous per volume as is urine. Its principal toxicity comes from its color- 
ing material—of which the bilirubin is the most powerful—and its salts, 
all of which, when precipitated, escape reabsorption. 
That facts above stated or others related thereto have not been 
entirely lost sight of by surgeons in time past is shown by such expres- 
sions as septic enteritis, enterosepsis, etc. which are used by various writers. 
In previous writings I have made a separate and distinct topic of so- 
called intestinal toxaemia, which here I have preferred to introduce as 
simply one of the many possible auto-intoxications. To be sure, it is a 
condition not always permitting of exact definition, nor, still less, can 
the exact toxic agency be certainly indicated in a given case. Neverthe- 
less, it has been made plainer and plainer within the past few years that 
there is perhaps no condition which so predisposes to saprcemia, septicaemia, 
or even pyaemia, as this vague condition of intestinal toxaemia, which, 
nevertheless, is so often present. I have long maintained that many 
surgical patients present forms of blood-poisoning in which the poison 
has not proceeded from the wound, and for which the surgeon is not 
responsible, except in so far as he may have neglected to avail himself 
of certain precautions based on facts which this chapter purports to 
teach. 
The practice of preparing patients for operation by a course of purgatives, 
emetics, etc., which has prevailed at many times in the past, is based upon the 
crude recognition of certain principles which it is desired here to make much 
clearer. Some one, if not each, of the general symptoms included under the name 
enterosepsis, siercorcemia, coprcemia, or whatever one may choose to call it, is cer- 
tainly due to the activity of the colon bacillus, which seems to be made more viru- 114 
SURGICAL DISEASES. 
lent by certain conditions of diet or retained fecal excretions, and to such an extent 
that it now wanders widely from its normal habitat and may be found in distant 
parts of the body. Enterosepsis may be mistaken for surgical fever, and is to be dis- 
tinguished from it, perhaps, only by the careful study of the excretions of a given 
case and establishing the fact that they are free, and that consequently pyrexia, 
etc. cannot be due to diminished elimination. Aside from the migrations of the 
colon bacillus, it is also possible for such a degree of auto-intoxication to occur 
that infection by other organisms is permitted, as it would not otherwise be; and 
thus that which is to-day stercoraemia may become in a day or two a genuine sep- 
ticaemia, vital resistance being lowered to the extent of permitting local infection 
that could otherwise not have occurred. The various conditions are clinically so 
often merged together that it is difficult or impossible to separate and identify them. 
Nevertheless, the fact should be taught as plainly as our language may permit that 
enterosepsis differs from sapraemia, to be considered shortly, in that in the one 
instance the putrefying material is contained within a normal cavity, whereas in 
sapraemia it is contained within an abnormal cavity, in either case corresponding 
to a septic suppository, varying, however, in the place of insertion, varying also in 
the nature of the surrounding tissues, which in the latter case are much more 
capable of absorption and of becoming infected than in the former. 
The practical outcome of such a chapter as this is, then, to insist as 
strongly as possible on the preparation of patients, whenever this is 
feasible, for an ordeal which comprises the combined etfect of anaesthesia 
and consequent disturbance of secretion and elimination, with loss of 
blood and of strength, and subsequent confinement in bed, with, more- 
over, all that this entails in further impairment of activities of important 
organs. It is not always possible, practically rarely so in emergency 
cases, to adopt these precautions; in which cases they must be atoned 
for,' so far as possible, by extra attention in the same directions after the 
emergency is passed or has been met. In the former case, however, the 
functions of the skin, the kidneys, and the abdominal viscera must be 
regulated—the first by hot-air baths; the second by this same measure 
in conjunction with copious draughts of pure water, the correction of 
hyperacidity of the urine, and the administration of whatever drugs 
may be of benefit as diuretics, etc.; and the third by a course, perhaps 
covering several days, of gentle or active purgation, by which the ali- 
mentary canal shall be entirely emptied of all that may serve to act as 
a source of poisoning. In addition to this, in certain cases careful mas- 
sage will dislodge from the muscles and other tissues material which 
they ought not to retain, and which shall be washed away, as it were, by 
the extra amount of fluid which this preparation necessitates. In addi- 
tion, also, the activity of the heart should be stimulated, perhaps by 
digitalis, but preferably by that best of all tonics, strychnia, which is to 
be administered hypodermically in average doses of a thirtieth or twenty- 
fifth of a grain, morning and night. When these precautions are taken 
patients will successfully pass through most trying ordeals without any- 
thing which may give rise to alarm. When they are not possible, the 
risk of operating, even in a small way, is materially enhanced. So, too, 
after operations when these precautions have not been taken it is neces- 
sary to give most careful pains to atoning for their lack by such active 
purgation as a now reduced patient may bear—by hot-air baths, if feas- 
ible, and by the administration of such intestinal antiseptics as charcoal, 
naphthaline, corrosive sublimate, bismuth salicylate, salol, etc., for the 
purpose of reducing to the lowest possible minimum the opportunity for 
formation of poisons which shall disturb the proper repair of injury. ON AUTO-INFECTION, ESPECIALLY IN SURGICAL PATIENTS. 
115 
APPENDIX. 
So much has appeared in the literature of the past few years with reference to 
so-called ptomaines and leucoma'ines—whose composition has-been more or less 
accurately studied—and there have been so many references to other poisonous 
substances which have been more or less loosely grouped as toxines and toxalbu- 
mens, that it will probably be of great assistance to the student to at least define 
these terms and give some brief description of the more important substances thus 
classified. The original distinction between the terms leucomciine and ptomaine was 
that the former was the result of bacterial activity in albuminoid substances, 
occurring during the life of the individual within whose interior these processes 
were actively going on, while the underlying idea in the definition of “ ptomaine ” 
is that the ptomaines as a class are alkaloidal substances formed by putrefaction 
of deal animal material. The terms, however, have been extremely loosely used, 
and, while it is well to maintain these distinctions so far as possible, they cannot 
be abruptly made, because it is known that certain of these toxic bodies may be 
produced under both circumstances. In a general way, however, we may still 
retain the idea that leucoma'ine formation may be a part of badly-performed diges- 
tive function, while ptomaine formation is connected with the death and putrefac- 
tion of the body tissues themselves, such as occur in many of the infectious dis- 
eases—e. g. suppuration, abscess-formation, septicaemia, gangrene, etc. 
The leucoma’ines are not necessarily all of alkaloidal construction, but are 
more or less proteid in their chemical arrangement. They are usually divided 
into two groups: the uric-acid group, comprising adenin, carnin, guanin, xanthin, 
spermin, gerontin, etc., and the creatinin group, in which are found its various 
derivatives, anticreatinin, xanthocreatinin, etc. Another class of betaine leucomaines 
has been formed, including betaine or oxyneurin, which has been found in the 
human urine, although it seems to exist normally in the red beet and is not toxic. 
The most poisonous of all these leucomaines seems to be gerontin. 
The ptomaines may also be divided into those which are free from oxygen, 
which persist throughout putrefactive action, and whose bacteria are not yet care- 
fully studied. They include collidin; parvolin; neuridin; cadaverin, found in 
herring brine and putrefying human flesh; putrescin, found under the same cir- 
cumstances ; mydalein, which appears after several days in cadavers and is quite 
toxic. Most of this group are but mildly toxic. 
The second group consists of ptomaines containing oxygen, whose bacteria are 
also, for the most part, as yet undetermined. This group forms a connecting link, 
as it were, between the previous group and the leucoma'ines, being found alike in 
dead and living tissue. It includes, among others, neurin, which is very toxic; 
cholin, less so; muscarin, first discovered in mushrooms, quite toxic; gadinin; 
mydatoxin ; rnethylguanadin ; mytilotoxin ; peptotoxin ; etc. Nearly all of these two 
groups have alkaloidal properties and form salts with acids. Physiologically, they 
have been divided into those having the properties of conium, atropine, delphinine, 
digitaline, morphine, nicotine, strychnine, veratrine, etc. 
A third group has been made of ptomaines known to be produced by certain species 
of bacteria, though as yet not necessarily solely identified with them. Tyrotoxicon 
is the best known of these. It includes also trimethylamine. 
A fourth group comprises ptomaines which have been isolated only from pure cul- 
tures of known species of bacteria, and includes typhotoxin, from cultures of typhoid 
bacillus; tetanin, tetanotoxin, and spasmotoxin, made from pure cultures of tetanus 
bacilli. 
Finally, a series of toxalbumens has been separated by precipitation from pure 
and filtered cultures of various pathological organisms, which have of late played 
a most important role among therapeutic agencies. It is not possible to describe 
them fully, even did space permit, but they include the active principle contained 
in Koch’s tuberculin and its modifications, in the serum prepared by Behring and 
others from diphtheria cultures, in the mallein prepared from cultures of the glan- 
ders bacillus, in the material made from the serum of animals rendered immune 
to tetanus, etc. These are for the most part precipitable by absolute alcohol from 
the glycerin solutions or blood-serum, in which they are held in solution, and may 
be produced and worked with in solid form. Their minute chemical composition 
is unknown. 
Of all of the substances above mentioned or alluded to, it probably may be 116 
SURGICAL DISEASES. 
stated without exception that they are formed as the result of the presence in the 
tissues or body juices of micro-organisms, without whose presence putrefaction is 
impossible, and without which many of the ordinary digestive processes could not 
be carried on. Thus, it may be made to appear that certain disease-manifestations 
which are in one sense the result of parasitic agents—i. e. of bacterial activity—are 
such, in effect, because of the intoxication—in one respect the auto-intoxication— 
produced by the peculiar activities of the alkaloidal, proteid, and albuminoid sub- 
stances which are produced within the tissues as the result of their presence, be it 
as their excretory products or as the consequence of their agency in producing 
metabolism. 
Very recently a large amount of most important work has been done, showing 
that of the various aromatic substances, including indol, phenol, cresol, catechol, etc., 
which are produced in consequence of the action of anaerobic organisms upon 
proteids and their resulting putrefactive decomposition, these substances are 
eliminated from the body, through the urine, if absorbed, almost exclusively in 
combination with sulphuric acid or acid sulphates in the form of ethereal sulphates. 
The deleterious character of potassium salts has been already alluded to, and their 
combination with these ethereal or aromatic sulphates is still more poisonous. 
Sulphates, as they appear in the urine, are spoken of as the preformed—i. e. the 
mineral—and the ethereal sulphates. It has been further demonstrated that 
indican as it appears in the urine is a combination of the conjugate sulphate of 
hydroxylated indol with an alkali, which may be termed indoxyl sulphate. Indol 
is a normal and constant constituent of the faeces, to which, in some part, the dis- 
agreeable odor of the latter is due. The relation between indol in the intestines and 
indican in the urine is now completely established, as well as that indol is the con- 
stant product of putrefaction of albuminous material in alkaline media. Indican 
elimination, then, may be regarded as an index of the degree of antiseptic—i. e. ger- 
micidal—activity of the digestive juices. Of these juices, the gastric juice is, by vir- 
tue of the free hydrochloric acid which it contains, the ideal intestinal antiseptic; 
whence it follows that the presence of indican in the urine means absence or deficiency 
of hydrochloric acid in the stomach} Simon has summarized the importance of this 
in the most thorough way, and his conclusions may be epitomized as follows: 
Intestinal putrefaction is in inverse ratio to the amount of free hydrochloric 
acid, and is inseparable from increased formation of indol. The conjugate sul- 
phates found in the urine form an index of the degree of absence of free hydro- 
chloric acid—i. e. of intestinal putrefaction. Indicanuria practically never occurs 
with normal acidity of gastric juice, save in the case of ulcer of the stomach, 
which is an apparent exception to this rule. Estimation of indican is a matter of 
consequent great importance, particularly in differential diagnosis—e. g. between 
ileus and coprostasis, where a small amount only of indican will exclude the 
former condition. Two possible surgical conditions are to be considered in their 
relation to indicanuria : If resorption of decomposing pus is taking place anywhere 
in the body, there will be increased elimination of indican. If there exist stenosis 
of the small intestine, the same will obtain. In order to get reliable and average 
results, it is necessary that the diet should be a normal mixed diet.2 
A convenient and reliable method of estimating the probabilities of entero- 
sepsis, etc. is, then, afforded by practical application of the test for indicanuria. 
From the facts above set forth one may learn also the advantage of administration 
of hydrochloric acid, probably in combination with minute doses of corrosive sub- 
limate, as one of the preparations or methods of fortification of a patient for a sur- 
gical ordeal. (See articles by Herter and Smith, N. Y. Med. Journ., June 22, 
1895, et seq., and by Simon, Am. Journ. Med. Sci., July and Aug., 1895.) 
1 A series of careful studies, by my colleagues, Drs. Stockton and Jones, has shown 
that these statements, while in the main correct, are not to be regarded as invariably 
reliable. 
2 Indicanuria should be estimated from a twenty-four-hour sample, of which a few 
c.c. are mixed with an equal amount of concentrated hydrochloric acid, two or three 
drops of a saturated solution of sodium hypochlorite or of common saltpetre being 
added, and, after mixture, one or two c.c. of chloroform. This mixture is then shaken 
and set aside. Indigo, if present, is set free and taken up by the chloroform, which is 
colored blue to greater or less extent. Before making this test albumen, if present, 
should be removed, and bile-pigments should be separated by carefully adding a solution 
of plumbic subacetate. CHAPTER VII. 
THE SURGICAL FEVERS AND SEPTIC INFECTIONS. 
Roswell Park, M. D 
Fever is an expression of constitutional disturbance whose most 
marked characteristic is elevation of body-temperature and augmenta- 
tion of surface-heat. 
This not being the place to go into a minute discussion of the causes of fever, 
it will be enough at this time to state that normal temperature of animal bodies is 
regulated by the heat produced from certain chemical changes, the result of the 
body chemistry, and for the most part controlled by the innervation of the tissues 
and organs, mainly of the muscles, these chemical changes consisting mainly in 
oxidation of tissues and elimination of carbonic dioxide. The so-called surgical 
fevers and infections are, for the most part, accompanied by, and often consist 
largely of, associated symptoms to which in a general way the name of fever has 
from time immemorial been given, the most prominent of which is the actual 
elevation of body temperature, which means either that heat-elimination goes on 
more slowly than normal or that heat-production is more active. In the surgical 
infections the latter is for the most part the case. Even before the first general 
sense of discomfort known as malaise some slight rise of temperature may be 
noted by means of an accurate thermometer. The association of the sense of 
extreme coldness—i. e. chill—with involuntary movements of the muscles is fre- 
quent, and may be noted while the temperature is steadily rising or after it has 
risen. If the so-called stage of invasion—i. e. rise of temperature—be gradual, 
chill is usually absent; on the other hand, chill is usually an expression of an 
acute invasion and serious disease. It is necessary, however, to distinguish between 
a genuine chill of this kind and spurious chills, which are often the result of 
nervous disturbance, in which the patient shivers and chatters, but in which 
temperature does not rise. Following chill, when it occurs, are dryness of the 
tongue, thirst, scanty urine, discomfort, often headache. Simultaneously with the 
occurrence of perspiration these symptoms subside and temperature falls, perhaps 
to normal. It is necessary to distinguish between high temperature and over- 
production of heat. The two do not necessarily go together. When temperature 
runs to an extreme height, we speak of hyperpyrexia. In these cases temperature 
exceeds 107° F., and there are authenticated cases, not strictly surgical, where 
temperature has risen to almost fabulous heights, even to 140° F. and more. In 
the majority of surgical fevers the disturbance is due to the presence of some 
extraneous material in the blood, while the severity of the fever appears to depend 
rather upon the nature of this material than its quantity. So it is in accordance 
with clinical experience that the presence of pus of recent origin within the tis- 
sues is nearly always accompanied by fever, while the old deposits of pus, which 
have been more or less metamorphosed (archepyon), never are thus accompanied. 
Again, the presence in the tissues of blood-clot, or infused fluid, like that from a 
hydrocele, or even pure water, is known to cause some elevation of temperature. 
Again, when certain tissues break down there are released fermentative substances 
similar to fibrin-ferment which have a pyrogenous action. Other ferments, such 
as pepsin and pancreatin, also cause fever when injected. Nearly all the products 
of decomposition or putrefaction have an analogous action. When we deal strictly 
with the surgical fevers, it may be maintained that fever is due to the presence of 
pyrogenous organic materials in the blood which are the result of bacterial activity, 
or to some ferment-like substance, or to the presence of living bacteria (Warren). 
With these general considerations we are better prepared to approach, first, the 
topic of 
117 118 
SURGICAL DISEASES. 
Surgical Fever, known also as Traumatic Fever, or 
Aseptic Wound-fever. 
In times past, when operations were never done aseptically and when 
ideal wound-healing was unknown, the surgical fevers were all grouped 
together, and a certain amount of febrile disturbance was looked for 
after any injury. But with the introduction of antiseptic methods and 
with healing of wounds by primary union, with absence of all septic 
phenomena, and at present when the careful use of the clinical ther- 
mometer is common, it is noted that there is, nevertheless, a certain 
rise of temperature more or less quickly after an operation or recep- 
tion of a wound, with fever of mild grade persisting for several hours 
or two or three days, and with certain other accompaniments which are 
usually noted along with it. This phenomenon has been carefully 
studied, and so completely separated from the septic fevers as to have 
deserved a distinct recognition under the names above given, of which 
the most common in this country is surgical fever. 
So long as this fever be free from indications of septic character it is 
without significance and needs only symptomatic treatment. It begins 
usually within the first twenty-four or thirty-six hours, after which tem- 
perature may rise progressively or with a morning intermission to a 
height of 102°, or possibly 103° F. In children we are more likely to 
get extremes in this regard than in healthy adults. It will be followed 
by some disturbance of alimentary function, glazing or drying of the 
tongue, deficiency in urinary secretion, and will nearly always subside 
spontaneously—invariably so if cathartics, diuretics, cool sponge-baths, 
etc. be properly resorted to. It is usually due to the retention of blood- 
clot, ligatures, etc., or tissues which have been ligated and whose stumps 
remain; in all of which instances there is some foreign material to be 
removed. This means unusual phagocytic activity, perhaps temporary 
leucocytosis, with active metamorphosis of clot and other material; of 
all of which, the elevated temperature is an accompaniment and expres- 
sion. It is not unlikely that the antiseptic materials sometimes used 
have also to do with this pyrexia. 
Iodoform and carbolic acid are among materials in common use which are 
known to be irritating and capable of producing toxic symptoms. Often after the 
use of the latter the urine will be discolored and will furnish the clue to the fever. 
In young children particularly, and not infrequently in adults, mental disturbance, 
even to the point of active delirium, may characterize the case. This is not always 
to be explained by cerebral anaemia due to loss of blood during the operation or 
accident, but is undoubtedly in certain instances due to drug-toxaemia, or in other 
cases to intoxication from materials furnished by the altered tissues. 
Surgical fever of strict type may merge into a more or less continuous 
fever as the result of intestinal toxaemia permitted by failure to thoroughly 
evacuate the bowels, and this intestinal toxaemia may be a predisposing 
cause of genuine septic infection. Consequently, a surgical fever which 
does not disappear within two days is to be viewed with suspicion, espe- 
cially if it do not subside after the administration of cathartics. 
Some of these surgical fevers are accompanied by eruptions, a number of which 
may be due to drugs, but some of which at least are due to intrinsic poisons. 
Thus, carbolic acid and iodoform give rise occasionally to erythematous eruptions, 
and the concomitant administration of drugs like potassium iodide, quinine, anti- THE SURGICAL FEVERS AND SEPTIC INFECTIONS. 
119 
pyrine, and copaiba may produce urticarial or other manifestations. Again, it is 
known that certain toxines—produced, e. g., by the bacillus pyocyaneus—are capa- 
ble of causing dilatation of the superficial vessels and various flushes or eruptions. 
To one of these, which dilates the capillaries, Bouchard has given the name of 
ectasme. Consequently, it by no means follows that every eruption or rash follow- 
ing operations or injuries is of a specific character. On the other hand, it seems 
to be established by numerous observers—among whom Paget is perhaps the most 
prominent—that surgical patients, particularly the young, are notoriously liable to 
infection by scarlatina; and in the experience of Thomas Smith, of 43 children 
whom he cut for stone 10 had scarlet fever. Consequently, in spite of the fact 
that a certain number of cases of eruption may have been mistaken for scarlet 
fever, it is undoubtedly true that in surgical and puerperal cases patients are more 
than usually liable to this invasion. 
Erythema multiforme or similar eruptions may also be produced by 
the purely local irritation of an antiseptic dressing. The same is true 
also of eczema, and slight elevation of temperature is not infrequently 
the result of this local disturbance. These toxic erythemas usually occur 
in patches, and when due to the above cause are well localized. When, 
on the other hand, they belong to the medicinal eruptions, they are seen 
on the body and extremities as well, and usually quickly disappear. 
Multiform erythema may also be due to absorption of wound-secretions, 
and consequently may accompany surgical fever. 
All these eruptions, which have but minor significance, are to be 
abruptly distinguished from others which are the known accompaniment 
of septic infection, and which serve often to complicate cases and make 
it difficult to assign them to their proper category. As a rule, however, 
eruptions which become hemorrhagic—i. e. purpuric—pustular, or erythem- 
atous, are not to be regarded as innocent. 
The whole subject of surgical fever may, then, be epitomized as con- 
sisting of elevation of temperature and certain accompanying disturb- 
ances, which appear to be essentially due to the results of tissue-metab- 
olism, including also metabolism of blood-clot, ligatures, etc. It is 
not a necessary nor conspicuous accompaniment of all surgical cases, and 
in some individuals, even after grave operations, will scarcely be noted. 
It is more likely to be extreme in children than in adults, other things 
being equal. As the result of excessive loss of blood it may be post- 
poned. It may be complicated, and more particularly prolonged, by 
any one of the auto-infections, particularly that already spoken of in the 
preceding chapter as intestinal toxaemia, as the result of which septic infec- 
tion may ensue, and that which was at first a legitimate surgical fever 
may thus become merged into one of the septic conditions next to be con- 
sidered. In the absence of auto-infection, and with kindly and sympto- 
matic treatment, surgical fever should quickly subside until it becomes 
indistinguishable, and this usually by the end of the second or third day. 
Proceeding, then, in the order of pathological complexities, the next 
of the surgical infectious fevers to be considered is Saprsemia. 
As between the various terms derived from the Greek which are applied to 
the different expressions of blood-poisoning, there is but little real difference of 
meaning. In time past there has been a great deal of misuse of all of them, and 
even to-day it is rare to find men using them correctly. This is not entirely the 
fault of their derivation, but because various conditions have been confused under 
one name or because various names have been applied to practically the same 
Sapr^emia. 120 
SURGICAL DISEASES. 
condition. Conceding that cases do not always pursue a clinically typical course, 
it yet is possible to make out three quite distinct forms of septic infection, which, 
occasionally merging from one into the other, are yet ordinarily distinct enough 
for easy recognition, which is the more important because treatment in no small 
measure hinges upon their differentiation. 
It is my purpose to use the term sapreemia here as indicating a con- 
dition which I often liken to an intoxication produced by a supposititious 
septic suppository, although the case is by no means imaginary in which 
this condition occurs. The term was first used by Duncan, and was 
largely confined, at least at first, to puerperal cases. This is its own 
justification, because some of the most ideal cases of saprsemia are 
those of puerperal origin. 
In each of the three conditions comprised under the general term of 
septic infection it is not now a question of particular organisms, but of 
intoxication by products which are more or less common to at least 
several of them. In a general way, they are, for the most part, due to 
the activity of the organisms already grouped as pyogenic. Those which 
produce pus are easily capable of causing septic infection. In addition 
to these, it is probable that certain of the saprophytes or ordinary putre- 
factive organisms may produce the same effect. For purposes of minute 
study it is of interest to isolate and, so far as possible, determine the 
exact action of, each organism. For present purposes, however, it is 
neither necessary nor, perhaps, wise. 
In saprsemia the symptoms begin promptly, depend for their inten- 
sity upon the dosage of poison, and recede quickly as soon as the source 
of poisoning is removed or its activity antidoted. Two illustrations 
of the possible causes of saprsemia will, perhaps, best illustrate its 
pathology. Take, first, that physiological operation of nature’s own 
performance—namely, the act of delivery of the full-term foetus. At 
the completion of this operation there is left a fresh, bleeding wound of 
large area which is more or less exposed to putrefactive agencies. This 
is reduced with the contraction of the uterine walls to a comparatively 
small cavity containing more or less freshly-coagulated blood. So long 
as this clot does not putrefy it is disintegrated inoffensively, to be dis- 
charged, at least for the most part, with the lochia?. Let, however, 
germs of putrefaction enter, either during the act of labor or afterward, 
and linger, and putrefactive processes are set up in the clot with the 
prompt production of certain toxines and ptomaines. We have here a 
septic suppository with conditions most favorable for absorption by the 
containing tissues. How quickly the poisoning may show itself, and 
how quickly subside after removal of the putrefying clot, daily experi- 
ence may tell. 
Another instance : In an amputation stump a certain amount of 
bleeding has occurred, due perhaps to insufficient haemostasis or to 
failure to ensure physiological rest after the operation. If, now, infec- 
tion have occurred from failure in technique, and this clot begin to 
putrefy, the patient shows signs of poisoning as promptly as in the case 
before mentioned. Speedy recognition of the character of the case, 
proper drainage, antiseptic irrigation, perhaps with re-opening of the 
wound, will permit the cessation of symptoms almost as quickly as they 
arose. THE SURGICAL FEVERS AND SEPTIC INFECTIONS. 
121 
Saprcemia, then, is intoxication produced by absorption of the results 
of putrefaction of a contained material within a more or less shut contain- 
ing cavity whose walls are capable of absorption of noxious products as 
they form. So long as putrefaction be essentially limited to the contained 
mass, and do not spread to and involve the containing or surrounding 
tissues, the case is one of sapraemia. So soon as the process spreads from 
the containing tissues the case merges from one of saprcemia into one of 
septiccemia. That this may occur in any case without prompt inter- 
vention will be readily understood. Patients may probably die of 
sapraemia, though rarely, and in such case ordinarily as the result of 
gross neglect. Once the septicaemic process be begun, however, its 
spread cannot be with certainty checked, and that case which to-day is 
saprsemic and redeemable may, to-morrow, become septicemic and prac- 
tically lost. 
The symptoms of sapremia are not essentially different from those 
common to septic infection, save that ordinarily they are, at least at first, 
milder. There are flushing of the face, dry tongue, mental disturbance 
often, a considerable degree of pyrexia, while usually the whole train of 
symptoms is ushered in by a chill which may have been preceded only 
by slight malaise. These are usually followed by nausea and vomiting, 
with headache, and often, later, by diarrhoea or active purging. Should 
a case go on so far, delirium may occur, possibly even fatal coma. On 
post-mortem examination of a fatal case there would be few changes 
revealed: alterations in the blood, a failure to coagulate, some softening 
of the spleen and liver would probably be the only notable changes. 
Treatment.—For a condition so easily recognized treatment should 
be prompt, and will then be almost always effective. It is all summed 
up in the urgent advice to remove the cause, although this may not 
always be easy of performance. In the first case supposed—i. e. one of 
puerperal sapraemia—the treatment would be to empty the uterus, to give 
vigorous antiseptic douches, to irrigate as often as necessary, to prevent 
offensive odor to the discharge, and to combat the general signs of poi- 
soning by plainly indicated measures. Heart-depression should be 
overcome by the use of diffusible stimulants and by hypodermic injec- 
tions of strychnia in doses of grain or more. The bowels should be 
promptly unloaded by a mercurial, followed by a saline cathartic, Sup- 
pression of urine may be treated by venesection and by hot-air baths or 
sweats; diuretics should also be prescribed, and fluids should be admin- 
istered copiously. If the patient be very restless, an opiate should be 
promptly given; if delirious, necessary restraint should be resorted to. 
Essentially the same measures should be carried out in a surgical 
wound, or in case of compound fracture, or any injury where retained 
material may be undergoing changes already alluded to. General meas- 
ures should be the same. Our forefathers were certainly wise in advis- 
ing the use of purgatives in these cases, for nature often sets us the 
example in the shape of watery and most fetid evacuations, showing 
that there is much retained whose evacuation should be hastened. 
By such measures as these the average case of sapraemia can be 
promptly and successfully combated so long as it be still such, and so 
long as putrefaction has been limited to material not a part of the living 
tissues, even if confined within them. 122 
SURGICAL DISEASES. 
Septicaemia. 
According to the views thus enunciated, the difference between sa- 
prsemia and septicaemia is not one of character so much as of location. 
In septiccemia the putrefactive action is no longer confined to material 
enclosed by, yet not of, the tissues themselves, bid has spread from this to 
the surrounding living cells, which are now being attacked by bacterial 
enemies; in other words, we deal now with infection of living tissues 
rather than with mere intoxication. This is now a progressive invasion 
of tissues by continuity, with a constantly proceeding systemic intoxi- 
cation by poisons produced ever in larger doses. So rapid may this 
action be—as may be seen in malignant diphtheria, for instance—that 
the individual speedily succumbs before abundant evidences of abscess 
or local gangrene appear. On the other hand, providing that the toxic 
action be less pronounced or the patient’s vitality more enduring—i. e. 
his tissues more resistant—abscess, phlegmon, or local gangrene may 
result, the destruction of tissue being limited to the environs of the 
parts first involved. 
While septicaemia, then, may be a direct continuance of an original 
sapraemia, it is not intended to intimate that it may not originate de 
novo ; that is, many cases may begin as a pronounced septiccemia from a 
local infection. This is the case, for instance, with the majority of dis- 
secting wounds, etc. 
Symptoms.—In septicaemia we have a period of incubation, usually 
two or three days at least, often longer. If this follow an operation, the 
mild fever which ’would indicate the slumbering fire is usually regarded 
as merely surgical fever. But when, instead of subsiding, this rises and 
is followed by prostration with alimentary disturbance, loss of appetite, 
headache, etc., quickly followed by those general symptoms which we 
speak of as typhoidal, the alarm is sounded and should be quickly heard. 
Usually, but not always, there is a preliminary or premonitory chill, after 
which prostration will be much more marked than before. The severity 
of the general symptoms can in no degree be foretold from the size, loca- 
tion, or character of a wound. The character of the fever is essentially 
continued, usually with morning remissions. Gnssenbauer has called 
attention to a class of cases in which subnormal temperature is caused 
by the absorption of ammonia compounds. To these he has given the 
name ammonicemia. This condition may be seen oftenest in connection 
with gangrenous hernia, and has even been mistaken for shock (Warren). 
In septicaemia proceeding from infection of a visible portion of the 
body there are usually seen evidences of lymphangitis and perilymphan- 
gitis—of course of septic character. These will be evidenced by tender 
and purplish lines, extending subcutaneously along the course of the 
known lymphatics or in connection with the more prominent subcutane- 
ous veins. The lymph-nodes, into which these visible vessels as well as 
the deeper ones empty, become quickly enlarged and tender ; the whole 
lymphatic system participates; the spleen in aggravated cases becomes 
notably enlarged, and even the bone-marrow more or less involved. 
Diarrhoea is commonly an early but controllable symptom. A lisema- 
togenous icterus of mild degree is another frequent accompaniment. The 
conjunctiva becomes plainly discolored, and the skin slightly so. Should THE SURGICAL FEVERS AND SEPTIC INFECTIONS. 
123 
the blood be examined, marked leucocytosis will be noted, and should 
cultures be made from it, in many instances at least the organisms at 
fault can be detected and recovered from it. The vigor of the heart- 
muscle is seriously impaired; the pulse becomes rapid, and weak. In 
scarcely any form of septic infection is this more prominent than in 
diphtheria ; and microscopic examination shows the rapid disintegration 
of the cells of the heart-muscle, as well as those of other parts of the 
body, even to the almost complete molecular disintegration of the nuclei. 
Erythematoid, pustular, even hemorrhagic eruptions are met with upon 
the skin, some of which are probably to be explained by thrombosis of the 
dermal capillaries. Certain complications are not infrequent, among 
which inflammations of the pericardium and endocardium—e. g. ulcera- 
tive endocarditis—are frequent. As the case becomes aggravated tem- 
perature rises irregularly; the hot, dry skin becomes cold and clammy; 
prostration and indifference more marked; diarrhoea more colliquative; 
icterus more pronounced ; urine more reduced in quantity or suppressed ; 
and these symptoms are succeeded by indifference, mental apathy, stupor 
or delirium, and finally death, patients being comatose and collapsed. 
While these are the general indications of septicaemia, the wound or 
site of injury has undergone changes which are also characteristic. They 
comprise, first, the oedema and redness of wound-margins, which may be 
seen even in sapraemia, followed by increasing tumefaction, escape of 
foul-smelling discharge, and finally by sloughing and gangrene of the 
parts involved. On microscopic examination the capillaries are filled 
with infective thrombi and vessel-walls infiltrated with micro-organisms, 
which abound also in the lymph-spaces. Bacterial infection can be 
traced in microscopic sections from the infected area, from the point in 
the neighborhood of the wound where microbes infest the tissues, to 
points remote from it, where they are sparsely found, if at all. The 
same evidences of infection may be traced along the lymphatic vessels, 
and often the veins. 
The post-mortem evidexces of septicaemia are plainly indicative 
on first sight: the blood is of a consistency like tar, does not coagulate; 
evidences of putrefaction are plain to sight and smell; the serous 
membranes, particularly the pia mater, are often extravasated ; the mus- 
cles are discolored and of a darker hue than natural; oedema of the lung 
is frequent; the intestines reveal a gastro-intestinal catarrh, the duode- 
num and rectum particularly showing punctate hemorrhages; the spleen 
is darkened, enlarged, and very much softened ; the liver shows similar 
signs, less marked, and at times an emphysematous condition due to 
putrefactive gases. Cultures can be made from all the fluids and tissues 
of organs thus affected. It is also of the greatest importance to empha- 
size that such material is powerfully, often fatally, infectious; and some 
of the worst forms of dissecting wounds and most rapid instances of 
fatal infection have come from carelessness in making these post-mortem 
examinations. 
So far as concerns the character of the wound, which is most likely 
to be followed by septicaemia, there is but little to be said. In a general 
way, wounds made by infected tools, the butcher’s knife, the anatomist’s 
scalpel, etc., are the most dangerous, and too often those which are so 
small as to either escape observation or be considered too trifling to call 124 
SURGICAL DISEASES. 
for treatment. All forms of phlegmonous erysipelas, many cases of 
gangrene following frost-bite, nearly all instances of traumatic gangrene, 
most cases of carbuncle, and, in fact, all similar lesions, are extremely 
likely to be followed by septicaemia. The so-called spontaneous cases 
have an equally infectious origin, though one which is concealed. In 
unrecognized instances of appendicitis, for instance, and in many other 
conditions, although the path of infection may not be easily traced, it is, 
nevertheless, always present, and can be found if diligent enough search 
be made. Too often the nasal cavity, the tonsils, the teeth, the middle 
ear, the deep urethra, and the rectum are overlooked as offering possi- 
bilities for septic infection which may follow this general type. 
Treatment.—This must be both local and general. Local treat- 
ment should consist in complete and absolute removal, so far as may be 
possible, of the active cause. This will comprise the reopening of wounds, 
evacuation of clot, cutting or scraping away of sloughs and gangrenous 
tissue, with cauterization of the exposed living tissue, in order that 
absorption may not be rather promoted than prevented, and will often 
include such heroic measures as the amputation or extirpation of a part. 
For tissues which are not too completely riddled by disease and lost 
beyond possibility of redemption continuous immersion in hot water offers 
often the best possible prospect. By it putrefaction seems checked, the 
separation of dead from living tissues is accelerated, relief of pain or 
discomfort is afforded, and prompt disinfection of material which is foul 
and infectious is guaranteed. The best local application known to me is 
the mixture, resorcin (5 parts), ichthyol (10 parts), ung. hydrarg. (40 
parts), and lanolin (45 parts), already mentioned in Chapter III. 
When powerful caustics are needed for the purpose above indicated, one 
may take his choice as between the actual cautery and some powerful chemical 
agencies, among which pure bromine and nitric acid rank as the strongest; while if 
weaker ones will suffice, they may be found among the zinc-chloride solutions of 
varying strength, pure carbolic acid, etc. To a sloughing wound where immer- 
sion is impracticable, powdered charcoal may be applied, which will be the next 
best substitute, since charcoal has the property of absorbing gases. There may 
be mixed with it iodoform, naphthaline, etc.; or, as I have often recommended, 
granulated sugar, which is of itself a most excellent and efficient antiseptic. A 
mixture of one-third sugar to two-thirds charcoal, with 5 per cent, of naphthaline, 
makes a very excellent deodorizer and antiseptic for local application. 
The general treatment of septicaemia is, in the main, stimulant and 
tonic. Fever is not now to be treated with arterial sedatives nor often 
with antipyretics. It is an expression of poisoning, and its too prompt 
suppression prevents both the recognition of the intoxication and the 
measure of its degree. Pyrexia, then, is best combated with cool 
sponge baths and stimulant measures of a general character. The 
principal reliance must be upon nutrition and stimulants. Assimilation 
must be impaired when gastro-intestinal catarrh is so prominent a fea- 
ture as it is in many of these cases. Consequently, the simplest and 
most assimilable food, often that which is predigested, should be admin- 
istered. Milk, eggs, beef-peptonoids, and fruits are among the most 
appropriate. Of all the stimulants and tonics which the materia medica 
affords, the two best are alcohol and strychnia. Strychnia is preferably 
administered hypodermically in doses of grain, subcutaneously, from 
two to four times a day, or even oftener. Heart-depression is best THE SURGICAL FEVERS AND SEPTIC INFECTIONS. 
125 
combated by this measure, or by quinine in large doses, while digitalis 
and atropine may be added if necessary. For internal use alcohol is, 
par excellence, the remedy. This is administered now in doses only to 
be measured by their effect. In fact, the administration of alcohol in 
these cases is a matter of effect, and not of dosage. It is sometimes dif- 
ficult to administer it in necessary amounts. The purest whiskey or 
brandy is of course the best form in which to give it. Owing to the 
difficulty in many places of obtaining these liquors unsophisticated, I 
have often resorted to the practice of administering pure alcohol, suf- 
ficiently diluted and flavored to make it palatable. This may be given 
with milk or in any other way. Should the stomach refuse to deal 
with it, it should be given by the rectum. It may be safely given in 
doses just short of producing intoxication. Aside from being a stimu- 
lant to the patient, it is the least harmful of substances which may be 
introduced as antiseptics, the relations between its absolute and relative 
toxicity being safer than with almost any other drug. Alcohol given 
in this way is life-saving: when not so given, one may fail to get its 
possible benefits in serious cases. Aside from these measures, the intes- 
tinal antiseptics should be administered, among these being corrosive 
sublimate, grain every three or four hours, salol in large doses, bis- 
muth salicylate, or naphthaline—any or all of these in connection, pre- 
ferably, with powdered charcoal. Intestinal pain and frequency of 
stool can be more or less controlled by opium, while real disinfection 
of the alimentary .canal is only to be accomplished by the above reme- 
dies, in connection perhaps with flushing of the colon with saturated 
boric-acid solution or something of that kind. Pain is to be controlled 
by morphia administered subcutaneously. 
Pyemia. 
The derivation of the term “pysemia,” which came into general use in 1828, 
is misleading. Although septic fever always accompanies suppuration, it is not 
the case that pus, as such, circulates in the blood, as the term pyaemia implies, the 
error having arisen originally from mistaking the contents of breaking-down 
thrombi for pus from ordinary sources. While a recognition of the etiology of 
the disease is new, the disease itself has been recognized for many centuries. 
Accurate study of it is due to recognition by Cruveilhier that septic phlebitis 
means coagulation of blood within the veins, and of Virchow’s investigations of 
thrombosis and embolism. (See Chapter II. for these subjects.) Virchow’s term, 
ichorrhcemia, should not be accepted as a substitute for the term pyaemia, unless 
the essentially underlying idea of metastatic abscesses is understood to be a 
part of it. 
Pyaemia is only met with in connection with suppuration; so far as 
known, never without it. In those cases which appear to be free from 
suppuration pus will be found on careful search. Pyaemia may be de- 
scribed as septiccemia plus thrombotic and embolic accidents which lead to 
distribution of infectious material to all parts of the body. This distri- 
bution is, for the most part, made by the blood-vessels, although to 
some extent the lymphatics undoubtedly participate. When pyogenic 
organisms reach blood-vessel walls they often set up a mycotic phlebitis, 
which, by virtue of the coagulating blood, becomes quickly what is 
known as thrombo-phlebitis. Infection proceeding through the vessel- 
walls, the endothelial lining is loosened, while to these rotting spots 126 
SURGICAL DISEASES. 
leucocytes adhere and coalesce into a more or less homogeneous mass. 
This so-called white thrombus becomes also infected with bacteria: por- 
tions of it, loosened and dislodged, are carried by the returning blood- 
stream to the right side of the heart, whence they are distributed through 
the lungs. Dislodgement may be by mere force of the blood-stream, or 
may be assisted by movements of the part or handling of the same. 
These particles of thrombi are loaded with the infectious organisms 
which have begun the disease, and wherever each one settles a repro- 
duction of the original thrombo-phlebitis is quickly produced. In this 
way numerous infected thrombi are formed within the vessels of the 
lungs, which, again, loosen, and are now swept into the left side of the 
heart, whence they are distributed with arterial blood in all directions. 
While it is true that they are probably equably distributed, it is also 
positive that certain tissues seem more capable of lodging and being 
attacked by the contained organisms than are others. When it is once 
appreciated that each particle of infected clot is capable of setting up, 
either in the lungs or in the other tissues, upon the second distribution, 
other abscess-formations analogous in etiology to that from which came 
the first disturbance, then, and then only, is the fundamental idea of 
metastatic abscess fully impressed. The term metastasis may be 
regarded as synonymous with transportation, and metastatic abscesses are 
those produced by transportation of infected particles from one part of 
the body to another. Wherever they lodge similar trouble will result, 
providing only that the patient live long enough. Contiguous minute 
metastatic abscesses quickly coalesce, and in this way large collections 
of pus are formed. The blood also contains organisms not attached to 
thrombi, and from the blood of the pysemic patient cultures can be 
made at almost any time. Until this be done it will be virtually im- 
possible to incriminate any particular organism as the one at fault. 
Thrombo-arteritis is the equivalent in the arteries of thrombo-phlebitis 
in the veins, and is accompanied bv the same detachment of endothe- 
lium, adhesion of leucocytes, etc. Whenever such a lesion occurs in 
artery or vein, coagulation-necrosis takes place and suppuration occurs 
around it. The metastatic abscess is thus the result of breaking down 
of this affected tissue, and is often spoken of as miliary abscess. Parti- 
cles of infective thrombi cling also to the valves of the heart, and a 
septic endocarditis may result. 
Per contra, on the roughened valve of a previously diseased heart organisms 
which may be temporarily circulating in the blood may cling; and the possibility 
of an acute infectious endocarditis as the result of previously disturbed valve- 
linings, in connection with possible infection from the intestinal canal or other 
tracts, cannot be denied. 
There is no organ in the body nor tissue in which we may not find these meta- 
static abscesses. The only conditions, however, under which ordinary pus is 
found floating in the blood is when an abscess has broken directly into a blood- 
vessel. Pus is more likely to be found in the lymphatic vessels than in the arte- 
ries or veins. This is particularly true in puerperal pyaemia, when pus will be 
found which has migrated along the lymphatics in the broad ligaments of the 
uterus. 
The possibility of so-called spontaneous or idiopathic pyaemia is 
occasionally discussed. This means nothing more than a pyaemia 
whose cause is concealed. The explanation will be found sometimes in THE SURGICAL FEVERS AND SEPTIC INFECTIONS. 
127 
an acute infectious osteomyelitis, sometimes in ulcerative endocarditis, 
or inflamed appendix or other portion of the peritoneal cavity. Again, 
it may proceed from middle-ear disease, in which there is so little 
discharge as scarcely to attract attention. Thus, causes which predis- 
pose to suppuration, which have already been discussed in Chapter III., 
come into play here, and the influence of exposure, fatigue, starvation, 
etc. is not to be ignored in furnishing an explanation for the so-called 
idiopathic cases. 
In the majority of instances, however, pyaemia follows surgical 
operations and injuries, among which are compound fractures, deep 
injuries with small superficial evidence thereof, compound injuries of 
the skull, and injuries by which veins are exposed. Inasmuch as the 
typical pysemic manifestations require a certain length of time for their 
development, the onset of this disease is more delayed than in the case 
of septicaemia. While the case may be manifestly one of septic infec- 
tion of unrecognizable type, the characteristic indications of pyaemia 
seldom appear in less than ten days, and frequently not for several days 
longer. 
Symptoms.—The symptoms of pyaemia do not essentially differ 
from those indicating the other septic infections already mentioned. 
The principal difference is in the frequency of chill and range of tempera- 
ture. Chills are much more common at the inception of the condition, 
and • much more frequent throughout its continuance, than in other 
septic conditions. The chill may be slight or assume the proportions 
of a rigor, and each chill is followed by colliquative sweat and exhaus- 
tion. In other words, chills, which are infrequent in septicaemia, are 
common in pyaemia. There is reason to think that with each fresh dis- 
tribution of emboli we have one or more chills as the objective evidence 
thereof. Distinctive also in large measure of pyaemia is the temperature 
curve, which much resembles that of intermittent fever, without the 
regularity of change characteristic of malarial fevers. It is without 
regular remissions, and has been spoken of as irregularly intermittent. 
The first rise is abrupt and usually excessive, while with each fresh 
chill or series of chills similar abrupt alterations will be noted. These 
occur so frequently and fluctuate so irregularly that in order to note 
them accurately the temperature should be taken at least every two 
hours. With all this irregularity, the temperature never drops to 
normal, except possibly toward the last. 
As the lungs fill up with the first crop of infected emboli, and the 
first series of metastatic abscesses form there, there is more or less 
dyspnoea and sense of oppression : there may be also pulmonary compli- 
cations—pleurisy, bronchitis, etc., even pulmonary oedema. Quite fre- 
quent it is to have expectoration of frothy and discolored sputum; 
occasionally there is blood in the sputum. A peculiar sweetish odor of 
the breath has been noted by many observers in this disease, and is sup- 
posed to be idiopathic and characteristic. With the dispersal of the 
second crop of emboli from the lungs we are now quite likely to get 
icterus, with, later, evidence of metastatic abscess in the liver, where we 
find large collections of pus as the result of coalescence of small abscesses. 
The sensorium is not so affected in pyaemia as in septicaemia, and in 
the former disease patients are more likely to be alert and active in 128 
SURGICAL DISEASES. 
mind. General hypercesthesia and restlessness are common. Colliquative 
sweats are also a feature distinctive rather of pyaemia. There is the 
same liability to eruptions, etc., which may mislead or complicate the 
diagnosis. There is undoubtedly a dermatitis met with sometimes in 
pyaemia, the lesions assuming a papular or pustular form, due to local 
infections of the skin. Purpuric spots are also seen, and vesication is 
not infrequent. Within the mouth sordes collect quickly upon the 
teeth or gums; the tongue becomes dry and brown and heavily coated. 
Diarrhoea is less common in pyaemia. The urine is usually scanty and 
high-colored, containing solids in excess; albumen is sometimes found 
therein, as well as peptone. The presence of peptone in the urine is 
probably an indication of the breaking down of pus-corpuscles in 
various parts of the tissues. 
One most significant objective evidence of pyaemia is met with in 
the metastatic collections of pus within the joints, which occur relatively 
early, and which, if multiple, may surely lead to a correct diagnosis. 
One of the earliest joints to be involved is the sterno-clavicular, 
although none of the joints are free from possibility of invasion. The 
articular serous membranes seem to have the property of carrying and 
holding the infective thrombi better than almost any other tissue in the 
body. The pyarthrosis of pycemia is for the most part painless, yet 
implies loss of function of the affected joints. The distention of these 
is usually evident to the eye, the fluctuation pronounced, tenderness 
not extreme, but the swollen part merges out into tissues which are 
cedematous and reddened. When pain in the limb is extreme, it is 
usually because of metastatic abscess within the bone-marrow cavity. 
In other words, we now have a metastatic osteomyelitis. 
In all cases of pyaemia prostration is marked, yet the pulse is seldom 
so weak as would be anticipated, at least until toward the last. As 
cases progress from bad to worse subsultus tendinum is often noted. 
The appearance of the wound or site of operation, if such there be, 
does not differ essentially from that already described under Septicaemia. 
There is usually, however, less discharge, granulations are smoother and 
dryer, and, if tissues be gangrenous, they are not so offensively wet and 
nasty as in the other case. Evidences of thrombo-phlebitis and lymphan- 
gitis will proceed from the wound toward the body, as in other instances 
of septic infection. 
Prognosis.—Prognosis is almost always bad. While recovery may 
occasionally follow where metastatic infiltration has not been too general, 
the ordinary case of pyaemia will die within twelve to fourteen days 
after its recognition. In other instances the entire process is much 
slower, and isolated cases occur which entitle us perhaps to make a 
separate designation for so-called chronic pycemia, which differs but little 
from the acute form, save in the extreme slowness with which the entire 
programme is gone through. The student should never be unwilling to 
recognize pyaemia, as such, simply because he finds no evidence of infec- 
tion from without—e. g. no wound. I have known a fatal case of 
pyaemia from a suppurating soft corn which was not discovered dur- 
ing life. Cases are also known from peridental abscesses, etc. which 
had been overlooked. Death is the result of tissue-destruction and TIIE SURGICAL FEVERS AND SEPTIC INFECTIONS. 
129 
septic intoxication. It is brought about, however, largely by sheer 
exhaustion. 
Post-mortem Appearances. —In the vessels these consist essen- 
tially of thrombosis, excellent examples of which may be seen, for 
instance, in the cranial sinuses and in the large veins. Aside from 
these, with the enlargement and softening of the spleen, the liver, and 
lymphatic structures, already described under Septicaemia, the principal 
objective evidences consist in the discovery of metastatic abscesses in 
many or all parts of the body. As stated above, there is no tissue nor 
organ in which they may not be found. The mechanism of their pro- 
duction has been already described. Infarcts may also be met with, in 
the kidneys especially, the liver and spleen as well, and indicate areas 
already cut off from blood-supply by thrombo-arteritis, in which 
abscess-formation would have occurred had time been given. In the 
liver large abscesses may be found; joint-cavities may be filled with 
pus; the lungs are usually the site of innumerable small abscesses. 
The other post-mortem changes commonly noted are not difficult of 
explanation, but are not so characteristic nor pathognomonic as to call 
for further mention. In a joint which has become tilled with pus there 
has usually been loosening of the cartilage and more or less disorganiza- 
tion of all the joint-structures, which appear to have undergone most 
rapid ulcerative destruction and putrefaction. 
Treatment.—Treatment of pyaemia is in large degree unsatisfactory. 
That which used to be the terror of surgeons in the preantiseptic era is 
now, thanks to Lister and others, almost abolished. Pyaemia is a rare 
disease in modern surgical practice. Its possibility should be borne 
constantly in mind, however, and the necessity for careful antiseptic or 
for a rigid aseptic technique is in large degree based upon fear of pyaemic 
consequences. 
When once established, the disease is to be treated on nearly sim- 
ilar lines to those laid down for septicaemia. Amputation or extirpation 
of the part from which infection has first proceeded may be of avail, 
though usually it will prove too late. Among the most successful, yet 
radical, of measures for surgical treatment of this disease is to expose 
the infected area, freely open the involved veins, and either excise them 
or scrape them out and thoroughly disinfect them. This treatment has 
been particularly successful in certain cases of cranial infection follow- 
ing middle-ear disease, etc. (For more with regard to this work in a 
special location consult AToliune II. Chapter I.) 
That there should be complete disinfection of the infected area, and 
that continuous immersion in hot water, if practicable, should be prac- 
tised, are just as important here as in other septic cases. Metastatic 
abscesses should be opened and freely drained, and every accessible col- 
lection of pus should be evacuated, either by the knife or perhaps with 
the aspirator needle—e. g. in the liver. 
So far as medicinal treatment is concerned, it is practically the same 
as in septicaemia, while the surgeon’s mainstays will be alcohol and 
strychnia. These, with cathartics and intestinal antiseptics, will prac- 
cally sum up the drug-treatment, the surgeon meantime not neglecting 
the matter of nutrition, crowding it in every assimilable form. 130 
SURGICAL DISEASES. 
Erysipelas. 
Erysipelas is an acute infectious disease characterized by its tendency to 
involve the skin and cellular structures, to extend along the lymphatic vessels, 
to involve wounds and injuries under certain conditions, accompanied by 
more or less fever of septic type, leading frequently to septic disturbances 
of profoundest character, yet tending in the majority of instances to spon- 
taneous recovery. It has been observed probably from prehistoric times, 
but has not found a proper description nor appreciation until perhaps 
within the past century. It occurs in so-called traumatic and idiopathic 
form—which latter simply means that the site of infection is not dis- 
covered—and also in a virulent and contagious type, which leads to the 
appearance of a large number of cases over a widespread area of terri- 
tory; in other words, it often appears in the epidemic form. On account 
of the characteristic reddening of the skin it goes by the suggestive name 
of the rose among the German laity. It may assume the type of an 
infectious dermatitis, subsiding without suppuration, or a similar lesion 
of exposed mucous membrane may be noted, or, occasionally, its viru- 
lence seeming greater, its lesions are met with in more deeply-seated 
parts, accompanied by suppuration or even gangrene, and it is then 
spoken of as of the phlegmonous type. In a small proportion of cases 
the infectious organism appears to be transported from one part of the 
body to another, and thus we have metastatic expressions of this disease. 
The most common expressions of this are seen in erysipelatous meningitis 
after erysipelas of the face or scalp, and erysipelatous peritonitis after 
the disease has manifested itself on the truncal surface. It is of a type 
which makes itself almost interchangeable with puerperal fever ; and in 
time past, when epidemics of erysipelas have involved certain states or 
areas, it has been noted also that nearly every obstetric case developed 
puerperal septicaemia. 
Etiology.—There is more than passing interest connected with this 
last statement. It is now definitely established that the infectious organ- 
ism is a streptococcus which is most strongly allied to, if not identical 
with, the streptococcus pyogenes, the ordinary pyogenic organism of 
this form. 
This is hardly the place to discuss the minute questions of their identity or 
differences. It is proper to state, however, that most forms of puerperal septicaemia 
are due to one or the other of these streptococci, and if they are essentially identi- 
cal, the interchangeability of the two diseases is thus easily explained. The epi- 
demic features of such cases, then, are no more difficult of explanation than those 
in any other epidemic, and the puerperal fever of these experiences is essentially a 
puerperal or uterine erysipelas. 
The specific organism has been separated, studied, and its role assigned 
unmistakably by Fehleisen, and the organism is frequently spoken of as 
Fehleisen’s coccus. Preserving always its morphological characteristics, 
it acts, as do many other pathogenic organisms, within wide limits in viru- 
lence. Cultivated from some cases, it scarcely seems infectious, while 
from others it is violently and quickly fatal. 
The experimental evidence of the specificity of this coccus is now complete, be- 
cause it has been intentionally used in a number of cases to deliberately provoke 
the disease in the endeavor to modify the course of certain malignant tumors. (See 
Treatment of Carcinoma and Sarcoma.) Each coccus varies from 0.3 to 0.4 ft in THE SURGICAL EEVERS AND SEPTIC INFECTIONS. 
131 
diameter, and the organisms collect in chains, as do other streptococci. The 
organisms divide by fission and are readily stained. 
Pathology.—The disease manifests a remarkable tendency to travel 
vid lymphatic routes. So long as it is confined to the skin and super- 
ficial tissues, we have the general 
appearance of an acute dermatitis. 
When it migrates deeper, it nearly 
always leads to suppuration, which 
is another reason for thinking that 
the streptococci of erysipelas and 
of pus-production are the same. In 
the affected and infected area the 
minute lymphatics will be found 
crowded with the cocci, which are 
seen much less often in the small 
blood-vessels; also in the tissues 
beyond the apparently infected area 
they may be found dispersed less 
freely. The bacterial activity seems 
most active along the advancing 
border of the superficial lesion. 
Here the phenomena of hypersemia 
and phagocytosis are most active. 
Even in the vesicles that are characteristic of the disease the organisms 
may be found. 
All the discharges from this region are infectious, often in the highest 
possible degree, and extreme caution should on this account be observed 
in any operation, even in dressing such cases. A finger pricked by 
a pin from a dressing may subject the individual to loss of life. The 
dressings containing the discharges should be promptly burned imme- 
diately upon their removal. 
The most frequent path of infection is through some wound, and so 
thoroughly recognized is this fact that it is now a duty upon first recog- 
nition of a case of erysipelas to separate it from all surgical cases, or, if 
the erysipelatous patient cannot be isolated, to remove from his prox- 
imity all other wounded individuals. 
Fig. 32. 
Streptococcus erysipelatis: section of skin 
showing invasion by cocci; X 500 (Frankel 
and Pfeiffer). 
Infection through the respiratory or alimentary tracts is always theoretically 
possible, and it is quite certain that the nose and pharynx are the port of entry for 
the germs in at least a certain number of cases of so-called spontaneous facial 
erysipelas. In other words, it is not likely that the disease can ever appear with- 
out some surface lesion which permits infection; but this surface lesion is often 
concealed, or may even be healed before careful inspection is permitted, so that 
it is by no means always easy to trace infection. Vaccination is a little operation 
which is frequently followed by infection of this character. On the absolutely 
unbroken surface of the normally healthy individual it is not likely that infection 
would occur. Erysipelas of the new-born is simply another expression of the same 
disease, infection being permitted through the umbilical cord or through contam- 
inated discharges which may have entered the nose, mouth, eyes, etc. during the pro- 
cess of parturition. It differs in no other sense from the other cases, is due to igno- 
rance or neglect in most instances, and is very fatal. Alcoholism, scurvy, exhaustion, 
etc. are conditions which seem to predispose toward infection. It is known that 
certain individuals are liable to almost annual recurrence of the disease. This is 
hardly to be explained on any known basis, though it has been suggested that their 
lymph-spaces are larger than is normal. 132 
SURGICAL DISEASES. 
The erysipelas which evidently follows injury, however slight, is always spoken 
of as traumatic. The term “idiopathic” or “spontaneous” should be restricted 
to those cases in which the path of infection is not discovered, and should be 
accepted then as simply an expression of ignorance in this regard. 
Symptoms.—With the exception of the local appearances, they are 
essentially the same in both of the above-mentioned forms. The most 
characteristic feature of the disease is the dermatitis with its peculiar 
roseate hue, which it is impossible to describe in words. In tint it dif- 
fers but very little from that noted in certain cases of erythema. It is, 
however, accompanied by an infiltration of the structures of the skin, 
so that the area which is reddened is at the same time elevated above 
the surrounding surface. Its edges are often irregular. As exu- 
date takes the place of blood in the tissues, the red tint merges into a 
yellow. At this same time there is more induration of the skin and 
more tendency to pit on pressure. Vesication of this involved area is 
now frequent, the vesicles often coalescing and forming large blebs and 
bulhe, which fill with serum that may, later, become discolored or puru- 
lent. When exposed to the air, unless the tissues become gangrenous, 
this serum usually evaporates and forms scabs. This disturbance of 
the skin is always followed after a number of days by desquamation. 
This infectious dermatitis shows a constant tendency to spread in all 
directions. Its most characteristic appearances are limited to the margin 
of the enlarging zone, while at the same time in its centre there may 
be evidences of recession of the disease. If it commence in the neigh- 
borhood of a wound, it will probably spread in all directions from it. 
Beginning in the face, it spreads upward usually; in the trunk, in all 
directions; while if on the extremities it tends to migrate toward the 
trunk. Wandering erysipelas is a term often applied to these phe- 
nomena. The metastatic expressions of the disease have been already 
alluded to. 
When this infection attacks a recent wound the local appearances are 
not essentially distinct from those already spoken of under Septicaemia. 
The wound-margins separate to a greater or less extent, the surfaces 
slough, and a very characteristic sero-purulent discharge occurs. Gran- 
ulating surfaces usually become glazed—often covered with a membrane 
resembling that of diphtheria; deep sloughs may occur, undermining of 
wound-edges, even hemorrhages, from destruction of vessel-walls. In 
rather rare instances, however, under the influence of the microbic stim- 
ulation granulations proceed even faster than normal. 
Whether, now, the disease proceed from an evident injury or not, the 
constitutional symptoms vary but little. There is usually a period of 
malaise with nausea, followed by evident alimentary disturbance, coating 
of the tongue, elevation of temperature, sometimes with, sometimes with- 
out, occurrence of chill. Within a short time complaint of pain or 
unpleasant sensation will lead to examination of the area involved, when 
the above symptoms will be noted along with evidences of lymphangitis 
and enlargement of lymph-nodes. When chill occurs it is very promptly 
followed by pyrexia. Temperature fluctuates according to no known 
principles, with a tendency to assume the remittent type. When the 
disease subsides spontaneously, it is by a gradual process of betterment, 
with gradual subsidence of temperature. In other instances the consti- THE SURGICAL FEVERS AND SEPTIC INFECTIONS. 
133 
tutional symptoms assume more or less of the septiccemic or typhoid type, 
and it is easily appreciated that the patient’s condition is practically one 
of mild septicaemia, which often becomes serious, sometimes even fatal. 
When, now, the disease assumes the phlegmonous type, the constitu- 
tional symptoms become more and more typhoidal and septicaemia 
becomes most pronounced. Locally, exudation goes on to the point 
of threatening, even of actual gangrene, unless tension be relieved by 
incisions. Pain is usually intense, partly because of confined exu- 
dates beneath unresisting structures. More or less rapidly the local and 
constitutional signs of pus-formation are noted, and unless these be 
observed and acted upon early we will have not only suppuration, but 
more or less actual gangrene, so that not only pus, but sloughs of tissue, 
will be discharged through the incision, or will, when this be delayed, 
make their escape by death of overlying textures. 
Everywhere it seems to be the cellular tissue which becomes most easily involved 
in the erysipelatous conflagration. Accordingly, muscles are separated from each 
other, and bones may be laid so bare as to lead to subsequent necrosis. When 
joint-surfaces are first exposed we usually get a prompt invasion of joint-cavities 
and sometimes extensive destruction, which compromises not only the joint itself, 
but the individual’s life. Under these circumstances he does well if he escapes 
with ankylosis. In these cases we get perhaps our best expressions of so-called 
purulent infiltration and burrowing of pus. Large areas of skin may in this way 
be separated, to subsequently slough. There is now no tissue in the body which 
is exempt from destructive attacks of this character. Excellent examples of phleg- 
monous erysipelas are seen in dissecting wounds of the fingers and hands and those 
produced by instruments in butcher’s shops. A trifling prick or abrasion in the 
dissecting-room may lead to most rapid involvement, more or less destruction and 
loss of function, and suffering which can scarcely be told in words. Pain in these 
cases is due to excess of exudation and tension. It is well that one familiarize 
himself thoroughly with the course of tendon-sheaths and bursae, about the hands 
and fingers especially, in order that he may appreciate the direction in which pus 
is most likely to travel. 
In those parts where tissues are loose, in either form of erysipelas, exudation 
may be so copious as to be disfiguring, if not dangerous. Thus, the eyelids become 
so infiltrated that it is impossible to open them, and the nostrils are more or less 
occluded ; the ears also show marked tumefaction ; while about the external gen- 
itals especially the puffing of tissues is most distinctive. Here, too, gangrene per- 
haps most often threatens, and here it is necessary to make incisions early to avoid 
dangerous tension. 
In all 'phlegmonous cases there is practically coincidence of septi- 
caemia, already described, and of the local appearances above noted. 
In proportion to the extent of the lesion in these phlegmonous cases, 
and failure to afford relief, will be the opportunity for septic intoxica- 
tion. 
Even the mucous membrane does not always escape, and in the nose, the 
pharynx particularly, but even in the vagina and rectum, a distinctive erysipe- 
latous lesion may be met with. The disease may travel from the pharynx through 
the nose to involve the face, or through the Eustachian tube to the ear and thence 
to the scalp, or vice versd. Erysipelatous laryngitis is most to be feared on account 
of oedema of the glottis, which would be quickly fatal unless promptly overcome 
by intubation or tracheotomy. An infectious exudation into the lungs is also 
known following erysipelas, and has been considered an erysipelatous pneumonia. 
The cellular tissue of the orbits may also be involved, in which case we will have 
abscesses which should be opened early; while, again, the parotid and other salivary 
glands may become involved, usually in suppuration. 
Many cases are accompanied by much gastric irritation, which it is 134 
SURGICAL DISEASES. 
difficult always to explain. Ulcers are sometimes found in the intes- 
tines, as after burns. These usually give rise to bloody diarrhoea. The 
cerebral symptoms may be simply those of delirium from irritation or 
of meningitis from infection. Strange phenomena have followed the 
disease in certain instances—cessation of neuralgic and of vague unex- 
plainable pain, improvement in deranged mental condition, spontaneous 
disappearance of tumors, etc. Advantage has been taken of this last in 
the treatment of these cases. (See Cancer.) 
In time past the supervention of so-called rheumatoid complications during 
erysipelas has been noted by various clinicians, and the coincidence of erysipelas 
and arthritis has been long recognized. That which previous observers have 
spoken of as complications of rheumatism and gout, or as arthritic erysipelas or 
suppressed gout, etc., must be explained by the fact, already stated, of the liability 
to involvement of the synovial membranes underlying superficial areas already 
involved in the infectious process. Cardiac lesions, especially endocarditis, are also 
among other complications. Joint-complications may be also purely metastatic, 
the fresh lesion to be explained after the same manner as the metastatic abscess of 
pyaemia. Thus, of 130 soldiers in hospitals suffering from gunshot fractures, who 
had been seized with erysipelas, pus was found in the interior of joints at least 5 
times. In each case there was also superficial redness. 
It is quite likely that some of the worst forms of phlegmonous ery- 
sipelas are due to mixed infection. It is known, for instance, that to 
inject the bacillus prodigiosus together with the streptococcus of ery- 
sipelas will greatly enhance the virulence of the latter, so that reac- 
tion may proceed even to gangrene. 
Post-mortem Appearances.—These are not distinctive, but are a 
combination of local evidences of suppuration and gangrene, with the 
deterioration of the blood, the softening of the spleen, etc., which are 
characteristic of septic poisoning. Only in the skin, and then under 
microscopic examination, can any distinctive pathognomonic appearance 
be made out. This will consist of the crowding of the lymphatic vessels 
and connective-tissue spaces with cocci, in the evidences of rapid cell- 
proliferation, in the quantity of exudate, in vesication, sloughs, etc. 
Diagnosis.—Diagnosis of erysipelas has mainly to be made from 
various forms of erythema, from certain drug-eruptions, and perhaps 
from other forms of septic infection which do not assume the clinical 
type of erysipelas. The gastric symptoms of this disease are some- 
times produced by certain poisonous foods or the distress which is pro- 
duced by medicines, such as quinine, antipyrine, etc. 
In nearly all the reflex eruptions proceeding from alimentary disturbances 
there will be such generalization of the erythema as to permit avoidance of error. 
Few, if any, of these troubles commence with the chill which often marks the 
onset of erysipelas. The appearance of the specific eruption is always distinctive, 
even pathognomonic. The irregular and advancing outline, the elevation of the 
involved surface, the peculiar tint, can scarcely be simulated by any other condition. 
Moreover, if watched for a few hours, vesication, or even formation of large bullae, 
may be noticed, along with marked tendency to oedema of loose tissues, like the 
eyelids, etc.; coupled with this, the ordinary evidences of lymphatic involvement 
—lymphangitis, enlargement of nodes, etc.—which are never simulated in non- 
specific diseases. 
Prognosis.—The majority of instances of idiopathic erysipelas run 
a certain limited course, although the eruption may spread to almost any 
distance from the body. When the disease attacks surgical cases, and 
especially when it involves wound-areas, the prognosis is not so good. 135 
THE SURGICAL FEVERS AND SEPTIC INFECTIONS. 
When, too, the disease assumes an epidemic type, and involves indis- 
criminately cases of all kinds, it will be found to have a virulence that 
may make it a most serious affair. In proportion to the extent to which 
it assumes the phlegmonous type it will be found locally, if not gen- 
erally, destructive. The ordinary case of facial erysipelas will get well 
with almost any treatment or perhaps with little or none. Nevertheless, 
unexpectedly, meningitis may develop, and even a mild case is to be 
treated with care and caution, as though one feared disaster. 
Treatment.—Danger comes from two sources—namely, from septic 
intoxication and local phlegmons or gangrenous destruction. Each is, 
therefore, to be combated so far as possible. Treatment, first of all, 
should consist of isolation—this rather for the benefit of others than for 
that of the patient himself. 
Especially from all other surgical and puerperal cases should the patient with 
erysipelas be completely isolated. So far as possible, he should be cared for by 
those who do not have to do with other surgical cases. Scrupulous care and atten- 
tion should be given that no contagion may be conveyed from hands, clothing, 
instruments, dressings, or by any other means. All well-regulated large hospitals 
are provided with separate wards for reception of such cases, and in many of them 
the professional attendants as well as the medical men are kept entirely distinct. 
If one must treat these and other cases as well, he should see the non-specific 
cases first, and then proceed to the erysipelas patients; after which he should most 
carefully disinfect his hands and everything that may have come in contact with 
them. 
Rather in opposition to views held a number of years ago, it must 
be stated that there is no specific internal treatment for this disease. The 
tincture of iron, for example, which was long vaunted as such, has 
proved utterly unsatisfactory, and is of benefit only as a supporting 
measure in a limited class of cases. In general it finds but little field 
of usefulness in this or in any acute surgical disease. Constitutional 
measures should be employed—first, for the purpose of maintaining 
free excretion by bowels and kidneys; second, for the purpose of sup- 
porting and maintaining strength; thirdly, for tonic and, more import- 
ant still, lively stimulant measures to certain thoroughly prostrated and 
debilitated patients ; and, fourth, for the purpose, so far as may be, of 
combating intestinal sepsis or intoxication from any other source. The 
robust patients with this disease need no particular tonic, but these are 
the patients whom it less often attacks. The aged, the enfeebled, the 
dissipated, the prostrated individuals, and the confirmed alcoholics are 
those who need vigorous stimulation, partly by alcohol and quinine, 
partly by strychnia, preferably given hypodermically, and by the other 
diffusible stimulants by which perhaps alone they may be kept alive. 
Pilocarpine, given subcutaneously and pushed to the physiological limit, 
has been highly praised by some. If, along with prostration, there occur 
restlessness and delirium, then anodynes and hypnotics are most ser- 
viceable, and should be administered to meet the indication—morphia 
hypodermically and any of the agents which produce sleep are now most 
serviceable. Finally, if there be any drug which can be administered 
in doses sufficient to saturate the system with an antiseptic which shall 
at the same time not prove fatal because of toxicity, this is the ideal 
medicament for constitutional use. Such a drug is not yet known, but 
it will be well in many of these cases to give some near approach to it 136 
SURGICAL DISEASES. 
internally, as by administering corrosive sublimate, salol, naphthaline, 
or something else of this general character in doses as large as can be 
comfortably tolerated. 
When patients become violent—and they sometimes do in the delirium 
of this disease—it is not only legitimate, but absolutely necessary, to 
resort to mechanical restraint—a strait-jacket, a restraining sheet, a 
camisole, etc. 
Nourishment must also be kept up by the administration of the easily 
assimilable and, if necessary, of predigested foods in sufficient quantities. 
Locally, the number of remedies that have been resorted to in time 
past is legion. In a very mild case of spontaneous erysipelas—i. e. 
where no infection can be traced—it will sometimes be enough to put 
on a simple soothing application, like the lead-and-opium wash of our 
forefathers. It often gives relief to a patient to have the part protected 
from air-contact, which may be done by some soothing ointment or by 
dusting the part with some powder, such as oleates of bismuth sub- 
nitrate, zinc oxide, etc., these being rubbed up with powdered starch 
if necessary. Again, it gives relief to protect by a film of rubber tissue 
or of oiled silk. 
Even before the distinctively bacterial origin of the disease was gen- 
erally accepted it had been suggested to use antiseptic applications, either 
in watery solution or combined with oil or some unguent ; and to-day, 
now that the infectious character of the disease is so completely estab- 
lished, this remains the ideal method of local treatment, the difficulty 
being only to find that which shall be efficacious as an antiseptic, yet not 
injurious in other ways. Compresses wrung out of solutions of various 
antiseptics are often serviceable. Of all the numerous applications which 
I have ever tried, however, I have found nothing which has given the 
universal satisfaction afforded by the following prescription or something 
equivalent to it: Resorcin (or naphthaline), 5; ichthyol, 5; mercurial 
ointment, 40 ; lanolin, 50. The proportions of these ingredients may be 
varied, and I often increase the amount of ichthyol, especially when the 
skin to which it is to be applied is not too tender. The affected parts 
are anointed with this, and then covered with oiled silk or some imper- 
meable material, simply to prevent its absorption by the dressings; the 
parts are then enveloped in a light dressing and bandaged. Whenever 
I have to deal with local evidences of septic infection, I use an ointment 
essentially the same as this, and have learned to count on it with more 
reliance than anything that I have ever resorted to. As the disease 
becomes mitigated the ointment can, if desirable, be reduced with simple 
lard, and may be discontinued when local signs have disappeared. 
Treatment of threatening phlegmon, or that which is from the out- 
set phlegmonous erysipelas, must be much more radical, and consists 
primarily of free incision down to the depth of the deepest tissues 
involved. For instance, in treating dissecting and other septic wounds 
of the fingers, this means incision down to the tendon-sheaths, often 
down to the bone itself. Unpleasant as this may be, possibly even 
crippling, it is only by such radical measures, early put into effect, that 
still worse disaster may be avoided. 
If, for instance, the finger which is involved in a dissecting wound and is exqui- 
sitely tender and painful, with increasing general septic symptoms, be thus early THE SURGICAL FEVERS AND SEPTIC INFECTIONS. 
137 
incised, it may be saved to usefulness. If incision be delayed, there will in all 
probability be sloughing and gangrene of tendons, stiffening of the finger, per- 
haps extensive phlegmonous processes extending up the arm, axillary abscesses, 
and possibly even loss of life. So, too, all wounds which show evidence of infec- 
tion must be freely opened, perhaps further incised, sloughs cut away, foul tissue 
washed, if necessary scraped away, and at every point between the wound and the 
centres where phlegmon threatens free incision should be made, not necessarily with 
the view of avoiding local infection, but of at least avoiding gangrenous destruc- 
tion by inflammatory distension. When these measures are promptly adopted, 
limbs and often life itself can be saved which wrould otherwise be inevitably lost. 
The incisions may be regulated by anatomical considerations, nothing yielding in 
importance to their necessity save location of large vessels and nerve-trunks, while 
for the purpose of doing the work thoroughly it is usually advisable to give a 
general anaesthetic. 
THE RELATIONS OF ERYSIPELAS TO CELLULITIS, ETC. 
Were it possible, I would like here to make an abrupt distinction 
between that which has been known in time past as cellulitis and the 
erysipelas already described. Neither clinically, however, nor bacterio- 
logically can such distinctions be maintained, and I hold it futile to 
endeavor to continue them. There can be no such disease as erysipe- 
las, cellulitis, nor anything similar which is not distinctly an infection; 
and if there exist any differences between them, they obtain rather in 
the port of entry or path of infection, or the character of the same— 
i. e. whether streptococcus or staphylococcus. In superficial tissues— 
e. g. palm of the hand—or in the deeper parts of the body—e. g. in the 
pelvic cellular tissue—infections are equally likely to occur. These go 
on always to the point of copious exudation, and almost always to the 
point of suppuration. When this is superficial, it is nearly invariably 
recognized and the pus evacuated. In the pelvis, however, it often goes 
so long unrecognized that collections of pus become encapsulated, and 
finally altered, by processes already alluded to, which consume a con- 
siderable length of time. 
Pus, when evacuated from such sources, proves sometimes a pure culture of a 
distinct organism, at other times a mixed infection. Whether this infection 
shall assume a fulminating type with rapid and disastrous production of 
abscess, or whether the whole course of the disease shall be slower, may depend 
less on location than on individual characteristics and resistance, as well as on 
the varying virulence of the infecting organisms. But I think it high time that all 
the older distinctions be dropped, and that all these forms of disease be regarded 
as infections varying but little one from another—all to be treated, so far as possi- 
ble, on the same general principles, with the invariable rule, already laid down, 
that pus left alone and unattacked will do more harm than will the surgeon’s 
instruments if judiciously used. It is on this principle that even such formidable 
procedures as hysterectomy and cleaning out the female pelvic organs is now 
a recognized and most valuable measure in cases of pelvic abscess from pelvic 
cellulitis. 
This, by some writers, is described under a separate heading, and is a term 
applied to a wandering erythema met with mostly upon the hands of those who 
handle dead animal tissues, such as butchers, tanners, oyster-openers, etc. It is 
certainly due to some infectious substance, its exact character not yet determined. 
There is infiltration of the skin with a reddish discoloration, itching, local discom- 
fort, etc., but without fever, the local lesion spreading slowly and seldom above 
the wrists. In its course it is obstinate and resistant to treatment. Rosenbach 
and Cordua claim to have produced this disease by inoculation of a coccus growing 
much like cladothrix dichotoma. 
Such a condition as this would best be treated by the resorcin-ichthyol oint- 
ment whose formula has already been given. 
Erysipeloid. CHAPTER VIII. 
SURGICAL DISEASES COMMON TO MAN AND THE DOMESTIC 
ANIMALS. 
Roswell Park, M. D. 
Tetanus.—Synonyms : Trismus, Lockjaw. 
Tetanus is an acute infectious disease, at present of infrequent occur- 
rence, invariably of microbic origin, characterized by more or less tonic 
muscle-spasm with clonic exacerbations, which, for the most part, occurs 
first in the muscles of the jaw and neck, involving progressively, in 
fatal cases, nearly the entire musculature of the body. Certain races of 
people seem predisposed, and in certain climates and geographical areas 
the disease is exceedingly prevalent. Negroes, Hindoos, and many of 
the South Sea Islanders show a peculiar racial predisposition, and, in a 
general way, inhabitants of warm countries are less resistant. This is 
shown partly by the fact that in various European wars the Italians and 
French have suffered more than the soldiers of more northern climes. 
Tetanus is by no means confined to adult life, since infants are far from 
exempt, and in the tropics the trismus of the new-born is the cause of a 
high mortality-rate. In Jamaica one-fourth of the new-born, negroes 
succumb within eight days after birth, and in various other hot countries 
the proportion is at times equally great. One plantation-owner states 
that fully three-fourths of the colored children born upon his plantation 
succumbed to the disease. The peculiar reason for this infection will 
appear a little later when speaking of tetanus neonatorum. Men seem 
more commonly affected than women, probably because of their occupa- 
tions, by which they are more exposed. Military surgeons have had to 
contend with the disease in its most frightful form, and it has been noted 
that soldiers when worn out by fatigue or suffering from the disaster of 
defeat seemed more liable to the disease. In 1813 the English soldiers 
in Spain suffered from tetanus in the proportion of 1 case to 80 wounded 
men. In the East Indies, in 1782, this proportion was doubled. Quick 
variations of heat and cold, such as warm days and cold nights, coupled 
with the other exposures incidental to military life, seem to exert a great 
effect. Curiously enough, the wounded in many campaigns who have 
been cared for in churches have suffered more from the disease than those 
cared for in any other way. Tetanus, however, is by no means neces- 
sarily confined to any one clime or race, but may be met with anywhere, 
at any time, providing only that infection have occurred. A celebrated 
Belgian surgeon was unfortunate enough to lose by tetanus 10 cases of DISEASES COMMON TO MAN AND ANIMALS. 
139 
major operations before lie determined that the source of the infection 
pertained to his haemostatic forceps. So soon as these were thoroughly 
sterilized by heat he had no further undesirable complications. If the 
disease can be so conveyed by the instruments of a careful surgeon, how 
much more so by the dirty scissors of a careless midwife, etc.! 
It is true, also, that the popular notions of the laity concerning the liability to 
tetanus after certain forms of injury is not ill-founded. Small ragged wounds of 
the hands and feet are those which ordinarily receive little or no attention, and 
are among those most likely to be followed by this disease. The toy pistol, which, 
a few years ago, was such a prevalent and widely-sold children’s toy, was guilty of 
many a small laceration of the hand, due to careless handling and the peculiar 
injury produced by the explosion of a small charge of fulminating powder in a 
paper or other cap. It was not the character of the laceration or injury thereby 
produced, but the fact that such injuries occurred in the dirty hands of dirty chil- 
dren, which were most likely to become infected, that has caused the so-called toy- 
pistol tetanus to be erected almost into the dignity of a special form of this disease. 
During the month of July of 1881, in Chicago alone, there were over 60 deaths 
from tetanus among children who had been injured in this way by these notorious 
little toys. This led to their sale being suppressed by law. 
Etiology.—In time past two theories have had strong advocates, 
one being that which would account for the disease by irritation of 
nerves—a nervous theory; while the second,the humoral,would explain 
the disease by alterations in the blood. Each has had its most ardent 
defenders, but both have now completely yielded to the investigations 
of a few observers, among whom Kitasato and Nicolaier are the most 
prominent. These ardent workers 
have been able to clearly establish 
the parasitic nature of this disease 
and to isolate and investigate the 
organisms by which it is produced. 
This was in 1885. 
Fig. 33. 
The bacillus of tetanus is a somewhat 
slender rod-shaped organism, with a pecu- 
liar tendency to spore-formation at one 
end, which gives it a drumstick appear- 
ance. It is essentially an anaerobic or- 
ganism, and can never be cultivated in 
contact with the air. In laboratory experi- 
ments it is grown in the depths of a solid 
culture-medium or else in fluids and on 
surfaces in an atmosphere of hydrogen 
gas. It is one of the apparent contra- 
dictions of bacteriology that this organism, 
wdtich can only be grown as an anaerobe, 
nevertheless abounds in earth, particu- 
larly the rich black loam which best sup- 
ports luxuriant vegetable life, and that it practically inhabits the upper layers of 
the soil, which accounts for the fact that so many contaminations and infections 
have occurred from stepping upon planks or boards with nails projecting, or from 
introduction of splinters, or from lacerations of the hands and feet which are so 
often followed by contact with such materials. There is nothing about a rusty-nail 
wound which, by itself, predisposes to tetanus, but the rusty nail upon which the 
barefooted boy steps is either itself infected or leaves a rent or wound which the 
boy may infect within the next few moments, and which is not likely to receive 
the careful attention which it ought to have. Yerneuil has of late laid stress upon 
the fact that in localities where horses are kept tetanus is more prevalent, and that 
the infectious organism abounds in and upon stable-floors, about barn-yards, and 
wherever the excretions of a horse may be found. Bacteriologists are all aware 
Tetanus bacilli, showing spore-formation 
(Kitasato). 140 
SURGICAL DISEASES. 
that in the intestine of herbivorous animals the bacilli (anaerobic) of tetanus and 
malignant oedema are often found. Verneuil has further shown that almost the 
only instances of tetanus which occur on shipboard are upon those ships which 
are used for transportation of horses and cattle. His statements are at least 
interesting, if not absolutely well founded. At all events, tetanus is certainly of 
telluric origin. 
The tetanus bacillus manifests other peculiar properties, for some of which it 
is most difficult to account. Upon susceptible animals it is violently infectious, 
but is very rarely found at any distance from the tissues in which it has first lodged, 
and it has never been satisfactorily demonstrated far away from them. In labora- 
tory investigations the period of incubation is seldom longer than forty-eight hours. 
Another peculiarity of the organism is that it generates certain poisons of most 
active properties which may be separated from pure cultures, by whose injection 
the peculiar spasms of the disease itself may be reproduced. These have been 
isolated, especially by Brieger, who has given to them the names of tetanin, tetano- 
toxin, spasmotoxin, etc. They will be found alluded to in the Appendix to 
Chapter VI. 
Tetanus has been spoken of as idiopathic and traumatic. Here, 
again, the term “idiopathic” is simply a confession of ignorance, and 
in the light of our positive knowledge concerning the infectious charac- 
ter of the disease should be abandoned. It simply means that the path 
of infection has not been discovered. Tetanus, then, is essentially a 
traumatic disease, since it has not been established that infection can 
occur upon unbroken skin or mucous membrane. 
Tetanus neo-natorum, or tetanus of the new-born, a condition already 
alluded to, is a remarkably fatal affection, very prevalent among the 
negro race, especially in hot climates. It in no wise differs from trau- 
matic tetanus, but is such in effect, since the infection in these instances 
always follows the division of the umbilical cord, which is usually effected 
by dirty scissors in the hands of a dirty midwife, while the thread with 
which the cord is tied is itself a possible source of infection, as well as 
the rags which are used to cover the umbilicus in the first dressing. It 
is virtually always fatal, because of the weakness and lack of resistance 
of these little patients. It occurs usually within a week after birth, if 
at all. Tetanus cephalicus, called also tetanus hydrophobicus and head- 
tetanus, is only a peculiar manifestation of this same affection, confined 
for the most part to the head and usually following injuries to this 
region. The muscle-spasms are, for the most part, confined to the 
facial, pharyngeal, and cervical muscles, sometimes extending to the 
abdominal. These manifestations may be in some measure reproduced 
in animals by inoculating them on the head rather than upon the extrem- 
ities. It is the least fatal form of the disease. 
Symptoms.—There is always a period of incubation, usually three or 
four days, occasionally a week in length, and rarely considerably longer. 
In my own experience I have seen the symptoms retarded until after complete 
and absolute healing of the wound to which they were apparently due ; and in one 
instance, to my positive knowledge, there must have been an interval of six, pos- 
sibly eight, weeks between the visible opportunity for infection and the first mani- 
festations of the disease, which proved fatal. 
It is generally held that the longer the period of incubation the more 
hopeful the prognosis. While for the most part the disease assumes a 
most acute type, a chronic tetanus is described and occasionally met with. 
The first warning of the disease usually comes as more or less stiffness 
of the cervical and maxillary muscles, .which is likely to be spoken of by DISEASES COMMON TO MAN AND ANIMALS. 
141 
the patient as a “sore throat,” because of the consequent difficulty in 
deglutition. A complaint to this effect should be always regarded as a 
warning, especially if, on inspection, no visible reason for it can be 
detected in the pharynx. This complaint is usually made in the morn- 
ing after an ordinary night’s rest. This muscle-stiff ness will be followed 
by increasing tonic spasm in the muscles of the jaw, making it difficult to 
open the mouth, while the head and neck gradually become stiffened 
and fixed by spasm of the cervical muscles. These muscles may now 
be felt more or less rigidly contracted, as if by voluntary effort, and the 
condition, which is at first not painful, becomes after some hours a source 
of discomfort, perhaps of actual pain, to the patient. If, now, the disease 
pursue the usual course, the other muscles of the body become grad- 
ually affected, usually in the order of their proximity, but not necessarily 
so. The abdominal muscles are firm and board-like, and the dorsal mus- 
cles more or less contracted, sometimes to an extent which causes arching 
of the spine. Should the original wound or port of entry for infectious 
germs have been in the hand or foot, the muscles of this limb become 
contracted, more or less rigidly, holding it in a position which is not easily 
changed, even by efforts of the attendant. Sensation is also often more 
or less perverted. In this condition of tonic rigidity the muscles remain, 
to relax usually only with death. 
Fig. 34. 
•Characteristic tetanic spasm in a rabbit twenty-six hours after inoculation with pure culture of 
tetanus bacilli (Tizzoui and Cattani). 
The most characteristic features of the disease, however, are the pecu- 
liar clonic exacerbations, which convert spastic rigidity into violent and 
convulsive muscle-activity, so that the limbs, and even the frame, of the 
patient are more or less contorted, the muscle-exertion being sometimes 
most painful to witness. Peculiar effects are thus produced : the mouth 
is peculiarly puckered, and its corners drawn upward and backward by 
the risorius muscles, giving to the face that peculiar expression known 
as the “ sardonic grin.” When the abdominal and flexor muscles of the 
thighs are especially involved, the body is more or less curved forward, 
and this is known as emprosthotonos. When the muscles of the back 
especially are involved, with the extensor muscles of the thighs, we have 
opisthotonos, while, when the body is bent to one side or to the other, it 
is spoken of as pleurosthotonos. It is said that opisthotonic convulsions 
occur to such extent in rare instances that the heels may even touch the 
head. At all events, the patient’s body is frequently raised from the 
bed, so that he rests upon the head and feet. 
Another most characteristic feature of the disease is the peculiar 142 
SURGICAL DISEASES. 
reflex irritability or hypercesthesia by which these convulsive attacks 
apparently are produced. Into this one falls more or less rapidly within 
the first day after the inception of the disease; and to such a height 
may it be augmented that the slightest movement in the room, jarring 
of the bed, or displacement of clothing, even noise or a flash of‘ light, 
may immediately bring on a convulsion. Rupture of muscles has been 
reported during some of these violent convulsions. 
During the course of this disease the jaws are so fixed that patients 
speak with extreme difficulty and the tongue cannot be protruded. The 
mind is clear until the end. The pain is rather the acute soreness due 
to intense muscle-strain. There is spasm of sphincters by which urine 
and faeces are often retained. There is nothing characteristic about the 
temperature, which is seldom much augmented. Attempts to swallow 
give pain, and are resisted specially because of the renewed muscle- 
spasm which is likely to follow the irritation inseparable from the act 
itself. As the result of spasm of the glottis peculiar respiratory sounds 
may be noted. 
Until the last only the voluntary muscles are involved. Finally, however, 
come spasms of the accessory respiratory muscles, and, lastly, of the diaphragm ; 
and death is usually produced by involvement of these muscles analogous to that 
of the others. Death results, then, usually from apncea or suffocation. During the 
last hour or two perspiration may be copious and temperature may rise. 
Chronic tetanus is characterized throughout by a milder and much 
more prolonged series of symptoms. The period of incubation is much 
longer, and, while the general programme of the acute form is adhered 
to, it is of less severe degree and is spread over a longer time; in fact, 
cases covering two months or more are reported. In chronic tetanus- 
the prognosis is much more hopeful than in the acute form. 
So far, nothing has been said about the appearance of the wound. 
This is but slightly, if at all, affected. In some cases it will be found 
to have completely healed before the onset of the disease. If suppu- 
rating or open, its evidences of repair will be found unsatisfactory and 
some indications of septic infection may be noted. Pricking or needle 
sensations may be subjective phenomena. 
Prognosis.—Prognosis is almost invariably bad. No case of acute 
tetanus under my own observation has ever yet recovered. Still, occa- 
sionally recovery does ensue. Whether this be due to a peculiarity of the 
patient or to the medication is, perhaps, still doubtful. If patients live 
more than live or six days, the prognosis is thereby certainly bettered. 
Post-mortem Appearances.—These are rarely distinctive. In 
most instances there are evidences at least of hypersemia, if not of more 
active changes, in the upper portions of the cord. Much less often 
slight changes have been noted in the brain, consisting, in some measure,, 
of disintegration and softening. Evidences of ascending neuritis in the 
nerve-trunks leading to the injured area have been claimed in some 
instances. As a matter of fact, however, few, if any, distinctive post- 
mortem changes can be described as due to this disease. 
Diagnosis.—This must be made as between strychnia-poisoning, 
hysteria, hydrophobia, tetany, and, in the very beginning, from pharyn- 
gitis, tonsillitis, etc. When the disease is fully developed it is not likely 
to be mistaken for anything else. DISEASES COMMON TO MAN AND ANIMALS. 
143 
In strychnia-poisoning the muscles of the jaw are the last to be affected, in 
tetanus the first. There is, too, in strychnia-poisoning hypersesthesia of the retina, 
and objects are often seen green. There is no foaming at the mouth in tetanus, 
and the symptoms of strychnia-poisoning which would probably lead to the ques- 
tion of diagnosis would extend over a comparatively brief period of time, after 
which there will be either amelioration or death. 
In hydrophobia the whole picture is of mental excitement and distress, and in 
genuine hydrophobia there is a definite history of particular accident, which will 
be always suggestive. The hydrophobic muscle-spasms are, for the most part, 
limited to muscles of respiration and deglutition. In tetanus the patient instinct- 
ively remains as quiet as possible; in hydrophobia he is restless, and perhaps 
requires mechanical restraint. In tetanus the mind is clear to the last; hydro- 
phobia is characterized by mania. 
Tetanus may be simulated by hysteria in patients of a certain class, but in this 
event the phenomena will be so uncertain, so contradictory, and the evidences of 
real organic disease so essentially lacking, that it is not likely that mistake can 
occur. 
Treatment.—If any case can be imagined in which efficient treat- 
ment is most urgently demanded, it is one of tetanus. In scarcely any 
disease, however, is treatment so unsatisfactory. In the rare instances 
in which patients recover one questions whether it is not due to indi- 
vidual resistance rather than to medication. Treatment may be sub- 
divided into local, constitutional, and specific. If there be still an open 
suppurating or discharging wound, it is well to anaesthetize the patient 
and to thoroughly cleanse this out, basing this advice in some measure 
upon general principles—largely upon the fact, already stated, that only 
the immediate surroundings of such a wound are found infected by the 
bacilli themselves. Consequently, thorough scraping, excising, and 
cauterization, either with powerful caustics or the actual cautery, are 
indicated. If it be in a finger or toe, amputation may be the simplest 
method of eradicating the local lesion. 
Nerve-elongation (stretching) has also been suggested, and for some years was 
practised in connection with these operations, the nerve-trunk supplying the 
affected part being exposed and vigorously stretched. This was done at a time 
when a specific cause was not yet determined, and may now be abandoned in the 
light of more recent knowledge, without detriment to patients. The use of hydrogen 
dioxide or caustic pyrozone about all local lesions would seem to be indicated, 
because the germs only grow in those tissues which are starved of oxygen, and 
because in the presence of excess of free oxygen they are killed. 
Constitutional treatment may be divided into nutrition and medication. 
The tendency too often in these cases is to be careless or indefinite with 
regard to the excretions and the nutrition of the patient. If, for instance, 
each attempt at catheterization throw him into convulsions, the bladder 
may become over-distended, and even may possibly burst. So, too, there is 
apprehension usually with regard to fecal evacuations. At the same time, 
these patients are allowed to almost starve because of the difficulty of 
feeding them. My advice first, then, is to resort to chloroform at least 
often enough to permit the introduction of a stomach-tube—through the 
nostrils, if necessary—by which nutrition may be introduced into the 
stomach without causing the violent convulsions that would certainly 
occur without an ansesthetic. At the same time, the catheter may be 
used if necessary. 
Along with nourishment may also be given such cathartics or purgatives as 
may be indicated, or at the same time a more or less copious high enema may be 
introduced for the purpose of thoroughly unloading the bowels. If one may be 144 
SURGICA L DTSEASES. 
permitted the Hibernicism, these patients, as often cared for, would starve to death 
if they did not die of suffocation ; and nutrition is certainly most important. 
In the way of active medication there is no agent so efficacious for 
controlling the tetanic spasms as chloroform, which may be administered 
occasionally, or more or less continuously, according to the wishes of the 
attendant. By its use the severest spasms at least can be kept in abey- 
ance, and the horrible character of the disease somewhat mitigated. 
Of the other medicaments used, most of them are of the nature of 
nerve-sedatives, such as chloral, the bromides, Calabar bean, cannabis 
indica, opium, etc. By continuous but mild dosage with Calabar bean 
(eserine, hypodermically) the severest manifestations can often be, in a 
measure, controlled, providing only it be given in small doses. Poncet 
suggests to give 1 to 1 f grains of extract by the mouth every four hours, 
or to inject 15 to 20 drops of a 1 per cent, solution of the same hypo- 
dermically. Chloral has been used by the mouth, the rectum, and 
injected into the veins. While more or less reliable in relaxing the con- 
vulsions, it is depressing in other ways, and apparently not finally suc- 
cessful. Opiates have been given in enormous doses, and are called for 
especially when there is severe pain. The bromides, if used, must be 
given in large and increasing doses. 
Curare, on account of its peculiar effect in paralyzing voluntary mus- 
cles, has been suggested and frequently resorted to. On account of the 
difficulty of getting a reliable specimen, it is not always at hand, and 
even then one must experiment with it in order to learn the exact dose 
of a given specimen which the patient can safely tolerate. Hot-air 
baths or diaphoretics, by which copious perspiration may be induced, 
have yielded good results in certain cases. In fact, they were in general 
use several centuries ago. Cold applications down the spine, or spraying 
the spinal region with ether or other volatile substances by which heat 
is abstracted have also had their advocates, the intention being to pro- 
duce spinal anaemia, so far as possible, as the reflex result of external 
cold. But to do this means to disturb the patient, and the practice has 
not been generally followed. 
Specific treatment means in these instances taking advantage of the 
now well-known properties which the blood-serum of an animal artifici- 
ally immunized against the disease possesses. This is in accordance with 
recent experimental labors with a number of different diseases, of which 
tetanus is one. It is, in effect, similar to the serum-therapy of diphtheria 
so recently introduced. 
The animal used is the horse, which is immunized by injecting at first small, 
then increasing, doses of active cultures of tetanus bacilli, sufficient to affect the 
animal, but insufficient to kill. In this way an increasing degree of immunity is 
produced, until a point is reached where the animal seems absolutely insusceptible 
to the disease, even in its most virulent form. Blood is now drawn from this 
animal, its serum separated, and this used for subcutaneous injection in doses usually 
determined by its ascertained strength and active properties. 
This is the method elaborated by Tizzoni and Cattani, while the 
material made from such serum according to their method is known as 
the tetanus antitoxine. It is prepared by precipitation by absolute alco- 
hol and solution again in glycerin. There are now on record a number 
of instances where men suffering unmistakably from the disease recov- 
ered after use of this antitoxine. Although the number is yet relatively DISEASES COMMON TO MAN AND ANIMALS. 
145 
small, and although some doubt has been attached to some of these case 
reports, it would seem that the majority of them at least are authenti- 
cated, and that a remedy has at last been supplied, more hopeful and 
full of promise than anything heretofore offered to the profession. 
Tetany. 
Under the heading of Diagnosis of Tetanus it was stated that it is 
necessary sometimes to differentiate tetanus from tetany. This latter 
condition is one which seldom pertains to surgical cases, and the subject 
is introduced here rather for the avoidance of error than because of 
desire to complicate this already abstruse subject. From the great 
resemblance in names the student may infer that there is resem- 
blance between the diseases. This is not the case. Tetany is a non- 
specific disease—i. e. a neurosis—characterized especially by tonic spasms, 
particularly of the extremities, and by increase of mechanical and elec- 
trical excitability of peripheral nerves. However, it follows certain 
operations, notably thyroidectomy, and, although in a measure inter- 
changeable with another distinct neurosis—namely, myxcedema—it may 
nevertheless occasionally cause alarm because of its convulsive manifes- 
tations. 
It occurs sometimes spontaneously in pregnant and nursing women, and is met 
with in children after exposure to cold or after such intestinal lesions as may be 
produced by typhoid or by parasites. It occurs also in endemic or epidemic form, 
and has been described under various names—as tetanella, idiopathic muscidar 
spasm, carpo-pedal cramp, etc.—the muscle-spasms occurring in reasonably regular 
order or rhythm, while patients do not lose consciousness. It is pathognomonic 
of the disease that the muscle-spasms of a part may be produced by compression 
of its great vascular or nerve-trunks. This was established by Trousseau, and is 
known as Trousseau’s sign. Another peculiarity was first described by Chvostek, 
in that a slight tap upon the side of the face over the point of emergence of the 
facial nerve from the parotid suffices usually to call forth a sudden spasm of that 
side of the face. 
The symptoms of post-operative tetany may supervene almost imme- 
diately after operation or may be delayed so long as ten days. The 
muscles of the face are first affected; then those of the upper extremity. 
The hands are usually flexed to the ulnar side with fingers bent at the 
metacarpo-phalangeal joints—that is, straight and stiff, the thumbs bent 
into the palms. Sometimes the fist is doubled up with the thumb between 
the first and second fingers. The muscles are in a condition of moderate 
tonic rigidity which is always difficult to overcome. During the muscle- 
spasms there is more or less pain, often with elevation of temperature. 
These spasms may last even fifteen minutes, but do not occur with such 
frequency as those of true tetanus. Nevertheless, in the severest cases 
of tetany is seen a facial spasm simulating the sardonic grin of true 
tetanus. Post-operative tetany is always serious, often fatal. It may 
be imitated by removing the thyroids of kittens or young cats. Usually 
within two or three days the symptoms of the disease are present and 
characteristic. Treatment seems to be unavailing, at least by ordinary 
drug-medication. In a case of tetany, either idiopathic or post-opera- 
tive, the most hopeful medication would be the administration of thyroid 
extracts, either fresh or prepared by desiccation. These in some instances 
have given great relief. 146 
SURGICAL DISEASES. 
In several instances where the disease has followed extirpation of 
goitre, thyroidal transplantation has been tried—i. e. the transplantation 
of a thyroid from another animal—either into the abdominal cavity of 
the patient or, better still, into some convenient cavity made for its 
reception ; for instance, behind the mammary gland, in the fleshy part 
of the thigh, etc. It has been pretty clearly established experimentally 
that there is always risk of tetany, myxoedema, or some other expres- 
sion of auto-intoxication when more than four-fifths of the thyroid body 
is removed. 
Hydrophobia. 
Hydrophobia is an acute specific or infectious disease, so far as known 
never originating in man, but transmitted to him, usually through the bite 
or by inoculation from the saliva of a rabid animal—in this country 
usually the dog, although the wolf, the cat, the skunk, and even certain 
of the domestic poultry, are capable of conveying the disease. It can 
also be inoculated in other animals, like rabbits. The virus is ordinarily 
conveyed in the saliva of the rabid animal. This may be wiped off as 
the teeth of the animal pass through the clothing of the injured indi- 
vidual ; consequently, infection does not certainly follow such bites. 
But those upon exposed portions of the body, where animals generally 
bite, are almost invariably followed by infection. Hydrophobia is fre- 
quently spoken of as rabies, sometimes as lyssa. While rare in this 
country, it is by no means rare in Central Europe, especially perhaps 
in Russia, where bites from infuriated wolves are relatively common. 
In the United States infection comes almost invariably from the rabid 
dog, in whom this disease presents two types. 
The so-called furious form is that which is marked by frenzy and canine mad- 
ness, the objective symptoms being more pronounced and alarming, though not less 
dangerous, than the other variety. After the period of incubation, which varies 
considerably, these animals show depression and uneasiness, and even thus early 
their saliva is infectious. Their sense of hunger becomes perverted ; they exhibit 
unusual tastes, secrete saliva abundantly, which becomes very tenacious and even 
frothy, exhibit a dry and oedematous condition of the faucial mucous membranes; 
the character of the bark is altered, while they are usually infuriated at the sight of 
other dogs. In this stage there is usually insensibility to pain. Finally, come 
more or less paralysis of deglutition, quickened respiration, dilated pupils, and 
frenzy and madness of manner, by which they attack indiscriminately men and 
other animals. To this stage of furious excitation succeeds one of paralysis, and, 
finally, death follows from exhaustion. These manifestations usually last about a 
week. 
Dumb hydrophobia is the more common form. Here paralysis appears much 
earlier and involves especially the lower jaw; the tongue falls out of the mouth; 
and the posterior extremities are quickly paralyzed. This form is much more 
quickly fatal than the other. 
Hydrophobia in man is rare in this country, yet is occasionally met 
with. Its etiology is as yet completely obscure. That a contagium 
vivum is present is positive, but its nature is absolutely unknown. 
Pasteur, who has done so much work in protecting from and treating this dis- 
ease, holds to the view that the peculiar virus is made up of two distinct substances 
—the one an organized living virus capable of multiplication, particularly in the 
nervous system; the other inorganic, and capable, when present in sufficient pro- 
portion, of arresting the development and growth of the other. Whether this 
contagium vivum is bacterial, protozoal, or something else is not known. Babes 
claims to have cultivated on blood-serum an organism extracted from the brain of 147 
DISEASES COMMON TO MAN AND ANIMALS. 
hydrophobic rabbits, which, upon inoculation, occasionally reproduces the disease. 
This, however, is far from being sufficient evidence to establish the bacterial nature 
of the disease. Fol has found small granules in large masses within the nerve- 
structures, each granule taking a deep violet stain, while from cultures which he 
claimed to have made he could produce a modified hydrophobia in animals. 
While everything, then, points to the organized character of this virus, we are not 
in position to speak with any definiteness concerning its exact nature. 
Symptoms.—The period of incubation in man is very variable, ten 
weeks being perhaps the average. It is shorter in children, as also when 
the bites are numerous. It is even stated that it may be so long as a 
year or more, during which time the poison seems to lie latent. When 
the active symptoms supervene there are, locally, discomfort about the 
wound, itching, heat, and peculiar unpleasant sensations. It is said also 
that, in some cases at least, vesicles make their appearance in the neigh- 
borhood of the original lesion. As in animals, so in man, the disease 
may assume either the furious or the paralytic type. These cases are 
nearly all marked by mental depression and apathy, with complete loss 
of courage. The earlier symptoms are connected perhaps with the 
respiration, which is infrequent, while inspiration is halting and speech 
is interfered with. The facial appearance is often changed to one of 
anxiety, even despair. The muscles of deglutition are next involved 
in a combination of spasm and paralysis, and the act of swallowing is 
interfered with, sometimes made almost impossible. Although patients 
can swallow their own saliva, they find it most difficult to swallow any 
foreign substances, such as water, etc. This is not due to the fear of 
water, as the term “ hydrophobia ” would imply—this being an absolute 
misnomer—but is due to reflex spasm excited by the attempt. It is 
accompanied by more or less sense of suffocation and palpitation of the 
heart. Indeed, a paroxysm of this kind may be precipitated by the 
attempt to swallow, so that the patient instinctively refuses water or any 
other fluid. Reflex excitability is also very great, and a breath of air or 
a trifling disturbance may precipitate a paroxysm, almost as in extreme 
cases of tetanus. As the case progresses the saliva becomes more tena- 
cious and viscid, faucial irritation more marked, and the attempts to 
expel the secretion, along with the disturbed respiratory efforts, have 
given rise to the foolish lay notion that these patients bark like dogs. 
The paroxysms, as the case progresses, become more marked, the patient 
more restless, until, later, furious mania or muttering delirium is present, 
to be followed by prostration and paralytic phenomena, muscle-tremor, 
etc., and death. 
The paralytic form in man, as in dogs, is marked by the much earlier paretic 
phenomena, anaesthesia, and, finally, respiratory paralysis, which terminates the 
case. Curtis and others have insisted that the hydrophobic paroxysms are not 
convulsions in the ordinary sense of the term, but are due to temporary inhibitions 
of the most important respiratory and cardiac centres as the result of peripheral 
impressions. He would liken them to the shock of a shower-bath. 
Post-moktem Changes.—Post-mortem changes are indistinct and 
only suggestive. For the most part they are found within the nervous 
centres—most prominently in the medulla, then in the hemispheres, and 
then in the spinal cord. There is hypersemia, with minute ecchymoses, 
with infiltration of the adventitia of the vessels and perivascular extrav- 
asation. The changes met with in the other viscera bear no constant 
relation to symptoms. Nevertheless, Gowers holds that because of the 148 
SURGICAL DISEASES. 
location of the lesions and their intensity in the neighborhood of certain 
nerve-nuclei we have here a distinguishing anatomical character of the 
disease. 
Diagnosis.—As between hydrophobia and tetanus, diagnosis is not 
difficult, as already described. In certain hysterical individuals nervous 
paroxysms, largely due to fright, may be precipitated by dog-bites and 
other incidents or accidents. In these cases there is rarely, if ever, such 
a period of incubation, and in a true hysterical case there will be no 
such mimicry, of this awful disease. A condition known as lyssophobia 
(fear of hydrophobia) has been described. It is seen for the most part 
in hysterical subjects. It is said to have even been fatal, but this must 
have been from other complications. 
Treatment.—There is no authenticated case on record of recovery 
after medication by drugs. It is probable that recovery has never fol- 
lowed anything save the modern inoculation-treatment. 
Reliable statistics are wanting as to the time during which it is possible to use 
caustics in a wound made by the rabid animal’s teeth, and thereby to avert inocu- 
lation. When it is known that a given injury has been produced by the bite of a 
rabid dog, local bleeding and suction of the wound, followed by complete cauter- 
ization or even extirpation of the injured area, would be advisable. It will be 
necessary for the medical man occasionally to combat that most foolish of all 
popular superstitions, that destruction of the animal will save the patient from 
active disease after an injury. This notion is quite prevalent. On the contrary, 
it would be much better to keep the animal safely restrained, in order that he may 
be watched, because if he develop the disease there will still be time to save tlfe 
patient by the Pasteur treatment, whereas if he do not develop the disease the 
patient’s fears may be completely set aside. 
The essential and only successful treatment for this disease has been 
elaborated as the result of the labors of that indefatigable French 
savant, Pasteur, and is among the most glorious triumphs of laboratory 
research, against which it is so often charged that it is not practical in 
its results. It is in some respects a curious commentary on the study 
of infectious disease that we can secure and work with the peculiar virus 
of hydrophobia, and at the same time be utterly unacquainted with its 
true character. To this fact is due the modern cure. It is based upon 
the fact also that the virus obtains not only in the saliva, but in the 
nervous system of animals suffering from this disease; also to the fact 
that its effects are intensified and hastened by inoculation directly into 
the cerebral substance. 
Virus obtained from the brain or cord and inoculated into the dura of another 
animal quickly precipitates the disease. It is, moreover, modified in virulence as 
it passes through successive animals of certain species—for example, monkeys. 
Curiously enough, it is increased by passage through rabbits, and the period of 
incubation thereby shortened. The weakest virus can by proper handling and 
manipulation in this way be so intensified as to produce disease within seven days 
after inoculation. Desiccation reduces the virulence, and preparations from the 
cord of an infected animal may be attenuated to almost any desired extent by 
drying. By inoculating a dog or a rabbit, for instance, with virus prepared from 
this weakened source, and daily making injections from stronger and stronger 
preparations, he is in the course of a couple of weeks rendered practically immune 
to the disease. Animals thus made immune are trephined, and the virus injected 
beneath the dura, by which much more certain results are obtained. 
Pasteur has, furthermore, shown us how to hasten the result by resorting to 
what he calls the intensive method—by the administration of virus of increasing 
strength at much shorter intervals. As in the case of vaccination against small- 
pox, if the vaccine virus be introduced sufficiently quickly after exposure to variola DISEASES COMMON TO MAN AND ANIMALS. 
149 
it may still serve as a protection, so in the case of hydrophobia, if the bitten patient 
can be treated by these preventive inoculations before the symptoms of the disease 
manifest themselves, they may be permanently averted. Upon this whole matter 
protection as against hydrophobia hinges. 
The conditions surrounding the laboratory work necessary in connection with 
this method of treatment are such that it is practicable only in some large institu- 
tion supported by government or other public means. Nearly all the rabic patients 
of Europe proceed to the Pasteur Institute in Paris, which is naturally their head- 
quarters. In New York a similar institute is conducted under the care of Dr. 
Gibier; and my advice to an individual bitten by a suspicious or positively rabid 
dog would be to place himself under treatment in one of these institutions. Injec- 
tions are made after the fashion indicated, by the subcutaneous method, about the 
trunk, and are daily repeated for two or three weeks. The results of this method 
have been such as to immortalize Pasteur and to effect a revelation in the consid- 
eration and treatment of certain infectious diseases. Statistics are fallacious and 
capable of manipulation. It is, however, positively established that a very large 
proportion of those who have received this treatment before the onset of specific 
symptoms have been redeemed from an otherwise certain grave. All honor, then, 
to the man and to the method which he devised! 
Glanders and Farcy. 
Glanders as it is ordinarily known in man is a specific infectious dis- 
ease, transmitted, for the most part, from the horse, characterized by rapid 
formation of specific granulomata, particularly in the skin and mucous 
membranes, which quickly break down into ulcers, and by the general 
toxaemia of any acute infection. In German it is known as rotz; in 
French, as morve; while its old Latin name was “malleus” (hence 
we speak of the bacillus mallei). It was also known in former days as 
equinia. In horses the disease has also been known as farcy, because of 
the peculiar subcutaneous nodules which farriers and hostlers almost 
from time immemorial have called “ farcy buds.” The disease, while 
capable of transmission from man to man, is virtually always produced 
by contagion from some of the domestic animals, most commonly the 
horse, although sheep and goats are known to occasionally have it, and 
dogs are quite susceptible, though seldom showing manifestations of it. 
Cattle are immune against general infection, but occasionally show local 
ulceration. In menageries it is known that lions and tigers may become 
affected. Field-mice are extraordinarily susceptible, while house-mice 
and white mice are quite exempt. The pigeon is the only bird known 
to be susceptible. Glanders has been met with occasionally among lab- 
oratory investigators, and the glanders bacillus is one of the most dan- 
gerous organisms with which students can work in the bacteriological 
laboratory. 
Like some of the other infectious diseases, glanders appears to be variable in 
its manifestations. While infection occurs probably through some superficial 
abrasion, it is almost certain that it may also occur through the unbroken mucous 
membrane of the respiratory organs. It is said to be also capable of transmission 
from mother to foetus in utero. So far as known in man, infection occurs practically 
invariably through some slight abrasion, either of the skin or the mucous mem- 
brane of the nose, the eye, or the mouth. The discharges from the nostrils of 
affected animals are extremely virulent, and infection comes usually from this 
source. It is said to have been communicated from one patient to another by eat- 
ing from the same dish or by drinking from a pail used by a diseased horse. 
Glanders is due to the specific bacillus known as the bacillus mallei. 
It is shorter and plumper than the tubercle bacillus, in length about 
one-third the diameter of a red corpuscle. It is a non-motile organism, 150 
SURGICAL DISEASES. 
occasionally spore-bearing, not very resistant, belonging to the facultative 
anaerobic forms, growing best at blood-temperature, taking stains easily, 
and losing them in the same way. By continuous cultivation its viru- 
lence is attenuated or almost lost; 
consequently, conditions outside of 
living organisms are unfavorable for 
its growth. It is conspicuously found 
in the granulomatous nodules which 
are characteristic of the disease. 
Symptoms.—Glanders is met with 
almost invariably in workers and 
hangers-on in stables. The acute— 
the common—form has a period of 
incubation of from three to seven or 
eight days, after which both local 
and general symptoms supervene. 
About the infected region a form of 
cellulitis appears, assuming often a 
more or less phlegmonous type, with 
implication of the adjacent lymphatic 
nodes and evidences of periphlebitis 
and perilymphangitis. Over the af- 
fected area vesicles appear, which become hemorrhagic, and later suppurate. 
A wound which has healed may reopen. Almost always there are accom- 
panying constitutional disturbances of septic type, occasional chills, 
pyrexia, etc. It is rather characteristic of glanders to have severe pain 
in the muscles and extremities, with epistaxis and formation of metastatic 
tumors and oedematous swellings in various parts of the body. Fre- 
quently, later in the disease, comes a somewhat distinctive eruption, 
papular in character, merging into pustular. Hemorrhagic bull® are 
also often seen. Pustulation and cedema of the face change its appear- 
ance notoriously. There take place also oedema of the eyelids and muco- 
purulent discharge from the conjunctives and the nose. This latter dis- 
charge is often even ozsenous in character. Upon inspection of the 
naso- and oro-pharynx a similar condition will be noted. In connection 
with these local signs more or less general furunculosis will also be 
observed. Obviously, as these local conditions intensify and multiply 
septic disturbance will be increased, and the patient dying of acute 
glanders dies in large measure of septicaemia or intoxication and exhaus- 
tion combined. 
Fig. 35. 
Bacillus mallei; section from spleen; bacilli 
seen between the cells; X 500 (Frankel and 
Pfeiffer). 
A chronic form is known, distinguished mainly by slowness or tardiness of 
lesions, though the local changes are not particularly different in character. There 
is perhaps more tendency to suppuration and less to lymphatic complications. The 
nodule which breaks down will leave a foul ulcer, the discharge from all these 
lesions being extremely infectious. 
Each of these nodules, or farcy buttons, is similar in make-up to the local col- 
lections of cells which constitute the so-called granulation-tumor or granuloma, 
and in these respects is analogous to tubercle and syphiloma. They are, therefore, 
expressions of cellular activity as a protection against the inroads of a specific 
irritant. They break down rather by superficial destruction, and constitute the 
ulcers above mentioned. They will be met with in all sizes, from the miliary 
nodule to the tumor of considerable volume. Similar masses will form wherever 
the lymphatic current carries the bacilli; consequently they may be met with in 
the muscles and elsewhere. DISEASES COMMON TO MAN AND ANIMALS. 
151 
Diagnosis.—This is not always easy, but may be based in suspicious 
cases to some extent upon the occupation of the patient. The presence 
of multiple lymphatic lesions and subcutaneous nodes, especially when 
breaking down as above described, and accompanied by ozsenous dis- 
charge from the nose, should at least be most suggestive, and will serve 
to distinguish between this disease and, for instance, typhoid fever. 
The chronic type of glanders might be mistaken for syphilis, and here 
is where the real difficulty of diagnosis will probably obtain. In doubt- 
ful cases the crucial tests would be microscopic examination of discharges 
after staining for bacilli, and the cultivation test. 
Prognosis.—A generalized attack of glanders is a matter of gravest 
import, especially when acute. Scarcely more than 10 or 15 per cent, 
of such cases recover. In the more chronic manifestations the prognosis 
is very much better, half of the patients making a final recovery. 
Treatment.—All infected animals should be quickly isolated and 
destroyed, their carcasses being burned. If possible, the infected wound 
or abrasion should be coaxed to bleed freely, and then cauterized with 
some active caustic. By prompt interference with the first manifesta- 
tions it maybe possible to cut short the disease. This would necessarily 
be done by excision, cauterization, packing, etc. Bayard Holmes has 
reported a case in which, during two and a half years of chronic mani- 
festations of this disease, he amesthetized the patient twenty times for 
the purpose of opening new foci or scraping out old ones, finally obtaining 
a permanent cure. There is no specific treatment, but the septic symp- 
toms should be combated as already indicated in the chapter on Sep- 
ticsemia. 
By making a glycerin extract from the filtered and evaporated culture of the 
glanders bacillus it is possible to prepare a toxalbumen analogous to tuberculin, 
which reacts in a similar way. By it animals may be fortified against inoculation, 
and by its use a peculiar reaction is produced in those affected by the disease. It 
is known as mallein, and by it are tested all horses used for the preparation of the 
diphtheria antitoxine, in order that all possibility of glanders may be eliminated. 
It is probable that it might be made of therapeutic value in treating the disease 
when actively present in man. 
Anthrax. 
Anthrax is more commonly known as splenic fever, malignant pus- 
tule, or ivool-sorter’s disease ; in Germany, as Milzbrand, and in France, as 
charbon. It is an infectious disease, which has devastated many parts 
of Central Europe of cattle, and which has been frequently met with 
abroad among men, though but rarely in the United States. All the 
domestic and nearly all the experimental animals are subject to it. 
Gronin has stated that in the district of Novgorod, in Russia, during 
four years more than 56,000 cattle and 528 men perished from anthrax. 
Poultry and dogs are not exactly immune, but possess a low suscepti- 
bility to the disease. It seems to prevail in low districts and in marshy 
grounds. 
The terms anthrax and carbuncle have been variously used, and confusion has 
at times arisen from this mistake. It would be best always to call the disease by 
the name anthrax, and never to use the term “ carbuncle” in connection with it, 
although in the cutaneous lesions most often seen in man anthrax-pustules assume 152 
SURGICAL DISEASES. 
the carbuncular type, being accompanied by considerable tissue-necrosis, which 
may be separated in the shape of sloughs. 
The disease is the result of the invasion of the bacillus anthracis, 
which is a relatively large-sized bacillus, varying in breadth from 1 to 
l\, and in length from 5 to 20 mikrons. It is most easily cultivated 
outside the body, and multiplies with great rapidity in the body of sus- 
ceptible animals, is the type of spore- 
bearing bacilli, and is so easily recog- 
nized and worked with, that it is 
commonly used in laboratory inves- 
tigations. The demonstration of its 
specificity we owe to Davaine in 1873, 
although he had described it in 1850. 
The organisms are non-motile bacilli, 
and reproduce by fission as well as 
by spores, both of which processes 
can be observed under the lens. They 
stain with all dyes, and are easy, 
though somewhat dangerous, to work 
with. While the mature organisms 
are of comparatively slight resistance, 
their spores are extremely durable and 
require relatively powerful antiseptic 
solutions or prolonged heat or the 
actinic effect of bright sunlight to 
destroy them. Pieces of thread dipped in a bouillon culture of anthrax, 
in which the spores form best, are used in laboratory investigations for 
determining the strength of antiseptic solutions necessary to kill. These 
are the so-called spore-threads. 
Anthrax bacilli may enter the body through the respiratory organs, 
through any abraded surface, and possibly even through the alimentary 
canal. They may also pass through the placenta and affect the foetus 
in utero. They are too large to pass through the walls of the capillaries 
of ordinary size; consequently, they plug them and produce a mechan- 
ical stasis which is rapidly followed by gangrene. From the kidney 
structures and capillaries, however, they must escape, since bacilli are 
found in the urine in certain cases of anthrax. 
t 
Fig. 36. 
Bacilli of anthrax; from splenic juice of in- 
fected guinea-pig; X 500 (Frankel and 
Pfeiffer). 
Anthrax bacilli better illustrate the possible mechanism of these infectious 
agents than any other organisms, save possibly the erysipelas cocci. They may be 
seen choking the capillaries and completely interfering with all function, thereby 
determining the death of the invaded part. They produce a toxine of virulent 
properties of somewhat uncertain strength; and, finally, they are aerobic, and 
hence secure their oxygen from the tissues in which they grow, thereby robbing 
them. The spores are so resistant that they remain for an indefinite length of 
time in the soil upon which carcasses of animals dying of the disease have rested 
or have decayed ; and such fields are dangerous grazing-grounds for cattle for an 
indefinite number of years thereafter, bacilli being, as Pasteur has shown, brought 
to the surface by earth-worms. They are also susceptible of being carried dry 
by the wind, or moist in currents of water, and spread for an indefinite distance, a 
constant menace to all vertebrate animals that partake thereof. 
Anthrax bacilli are capable of attenuation by successive cultivation, also of 
having their virulence restored by passing through the bodies of animals. These, 
however, are all points of interest which concern the bacteriologist rather than DISEASES COMMON TO MAN ANI) ANIMALS. 
153 
the practising surgeon, although the latter must be familiar with the researches of 
the former. 
In man the disease occurs usually as the so-called malignant pustule 
or wool-sorter’s disease, the latter name being given because of the 
liability of those individuals who come in contact with the carcasses 
and Hides of diseased animals or their immediate products. The period 
of incubation is brief—on the average 
two or three days. The first lesion 
appears usually on the face, hands, or 
arms, and is characterized by local 
discomfort with formation of a small 
papule, which rapidly becomes a ves- 
icle with an areola of cellulitis about 
it. This is rapidly followed by indu- 
ration and infiltration, and these by 
local gangrene, the result being the 
separation of a core-like mass, much 
as in certain cases of carbuncle. The 
affected area is usually discolored, 
often quite black. The process is not 
usually accompanied by suppuration, 
nor is there the pain of true carbuncle. 
The lesions tend to spread peripher- 
ally, but there is more or less vesi- 
cation of the surrounding skin. On 
account of the local ischaemia there will always be oedema of the affected 
region, and sometimes the swelling and local disturbance become ex- 
treme. These peculiar lesions have given rise to the common name, 
malignant pustule, which is well deserved. At last a line of demarca- 
tion becomes manifest, and if the disease progress favorably the included 
area is sloughed out, leaving a surface which it is hoped will soon become 
covered with reasonably healthy granulations. 
Absence of pain, and usually of pus, are significant features of anthrax. 
Should, however, mixed infection occur, we are quite likely to get pus- 
formation. When the disease partakes less of the characteristics of 
malignant pustule and more of a general infection, the local symptoms 
may not predominate, but, on the contrary, septic indications may be- 
come serious and even fatal. The evidence of more or less toxaemia 
is usually at hand, however, and the toxine of anthrax is almost as 
destructive of muscle-cell integrity as is that of diphtheria. 
The local lesions may be single or multiple, but will be met with 
almost always upon exposed areas of the body. 
Post-mortem Appearances.—These will depend upon the clinical 
course of the disease. In the sloughing tissues the bacilli are very 
numerous, while around the margin more than one bacterial form will 
probably be met with—i. e. mixed infection. Should saprophytic organ- 
isms complicate the case, they may have replaced the anthrax bacilli 
by the time the examination is made. The latter abound, however, in 
the blood, and may usually be found occluding the capillaries of the 
liver, spleen, kidney, etc. In intestinal infection, particularly in ani- 
mals, the mesenteric nodes are involved. Inasmuch as septic features 
Fig. 37. 
Bacilli of anthrax: section from liver; X 500 
(Friinkel and Pfeiffer). 154 
SURGICAL DISEASES. 
accompany all fatal cases, putrefaction will be found to begin early, 
and the changes in the blood and the gross changes in the other 
organs will, for the most part, remind one of sepsis rather than of 
anthrax. 
Prognosis.—Prognosis for man is not usually unfavorable, the 
majority of cases recovering with more or less local destruction of tis- 
sue. Should, however, infection become generalized, the case will prob- 
ably terminate fatally. 
Treatment.—This must be both local and constitutional. The 
former should consist of the most radical possible attack, and should 
include complete excision of the infected area, with the use of active 
caustics or the actual cautery. In fact, the latter instrument offers a 
most valuable means for combating the destructive tendency of the dis- 
ease. Sloughing and separation of the cauterized mass may be hastened 
by warm antiseptic poultices. Subcutaneous injections of 5 per cent, 
carbolic solution have been practised with apparent benefit in a number 
of cases, but should only be relied upon in the treatment of the milder 
manifestations. 
Benefit will accrue from the use of the ichythol-mercury ointment whose for- 
mula I have given when considering the treatment of Erysipelas. It has been 
suggested to treat these cases by the employment of the bacillus pyocyaneus, since 
it is known that this organism when injected with the anthrax bacillus materially 
attenuates its effect. 
An albuminose corresponding to tuberculin has been prepared by filtration 
from anthrax cultures, and a glycerin extract or other preparation of this is found 
to confer immunity upon many experimental animals and to mitigate the disease 
in those suffering from it. Pasteur has demonstrated also the possibility of pro- 
tecting animals by a sort of vaccination with attenuated organisms, and it is 
demonstrated that animals may in this way be protected from the disease or 
redeemed from its ravages. It is quite likely that treatment based upon these 
experimental results will be introduced to combat the disease in man should it ever 
show more than a tendency to involve solitary individuals. 
Malignant (Edema. 
This disease has been recognized for some time, mainly by French 
and Continental clinicians, and under such names as gangrene ,/oudroy- 
ante, gangrbie gazeuse, gangrenous septicaemia, and gangrenous em- 
physema. The name malignant oedema was given by Koch, who 
identified the infectious organism. It is one of the most dangerous 
forms of gangrenous inflammation, and occurs sometimes after serious 
injuries, and, again, after most trifling lesions, such as those inflicted by 
the dirty pointed instruments of the gardener, etc., or even the stings of 
insects. Two cases are on record where the disease followed a puncture 
of the hypodermic needle for the administration of morphine. In one 
of these the organism was found in the solution; in the other it prob- 
ably had been deposited upon the skin. 
Malignant oedema is essentially a specific form of gangrene (see 
Chapter V.), and is mentioned here rather because of its specific cha- 
racter. It is characterized by rapidity of spread and the specific nature 
of the exudate, as well as by the speedy destruction of the tissue in- 
volved, and by more or less gas-formation. It is not the same as the 
gaseous phlegmons described by some German surgeons, yet partakes of 
their general character. (Gas phlegmons have been rarely noted, their DISEASES COMMON TO MAN AND ANIMALS. 
155 
peculiarity being formation not only of pus, but of more or less offensive 
gases, which escape when the plegmon is incised. The gases are due 
to the presence of saprophytic organisms, and gas phlegmons, as such, 
are to be regarded as instances of mixed infection.) 
Malignant oedema is known by the brownish discoloration of the overlying skin, 
which is streaked with blue where the overfilled veins show through it, while the 
underlying tissues are sodden with fluid and more or less blown up by the gaseous 
products of decomposition, so that the finger detects a firm crepitus, as is common 
in subcutaneous emphysema. From the wound, if one there be, flows a thin, foul- 
smelling secretion, which may also be expressed from the deeper layers. That the 
neighboring lymph-spaces and nodes are actively involved is evident from the 
enormous swelling of the latter, as well as from the general condition of the 
patient. The rapid elevation of temperature with but trifling remissions remains 
constant until shortly before death. The tongue early becomes dry and cleaves to 
the palate, its surface being covered with a thick, foul fur. Patients early become 
apathetic, complaining only of pain and burning thirst. Delirium and coma 
usually precede death, which may occur in even so short a time as fifteen to thirty 
hours. After death the cadaver bloats quickly and putrefaction goes on with 
amazing rapidity. 
Post-mortem Appearances.—At the seat of the lesion even mus- 
cles and tendons will be found macerated, bone denuded and surrounded 
by a putrid fluid, the entire region presenting a notable swelling and 
infiltration of soft parts with reddish fluids and stinking gases. The 
overlying skin will be stretched, and superficial blisters may deepen the 
intensity of the process. The veins are clogged with decomposed blood 
and broken-down thrombi, and in the heart and large vessels will be 
found putrid liquid as well as gas, to whose presence early and sudden 
death is probably due. 
The bacillus of malignant oedema was demonstrated by Koch in 1882. It is the 
same as the vibrion septique of Pasteur. It much resembles in form and shape that 
of anthrax, yet differs widely from it in 
that it is motile, but particularly in that it 
is strictly an anaorobic organism, growing 
on surface of culture-media only in the 
strict absence of oxygen. The bacillus of 
malignant oedema may be found in rich 
black loam at almost any time, in this 
respect strongly resembling the tetanus 
bacillus. In fact, a guinea-pig inoculated 
with ordinary garden-earth is very likely 
to display symptoms either of tetanus or 
of malignant oedema. An interesting case 
of this disease following typhoid fever has 
been reported by Brieger and Ehrlich. 
While this distinct organism produces 
constant effects in the direction already 
indicated, there are doubtless other or- 
ganisms capable under exceptional circum- 
stances of producing analogous disturb- 
ances : and it does not follow that every 
case of gangrenous emphysema, gaseous 
phlegmon, etc. is necessarily due to this 
bacillus. I have known personally of one 
case of extensive gangrene of the integument of the back accompanied with gaseous 
decomposition which was distinctly not due to this cause. 
Fig. 38. 
Bacilli of malignant oedema, from tissue-juice 
of infected guinea-pig; x. 1000 (Frankel and 
Pfeiffer). 
Prognosis.—This, for the most part, is bad, especially when the 
bacillus of malignant oedema is alone at fault. Patients may escape 156 
SURGICAL DISEASES. 
with their lives, but always at the expense of more or less tissue- 
destruction. 
Treatment.—This must consist of extensive incision to permit 
escape of fluids and gases and relieve tension ; of such antiseptic appli- 
cations as can be made available; of immersion of the affected part in 
a hot antiseptic bath, if this be possible; and of such vigorous stimu- 
lation by the most powerful measures—strychnia, alcohol, etc.—as may 
be possible, in order to support the patient through the period of pro- 
found depression characteristic of the disease. 
Rauschbrand, or Black Leg. 
This is a disease quite common among cattle in Central Europe; it 
is known to the French as symptomatic char bon, and among the English 
as black quarter. Clinically, it pur- 
sues a course similar to that of 
malignant oedema, with this principal 
clinical difference—that the gases 
produced in rauschbrand have no 
putrefactive odor, while those dis- 
tending the tissues in malignant 
oedema have. Moreover, the disease 
is due in this instance also to an 
anaerobic bacillus much resembling 
that of gangrenous oedema, although 
there are minute differences between 
the two organisms. It is known 
also that one attack of rauschbrand 
confers immunity, which fact is not 
yet established for malignant oedema. 
It has been established also that the 
organism is capable of transmission 
from mother to foetus, and that pro- 
tective inoculations can be performed 
much as in the case of anthrax. With some of the animals at least the 
rauschbrand bacilli can be intensified in action by mixture with the 
bacillus prodigiosus. 
Fig. 39. 
Bacillus of rauschbrand; from pure culture 
showing spore-formation; X 1000 (Friinkel 
and Pfeiffer). 
Actinomycosis. 
This also is a subacute, but always destructive infection by a specific 
micro-organism, though not a bacterium. Known always as actinomy- 
cosis in man, the disease, which is most common in cattle, has been 
known commonly as lumpy jaw or swelled head, and years ago was 
usually regarded as cancer or as a malignant affection. 
Many old museum specimens labelled as cancer of the tongue, jaw, etc. have 
of late been shown to be instances of actinomycosis of these parts. It is occasion- 
ally met with in man, so that now there are probably at least three hundred cases 
on record in this country and in Europe. The organism was recognized some fifty 
years ago by Langenbeck and Lebert, but was not scientifically described until 
thirty years later. The names of Bollinger, Israel, and Ponfick will always be 
connected with these researches. 157 
DISEASES COMMON TO MAN AND ANIMALS. 
The organism itself belongs among the ray fungi, is known as the 
actinomycis, and occupies a somewhat uncertain place in classification. 
It is large enough, when entire, to be noted by the naked eye, has ordi- 
narily a yellowish tint, a tallowy consistence, and may be seen under 
the microscope to consist of a cluster of branching prolongations, club- 
shaped at the end, radiating from a common centre. They give it rudely 
Fig. 40. 
Fig. 41. 
Actinomycosis bovis, from sections of a “ lumpy 
jaw,” showing ray fungus (Crookshank). 
Actinomycis, from liver of a male patient: 
a, rays of fungus (,V oil immersion). 
a sunflower appearance. It is stained with difficulty, best with a com- 
bination of picrocarmine and some aniline dye. In tissue-sections the 
Gram stain is the best. It is cultivated with difficulty, but can be 
grown upon solid media and may be inoculated. 
As met with in tissue or in 
pus, these fungi constitute small 
granulations, giving usually a 
gritty sensation to the finger, 
which is due to the presence of 
calcium salts. The recognition 
of this calcareous material is of 
great importance, since it may 
enable a diagnosis to be made 
offhand which otherwise might 
puzzle one. In the only case so 
far met with by the author the 
diagnosis was established within 
a minute by the detection of 
these little particles. 
The disease is very common 
among cattle in certain regions, and 
causes the condemnation of many 
animals in every large stockyard 
establishment where inspection's careful and scientific. It occurs oftener in young 
than in old animals, and most often in those which come from valley regions and 
marshes. In animals infection occurs almost invariably through the mouth, which 
Fig. 42. 
Actinomycis, from submaxillary gland of a steer 
(iV oil immersion). 158 
SURGICAL DISK ASKS. 
is easily explained by the fact that in grazing the lips, tongue, and gums are likely 
to be irritated and infected at any time from soil containing these fungi along with 
growing grain. The path of infection, then, is usually by the mouth, while acci- 
dent seems to determine whether the infection shall manifest itself mainly in the 
intestinal canal or the respiratory tract. In animals there is less tendency to sup- 
puration than in man, the infection in man being usually a mixed one. The name 
lumpy javj, so generally given to the affection, is indicative of the most conspicu- 
ous lesion in cattle, for the organism, having once invaded the gum, for instance, 
passes quickly to the bone, or, having involved the tongue, is not slow to infect 
the lymphatics of that region. In consequence we have tumors, often of inordinate 
size, which may involve the hones or the soft parts and cause great disfigurement, 
along with necrosis, leading eventually to the death of the animal. These tumors 
are essentially granulation-tumors due to the presence of a specific irritant—namely, 
the adinomycis—which acts here as do the tubercle bacillus, the lepra bacillus, 
etc. in other infectious granulomata. 
In man the disease is almost always accompanied by abscess-forma- 
tion, the pus containing the distinctive yellow gritty particles which are 
found in no other disease. The strong resemblance between the lymphoid 
cells of this form of granuloma and the embryonal cells of sarcoma has 
Fig. 43. 
Actinomycosis bovis (Crookshank). 
permitted the perpetuation, until recently, of confusion between these two 
neoplasms. 
Large abscesses form as the result of the coalescence of small ones, 
and by the time the disease is recognized extensive destruction and loss 
of substance may have taken place. In man it is not alone about the 
mouth that the disease is noted, although primary lesion here is by no 
means infrequent. It leads to affections similar to that already spoken 
of in cattle, with a progressive infiltration and breaking down, including 
actual necrosis of bone, etc. The pus will escape at various points, 
and may give to the surface an appearance as of many craters with a 
central cause. When the disease has involved the lung, either directly 
or indirectly, the fungi and the calcareous particles may be found 
in the sputum. Should there be suspicion of this involvement, the DISEASES COMMON TO MAN AND ANIMALS. 
159 
sputum should always be examined. Even in the heart-substance 
tumors of this same character have been found. The tirst case noted 
in man had undergone extensive vertebral caries. Intestinal infection 
is possible, in which case multiple lesions will form in the intestinal 
walls, which may contract adhesions to the abdominal parietes and dis- 
charge externally through them. The appendix has been found involved 
in such lesions. Infection of the skin has also been described, though 
this occurs more rarely. 
Diagnosis.—Actinomycotic lesions have been in time past mistaken 
for cancer, sarcoma, tuberculosis, syphilis, etc. Without going more 
minutely into differences, it is enough 
to say that in man it will always be 
characterized by more or less sup- 
puration, and that in the purulent 
discharge from the infected focus the 
characteristic yellow calcareous par- 
ticles should enable recognition of 
this disease at once. 
Prognosis.—So long as the focus 
is accessible it is a purely local 
matter, and prognosis is as favorable 
as in local tuberculosis; but, inas- 
much as in too many cases infection 
has proceeded to a point where the 
surgeon cannot safely follow it, prog- 
nosis must be guarded. Actinomy- 
cosis is free from acute manifestations, 
for the most part free from pain, pur- 
sues a chronic course, and is charac- 
terized, as are the other slow infec- 
tions, by progressive emaciation, 
prostration, etc. Inasmuch as it is 
essentially a chronic condition, time 
is afforded for careful study in doubt- 
ful cases, for microscopic examination, etc. 
Treatment.—This must consist of radical extirpation of all infected 
tissues and areas. If this can be done thoroughly, and safely in other 
respects, one may hold out a prospect of positive cure. Free incision, 
wide dissection, the use of the actual cautery, etc. are always called 
for in these cases. If it involve the tongue alone, for instance, there 
is an excellent prospect ; if but a portion of the jaw be involved, 
a complete excision of one-half or more may be followed by excellent 
results. If, however, the lung, liver, vertebrae, or other vital and inac- 
cessible parts be involved, surgical measures may afford amelioration, 
but can hardly be expected to cure. 
Fig. 44. 
Actinomycosis in man (Musser). CHAPTER IX. 
SURGICAL DISEASES COMMON TO MAN AND THE DOMESTIC 
ANIMALS (Continued). 
Roswell Park, M. D. 
Tuberculosis. 
The most important and frequent of the infectious diseases common 
to animals and man is tuberculosis. This is, for the most part, a sub- 
acute or chronic affection, although in a small proportion of cases it 
assumes an acuteness of type which may make it fatal within so short a 
time as fourteen or fifteen days from the first recognizable symptom or 
even less. Tuberculosis as a form of disease is more prevalent than 
any other, and is the cause of death of a proportion variously estimated 
at from 20 to 30 per cent, of mankind. It is a disease which intimately 
concerns the surgeon, perhaps even more than the physician, inasmuch 
as it is also the most common of all the so-called surgical diseases. The 
frequency with which it is met varies in different parts of the country, 
and in some measure with the character of the population. In the 
average surgical clinic of the United States probably 25 per cent, of 
cases of surgical disease are manifestations of this affection. 
Surgical tuberculosis now covers the entire range of disease-manifestations 
formerly inaccurately and inaptly described as scrofula. The term scrofula is now 
expurgated from medical terminology, and 
there is no longer any excuse for its con- 
tinuance, save possibly in making certain 
explanations to the laity, who are not yet 
educated to the new term. All of the 
active manifestations formerly regarded as 
scrofulous are now known to be due to 
tuberculosis. 
Our views with regard to tuberculosis 
have been completely revolutionized within 
the past twenty years, since the specific 
nature of its cause has been established, 
and the distinctions made in the old text- 
books between yellow and white tubercle, 
etc. are now relegated to the oblivion which 
they deserve. Since the inoculation-ex- 
periments of Villemin in 1865, who first 
demonstrated the inoculability of tuber- 
culous products, and the epoch-making 
discovery of Koch, who in 1882 established 
beyond cavil the parasitic nature of the 
disease, the views and descriptions of the 
old writers have had to be entirely revised. 
The infectious character of the disease is now so well established that the chain 
of evidence was years ago regarded as complete. The tubercle bacillus (bacillus 
tuberculosis) is a thin, rod-shaped organism, from 3 to 4 mikrons in length (averag- 
Fig. 45. 
Section of tubercular liver, showing bacilli; 
X 500 (Frankel and Pfeiffer). DISEASES COMMON TO MAN AND ANIMALS. 
161 
ing in length half the diameter of a red blood-corpuscle), often slightly curved, with 
ends usually rounded. It is often found in pairs, arranged in V-form, sometimes 
in chains. Spore-formation is the exception, the organisms usually dividing by 
fission. Free spores are never observed, although when properly stained the 
bacilli exhibit spots which seem to indicate spore-formation. The organism seems 
to possess a quite tough cell-wall or capsule, which enables it to pass through the 
entire alimentary canal without destruction by the digestive juices, and which gives 
it a vitality that permits existence outside the body for a considerable length 
of time. It is a facultative anaerobe, growing either with or without oxygen. It 
has a distinctive manner of taking stains which enables its recognition and differ- 
entiation from other forms. In cultures it grows very slowly at body-temperature. 
To the presence of tubercle bacilli in the tissues is due that distinctive 
aggregation of cells which constitutes the so-called miliary tubercle. 
Its presence and arrangement is apparently the direct outcome of the 
irritation produced by these minute foreign bodies, and its method of 
grouping is so characteristic that it may be everywhere and usually 
easily recognized. Its centre is composed of one, possibly several, giant 
cells, whose nuclei are usually arranged around the margin, with perhaps 
degenerative changes going on in the interior of the cell itself. In this 
giant cell, as well as outside of it, may be seen one or several tubercle 
bacilli. Around this centre are clustered a number of large cells, known 
as epithelioid, which may also contain bacilli. These cells are probably 
Fig. 46. 
Synovial membrane with tubercles; X VO: giant-cell in the middle of a sharply outlined tubercle 
about it round-cell infiltration (Krause). 
derived from epithelium when at hand, or from the endothelium of the 
vessel-walls, or from the fixed tissue-cells. Outside of this are yet other, 
usually spindle-shaped, cells, contained in a connective-tissue network 
and regarded usually as lymphoid cells. When tubercle is experimentally 
produced the bacilli seem more numerous than they do in instances of 
spontaneous disease. This little aggregation of cells constitutes a mass 
which may be recognized by the naked eye—a minute, usually white 
point or nodule, which is known as a miliary tubercle. It is subject to 
any one of several changes to be presently considered, and it is usually 
found in large numbers when present at all. The punctate appearance 162 
SURGICAL DISEASES. 
of miliary tuberculosis is perhaps best seen upon the cerebral membranes 
or the peritoneum in cases of acute miliary tuberculosis. By coalescence 
of a number of these nodules larger tubercles are formed, and by com- 
bination of coalescence and caseous degeneration are produced the large 
cheesy masses which our forefathers called yellow tubercle. 
Fig. 47. 
The epithelioid cells are by some re- 
garded as modified leucocytes; by yet 
others, as the product of division of the 
fixed cells. The giant cell is probably the 
result of irritation in one of these cells, the 
stimulus being sufficient to provoke division 
of the nucleus, but not of the entire cell. 
Since the principal cellular activity occurs 
in the interior of this nodule, the result is 
a condensation about the periphery which 
furnishes eventually a sort of' capsule, as 
it were, the tissues being hardened and 
condensed as if for this special purpose. 
The effect of this is to interfere with vas- 
cular supply, and finally to completely shut 
it off. So long, now, as no pyogenic infec- 
tion occur, the original tubercle may grad- 
ually shrivel down and disappear, or, most 
likely, caseous degeneration will occur, and 
it may persist as a cheesy nodule for an 
indefinite length of time. As such a tuber- 
cle grows old the cells lose their identity, 
refuse to take stains, and a slow or quiet 
coagulation-necrosis results. In this nest 
sometimes calcium salts are precipitated, 
the result being a calcareous nodule. On 
the other hand, during the active stage 
of this tubercle-formation cell-resistance 
may be lowered, either from general or con- 
stitutional causes; the original focus dis- 
integrates ; tubercle bacilli are liberated, 
and are now carried hither or thither, meta- 
static tubercles being the result of their dis- 
semination. 
Spontaneous healing of tubercle is 
possible, and may be due to three 
different causes: 
(a) Necrosis and exfoliation of 
diseased tissue (e.g. in lupus); 
(b) Cicatricial formation; 
(c) Retrograde metamorphosis. 
Looked at from another point of view, the possible fates awaiting the 
miliary tubercle are the following : 
(a) Absorption; 
(/>) Encapsulation ; 
(c) Cheesy Degeneration ; 
(d) Calcareous Degeneration; 
(e) Suppuration. 
Absorption of tubercle undoubtedly is possible under favorable 
circumstances, but just what constitute these favoring circumstances no 
one knows, since they occur in cases which do not terminate fatally. 
To be able to describe them would be to detail minutely the changes 
Tuberculosis of serous membranes [tunica 
vaginalis testis]; round-cell infiltration 
(Goldmann). DISEASES COMMON TO MAN AND ANIMALS. 
163 
which permit of recovery after non-traumatic tubercular infection; 
which clinical fact is amply demonstrated by the experience of the pro- 
fession. Absorption is probably largely a matter of phagocytosis. 
Encapsulation has already been spoken of, the capsule being formed 
by the condensation of the original cells of the tubercular agglomera- 
tion, the infectious organisms being thereby imprisoned so long that they 
are practically starved, and finally die. The tubercle bacilli, however, 
may long lie latent in such a cellular prison, and should anything occur 
to break the prison-wall, they may escape and still prove actively infec- 
tious. In this way are to be accounted for the fresh eruptions from old 
miliary or other deposits. 
Caseation is a condition more fully to be described in works on 
pathological anatomy. It comprises a series of changes in the chemical 
constitution of the cells by which an albuminoid mass much resembling 
casein in composition and appearance is produced. The English equiv- 
alent cheesy well describes many of these masses, which both cut and 
appear very much like domestic cheese. They have a yellowish color, 
and are met with in masses in size from a pin’s head up to a robin’s egg. 
These are the yellow tubercles of the older writers, and such a cheesy 
tumor has been called tyroma. 
Calcification refers to a peculiar deposition of calcium salts within 
the interior of these nodules, the first precipitation occurring usually in 
the centre of the giant cell, which is itself the topographical centre of 
the miliary tubercle. As time goes on it may spread from this, until a 
mass easily recognizable by the naked eye and detectable bv the finger 
is produced. Such calcareous particles are frequently found in sputa, 
and are always an index of the tuberculous character of the case. They 
differ markedly from the yellow calcareous nodules found in the pus of 
actinomycosis, and the only circumstances under which they are likely 
to be confused are met in pulmonary disease, which may prove to be 
either one or the other. 
Cold Abscess. 
Suppuration, as indicated, is the result, for the most part, of a mixed 
or secondary infection with pyogenic organisms. I have in the previous 
chapter grouped tubercle bacilli as among the facultative pyogenic bac- 
teria, yet I must say that, for the most part, pus is not formed in this 
disease except in consequence of coincident activity of other bacterial 
organisms. The matter of suppuration of tubercular foci is one of the 
greatest importance to the surgeon, because thereby is produced a dis- 
tinct class of so-called abscesses—namely, the cold or congestion abscesses. 
These, as usually coming under the surgeon’s notice, are of the chronic 
type, and are free from almost all the ordinary signs of abscess-forma- 
tion. They are invariably the result of local infection, sometimes per- 
haps by the tubercle bacilli alone, but most often by combined action of 
these with pyogenic forms. For their formation a previous tubercular 
lesion is essential, and such is always met with. Wherever old tuber- 
cular lesions are met with, there may cold abscesses also form. No 
tissue or organ is exempt: they are found in the brain, in the bones, 
"viscera, joints, skin, and everywhere. 164 
SURGICAL DISEASES. 
Cold abscesses have not only a significance of their own, but for the 
most part an identity. Their most distinguishing feature is a limiting 
membrane, which forms whenever sufficient time has elapsed. Much has 
been written about this in time past, and much error has been perpetu- 
ated with regard to it. This is the membrane formerly considered and 
Fig. 48. 
Pyophylactic membrane dotted with tubercles containing giant-cells ; X 70 (Krause) 
called pyogenic, under the misapprehension that by it the pus or contents 
of the abscess were produced. I wish to emphasize in every possible 
way that this is a sad error. This membrane does not act to produce 
pus, but is rather the result of condensation of cells around the margin of 
the tubercular lesion, forming, as it were, a sanitary cordon for the abso- 
lute and definite purpose of protection against further ravages. I there- 
fore insist that the term pyogenic membrane be abolished, there being 
no such membrane under any circumstances, and that this be known as 
that which in effect it is—namely, a pyophylactic membrane. It is a 
protection against pus, and, were it not for its presence, there would be 
no limit to the spread of tubercular invasion. As it is, a lesion thus 
surrounded is shut off from most possibilities of harm, rarely encroaches, 
except by the most gradual processes, and, on the contrary, often con- 
tracts and reduces its dimensions, the watery portion of its contents being 
gradually absorbed and the more solid and cellular portions becoming 
condensed, finally, into matter which undergoes caseous degeneration, so 
that eventually recovery may ensue as the consequence of a metamor- 
phosis of an original cold abscess into a caseous nodule surrounded by 
the old pyophylactic membrane, which is now serving as a capsule. 
The contents of the cold abscess are, in some instances at least, of rather acute 
origin, and consequently may have been originally pus or its near ally. Upon the 
other hand, in cases which have occurred very slowly this material never is, and 
never was, real pus, but is a semifluid debris having certain properties which 
remind one of pus. It has been my effort hitherto to devise for this material a 
name which should distinguish it from pus and indicate what it really is. Inas- DISEASES COMMON TO MAN AND ANIMALS. 
165 
much as most of it has been of a puruloid character, at least at one time, I have 
suggested that it be called archepyon (i. e. originally pus or puruloid). As this 
flows from such a cold abscess, it is more or less watery and contains caseous, some- 
times calcareous, nodules in masses of considerable size, and not infrequently 
sloughs of tissue and old shreds of white fibrous tissue which resist decomposition 
for a long time. This material has been thus imprisoned, sometimes-for months or 
even years, and consequently has lost most of its resemblance to what it originally 
was. The organisms which first produced it have long since died out, and it is 
practically sterile. If any organisms survive, they are the tubercle bacilli, which 
are very much more resistant and tenacious of life than the ordinary pyogenic 
organisms. This is why most culture-experiments fail, and why even inoculation 
with the contents of an old cold abscess is often without effect even on most sus- 
ceptible animals. Nevertheless, the bacilli which the semifluid contents do not contain, 
may yet linger in the meshes of the pyophylactic membrane ; and here lurks the greatest 
danger in dealing with these lesions. In order to incise and expose them, opening must 
be made through tissues as yet uninfected and down 
upon tissues where may still lurk the living, though 
apparently inactive, organisms. Transplanted, 
however, into fresh living tissue, they may there 
attach themselves and bring about a fresh local 
infection. This is the explanation for many lesions 
and untoward events so bemoaned by surgeons 
of previous generations. For example, the ma- 
jority of anal fistulae are essentially tuberculous 
sinuses. When treated by the old method of sim- 
ple incision without disposal of the infective mem- 
brane, the result was simply to expose a fresh 
wound to a new infection; and it is not strange 
that certain consumptive and other patients were 
made worse and had their lives shortened in this 
way. On the other hand, if such a lesion as this 
be treated not merely by incision, but by radical 
extirpation of the whole tubercular focus down to 
fresh and normally-bleeding tissue, and if such an 
operation be thorough, or, when it cannot be 
thoroughly done, if the cavity be thoroughly cau- 
terized with a powerful caustic, we may then see a 
fresh crop of granulations appear after separation 
of the sloughs, or in the former instance we may 
get perfect primary union by suitable apposition 
of the parts ; and all this without re-infection and 
without anything but resulting good to the patient. 
Fig. 49. 
In old cases the pyophy lactic membrane 
is very tough and very adherent by its outer 
surface. It can sometimes be peeled off in 
strips of considerable extent, at other times 
cannot even be separated, or sometimes is so 
placed as to render it impossible to follow 
it to its termination. Complete extirpation of 
this membrane, or at least complete destruc- 
tion, is the duty of any one who attacks such 
a tubercular lesion; and when its complete 
removal is impracticable, failure to remove 
it should be atoned for by some powerful caustic, such as zinc chloride, 
nitric acid, caustic pyrozone, or the actual cautery, which shall be made 
to follow it to its ultimate ramification. The membrane and the tissues 
underlying when thus cauterized will separate as sloughs, and these will 
be replaced by presumably healthy granulations, which should be encour- 
aged until the original cavity be filled or the surface healed over. 
Psoas (cold) abscesses displacing 
other tissues (Lannelongue). 166 
SURGICAL DISEASES. 
In a general way, then, it may be said that acute abscesses, as indi- 
cated in the previous chapter, have no real limiting membrane, although 
there is more or less condensation of tissues about the focus of infec- 
tion. A typical membrane is distinctive of tubercular abscesses, and is 
to be regarded always as their natural protection and a barrier against 
their further encroachment—nevertheless, a membrane whose inner sur- 
face may harbor still active organisms, which yet cannot escape through 
its outer texture. Consequently, to simply incise it or inefficiently scrape 
it is to do a worse than useless thing; and one should never attack it 
unless he is prepared to thoroughly extirpate it or destroy its integrity, 
and in this way finally dispose of it. 
Cold abscesses, when near the surface, cause a bluish or dusky dis- 
coloration of the overlying skin, while the superficial and subcutaneous 
veins of this region are usually enlarged. Fluctuation is also a promi- 
nent phenomenon in connection with them when they can be palpated. 
Deep collections of this kind may be mistaken for cysts or tupiors, in 
which case the aspirator needle may be used to facilitate diagnosis. They 
vary in size from the smallest possible collection of fluid to abscesses 
which may contain a gallon or more of puruloid material or archepyon. 
They are known often as gravitation-abscesses, because by the mere weight 
of the contained fluid they tend to elongate or spread themselves in the 
direction in which gravity would naturally carry a collection of fluid. 
Thus, cold abscesses originating from tubercular disease of the lower 
spine frequently work their way along the psoas muscle and present 
below Poupart’s ligament as psoas abscesses, or elsewhere about the 
thigh, while those which come from similar disease of the uppermost 
cervical vertebrae may present behind the pharynx, as the so-called 
retropharyngeal abscesses; and those from the dorsal spine present not 
infrequently as lumbar abscesses. These are but two or three familiar 
examples of what may occur in any part of the body. 
Treatment.—Aside from the treatment of cold abscesses, already 
indicated, by radical measures, other means have been suggested, and 
particularly for the treatment of those in which such extreme measures 
are impracticable or simply impossible. It is sometimes efficacious to 
simply tap or remove by aspiration the contents of such a cavity. It 
may never refill, or but slowly, and after repeated tapping alone a very 
small percentage of such cases will subside into inactivity and the lesion 
be subdued, if not absolutely cured. Of late treatment by injection of 
solutions or emulsions of iodoform has been quite generally accepted. 
This is based upon the alleged specific properties of iodoform as being pecu- 
liarly fatal to tubercle bacilli, presumably by liberation of free iodine. A cavity 
to be thus treated should be first emptied as completely as possible, after which 
may be thrown into it a glycerin emulsion or an ethereal solution, or a suspension 
in sterilized oil of iodoform, usually in strength of 5 to 10 per cent. From 25 to 
200 c. c. of some such preparation is introduced, while the walls of the abscess are 
more or less manipulated in the endeavor to completely disseminate the mixture. 
The cannula through which it has been introduced is then withdrawn ; and this 
can usually be done without any, or at most with but little, unpleasant iodoform 
effects. This is due to the pyophylactic membrane, which limits the activity of the 
iodoform, as it has done that of the previous contents of the abscess. Such cavities 
have also been treated by washing out through a trocar with an injection of various 
antiseptic or stimulating solutions, among which we may mention hydrogen per- 
oxide, weak iodine solutions, etc. My own advice is to treat all tuberculous lesions 
radically when such measures are not contraindicated by their multiplicity or by DISEASES COMMON TO MAN AND ANIMALS. 
167 
too great depression of the patient, and so long as lesions are accessible to ordinary 
operative procedures. This same advice pertains also to those which have already 
spontaneously evacuated themselves or where the overlying skin is threatening to 
break and permit escape of contents. Almost any case where this is imminent is 
one in which the surgeon, as such, ought to interfere. On the other hand, in deep 
collections and in debilitated individuals the treatment by injection may at least be 
tried. 
With added years of experience my conviction has grown, however, 
that the best way in which to treat accessible tubercular lesions is by the 
most radical and merciless extirpation, and that, while this subjects 
patients to operative ordeals, it nevertheless shortens the period of time 
during which they are under treatment, hastens convalescence, and leads 
to very much more permanent results. 
The Gummata op Tuberculosis. 
The other and essential characteristic of tubercular disease, by which 
it manifests itself in surgical lesions at least, is the infectious granu- 
loma to which it gives rise. This is a term first applied by Virchow to 
new formations of granulation-tissue, which are the result of the presence 
of an invading and specific irritant. This tissue varies little in type, if 
at all, from that already described when dealing with the healing of 
ulcers, and is common to the neoplasms which are met with in tubercu- 
losis, syphilis, leprosy, glanders, and some of the other local infections. 
So little does the tissue-type vary in these different instances that it is 
difficult, if not impossible, to distinguish by microscopic sections of the 
unstained tissues, or at least those unstained for bacteria, to which class 
of lesions they belong. The production of granulation-tissue is, how- 
ever, of such general prevalence and such important significance that it 
must be spoken of at some length in this place. 
This tissue may be met with in any of the tissues of the body, but is seen per- 
haps least often upon the serous membranes of the cranial and peritoneal cavities, 
whereas in the joint-cavities it is common. It is provoked, as just stated, by the 
presence of tubercle, and has the power of penetration into and substitution for 
almost all the other tissues of the body. Thus in a primary tubercular focus within 
the bone a granuloma will form and extend its limits, while the surrounding bony 
tissue melts away before it; and it is by the growth of this tissue in a particular 
direction that tubercular products from within the bone-cavity are finally carried 
to the surface. When this material has escaped from bone or from tissues without 
the bone toward the surface, its presence is marked by induration, by livid dis- 
coloration of a limited area of skin, with elevation of the surface, which finally 
breaks down and shows discolored, bleeding, and pouting granulations, which in 
the absence of restraint now proliferate more rapidly, and often to the point where 
they get away from their own blood-supply, and consequently necrose upon the 
surface. This is the fungous granulation-tissue, especially of the German writers, 
and may be met with upon the surface, or is frequently seen in opening into joint- 
cavities and other tissues infected by tubercle. The appearances of this fungous 
tissue are modified somewhat by environment and pressure: in joints flat and 
radiating, masses of it will be found, extending along the synovial surfaces and 
into the articular crevices. This fungous tissue may grow in any direction, but 
apparently always does advance in the direction of least resistance. It leads to 
complete perforations of the flat bones, like those of the skull, while tuberculous 
masses from the dura may cause multiple perforations, the granulation-tissue finally 
escaping through the overlying skin. In tuberculosis of synovial sheaths and 
bursee it extends along, and may completely fill and even distend, them. It will 
separate tissues which are united together, and it may lead to disintegration and 
disorganization of the firmest textures in the body. So long as it be not exposed 
to the air nor to pyogenic infection it will preserve its characteristics for a con- 168 
SURGICAL DISEASES. 
siderable length of time. Immediately upon exposure it is likely to break down, 
and infection will travel speedily along it into the deeper cavity whence it has 
sprung. A mass of this tissue contained within the normal tissues, condensed 
more or less by pressure, uninfected, and not freely supplied with blood, is entitled 
to the name of tuberculous gumma, whose tendency, however, is for the most 
part to break down and suppurate. Such gummata may be found in any part of 
the body, and differ only in unessential respects from the diffused and more or less 
infiltrated masses of granulation-tissue which occupy serous cavities or which 
extend in various directions. 
The lesions of surgical tuberculosis, except those already spoken of 
as constituting cold abscess, are so essentially connected with the presence 
of granulation-tissue, just described, or of this form of the infectious 
granulomata, that no student can appreciate the subject until he is quite 
familiar with this tissue in its various phases and in various locations. 
Of such great importance is it that this be realized that some of the 
local manifestations of this new tissue must here be considered, although 
they may be rehearsed in other form in succeeding chapters. 
Fig. 50. 
Fig. 51. 
Lupus of hand, tubercular disease of bones, 
with absorption (Krause). 
Epithelioma developing upon lupus—“ lupus- 
carcinoma ” (Stemhauser). 
In the skin and subcutaneous tissues and in and under mucous 
membranes this granulation-tissue may be studied at places where it is 
free from most of the mechanical restraints to growth, and where in 
other respects its appearances are typical. The most characteristic 
manifestations in the skin occur as lupus, a disease for a long time con- 
sidered cancerous or of uncertain etiology. We are in position now to 
teach, however, that lupus is always a cutaneous manifestation of this 
protean disease. 
In its incipient stages lupus consists of multiple minute nodules of granulation- 
tissue just beneath the surface, containing all the elements of true miliary tubercle, DISEASES COMMON TO MAN AND ANIMALS. 
169 
with infiltration of the surrounding skin, even into the subcutaneous fat. The 
most common location of these lesions is on exposed surfaces. Bacilli are not 
numerous, yet may be demonstrated in all these lesions. The tendency is more or 
less rapidly to break down, the result being a tubercular ulcer, which, as it extends, 
manifests usually a disposition to cicatrize in the centre while enlarging around 
its periphery. The dermatologists describe several different forms of lupus under 
the names hypertrophicus, vulgaris, maculosus, etc., all of which are essentially the 
same in character, the differences being largely constituted by the rapidity or slow- 
ness with which the granuloma of the skin breaks down. From the surface these 
growths may extend and involve parts at considerable depth, even the periosteum. 
This name should also include the lesions described as scrofuloderma or scrofulous 
ulcers of the skin, they being all of the same real character. 
A variety known as anatomical tubercle has been described by numerous writers, 
found especially upon the hands of those who haunt dissecting-rooms or handle 
dead bodies, and is supposed to be the result of local inoculation. It appears 
usually as a warty growth, which ulcerates and becomes covered with a scab—is 
usually most indolent in character, but is followed by lymphatic involvement, and 
in rare instances by death from tubercular disease. 
Any lesion of the skin—puncture, abrasion, etc.—may be infected and become 
a tuberculous sore. Thus, ears punctured for ear-rings have become diseased in 
this way. 
On the mucous membranes primary lupus is rare, usually spreading there from 
a skin surface. Nevertheless, distinct forms of it may be noted in the pharynx, in 
the nose, etc. In fact, tubercular disease of the nasopharynx is quite often mis- 
taken for malignant disease, but will almost ahvays clear up on proper treatment. 
Upon the tongue, in the larynx, in the rectum, and on other mucous surfaces dis- 
tinct tubercular lesions are occasionally seen, always partaking, however, of the 
granulomatous characteristics already described. 
In the lymphatic structures and lymph-nodes tuberculosis is a most 
frequent affection. In these localities it may occasionally be primary, 
but is almost always a secondary lesion. It is in separating from the 
lymph-stream the tubercle bacilli, which would otherwise be passed into 
Fig. 52. 
Fig. 53. 
Tuberculosis of mesenteric lymph-node; X 200 
(Friinkel and Pfeiffer). 
Tuberculosis of cervical lymph-nodes 
(Holloway). 
the general circulation, that the lymph-nodes, acting as filters, render us 
the greatest possible service. These filters, however, almost always 
become themselves infected, and, enlarging, they assume the appearances 170 
SURGICAL DISEASES. 
known to the laity as scrofula, which in time past have been so generally 
spoken of as scrofulous glands. These lesions abound rather about the 
axilla and the cervical and bronchial nodes than about the lower extrem- 
ities. Nevertheless, the retroperitoneal, mesenteric, and inguinal nodes 
are occasionally infected. In these nodes will be found giant cells sur- 
rounded with epithelioid cells, containing bacilli and undergoing cheesy 
degeneration or suppuration. Infection often proceeds from centre to 
periphery, and then to the surrounding tissues, the filter, as such, having 
become so choked that nothing seems to pass it. By virtue of this sur- 
rounding infiltration (which used to be known as 'periadenitis, when 
lymph-nodes were spoken of as lymph-glands) generalized infection is in 
some measure prevented, while the natural barriers are altered and nat- 
ural distinctions between tissues are lost. This makes complete extirpa- 
tion of these tubercular foci often very difficult, while the adhesions 
which they contract, for instance, in the neck are often to the large vessels 
and nerve-sheaths, by all of which their operative treatment is naturally 
complicated. When infection from the superficial nodes extends toward 
the surface it is easily recognized by the dusky hue of the overlying 
skin, the hardness, infiltration, and, later, the fixation, of these masses, 
accompanied usually by evidences of suppuration. 
Fig. 54. 
Tubercular spondylitis (caries): a, osteogenesis and osteosclerosis; c, cavity formed by degenera- 
tion of tubercular focus (Krause). 
In the bones we find as often as anywhere expressions of tubercular 
disease. Strange to say, it is not much more than fifty years since 
Nelaton called attention to the frequency of these intraosseous lesions, DISEASES COMMON TO MAN AND ANIMALS. 
171 
and demonstrated the essentially tuberculous character of much that had 
hitherto been overlooked or considered under that vague term scrofula. 
All those forms of bone disease comprehended under the names Pott’s 
disease, spina ventosa, tumor albus, etc. are now known to be distinctly 
tubercular lesions. In many instances these follow the slight circulatory 
disturbances brought about by contusions, sprains, etc. This is espe- 
cially the case in those who are predisposed to this disease. 
Tuberculosis of bone always assumes the phase of miliary lesions, followed by 
the formation of a granuloma, which may gradually encroach upon surrounding 
tissues or may assume a more fulminating type and spread rapidly. Apparently 
because of the circulatory conditions, these lesions are most common near the 
epiphyseal lines of the long bones, seeking seemingly the ends of the bones, as 
pulmonary lesions seek the terminations of the lungs. These lesions may be 
solitary or multiple. Beginning always minutely, they spread so as to produce 
foci perhaps even two inches in diameter. As the result of the formation of 
Fig. 55. 
Section through upper end of femur, showing osteosclerosis in line of pressure, with alteration 
in shape—i. e. flattening of head and widening of neck. 
granulation-tissue, the surrounding bone melts away and disappears, the result 
being a great weakening of its structure and expansion of its dimensions in order 
to make room for the growing mass within. The tendency of this granulation- 
tissue thus imprisoned is always to escape in the direction of least resistance. 
This carries it sometimes into the joint, sometimes out through epiphyseal junc- 
tions, and sometimes through channels in the bone made by its own pressure, with 
external escape and appearance of the dusky distinctive tissue, felt beneath and 
then upon the skin. Where bone is so weakened in one direction it is usually 
strengthened by compensatory deposition of calcium salts at other points, and the 172 
SURGICAL DISEASES. 
result frequently is a striking combination of osteoporosis in the immediate presence 
of the disease, with osteosclerosis, sometimes to a remarkable degree, even to eburna- 
tion, of an adjoining portion. When this mass undergoes caseous degeneration, the 
progress of the disease is much slower and the pain less. When it undergoes sup- 
puration, there are more evidences of inflammation, with more pain and systemic 
disturbance, as well as local swelling, tenderness, etc. The surrounding muscula- 
ture is rarely involved, although the periosteum is nearly always so. In fact, it is 
stated that in an inflamed and suppurating bone-lesion, if the muscles are exten- 
sively invaded, it maybe regarded as of syphilitic rather than of tubercular origin. 
The pyophylactic membrane already alluded to is seen in almost every instance of 
tubercular disease. The spina ventosa of old writers refers to the expansion of the 
shaft and medullary cavity of a long bone whose interior is occupied by a mass of 
tubercular gumma, which is perforated at one point, and through which opening 
it escapes as does lava from a crater to involve the structures on the outer side. 
The appearance of this granulation-tissue in joints as fungous tissue has already 
Fig. 56. 
Tuberculosis of hip (coxitis); disintegration and destruction of bone. 
been alluded to. In a general way it preserves its fungoid characteristics until 
attacked by pyogenic or saprogenic organisms, when it quickly breaks down, form- 
ing an ulcer if upon the surface, or a cold abscess if not externally open. Tuber- 
cular disease of the bone is most common in the young, and in them the majority 
of tubercular joints are those whose bony structures have been first involved. In 
other words, the majority of cases of tubercular pvarthrosis are due to primary 
bone disease. As the result of the tubercular infection the bones become distorted, 
best illustrated in Pott’s disease of the spine; while, as the result of the constant 
irritation, joint-ends become displaced by chronic muscle-spasm, and joint-contours 
entirely altered by expansion of the affected bone and thickening and infiltration 
of the overlying soft parts. 
I have often, for the sake of illustration to medical students, drawn a certain 
analogy (following Savory) of the gross resemblances between lungs and bones in 
their behavior when involved in tubercular disease. In either case the structure 
is in a measure spongy and contains cavities and networks of tissue; in each case DISEASES COMMON TO MAN AND ANIMALS. 
173 
the structures are invested by a resisting membrane—in the one instance, pleura, 
in the other, periosteum. Again, each is closely related to a serous cavity—the 
lungs to the pleural cavity, the bones to the serous cavities of the joints. Tuber- 
cular disease manifests a predilection for the extremities of both organs. Perfora- 
tion into the adjoining serous cavity is frequent, and previous to perforation col- 
lections of serous fluid are frequently noted—in the one instance pleurisy, in the 
other hydrarthrosis. Moreover, these fluids quickly or often become contaminated, 
and then become purulent, constituting empyema or pyarthrosis as the condition 
may be. One sees, too, in each place the same striking combinations of weaken- 
ing of tissue and strengthening in order to atone for the undermining of the disease. 
These are not all of the similarities that might be adduced, but are perhaps suffi- 
cient for the purpose of showing that tubercular disease is essentially one and the 
same thing, no matter what tissue be invaded. 
In the tendon-sheaths and bursae we frequently find manifestations 
of tuberculosis. When seen early these are always in the direction either 
of miliary affection or, most commonly, of tuberculous gumma, while 
when seen late the disease has usually advanced to the point of suppura- 
tion, and we now have cold abscess of the affected parts. 
Fig. 57. 
Section through shoulder of a tuberculous animal: e, thickened capsule; g, caseous focus 
h, miliary tubercles (Krause). 
In many joints and tendon-sheaths, particularly the latter, we find certain 
detached, usually colorless, firmly resistant masses, of smooth and polished sur- 
face, lying in a collection of fluid, in size from a minute particle up to that of a 
melon-seed. These have been known at various times as rice-grains, melon-seed 
bodies, corpora ori/zo'idea, etc., and for a long time their explanation was a mystery. 
It is now well established that in the majority of instances at least these are the 
result of fungous granulations which have become detached in small pieces, which 
then, in the absence of infection, have shrunken and become rounded and polished 
by attrition. The bursal enlargement and distention with fluid in which they 
are usually found is commonly spoken of as hygroma of that particular bursa. 
Tuberculosis of these bursa?, however, does not always result so harmlessly as the 
formation of these bodies, but, on the contrary, tubercular infiltration may extend 
beyond the serous limits to the surrounding soft parts, with a tendency finally to 174 
SURGICAL DISEASES. 
external escape, just as in the case of bone-lesions. These constitute affections of 
the soft parts which are more or less destructive, and are always difficult, often im- 
possible, to deal with, because of the mutilation which a thorough extirpation of 
the disease would necessitate. 
In the testicles and ovaries, particularly in the former, tubercular 
disease is frequently met with. In the testicles it begins usually in the 
epididymis, forming a somewhat dense nodule and a distinct tumor, 
easily appreciated from the outside, although its minute character may 
be still concealed. The tendency here almost invariably is to progres- 
sive infiltration and breaking down, either into a caseous mass or, more 
commonly, into puruloid material, while sometimes acute infection 
supervenes. 
It is not always easy to distinguish between syphilis and tuberculosis of the 
testicle, though the latter is usually characterized by the same tendency to effusion 
into the adjoining serous cavity (i. e. that of the tunica vaginalis) as is manifested 
in disease of the lungs or bones. When the disease is extensive the overlying 
skin is involved, and frequently by the time the surgeon has to deal with these 
cases perforation and escape of fungoid tissue on the outside have occurred. 
In the kidneys, in the ureters, as also in the bladder, tubercular 
lesions are noted, the miliary form being particularly frequent in the 
former. Tubercular disease of the kidney leads sooner or later to casea- 
Fig. 58. 
Gross and microscopic appearances in tuberculosis of the mamma (Dubar). 
tion and a condition of pyonephrosis or its equivalent, which calls 
practically always for extirpation of the affected organ. Tubercle 
bacilli are sometimes recognized in the urine, but only when the lesion 
has an opportunity of discharging into one of the urinary passages. DISEASES COMMON TO MAN AND ANIMALS. 
175 
In the peritoneum tubercle appears usually in the miliary form, 
leading sometimes quite rapidly to such extensive involvement of, and 
interference with, visceral functions as to produce anasarca or more 
general disturbance prior to death. Acute miliary disease here is as 
rapid arid as essentially fatal as the same atfection of the dura or pia, 
while the more chronic forms are followed by degenerations that may 
involve the intestines either in agglutinated masses or in ulcerations 
and possible perforations. The indication in all tubercular lesions of 
serous membranes is for exposure by operation, disinfection of the sur- 
face, and evacuation of retained fluids. Recovery from tubercular per- 
itonitis, even of acute type, after abdominal section is now definitely 
established as a possibility. The same would probably be true of tuber- 
cular meningitis were we permitted to expose the membranes and attack 
them or drain them in the same way. 
Although a few distinct organs or tissues have here been specifically 
considered in their relations to tubercular disease, there is no organ nor 
tissue in the body which is exempt from its ravages and in which 
evidences of tubercular disease may not be found. Even the mammary 
gland occasionally presents tumors composed of tubercular granuloma 
which more or less simulate malignant disease, while, nevertheless, 
calling for the same radical treatment. (Vide Fig. 58.) 
Paths of Infection.—The tubercular virus may enter the body 
through various channels. Probably in the majority of instances it 
gains entrance through the respiratory tract, less often by the aliment- 
ary canal, and occasionally by air-contact of open wounds or direct infec- 
tion by local agencies. It is now well established that tubercular disease 
is not inherited, although a predisposition to its ravages certainly is 
transmitted from parents to children. 
Iii what this predisposition consists is not always easy to say. As the tubercle 
bacillus grows in the tissues, it is by preference an anaerobe, and it seems to be 
lowered in activity or banished by access of oxygen. It has been shown that in 
those individuals in whose pallid skin, long bones, flabby muscles, and pale con- 
junctive we recognize a predisposition to this disease, the heart is disproportion- 
ately small as compared with the weight and size of the lungs. This means a 
relatively feeble pumping-power, and is perhaps the best explanation yet offered 
for what is everywhere accepted as a fact. The mucous membranes of the nose and 
throat are the first lodging-places usually for germs carried by the air, these find- 
ing here the warmth and moisture necessary for their detention, development, and 
growth. So long as these membranes be unbroken and healthy, infection is rarely 
possible, but let tubercle bacilli become caught in the crypts of the tonsils or the 
adenoid tissue in the nasopharynx, and the other disturbance, set up by irritant 
organisms of various species, will usually bring about conditions favoring their 
growth and incorporation into the living tissues. This lymphadenoid tissue, then, 
is as often as any the port of entry for these organisms. The explanation for 
local and surgical tuberculosis in bones and other accessible tissues probably is 
connected with causes determining at these points an area of least resistance in 
which the germs find tissues more susceptible than elsewhere, and in which they 
may live and thrive. 
Not the least interesting and important of the considerations regard- 
ing tubercular disease is the possibility of an acute outbreak of tubercu- 
losis after long latent or chronic manifestations of the disease. This 
means, in effect, the onset of general miliary tuberculosis which shall 
quickly terminate fatally, and death is not the infrequent result of such 
extremely rapid outbreaks from tubercular disease of joints, bones, 176 
SURGICAL DISEASES. 
ovaries, etc. For the disease when it has assumed this extremely rapid 
type there is, so far as we vet know, no he!]). 
That tubercular infection may follow slight abrasions and wounds 
is a matter of grave importance for the surgeon, since a wound made 
for an entirely different purpose may become infected and require a 
second operation for relief of the specific infection produced in this way. 
Thus, I have seen tubercular infection of a recently resected elbow, 
operation being made for compound fracture, in which the infection 
seemed to follow closely upon confinement in quarters inhabited by 
consumptives and presumably thoroughly infected with tubercle bacilli. 
Such experiences as these may be duplicated or many times repeated in 
the practice of most busy surgeons. 
Diagnosis.—So far as the general recognition of tubercular disease is 
concerned, it is not often difficult. It is accompanied usually by more 
or less marked cachexia (at least this is the case when infection is serious 
and widespread), one of whose principal characteristics is the so-called 
hectic (habitual) fever of old writers. This was a fever of a remittent type, 
accompanied also by more or less colliquative night-sweats, with dryness 
of the skin during the daytime, flushing of the face, etc. Plectic fever, 
as a matter of fact, often accompanies tubercular disease, but is seldom 
met with until pyogenic infection has occurred and suppuration is taking 
or has taken place. There is now much reason to consider hectic fever 
as an auto-intoxication from absorption of morbid products. In advanced 
cases we may find evidence of amyloid changes, although these are seldom 
recognized prior to autopsy. Tuberculosis of the skin is distinguished 
from most other affections in that, while the disease advances around 
the margin, it tends to cicatrization in the centre of the old lesion. (See 
Diagnosis of Malignant Growths.) Tubercular infection and degen- 
eration of lymph-nodes are usually easy of diagnosis, because there is prac- 
tically no other disease which produces this type of enlargement with 
the accompanying cellulitis and infiltration. In fact, the other principal 
conditions which produce lymphatic enlargement are septic disturbance, 
in which it is acute; syphilis and Hodgkin’s disease, in which it is gen- 
eralized ; and malignant disease, in which distinct evidence of the pri- 
mary infection is found on the distal side of the involved lymphatics. 
In bones and joints tubercular disease usually makes itself known by 
posture-deformities, which are themselves due to muscle-atrophv and 
muscle-spasm—the two together being characteristic—the tendency being 
toward subluxations or sometimes complete displacement, the expansion 
of the joint-ends, the atrophy of the parts above and below, and the 
nocturnal and osteocopic character of the pains (starting pains). All 
caries and most necrosis of bone not due to the poison of syphilis and 
not distinctly of traumatic origin are to be accepted as evidences of tuber- 
culosis, at least in general practice. Altogether, it is seldom difficult to 
recognize tubercular disease except when at a considerable depth. Here, 
so long as there be no suppuration, there is little tendency to leucocytosis, 
by which diagnosis as between sarcoma and tubercular infection may per- 
haps be made. Sometimes when in doubt the exploring trocar or an 
exploratory incision may be resorted to, it being always best to be pre- 
pared at the same time to proceed with whatever further operative pro- 
cedure the findings may indicate. DISEASES COMMON TO MAN AND ANIMALS. 
177 
Treatment.—It is well to emphasize, first of all, that tubercular 
disease when circumscribed and accessible is a distinctly curable affection. 
If this be once accepted, it puts a much more hopeful aspect upon the 
condition than it formerly bore. It moreover justifies operations of a 
much more radical nature than were formerly practised. Treatment 
should be divided into the hygienic and constitutional and the local and 
operative. 
Of all the natural remedies, oxygen undoubtedly ranks first. This means the 
best of ventilation, an outdoor life if possible, and preferably in localities and at 
altitudes free from dust and well supplied with ozone. When this is impossible 
inhalations of dilute oxygen are capable of doing much good. The diet should 
be rich and nutritious, at the same time capable of complete digestion. The 
emunctories should be stimulated and elimination favored in every possible way. 
Undoubtedly the old standard remedies—cod-liver oil, compound syrup of hypo- 
phosphites, et al.—are beneficial, and much good may be accomplished by their 
proper use. 
Certain remedies have been at various times supposed to be endowed 
with specific properties, and for many years clinicians have endeavored 
to find that substance with which the system could be safely saturated 
which should yet prove inimical to the parasite causing this disease. 
Such agent has not yet been discovered; nevertheless, much has been 
done in this direction. Of the remedies which to-day are lauded for 
this purpose, I will speak of two—namely, creosote and guaiacol. These 
are somewhat difficult of administration, but if the latter be given in the 
form of the carbonate, generally known as benzosol, it comes the nearest 
in my estimation to the ideal for which we are striving that has yet been 
discovered. Benzosol should be given to the adult in doses of at least a 
gram a day, perhaps more. It is much better tolerated and much less 
offensive than the gnaiacol from which it is made. I have never seen 
anything but benefit result from its use, and yet would not laud it as by 
any means a positive cure. Nevertheless, in conjunction with other local 
and constitutional measures its administration may be followed by com- 
plete recovery. 
Of the various local measures, I would place first of all physiological 
rest, which can be achieved in some places better than in others. The 
various forms of apparatus resorted to by orthopaedists are simply 
mechanical measures in furtherance of this purpose. A number of 
surgeons have much faith in iodoform, used locally in solution or sus- 
pension in some menstruum like glycerin, oil, etc. The benefit which has 
been claimed in some cases is certainly not duplicated in the experience 
of all surgeons; nevertheless, it has undoubtedly been of service. A 
recent and most promising method of treating tubercular disease of the 
extremities has been suggested by Bier, and consists in the establishment 
of a permanent hypercemia by the application of a rubber tourniquet on 
the proximal side of the lesion. 
It would appear that the access of more blood which is thus permitted is inim- 
ical, presumably by the presence of the oxygen which it brings, to the develop- 
ment of the disease-germ. The method depends for its rationale upon the fact that 
the congested lung does not become tubercular. Lannelongue has suggested what 
he calls the sclerogenic treatment of tubercular lesions, by injection of a very dilute 
solution of zinc chloride, which serves as an irritant and produces a tissue-sclerosis 
that serves the purpose of a pyophylactic membrane, while at the same time the 178 
SURGICAL DISEASES. 
solution is fatal to those germs with which it comes in contact. This treatment 
is painful and has not found wide acceptance. 
The astute surgeon, who gains the confidence of his patients and 
retains it, will not hesitate to remove by a suitable operation that tuber- 
cular focus which he feels confident that he can reach and extirpate. 
The resulting tissue-defects may be in many instances atoned for bv 
plastic operations. At other times this procedure means excision of some 
joint, which leaves usually a much better functionating member than 
would the disease if permitted to go on to spontaneous recovery—i. e. 
ankylosis—and at the same time removes a focus of disease which is a 
menace, if left, to the. future welfare of the patient. It may mean at 
other times amputation, but the artificial limb-maker now supplies a 
member vastly more useful than a natural one crippled by this infec- 
tious disease. In a general way, then, time may be saved and recovery 
ensured by early and judicious operation, while later in the course of this 
protean malady it may be absolutely necessitated in the endeavor to save 
life. How much better, then, to operate early when less is required and 
when the future outlook is so good ! 
After operations where clean extirpation and reunion of the parts 
with primary healing is impossible, I recommend a local dressing of 
balsam of Peru containing 10 per cent, of guaiacol and 5 per cent, of iodo- 
form. Gauze saturated with this and packed into the cavity best accom- 
plishes the purposes of a surgical dressing for such cases. 
Deep pain of tubercular lesions, especially in bone, is often relieved 
by ignipuncture, meaning thereby a perforation into the depth even of 
the bone-marrow by the actual cautery (Paquelin’s), which maybe thrust 
directly through the skin or which may be used after exposing the bone 
by incision. The use of the actual cautery, by the way, is indicated in 
eradicating and destroying tubercular tissue when a neat dissection or 
extirpation is impossible. 
Tuberculin.—Finally, the treatment of tuberculosis cannot be dismissed with- 
out a reference to the glycerin extract made from a filtered culture of the tubercle 
bacillus, containing the peculiar toxalbumen first prepared by Koch, for ever asso- 
ciated with his name, and first given to the world in 1890, when its announcement 
created a perfect furore and aroused hopes that have never yet been, perhaps never 
may be, completely realized. Yet, in spite of disappointments which have often 
followed its use, I wish to state here my own convictions that it is a remedy of 
great value when judiciously used in selected cases. I have never faltered in 
moderate confidence in its efficiency, and have not ceased to use it since it was first 
introduced. To-day I believe that in almost any case of surgical tuberculosis, 
when properly used, it is capable of doing great good, but I would by no means 
rely upon it alone, but would use it as an adjuvant in the after-treatment of ope- 
rative cases or as a remedy of prime importance in certain cases not adapted to 
operation. One should begin its use by doses of 1 milligramme, injected beneath 
the skin near the lesion two or three times a week, depending upon the reaction 
produced, increasing the dose gradually until even a decigramme may be given at 
once without undue reaction. The diagnostic value of the material must also not 
be forgotten, since by its use one may possibly decide in mooted cases as between 
tubercular or some other disease. Of the modifications of this remedy introduced 
by Klebs, Hunter, and others there is not time here to speak in detail. Undoubt- 
edly they all have virtues of a common character, and, so far as my own observa- 
tion is concerned, one has but little to choose as between them. LEPROSY. 
179 
APPENDIX TO CHAPTER IX. 
Leprosy. 
This is known also as lepra and elephantiasis Grsecorum. It is 
an infectious disease, in many respects resembling tuberculosis (hence 
included in this chapter), rarely presenting any acute phases, however, 
and met with in the United States only among foreigners, and, save in 
a few restricted localities, but very rarely. In ancient and sacred his- 
tory the disease figures very extensively, and would appear to be dying 
out rather than gaining ground. I was assured, for instance, by the 
director of the Lepers’ Hospital, in Jerusalem, in 1894, that there were 
only about 60 cases of leprosy remaining in all Palestine, and that the 
disease might easily be stamped out did the government exercise the 
slightest precaution or take the slightest interest in so doing. 
To Hansen and Neisser we owe the recognition of the Bacillus leprae, 
the parasitic agent which produces leprosy. It closely resembles tubercle 
bacilli, except that it is somewhat shorter. It is non-motile—divides 
mostly by fission, perhaps also by 
spores. These bacilli are found in 
the granulomata produced by this 
disease, which new formations occur 
especially in the skin, in the nerves, 
the lymph-nodes, and in the viscera. 
These bacilli appear to lie preferably 
in the lymph-spaces of the tissues, 
but are often found enclosed within 
giant and other cells. The disease 
is apparently incapable of transmis- 
sion to animals. Inoculation upon 
criminals condemned to death has 
succeeded. Leprosy, being due to a 
contagium vivum, is not only an in- 
fectious disease, but appears to be 
communicated by contagion or at 
least by cohabitation. Transmission 
by inheritance is not proven. 
Symptoms.—Two types of leprosy are described by all writers—the 
anaesthetic and the tubercular, the latter referring to gross appearances, 
not to its specific nature. Leprosy of the skin is marked first by hyper- 
semic areas which become pigmented and thickened and form, finally, 
brownish-red nodes the size of a robin’s egg or larger. These develop 
most rapidly upon the face, either singly, or in numbers which finally 
coalesce, with great physical deformity as the result, and the peculiar 
appearances which have been given the name of elephantiasis Graecorum. 
It has sometimes been (falsely) spoken of even as leontiasis. These 
nodes consist of granulation-tissue, which by itself is not dissimilar from 
that produced by any other of the surgical diseases characterized by 
granuloma. 
When the nerves become involved the disease begins with hvperses- 
thesia and pain, followed later by anaesthesia and trophoneurotic disturb- 
Fig. 59. 
Bacilli of leprosy, from the juice of a leprous 
nodule ; X 100° (Frankel and Pfeiffer). 180 
SURGICAL DISEASES. 
ances of nutrition; as the result of which ulcerations or dry necroses 
occur in the extremities, which are gradually lost in this way. Thus it 
is a common thing to lose the fingers and toes, while the loss of a hand 
or foot is not uncommon. I have seen one patient, in Jerusalem, whose 
fingers had become thus affected, one after another, and who had him- 
self bitten them off as they became useless, so that each hand showed 
Fig. 60. 
Fig. 61 
Leprosy (kindness of Dr. Craig). 
Leprosy (kindness of Dr. Winfield, 
Brooklyn). 
the loss of all five digits. Later, the disease affects the lymphatics, the 
mucous membranes, then the larynx, liver, spleen, testicles, etc., with 
progressive loss of function of each. Joints which are involved in 
leprous disease bear a strong resemblance to those affected by the tumor 
albus of tuberculosis, in some instances the pain complained of being 
very great. 
Prognosis.—The disease is curable when taken early and rigorously 
treated. This is possible, however, or at least practicable, in so small a 
percentage of cases that ordinarily the prognosis appears very unfav- 
orable. Patients rarely die in less than one year, and often live as 
many as twenty years before finally succumbing to the lesions of the 
disease. LEPROSY. 
181 
Treatment.—In the way of treatment there need be but little said 
here. All the local lesions which can be attacked should be treated 
radically, as in the case of tuberculosis. Chaulmoogra oil has been 
vaunted as a remedy of great value, but the specific cure for the disease 
has not yet been discovered. So far as concerns the present purpose of 
this article, the treatment is practically surgical and operative. CHAPTER X. 
SYPHILIS. 
By J. A. Fordyce, M. D. 
Synonyms.—Lues venerea; Morbus gallicus; Pox; Verole, etc. 
Syphilis is a chronic, general infectious disease, acquired by direct con- 
tact with a lesion of the malady in another individual, through the medium 
of some infected object, or by inheritance. It is generally a venereal 
disease, though many exceptions to this rule exist. 
The infection pursues a somewhat regular though indefinite course, 
periods of activity alternating with periods of repose or latency. It 
begins with an initial sore, the point of entrance of the virus, after a 
period of incubation following exposure. In inherited syphilis no 
primary sore is present. The initial lesion is followed by a second 
period of incubation, during which time a slow, general infection of the 
body is taking place, characterized by lymphatic node-enlargement, pains 
in the joints and bones, usually worse at night, anaemia, fever, loss of 
strength, and by other symptoms indicating a progressive intoxication 
of the organism. 
Syphilis presents many points of similarity in its symptomatology and morbid 
anatomy to the chronic infective granulomata with which it is usually classed. In 
many of them the virus retains its activity for long periods of time, and in certain 
stages produces lesions which are local rather than general. Attention has also 
been called to the resemblance which exists between syphilis and the acute exan- 
themata, in that a definite period of incubation in all these diseases is followed by 
symptoms of general infection, with an outbreak on the skin and mucous mem- 
branes and transitory congestions of various organs and tissues. The acute erup- 
tive fevers and syphilis are alike in conferring a partial or complete immunity 
against subsequent attacks, and it is a noteworthy fact that the essential nature of 
the contagion of these affections has eluded our investigations. 
Although in some of its manifestations syphilis may be compared to 
the acute exanthemata, it is essentially different in having a fixed virus, 
in its protracted course, and in the multiplicity of its symptoms. After 
tuberculosis, syphilis is probably responsible for a greater variety of 
morbid processes than any other disease. The gummatous deposits, 
interstitial growth of connective tissue, and vascular changes which take 
place in the later periods of the affection are responsible for many of 
the chronic pathological changes which appeal for diagnosis and treat- 
ment to both the physician and surgeon. Syphilis of the bones and 
joints, testes, and of other organs has been wrongly treated for tubercu- 
losis, while amputation of the tongue has been performed for gumma 
under the mistaken diagnosis of epithelioma. 
The cutaneous lesions of syphilis often present many features in 
common with lupus and leprosy, as well as with the more usual and less 
serious dermatoses. 
182 SYPHILIS. 
183 
Stages of Syphilis.—Although not separated by well-defined 
limits, it is generally customary to divide syphilis into three stages or 
periods, which may be briefly defined as follows : 
Primary syphilis embraces that period of the disease which elapses 
from the moment of infection to the appearance of general symptoms, 
including the first incubation, the time from exposure to the appearance 
of the initial sore, as well as the second period of incubation, the time 
following the primary lesion to the appearance on the skin of the charac- 
teristic exanthem. The first stage of syphilis, while varying in dura- 
tion from eight weeks to four or five months, is pretty regular in its 
evolution. 
The secondary stage, or secondary syphilis, includes for conve- 
nience of study and classification the early eruption on the skin and 
mucous membranes, as well as the accompanying disturbance of the 
general health and other phenomena which are pecidiar to the time in 
question. One type of eruption may be rapidly succeeded by another, 
or intervals of latency may occur between the successive outbreaks of 
the disease for a period of from one to three years, or longer, before the 
development of lesions which belong to the so-called tertiary stage. 
This period of syphilis, which is of exceptional occurrence and multi- 
form in its manifestations, is spoken of as the stage of gummatous for- 
mation, and includes the deeper-seated and destructive lesions of the 
skin and underlying tissues, visceral and bone affections, as well as other 
pathological changes which are directly or indirectly due to the specific 
virus. 
The early eruptions are usually superficial, of symmetrical distribu- 
tion, rapid in their development and course, while the later ones occur 
without order, are slower in their evolution, and show a greater tendency 
to undergo degenerative processes with destruction of the implicated 
tissues. 
In primary and secondary syphilis the disease can be conveyed by 
inoculation and heredity, while in the later stages it is exceptional for such 
transmission to take place. 
In whatever way syphilis manifests itself, the process is of an inflammatory 
nature, both in the initial lesion, the transitory eruptions on the skin, to the forma- 
tion of gummy tumors and interstitial connective-tissue growth in the late stages 
of the disease. The implication of the blood-vessels in the inflammatory process, 
leading to thickening of their coats and partial or complete obliteration of their 
calibre, plays an important role in the pathology of the syphilitic disease and its 
results. This blood-vessel inflammation is found in the initial lesion, the secondary 
eruptions, in gummatous tumors, and in connection with the chronic connective- 
tissue hyperplasia resulting directly from the irritant action of the specific virus 
or which occurs in organs which are or have been the seat of syphilitic new 
growths. 
The tendency which specific lesions have to undergo absorption or necrosis is 
explained in part by the peculiar nature of the virus, as well as by their lack of 
nutrition caused by the narrowing or obliteration of their nutritive blood-vessels. 
The gummy tumor, which is looked upon as the type of the late syphilitic prod- 
ucts, is a granulation-tissue growth which frequently develops at the site of the 
chancre or of earlier eruptions as the result of irritation, seeming to show that the 
virus has remained in a latent condition in certain localities. It may occur as a 
single, sharply-defined tumor, surrounded by condensed connective tissue, as mul- 
tiple pinhead-sized or larger tumors, or as a diffuse infiltration. In color gummata 
are grayish-white when situated in the viscera or subcutaneous tissue, and are sel- 
dom painful except when in the periosteum or the meninges. The cells compos- 184 
SURGICAL DISEASES. 
ing them are small round cells, with occasionally giant cells. According to Unna, 
the cell-mass is made up principally of plasma-cells. These cells gradually degen- 
erate into a central mass of yellowish-white, cheesy-looking material which may 
be absorbed, or into a semifluid mucilaginous substance which gives the name 
“gummy tumor” to the new growth. The investigations of Neumann and Unna 
have shown that, after the disappearance of the initial lesion and the secondary 
accidents, microscopic evidences of pathological conditions remain as a cell-infil- 
tration about the vessels. It is quite probable that the localization of the late 
lesions of the disease is determined by such remains of the morbid process. 
Etiology.—Most of the chronic infective granulomata have been 
shown to depend on the presence of specific micro-organisms. As 
syphilis presents so many features in common with these affections, it is 
rational to suppose that it depends on a similar cause. The infectious 
character of the disease, its period of incubation, its gradual implication 
of the lymphatic system, the blood, and all the tissues of the body, 
clearly point to some infectious agent which multiplies in the system, 
and either directly or by virtue of its chemical products evokes the 
tissue-reaction and a general condition which constitute the morbid 
process. 
The facts that the lower animals are immune to syphilis and that cultivations 
from the infectious lesions yield no uniform or satisfactory results, render the 
study of its etiology one of great difficulty. The claims made regarding the pres- 
ence of micro-organisms in syphilitic lesions before modern bacteriological methods 
came into use are without value. In 1884, Lustgarten1 claimed, by a special method 
of staining, to have found bacilli in the initial lesion, secondary papules, and in 
gummata, which closely resembled tubercle bacilli, but were thought to differ from 
the latter in their staining reaction. It has since been found that the tubercle 
bacilli cannot well be differentiated from the so-called syphilis bacilli by the 
method in question. 
The presence of micro-organisms in syphilitic lesions has been confirmed by 
Doutrelepont, De Giacomi, Gottstein, Matterstock, and many others, while Zeissl 
and equally good microscopists have attained negative results only. The specific 
claims for the bacillus of syphilis received a severe blow from the results of Alvarez, 
and Tavel’s investigations.2 Negative results were obtained by them in the exam- 
ination of many syphilitic lesions, while bacilli were found in the smegma from 
the prepuce and female genitals which resembled in every respect those described 
by Lustgarten as peculiar to syphilis. Alvarez and Tavel’s results, as regards the 
smegma bacilli, have since received general confirmation. Bacilli undoubtedly 
exist in the products of syphilis, although they are few in number and the results 
attained by various workers are not uniform. Their small number in such highly 
infectious lesions as the chancre and mucous patches speaks against their etiolog- 
ical relationship to the disease, unless the coloring methods are at fault. It is 
possible, as pointed out by Lustgarten, that the bacilli are only capable of taking 
up the stain during a short period of their existence. As a rule, the spores of 
micro-organisms take the aniline dyes with difficulty, if at all; and it is known 
that in certain tubercular lesions their specific nature can only be positively demon- 
strated by cultures and inoculation-experiments. 
Although many essential conditions are wanting to establish conclusively the 
etiological connection of the bacillus of Lustgarten, it is still held by many com- 
petent syphilographers to bear some relationship to the disease, in spite of its close 
resemblance to the bacillus of smegma. The presence of bacilli in gummata would 
lend some support to this view, were it not that it so closely resembles the tubercle 
bacillus and stains in the same way. Bacilli have been found in lesions resem- 
bling gummata which were shown by inoculation-experiments to be tubercular 
(Sabouraud). 
Secondary Infection in Syphilis.—Pyogenic cocci have been found 
in syphilitic skin-eruptions, the bones, liver, and lungs of children who 
1 Wiener med. Wochenschrift, No. 47, 1884. 
2 Archives de Phys., Oct., 1885. SYPHILIS. 
185 
had died with hereditary syphilis (Kassowitz and Hochsinger). Kolisko, 
Chotzen, and Dontrelepont made similar observations, and believed they 
gained entrance to the general circulation through the skin-lesions. 
While attributing to them no etiological importance in producing the 
disease, they yet thought the fatal issue in some cases of hereditary 
syphilis depended on septic processes brought about by such secondary 
infection. Their presence in the bones was believed to explain the sup- 
puration which is here sometimes met with in children with the disease. 
As the specific lesions in acquired syphilis seldom suppurate, many 
modern writers believe that the exceptional occurrence of suppuration 
is determined not so much by the direct action of the virus of syphilis 
as by a secondary or mixed infection with pyogenic germs which gain 
access through solutions of continuity or are incited into activity by the 
diminished resisting power of the diseased tissues. 
The presence of pyogenic cocci in the deeper layers of the normal epidermis, as 
shown by Welch and others, renders the theory of the secondary infection of 
the specific lesions extremely probable. Gummata of the skin suppurate much 
more frequently than similar lesions of the internal organs, and pustular lesions 
in general are more frequent among the poorer classes of society who pay less 
attention to personal cleanliness. It is not improbable, however, that the agent 
causing syphilis may under certain conditions acquire a greater virulence, and 
either directly or through an increased production of toxines give rise to suppura- 
tive lesions. Unna1 believes, as the result of his own investigations, that mixed 
infection with pus-cocci is of very exceptional occurrence. One would infer from 
his statements that the virus of syphilis is in itself responsible for most of the 
pustular eruptions of the disease. 
Campana2 and his pupils have by means of cultures and inoculation-experi- 
ments shown that suppuration in many such eruptions depends on the presence of 
the staphylococcus aureus and albus, and Lang,3 in a case of a malignant pustular 
syphilide, found the staphylococcus albus in the tissues at a distance from the 
lesions. 
The character of the syphilides is altered by other forms of mixed 
infection, notably by a combination about the face and scalp with the 
seborrhoeal eczema of Unna. Finger,4 in a very interesting and sug- 
gestive article, was the first syphilographer who endeavored to classify 
the symptoms which might be produced by the virus directly and those 
which presumably depended on its toxic product. The initial sore, as 
well as the lymph-node enlargement, he considers due to both the 
specific germ and its ptomaine. The latter, absorbed into the general 
circulation from an early date, confers the immunity which syphilitics 
present from an early period and long before the outbreak of the general 
eruption. The ancemia and other evidences of impairment of the 
general health are to be referred to a progressive intoxication from the 
chemical products which are being gradually absorbed into the general 
circulation. The secondary eruption, containing as it does the con- 
tagious element in a concentrated form, must be due to the bacillus 
alone or combined with its toxine. This hypothesis explains in a satis- 
factory manner the partial or complete immunity acquired by mothers who 
bear syphilitic children from the father with the latent disease, and other 
facts, which no other theory had attempted to do. 
1 Die Histopathologie der Ilautkrankheiten, S. 532, 1894. 2 Morgagni, April, 1894. 
3 Pathologie und Therapie der Syphilis, Zweite Auflage, 1895. 
4 Archivf. Dermat. u. Syph., p. 331, 1890. 186 
SURGICAL DISEASES. 
Predisposing Causes—Aside from the virulency or attenuation 
of the virus which must be considered in explaining the severer and 
milder forms of infection, the resisting power of the individual upon 
whom the poison is inoculated plays an important role in the future 
development of the disease. The extremes of life—youth and old age— 
all conditions which impair the resisting power of the patient, as tuber- 
culosis, anaemia, malaria, alcoholism, etc., render it probable that the 
future course of the affection will be grave. Tuberculosis, while it 
renders the course of syphilis more severe, limits the free use of mer- 
cury, and thus deprives us of our most useful therapeutic agent. 
Syphilis sometimes renders a latent tuberculosis active; tubercular 
abscesses of the lymph-nodes not infrequently occur during secondary 
syphilis in individuals who were apparently in robust health before 
their infection. Tuberculosis of the lungs has been precipitated by the 
presence of syphilis. 
Chronic alcoholism is an important factor in increasing the vulner- 
ability of the tissues to the specific poison. As both alcohol and syphilis 
have a predilection for the blood-vessels, their combined effects result 
in a more serious pathological condition. 
The Lesions and Secretions which Convey the Infection.—It 
is necessary for the syphilitic virus to come in direct contact with an 
abrasion of the skin or mucous membrane to convey the disease. This 
may occur directly or through the medium of some infected object. The 
initial lesion and all the early eruptions have been proven to be virulent 
by many observations, as well as by experimental inoculations. The 
secretion from condylomata lata, which are so frequently found on the 
female genitals, are believed by many to be the most frequent source of 
infection. Successful inoculations with the blood of patients during the 
early eruptive period have been made. It is not definitely established 
how long the blood retains its infective properties, but in the opinion of 
Finger and others it does not contain the virus during the latent stages 
of the disease—in the intervals between the periods of the eruptions. 
It is generally believed that the physiological secretions, milk, saliva, 
perspiration, tears, and urine from syphilitic subjects do not contain the 
virus or in such a diluted form that infection from them is not possible. 
As the micro-organisms of certain infectious diseases may pass through 
the glandular epithelium and appear in the saliva, milk, urine, etc., the 
possibility of transmitting the disease by such secretions is not abso- 
lutely excluded. The semen from syphilitic individuals cannot give rise 
to the disease by inoculation. The hereditary transmission of the dis- 
ease from the father to the child without a previous infection of the 
mother is well established. The infection of the ovum by the diseased 
spermatozoon is accomplished by a different process from experimental 
inoculation. The mother may convey the disease to her child through 
an infected ovum, the father being healthy. It is generally conceded 
that pathological secretions not properly belonging to syphilis are not 
infectious unless mixed with the patient’s blood or disintegrated portions 
of specific lesions. 
Gonorrhoea or chancroid may be contracted from a patient with syph- 
ilis, and yet no constitutional infection follow. When vaccinal lymph is 
taken from a syphilitic subject, syphilis will not be conveyed unless SYPHILIS. 
187 
there is an admixture of blood. Experimental inoculation made with 
the secretions of tertiary lesions have given negative results only. 
These results coincide with our every-day experience, which teaches us 
that the late lesions are, as a rule, neither inoculable nor transmitted by 
inheritance, and that such persons may be reinfected. As at one time 
the innocence of the secondary lesions of syphilis was affirmed, a wider 
experience may modify our view regarding the infectious character of 
the later ones. 
Modes of Infection.—The delicate mucous membrane of the gen- 
ital organs is easily abraded during sexual intercourse, and the absorp- 
tion of the virus is thus facilitated. It is not difficult, therefore, to under- 
stand that over 90 per cent, of all primary sores occur on the genitals. 
In man the chancre is most frequently found on the inner side of the 
prepuce, its free edge, the glans, or sulcus coronarius. It is also met 
with on the skin of the penis, the scrotum, in the urethra, on the peri- 
neum, about the anus, etc. In women the labia, the tissues about the 
clitoris and urethra, and the fourchette are frequently its seat. It is 
found less often on the vaginal walls and the os uteri. Chancres on 
extragenital parts, as the lips, the tongue, the tonsils, the eyelids, and 
nipples, are not infrequently met with as the result of unnatural prac- 
tices. Chancres of the lips are found in 3 per cent, of all cases, many 
being acquired in an innocent manner. Wet-nurses are infected on the 
nipples by syphilitic children, multiple chancres sometimes resulting; 
children, too, are infected by wet-nurses with lesions on the nipples. 
Chancres on the face and fingers sometimes follow bites. Surgeons may 
acquire the disease on cuts or lesions of the hands when operating on 
patients with active syphilis. Accoucheurs and gynecologists are some- 
times infected on the fingers in vaginal examinations. Infants may be 
inoculated during parturition. These modes of infection are by direct 
contact. 
Mediate Contact.—The syphilitic poison may be conveyed by drink- 
ing vessels, eating utensils, or any articles used in common by members 
of a family or by individuals. In certain occupations, as where an im- 
plement like the blowpipe in glass-factories is passed from one person to 
another, infection has been produced. The disease has also been con- 
veyed by surgeons’ instruments, dentists’ instruments, etc. 
Vaccinal syphilis is now seldom encountered, as “ humanized lymph ” 
is not often employed. Syphilis may, however, be conveyed during vac- 
cination by the use of an infected instrument. 
The disease when acquired in an innocent—i. e. non-venereal way—is 
often spoken of as syphilis insontium. 
The Chancre. 
Synonyms.—Initial lesion ; Primary sore ; Syphilitic chancre ; 
Initial or Primary sclerosis; the Hard or Infecting- chancre ; Hun- 
terian chancre, etc. 
The interval that elapses from exposure to the syphilitic virus to the 
appearance of the primary sore, or chancre, is called t\\Q first incubation- 
period. Experimental inoculation made on healthy persons showed that 
the minimum duration of this period was ten days; the maximum, forty - 188 
SURGICAL DISEASES. 
two days; its most frequent duration, from three to four weeks. After 
accidental inoculation clinical observation has shown the mean dura- 
tion to be about three weeks. It may exceptionally last seventy days 
or longer. 
Every case of syphilis, with the exception of the hereditary form, or 
syphilis conveyed from the infected foetus to the mother, begins with a 
primary lesion. It may be so slight and heal so rapidly as to escape 
observation, or in such a locality as not to be readily found. It must, 
however, have been present. It is seldom that an absolutely typical 
sore in its early stages comes under the observation of the surgeon. It 
is frequently complicated with other infections or its appearance has 
been changed by caustic applications. The classical sign, induration, 
may be wanting from a primary lesion which is followed by the consti- 
tutional disease, or it may exist in a purely local sore. Errors in diag- 
nosis are of frequent occurrence from placing too much diagnostic im- 
portance on a single feature. A typical chancroid may be converted 
into an indurated initial lesion, and instances of well-defined indurated 
sores have been observed without any constitutional disturbance. 
The initial lesion is usually single, unless several abraded spots are inoculated 
at the same time, or other eruptions, like herpes or the lesions of itch, are present 
where infection takes place. It is not at all unusual to see two or three chancres 
at the same time, and as many as a dozen have been observed to develop simul- 
taneously. Immunity to subsequent infection seems to take place very soon after 
a successful inoculation, although it is possible for a second infection to occur 
within a short time after the original one. 
Induration.—This one sign is almost, pathognomonic of the chancre. 
It is present to some extent in the vast majority of cases. When well 
developed it extends beyond and beneath the limits of the superficial 
erosion or ulceration, and feels, when grasped between the thumb and 
fingers, like a piece of cartilage imbedded in the skin. Its firm and 
elastic consistency serves to distinguish it from other inflammatory 
infiltrations, while its boundaries are much better defined than in the 
chancroid. The superficial variety gives to the finger the sensation of 
feeling a thin piece of cardboard or parchment beneath or in the skin. 
The characteristic induration met with in the initial sore is found only in two 
other conditions—rhinoscleroma and scleroderma. It is thought by Unna to 
depend principally on hypertrophy of the gelatinous connective-tissue substance, 
and secondarily on the cell-infiltration present at the same time. The cell-infiltra- 
tion is found in the early stages of the chancre before induration is at all marked, 
and also in many other conditions without such induration, so that its presence 
alone does not account for the peculiar hardness of the new growth. 
The development of the uncomplicated initial lesion is, as a rule, 
unattended by any subjective sensations, and frequently its possessor is 
ignorant of its existence. The ulceration or abrasion rapidly heals, but 
the specific induration passes away slowly and is of uncertain duration. 
It sometimes disappears within a few weeks after the secondary eruption, 
or in exceptional cases may last for six months or a year. It generally 
leaves no trace of its existence, but may terminate in a superficial pig- 
mented or pigmentless scar or spot or a keloid-like induration which 
gradually disappears. 
Varieties of Chancre.—After experimental inoculation on parts 
of the cutaneous surface removed from sources of irritation or infection Ulcerating Initial Lesions. In one sore the 
healing process is more advanced. 
FIG. 1. 
An Ulcerating Initial Lesion, showing central 
gangrene. Secondary eruption present 
at the same time. 
FIG. 2. 
Chancre of the Lip. 
FIG. 3- SYPHILIS. 
189 
it assumes the appearance of a dry scaling ‘papule. A small patch of 
round or oval redness marks its beginning: this soon becomes more 
prominent and infiltrated, developing into a pea or bean-sized nodule, 
over which the epidermis may be slightly thickened. An abrasion may 
develop over the centre of the papule, giving exit to a serous discharge 
which dries as a thin crust. The papule may slowly disappear without 
ulceration, or become more infiltrated at the base and present a super- 
ficial ulcerated surface surrounded by a slightly elevated margin. The 
ulceration in this, as well as in other varieties of the initial lesion, takes 
place at the expense of the cell-infiltration rather than of the normal 
elements of the skin, being apparent rather than real, and healing with- 
out loss of the connective tissue of the derma. 
The Superficial Erosion.—This is the primitive lesion in the vast 
majority of chancres which are not preceded by the soft sore. When 
seen sufficiently early, it appears as a rounded, sharply-defined spot, of a 
dark-red color, from which the superficial epithelium has been detached, 
exposing a moist, smooth, or slightly granular surface. There may be 
an insignificant central depression, but the edges of the erosion are 
usually on a level with the surrounding skin. One or more such lesions 
may exist, which gradually develop an indurated base and heal more 
slowly than an ordinary excoriation or abrasion. The induration may 
be superficial and thin, assuming the parchment-like form, or extend 
deeper, giving rise to a distinct nodule. 
As the cell-infiltration in the initial lesion is in the main located 
about the blood-vessels, their anatomical distribution explains in part 
the varied outlines of the scleroses. The presence or absence of much 
loose connective tissue beneath the sore also moulds the outlines of the 
infiltration. 
The Hunterian chancre, or ulcerating1 initial lesion, is the most 
pronounced and well-developed form of the syphilitic sore. It orig- 
inates in an erosion or papule which increases slowly in size, is sharply 
circumscribed, of round or oval outline with a somewhat flattened top. 
With the increase in size its consistency becomes harder until it approx- 
imates that of cartilage. In color the new growth is brownish- or 
bluish-red. After a duration of ten or twelve days its epithelial cover- 
ing becomes macerated, giving rise to a serous discharge, or it becomes 
covered with a gray film. The centre of the infiltration undergoes a pro- 
cess of molecular disintegration; its edges become elevated, so that an 
appearance of ulceration is presented which gives the impression to the 
observer of a greater loss of tissue than is in reality the case. 
A well-marked Hunterian chancre therefore presents an infiltration or sclerosis 
from the size of a silver dime to that of a quarter dollar, or larger, in circumference, 
surmounted by an ulcer with elevated sloping edges involving an area much less 
than the underlying cell-growth. In Plate V. Fig. 1 two typical sores of this kind 
are shown, in one of which the ulceration has healed, leaving only a slight central 
depression; in the other the surface of the ulcer is granular and the cicatrization 
is beginning to form about the edges. In unfavorable conditions of health, from 
local infection or from obliterative endarteritis and endophlebitis, gangrene may 
attack the sore, causing the loss of a part or the whole of the diseased tissue 
(Plate Y. Fig. 2). Spreading phagedena is, however, not so frequently met with as 
a complication of the specific sore as formerly. 
After three or four weeks’ duration the Hunterian chancre begins to 190 
SUBOICAL DISEASES. 
undergo a slow process of involution, which is hastened by the local and 
internal use of mercury. It heals without loss of tissue or with an 
insignificant scar. 
The Mixed Sore.—The subject of chancroid is considered in another 
part of this work (Vol. II. Chap. XII.). It is sufficient to state here 
that it is a local infectious ulcer, with a short period of incubation, almost 
exclusively met with on the genital organs. Infection with the virus 
of chancroid and syphilis may take place at the same time, the former 
passing through its stages of papule, pustule, and ulceration, with free 
suppuration. At the end of two or three weeks, the incubation-period 
of the syphilitic sore, the base and edges of the chancroid assume a 
characteristic induration and a brown-red color; granulations spring up 
and the secretion of pus becomes less. Within a few days the local 
infectious ulcer is converted into a typical sclerosis which pursues the 
ordinary course of the latter. The syphilitic infection may, of course, 
follow that of the chancroid, but usually is simultaneous. 
Induration or sclerotic oedema is looked upon by some syphilog- 
raphers as a distinct variety of the initial sore; by others as a compli- 
cation of one of the forms previously described. It is of rare occur- 
rence, being generally found on the labium majus, occasionally on the 
mucous surface of the prepuce or the skin of the scrotum. The usual 
erosion or papule is not present, the only lesion being a firm and elastic 
swelling which gradually increases until the parts become two or three 
times their normal size. It is much firmer than inflammatory oedema, 
but less so than the induration about the initial sore. In consistency it 
more nearly approaches that of scleroderma. This indurative oedema 
passes away slowly and leaves no mark of its former existence. 
Complications of the Chancre.—Local pyogenic infection is 
responsible for an extensive ulceration or suppuration of the primary 
sore. At times the inflammatory process may be so intense that the 
parts become much swollen and painful. When the preputial opening 
is narrow the occurrence of a chancre on its inner surface or in the 
sulcus coronarius often leads to complete phimosis or paraphimosis. 
The retention of the secretion from the sore in the preputial sac mace- 
rates the epithelium of the glans, producing an intense balanoposthitis, 
the discharge from which may simulate a gonorrhoea. Under such con- 
ditions the entire penis may become red, painful, and swollen. A 
neglect at this time to relieve the tension by a dorsal incision of the 
prepuce may result in superficial or deep gangrene, with partial or com- 
plete destruction of the glans, and possibly urethral fistulas or other 
complications. 
Bxtrag-enital Chancres.—Certain peculiarities are presented at 
times by chancres of the general integument or mucous membranes at 
a distance from the genital organs. A chancre at the margin or bed of 
the nail seldom shows marked induration; exuberant granulations are 
sometimes seen, and frequently suppuration is profuse. On the cheek 
or chin, where the tissues are lax, it attains a large size. It may ulcer- 
ate and be covered by crusts, and has been mistaken for malignant dis- 
ease. A tonsil which is the seat of a chancre enlarges, generally ulcer- 
ates, and at times is covered by a pseudo-membrane simulating the 
diphtheritic membrane. Enlargements of the submaxillary and cervi- SYPHILIS. 
191 
cal lymph-nodes are simultaneously present. Difficult deglutition is 
often experienced. Chancres on the lip are commonly indurated, and 
sometimes present well-marked ulceration with a dark-red granulating 
surface (Plate V. Fig. 3). 
Enlargement of the Communicating Lymph-vessels and Nodes. 
—After the appearance of the initial sore, the next manifestation of the 
specific infection is in the lymph-nodes in anatomical communication 
with the lesion. Exceptionally, one or more lymph-vessels or thick- 
ened veins may be felt as firm, hard, painless cords extending along the 
dorsum of the penis to its root. At times nodules form in the course 
of these thickened vessels, which undergo spontaneous involution or 
ulcerate. 
The characteristic lymphatic involvement appears, usually, within a week 
after the initial lesion. In genital chancres the nodes are seen and felt along the 
line of Poupart’s ligament, although it has been shown that the crural and iliac 
nodes are also involved. The enlargement may at first be more evident on the 
side corresponding to the lesion, but later both inguinal regions are generally 
similarly implicated. The nodes are painless, hard, freely movable, and not 
attached to the overlying skin. Several nodes on both sides are involved : they 
remain sharply defined, and seldom exceed the size of an almond. There is no 
redness of the skin or other evidence of an acute inflammatory process, unless an 
infection with pus-producing organisms takes place at the same time. When such 
is the case, a number of nodes may be matted together by the septic inflammation, 
miliary abscesses form in them, and a condition results which can only be satis- 
factorily treated by their excision. 
The presence of localized lymphatic complications may sometimes be a guide 
in finding the initial lesion when on extragenital parts. Chancres on the body 
below the umbilicus, except on the os uteri, first involve the inguinal nodes ; chan- 
cres on the hand, arm, and breast, the axillary ganglia. The submaxillary nodes 
are enlarged in chancres of the lip and chin; the subhyoid in chancres of the 
tongue; the preauricular in chancres of the eyelid. 
Diagnosis of the Initial Lesion.—Chancroids are practically 
always found on the genitals. They are generally multiple, have a 
short period of incubation, and begin as a pustule or small ulcer sur- 
rounded by a red areola; a pseudo-induration may result from caustic 
or other applications. The floor of a chancroidal ulcer is irregular, 
covered by a grayish membrane ; its edges are frequently undermined, 
and it secretes pus freely. Chancroidal pus is auto-inoculable, both on 
the genitals and general integument. A single or double bubo, with a 
marked tendency to suppurate, is found in about 25 per cent, of cases 
of chancroid. It must be borne in mind that a chancroid frequently 
assumes an induration as the result of a double infection, and that the 
initial lesion of syphilis, from local infection or irritating applications, 
ulcerates and secretes pus. 
Herpes of the genitals occurs as a grouped vesicular eruption which seldom 
lasts longer than a few days. A history of former attacks is of aid in diagnosis. 
Cauterization of such lesions with carbolic or nitric acid may obscure their normal 
features and cause them to simulate chancres or chancroids. 
A chancre of the lips or genitals has been mistaken for an epithelioma. The 
latter occurs later in life, is slower in its evolution, and does not implicate the 
lymph-nodes as soon as the initial lesion. 
A late lesion of syphilis is sometimes found at the site of the original chancre, 
or elsewhere, which has been mistaken for a primary sore. The serpiginous exten- 
sion or central ulceration, as well as the absence of the primary lymphatic involve- 
ment, would serve to distinguish it from primary syphilis. 192 
SURGICAL DISEASES. 
Pathological Anatomy of the Chancre.—The blood-vessels, 
including both the arteries and veins, show marked changes in the earliest 
stages of the development of the initial lesion. They are surrounded 
by large numbers of single, nucleated polyhedral cells, which are believed 
by Unna to represent proliferating connective-tissue cells (“plasma- 
cells ”) (Fig. 62). Few multinucleated leucocytes are seen. The endo- 
Fig. 62. 
Fig. 63. 
Showing the cell-infiltration about a blood-vessel 
in the chancre. The proliferation of the endo- 
thelium is also shown. 
Section through a chancre under low power. 
Zeiss, 70 mm. No ocular. 
thelial cells of the vessels multiply, as shown by numerous mitoses and 
thickening of their intima; the middle and outer coats are also thick- 
ened and infiltrated by leucocytes. As a consequence of the involve- 
ment of the vessels’ walls and from outside pressure their calibre is 
encroached upon and frequently found to be obliterated. 
A section through a chancre, at the height of its development, reveals a dense 
cell-mass in the papillary and subpapillary region of the derma, which is pretty 
sharply defined on all sides (Fig. 63): the blood-vessels lying for some distance 
outside of the infiltration are surrounded by the cells previously mentioned and 
present thickened walls. The epidermis at the edge of the induration in many 
cases is hypertrophied, the interpapillary process extending for some distance into 
the cutis. Leucocytes are also to be found between the cells of the epidermis, 
which is in part or wholly destroyed over the centre of the sclerosis. When the 
sclerosis is uncomplicated by a secondary infection, remains of the epidermis can 
frequently be seen over the central erosions, so that its complete restoration after 
the involution of the chancre generally takes place. 
In addition to the dense inflammatory cell-infiltration about the vessels, changes 
in the connective tissue of the derma take place which result in its hypertrophy 
and a peculiar change in the gelatinous tissue-substance to which Unna refers, in 
part, the induration. Although there is nothing absolutely pathognomonic in the 
minute anatomy of the initial sclerosis, there are certain characteristics which, 
when found associated, will frequently enable one to make a microscopic diagnosis. 
These features are—the superficial character of the infiltration surmounted by a 
central erosion, with vestiges of the epidermis still remaining; thickening of the 
epidermis, with infiltration of leucocytes at the edges of the erosion ; obliterating 
endarteritis and endophlebitis of the vessels away from the central sclerosis, 
together with their surrounding cell-infiltration. The involution of the chancre 
is hastened by the changes in the blood-vessels which limit its supply of nutrition, 
causing degeneration of its constituent cells, and probably by the character of the 
poison, which in itself may lead to necrosis of the new growth. 193 
SYPHILIS. 
Prognosis of the Chancre.—It has been maintained by some 
writers that the future course of syphilis depends to some extent on the 
size or number of the initial lesion, and that an extragenital location of 
the chancre is apt to be followed by a severer type of the disease. The 
character of the tissues on which the virus is implanted has more to do 
with the future evolution of the constitutional disease than the size, number, 
or location of the primary sores. The most insignificant chancre may 
be followed by a malignant form of syphilis, while large and multiple 
initial sores may cause only a slight constitutional reaction. 
The chancre in patients with nephritis, diabetes, tuberculosis, or other severe 
systemic diseases may become gangrenous and produce extensive local destruction 
of the parts. Constitutional syphilis is also apt to be a more serious disease in such 
patients. Under such conditions the local and general reactions are to be referred 
to the same cause, rather than to be considered as cause and effect. Several indi- 
viduals infected from the same source react in different ways to the specific disease. 
In malignant types of syphilis destructive lesions are apt to be an early manifesta- 
tion, anticipating their average time of development. A short duration of the 
periods of incubation may imply, therefore, less resisting power on the part of the 
tissues, and indicate a severer form of the disease, while a longer period of incuba- 
tion may point to milder constitutional reaction. 
Treatment of the Chancre.—In the opinion of the great majority 
of syphilographers at the present time it is not possible to abort syphilis 
by chemical agents or the actual cautery, nor by excision of the initial lesion, 
even in conjunction with removal of the inguinal ganglia. 
When a chancre is situated at the preputial margin in a patient with phimosis, 
it may be removed by a circumcision. No hope should be entertained, however, 
of preventing or modifying the future course of the disease by such procedure. 
It is only mentioned as a hygienic measure which may, under certain circum- 
stances, be indicated. The fact that immunity to further infection is present 
during the first period of incubation, before the characteristic sore has appeared, 
shows that some infectious matter has entered the general circulation, and that 
syphilis, before and at the time the chancre appears, is something more than a 
local disease. 
Local Treatment—The sore should be kept clean by the free use of 
soap and water. Where an erosion or superficial ulcer is present, calo- 
mel is perhaps the best application to use until the raw surface has 
healed. The ordinary black wash, a solution of bichloride of mercury 
(1:2000 or 1:3000), or a solution of permanganate of potassium 
(1 :3000) may also be employed several times a day as local antiseptic 
agents. 
When gangrene or phagedenic ulceration occurs as a complication, 
more active local medication is indicated. Compresses wet in a weak 
solution of chlorinated soda and kept constantly applied are an effica- 
cious method of limiting the spread of gangrene or phagedena. The 
free use of iodoform is also valuable in stimulating healthy granulations 
after the separation of the gangrenous mass or limiting a spreading ulcer- 
ation. After ulceration has healed the application of equal parts of mer- 
curial ointment and vaseline, mercurial plaster, or ointments containing 
other mercurials, hastens the absorption of the induration. Its absorp- 
tion is also more rapidly carried on during the internal use of mercury. 
Chancres on the female genitals should be treated in the same way, more 
care being here required, however, to preserve cleanliness. Chancres of 
the vulva should be freely covered with calomel and the parts kept sepa- 194 
SURGICAL DISEASES. 
rated by pledgets of absorbent cotton. An initial sore at the meatus or 
within the urethra is difficult to treat satisfactorily. When at the meatus 
it may lead to stenosis of this orifice if the canal is not kept open by 
means of a small roll of lint saturated with a dilute mercurial ointment 
or a tampon of iodoform gauze. Deeper-seated chancres may be treated 
by astringent injections, combined with the liberal use of mercurial oint- 
ment externally. 
If the initial lesion be in every way typical and the inguinal or other 
nodes present the characteristic enlargement, the internal use of mercury 
is indicated even before the eruption appears on the skin. 
Chancres always gives rise to much mental distress, and when on extragenital 
parts, as the face, are disfiguring. They may be painful when located on the 
glans or prepuce in patients with phimosis. In such cases, when the diagnosis is 
clear, one should not hesitate to resort to mercurials internally, as the involution 
of the sore is thereby hastened. When, however, the character of the sore is at 
all doubtfid, one should await the appearance of the secondary eruption before 
beginning the general treatment. 
Constitutional Syphilis. 
The time between the appearance of the chancre and the outbreak 
of an eruption on the skin and mucous membranes is called the 
second incubation-period. Its average duration is forty-jive days: 
the shortest time reported is twelve days, the longest two hundred 
days. After experimental inoculation the shortest duration was eight 
to fourteen days; the longest, one hundred and fifty-nine days. 
During and before this time a slow infection of the entire economy is 
taking place, which may produce a serious disturbance of the general 
health or be of such slight intensity that the patient is unaware of 
any change in his condition. A generalized hypertrophy of the lym- 
phatic nodes, in addition to those in direct communication with the pri- 
mary sore, can be made out by the end of this second incubation-period. 
In some cases enlarged nodes can be detected two or three weeks before 
the skin-eruption appears; again, not until or after the cutaneous out- 
break. The nodes along the posterior border of the sterno-cleido-mastoid 
muscle, other nodes about the neck, the supraclavicular, the axillary 
nodes, and the epitrochlear, are the ones which can usually be felt. In 
addition to those mentioned, any of the superficially located nodes may 
undergo hypertrophy, and the visceral nodes have been found enlarged 
in certain cases where autopsies have been made. The enlarged nodes 
vary in size from that of a bean to a pigeon’s egg: they are rounded or 
oval in outline, painless, somewhat hard, and never suppurate unless 
some local condition produces a secondary infection. In tuberculous 
subjects previously enlarged nodes may become inflamed and even sup- 
purate, the syphilitic virus seeming to render active the bacillus of tuber- 
culosis, which is probably present at the same time. The duration of the 
enlargement is indefinite. It may pass away in a few months, a year, 
or some evidence of its presence may be detected after two or three 
years. When other causes are excluded the presence of a generalized 
lymphatic involvement may he of service in diagnosticating a past syphilitic 
infection after the cutaneous manifestations have disappeared. In late 
syphilis a gummatous or interstitial change, involving one or more nodes, 
has been occasionally observed. SYPHILIS. 
195 
Among the evidences of a progressive intoxication of the system dur- 
ing this period, anaemia is frequently met with in a greater or less degree. 
Stoukovenkoff’s 1 investigations showed that the first blood-change con- 
sisted in a rapid increase of the number of white blood-corpuscles, a 
diminution in the amount of oxyhaemoglobin and in the number of red 
blood-corpuscles. These blood-changes were found to be more pro- 
nounced in cases where fever was present. Biegansky2 has, in the 
main, confirmed these observations. 
The blood-changes are more pronounced in women than in men, 
sometimes producing a feeble action of the heart, extreme prostration, 
and other accompaniments of the anaemic state. The pathological state 
of the blood continues in a more or less marked degree during the erup- 
tive stage. 
Fever is present in a certain percentage of cases shortly before and 
during the early eruptive period. The majority of patients are affected, 
according to the observations of some writers, while less than half show 
febrile reaction, according to others. As a rule, the rise of temperature 
occurs only in the evening, and seldom exceeds 100° or 102° F. In 
exceptional cases it has reached 105° F. A form of intermittent fever 
has been observed during the existence of late visceral or nervous 
syphilis. 
Early syphilitic fever is a transitory manifestation, lasting, as a rule, 
but three or four days. It not infrequently precedes the outbreak of a 
pustular syphilitic eruption, and when accompanied by severe pain in 
the head and back the condition may closely simulate a variola. 
Pains of a neuralgic or rheumatoid character are often experienced in 
the joints, bones, and muscles. Sometimes an effusion into one or more 
joints can be made out, and not infrequently a painful thickening of the 
periosteum, especially over the long bones or cranium, is distinctly evi- 
dent. Localized or diffuse headaches of a severe character, with inability 
to sleep, or dull, ill-defined pains in the head, are often exceedingly 
troublesome. All the pains men- 
tioned are intensified at night. 
Fig. 64. 
Vertigo, epileptiform attacks, hysteria, tem- 
porary paralysis of certain muscles, analgesia 
of the extremities, increased tendon and skin 
reflexes are among the rarer manifestations 
of this period. Attacks of subacute pleurisy, 
enlargement of the spleen, and jaundice have 
been noted during the secondary stage of 
syphilis. 
In addition to amyloid changes and gum- 
matous lesions of the kidneys, which are 
met with late in the disease, the occur- 
rence of albuminuria, both with and with- 
out oedema, has not infrequently been ob- 
served during the outbreak of syphilitic 
manifestations. Early syphilitic albumi- 
nuria is generally a transient symptom, 
disappearing under the use of mercury 
and a proper diet. A severe form of ne- 
phritis may, however, develop, which is 
characterized by scanty urine containing albumen, blood-casts, a general oedema, 
Endarteritis syphilitica (kidney) from a case 
of chronic syphilitic nephritis (X 200). 
1 Ann. de Dermal, et Syphil., 1892, p. 928. 
2 Arch. f. Dermal, u. Syph., 1892, p. 43. 196 
SURGICAL DISEASES. 
and uraemic manifestations. Such severe cases may recover or develop a chronic 
interstitial nephritis which terminates fatally. In a case of this kind which was 
under my observation for several years an autopsy revealed contracted kidneys, 
atrophy of the glomeruli, and marked changes in the blood-vessels. A thickening 
of the intima, the result of a proliferative endarteritis, together with implication 
of the other coats, leading to an obliteration of the vessel’s calibre, is shown in 
Fig. 64. The changes are of a similar nature to those first described by Heubner 
in the arteries of the central nervous system. 
The relationship of syphilis to other diseases, and the influence which 
it exerts on the healing of wounds, are interesting questions to consider. 
Reference has been made to the increased gravity of the disease in 
tuberculous and alcoholic subjects. Bright’s disease and rheumatism 
are aggravated when an added specific infection is present. A latent 
syphilis sometimes becomes active after an attack of malaria. Some 
observations seem to show that fractures occur more readily in syphilitic 
subjects, probably as the result of local bone disease, and that their 
union is at times delayed. Cooper relates a case where the callus which 
formed around a fracture of the arm was rapidly dissolved by the admin- 
istration of iodide of potassium for a rupial eruption. 
A specific lesion of the skin, of subcutaneous tissues, or of hone may be local- 
ized by an injury or chronic irritation of the parts, but wounds or surgical opera- 
tions which are made during the active stage of syphilis heal as readily as on a 
non-syphilitic individual. A specific eruption, gumma, exostosis, or ulceration 
may rapidly disappear after an attack of erysipelas at the site of the lesions. A 
recurrence is apt to follow the disappearance of the erysipelas. 
Epithelioma may occur at the site of an ulcerating gumma of the 
skin or mucous membrane. An intimate relationship exists between the 
development of cancer of the tongue and the peculiar change in the 
epithelium known as leukoplakia, which sometimes follows specific 
lesions subjected to chronic irritation. 
The development of aneurism is closely connected with arterio-sclerosis, which, 
by weakening the coats of the vessels, renders them liable to dilatation after 
violent exertion. Although by no means the only cause of the vascular disease, 
syphilis is a frequent and potent factor in its production. 
Syphilis of the Skin; the Syphilides; Syphiloma. 
The administration of mercury during the second incubation-period, 
a greater resisting power on the part of the tissues, or other causes may 
retard the appearance of the specific eruption oil the skin or mucous 
membranes. It must be borne in mind, however, that the disease is a 
constitutional one, with or before the appearance of the chancre, although 
at times slight evidence of its presence can be detected. In some 
instances the primary sore is of so doubtful a character that a diagnosis 
cannot with certainty be made before the appearance on the skin of the 
characteristic rash. As well-marked indurated chancres with inguinal 
lymphatic involvement have been observed that were not followed by 
any secondary eruptions, it is possible for syphilis to end its existence 
during the primary stage. We have no absolute proof, however, that 
this can occur. Many cases of syphilis are of so benign a character 
that after the appearance of an erythematous rash, which may and fre- 
quently does escape the observation of the patient, no further symptoms 
are ever seen. In other cases which pursue a mild course one type of SYPHILIS. 
197 
superficial eruption may rapidly follow another for a period of months 
or years, the general health being little impaired. 
In malignant, precocious, or galloping syphilis destructive lesions 
occur early in the course of the disease, anticipating by months or years 
their usual date of evolution. Gummata appear on the skin, mucous 
membranes, or in the viscera, producing deformity or the permanent 
impairment of the functions of important organs. A profound cachexia 
results from the intensity of the infection and the accompanying lesions. 
The historical account of the European epidemic of syphilis in the fif- 
teenth century shows that such forms were not so infrequent as they 
now are. 
The cutaneous eruptions of syphilis are the most constant and cha- 
racteristic manifestations of the disease: they are known as syphiloder- 
mata or syphilides, a qualifying adjective being employed to designate 
a special form of primary lesion or combination of lesions which is 
present. Syphiloma is a term which is sometimes used to include the 
late nodular or gummatous formations in the skin, mucous membranes, 
and viscera. 
All the primary and secondary lesions which are met with in non- 
specific dermatoses are also found in syphilitic ones. The latter can 
readily be recognized in the majority of cases by certain peculiarities of 
development, distribution, involution, color, grouping, polymorphous cha- 
racter, absence of itching, etc. Syphilis may imitate a psoriasis or lupus 
in its cutaneous expression, so that it is difficult to determine which affec- 
tion is present. It is incorrect, however, to refer to such an eruption as 
a syphilitic psoriasis or syphilitic lupus, as these terms would imply a 
combination of the two diseases; which does not occur. 
The early syphilides occur in a symmetrical manner, have a general 
distribution, are superficially seated, disappear spontaneously, and pursue 
a more rapid course than the later ones. They show a tendency to lose 
their symmetrical distribution after a number of months have elapsed 
from the time of infection. The individual lesions composing the erup- 
tion now group themselves or assume circular or gyrate outlines, indi- 
cating to the trained observer a relapsing syphilide and also the proba- 
ble duration of the disease. 
The first eruption, which usually appears in the form of macules, is 
often followed, before its complete involution, by a papular, and this by 
a pustular or ulcerative, syphilide, so that a mixed or polymorphous erup- 
tion is present. 
The color of syphilitic lesions is due in great measure to the marked implica- 
tion of the blood-vessels in the pathological process, which favors blood-stasis and 
exudation of the red blood-corpuscles into the tissues. The pigment which results 
from their disintegration in greater or less amount gives to the lesion a lighter or 
darker shade. At first the lesions may have a pinkish-red color which soon 
assumes a brownish or yellowish-red tint that has been compared to the color of 
raw ham or copper. A yellowish or brownish-black pigmentation may remain 
at the site of the lesions after their disappearance. Exceptionally, the absence of 
the normal skin-pigment, leukoderma, may mark the location of the lesions. It 
should be remembered that other skin affections may present equally marked pig- 
mentary changes, and that the color of the eruption is only of diagnostic value 
when taken in conjunction with other features. The absence of itching, burning, 
or other subjective sensations in connection with the eruption is of diagnostic 
importance. 198 
SURGICAL DISEASES. 
The later or tertiary cutaneous manifestations of syphilis differ from 
the earlier ones in their irregular and exceptional occurrence, their local- 
ized distribution, deeper seat in the tissues, slower course, and in their 
tendency to cause loss of tissue and leave permanent cicatrices. The cen- 
tral involution and peripheral extension of the infiltration is also more 
marked in the late syphilides. The secondary lesions contain the virus of 
syphilis in an active state, while the tertiary lesions are slightly if at all 
virulent. Experimental inoculation of the secretions of late syphilides 
has invariably given negative results. 
The specific influence of mercury on the early eruptions, and of the 
iodides in causing the disappearance of the later ones is a remarkable 
instance of the selective action of drugs in different stages of the same 
affection. In many cases the two stages are not separated by well- 
defined limits, but are united by intermediate eruptions which present 
many of the characteristic features of both. 
Roseola syphilitica, the macular or erythematous syphilide, is usu- 
ally the first cutaneous manifestation of syphilis. It appears at the end 
of the second incubation-period as a generalized eruption of circum- 
scribed spots of hypersemia from the size of a split pea to that of the 
finger-nail. The spots are bright-red or bluish-red in color, and are not 
elevated above the skin-level. The eruption begins, as a rule, on the 
abdomen, then on the chest, and finally on the extremities. The face is 
exceptionally attacked. A week or two elapses before the eruption 
appears on the extremities. It may last for several days or several 
weeks, and usually disappears without desquamation, leaving at times 
light-brown pigment-spots to mark its former situation. 
A relapsing macular syphilide sometimes occurs within the first or second year 
in the form of circular patches, which may reach or exceed the size of a silver 
quarter-dollar. This variety of the macular eruption, which has a limited and 
irregular distribution, is attributed by Unna to changes in the nerves supplying 
the aflected area, similar to the nerve-changes in leprosy, which produce certain 
skin lesions in that disease. 
The macular eruption is more than a localized liypertemia. A cell-infiltration 
of slight grade is found about the blood-vessels and sweat-glands; also changes in 
the endothelium and adventitia of the vessels. An increase in the severity of the 
inflammatory process produces the syphilitic papule, which not infrequently arises 
from the centre of a macule, constituting the maculo-papular syphilide. 
Diagnosis.—When considered apart from other symptoms of syphilis 
the macular eruption in its early stages may be mistaken for the erup- 
tion of another exanthem, measles, or the erythema which follows the 
internal use of copaiba, antipyrine, salicylate of soda, or other drugs. 
In its declining stage it has been confounded with pityriasis versicolor. 
A careful examination of the patient and a proper consideration of the 
concomitant symptoms serve to make the diagnosis clear. 
The papular syphilide may be the first eruption or follow the 
macular syphilide. It occurs in the form of large or small papules, 
constituting the lentieulo-papulav and the miliary-papular eruptions. 
The papular eruptions are generalized in the early months of the dis- 
ease (Plate VI.); later, their distribution is circumscribed, and finally 
they may form transition types from the early to the later tubercular or 
gummatous new formations. The papule is the initial form of all the 
subsequent secondary lesions. It varies in size from a pin’s head (the PLATE VI. 
Grouped Miliary Papular Syphilide. 
I PLATE VII. 
Mixed Papular and Papulo-Pustular Syphilide. SYPHILIS. 
199 
miliary papule) to that of a split pea and larger (the lenticular papule). 
It consists of a sharply circumscribed, solid infiltration in the derma, of 
a light-red or brownish-red color, projecting above the level of the skin. 
When not the seat of secondary changes, as suppuration, it heals with- 
out scarring. In its declining stage it frequently scales, forming the 
papulo-squcmous syphilide, a common form and one often mistaken for 
psoriasis. 
On the palm,s and soles a number of scaling lesions may coalesce, giving rise to 
the eruption which has been erroneously called syphilitic palmar and plantar psoriasis. 
Annular and gyrate forms result from the central involution and peripheral exten- 
sion of the lesions. The papule may be surmounted by a vesicle, bulla, or pustule, 
giving rise to a great variety of lesions to which distinct terms have been applied, 
as the varicella-form, the variola-form, the impetigo-form, the ecthyma-form, and the 
acne-form of the syphilides. It should be remembered that all these forms of 
eruption represent changes which take place in the papule and follow its localiza- 
Fig. 65. 
Grouped papulo-pustular syphilide and numerous pigmented spots from former lesions, 
tion, size, and outlines, papular, pustular, and transition forms of eruption being 
frequently seen on the same patient (Plate VII. and Fig. 65). They do not repre- 
sent essentially different lesions, but occur, as a rule, after the papule is developed 
from some condition of the patient or an increased virulency of the syphilitic 
poison. 
In cachetic or alcoholic individuals, or in those whose resisting power is slight, 
the papule may not reach its complete development before breaking down into a 
pustule. In such patients the primary eruption of the disease may rapidly assume 
a pustular form, leaving pigmented scars after healing. 
The ecthyma-form syphilide, or the large pustular variety, occurs 
by preference on the lower extremities or scalp as a superficial or deep 
affection, giving rise to large, irregularly-shaped ulcers, having a livid, 
grayish, or gangrenous floor which secretes a bloody pus that dries in 
the form of dark-brown or black crusts. Ulceration extends beneath 
the crusts. This type of eruption is rarely seen during the first six 
months. It. is more usual as a late secondary or intermediate eruption. 
In Fig. 66 two symmetrically situated ulcers on the legs are shown 
which are the result of this form of the syphilide. They can be differ- 
entiated from the ulcers resulting from broken-down gummata of the 
subcutaneous tissue, as the latter are scarcely ever symmetrical, and have 
as their antecedent stage a deep-seated solid tumor, which ulcerates in 
the centre and affects the skin secondarily. 
Rupia, or the rupial syphilide, is a form of the large pustular erup- 200 
SURGICAL DISEASES. 
tion resulting in ulcers which are covered by concentric layers of crusts. 
It may occur within the first six months as a precocious eruption, as a 
late secondary, or as a tertiary outbreak. The papule, if it exist at all, 
has a very transient duration, the first lesion being a bulla or pustule. 
Fig. 66. 
Ulcers resulting from the deep ecthymatous syphilide. 
The secretion is abundant, thick, and dries rapidly in superimposed 
layers of greenish-brown or blackish-brown crusts, beneath which the 
ulceration extends on all sides: as a consequence, each newly-formed 
layer is larger than the one which precedes it, which gives to the lami- 
nated layers a conical shape (Plate VIII.)- If the crusts are removed, 
an indolent ulcer with an irregular base and undermined edges is revealed, 
which is frequently slow in healing. Irregularly rounded, depressed 
white scars, surrounded by a pigmented areola, are left after the ulcer 
heals, and are quite characteristic of a past syphilis. A rupia is pathog- 
nomonic of syphilis, as no other dermatosis assumes such a form. PLATE VIII. 
Early Rupial Syphilide. PLATE IX. 
Tubercular Ulcerating Syphilide, showing lesions in different stages. SYPHILIS. 
201 
The prognosis of this eruption is not favorable in its severe and 
generalized forms. It is slow in healing, and death has resulted from 
sepsis due to absorption of purulent matter beneath the crusts. By 
careful local and general treatment the majority of cases terminate in 
recovery. 
Ulceration with permanent scar-formation may result from any of the pustular 
eruptions during the secondary stage. The existence of ulcers in syphilis does not 
imply, therefore, that the disease has reached the so-called tertiary stage. A pap- 
ular eruption on the trunk is apt to be accompanied by pustules on the scalp and 
hairy portions of the leg, as if the papules in these localities had been infected by 
pus-organisms. 
Tertiary Syphilis. 
The statistics of Haslund1 show that tertiary syphilis in general 
occurs in about 12 per cent, of all cases infected. The skin is involved 
more frequently than any other tissue or organ, and nearly as often 
as all the other organs combined. If we assume that tertiary lesions 
develop at the site of the earlier ones from latent virus that is rendered 
active by irritation or other causes, the increased frequency of skin 
lesions in late syphilis can be explained by the more frequent implica- 
tion of the skin during the secondary stage, and its greater liability to 
traumatisms and irritation. 
The syphilides of the late period of the disease are the tubercular 
or nodular and the gummatous. The former are found in the superficial 
or deeper layers of the skin as grouped or discrete, circumscribed, brown- 
red nodules, from the size of a pea and larger, which may coalesce into 
large, flat areas of infiltration. The nodule or tubercle resembles the 
early papule in its histological structure, and is considered by some 
writers to be a more highly developed form of this lesion. In its early 
tendency to degeneration and ulceration, producing atrophy and scarring 
of the skin, it is closely related to the gumma. Both the nodule and 
the gumma are considered by many syphilographers as varieties of the 
same lesion. The tubercular syphilide can exceptionally undergo absorp- 
tion without leaving a scar. As a rule, it spreads in a serpiginous man- 
ner, healing with loss of tissue, and advancing by a broken, elevated 
margin which represents the most recent deposit. In this way it pro- 
duces lesions with the outlines of circles, segments of circles, and horse- 
shoe- and kidney-shaped infiltrations. When absorption takes place with- 
out ulceration, a clinical picture is formed sometimes closely resembling 
lupus vulgaris (Fig. 67). 
The serpiginous infiltration, instead of undergoing interstitial absorption, as in 
the last form, may ulcerate, become infected, and secrete pus or pus mixed with 
blood, which dries in the form of yellowish-gray or greenish-black crusts, giving 
rise to the tubercular ulcerating or the pustulo-ulcerating syphilide. A part or the 
whole of the marginal infiltration may break down, and numerous foci are some- 
times met with in various stages of development (Plate IX.). 
The entire duration of the tubercular syphilide may, in severe cases, be fifteen 
to twenty years. The ulcerating serpiginous syphilide develops at times from the 
papulo-pustules of the late secondary or intermediate period of syphilis. The 
cicatrices resulting from these forms of syphilide are generally white, superficial, 
smooth, with scalloped or irregularly outlined borders, surrounded by a pigmented 
zone, and are quite suggestive of the condition which preceded them. The scar- 
1 “On the Causation of Tertiary Syphilis,” Brit. Journ. of Dermat., 1892, p. 210. 202 
SURGICAL DISEASES. 
tissue is less than would be anticipated from the appearance of the active stage of 
the disease. 
The Gummatous Syphilide.—The true gumma begins, as a rule, in 
the subcutaneous tissue, affecting the skin secondarily. It is observed as 
a round or oval tumor, from the size of a cherry or smaller to one as 
large as the fist. The gummy tumors in the beginning are hard, elastic, 
Fig. 67. 
Tubercular serpiginous syphilide resembling lupus vulgaris. 
sharply circumscribed, and freely movable beneath the skin, which may 
not be elevated. This may be painful or only slightly sensitive to 
pressure. In their development they may become attached to the tis- 
sues beneath, as well as to the overlying skin, forming projecting tumors 
which closely resemble other non-specific growths. The skin covering a 
gumma which has undergone central softening becomes somewhat red- 
dened and swollen, or it may be the seat of a nodular infiltration. An 
examination at this stage reveals distinct fluctuation: an incision made 
into the growth gives exit to a thick, viscid, mucilaginous-looking fluid 
of a yellowish-gray color containing few pus-corpuscles. The appear- SYPHILIS. 
203 
ance of the contents of the broken-down gumma has given the growth 
its name. The tumor may be absorbed during the stage of fluctuation, 
leaving the skin covering its former seat thin, depressed, and somewhat 
pigmented. The subcutaneous and cutaneous tissues have been in part 
destroyed by the new growth, so that a permanent atrophy of the 
atfected area remains. The 
detritus of the gummy tumor 
at times undergoes a cheesy 
or calcareous degeneration 
which becomes encapsulated 
or is eliminated by ulceration. 
One or several openings form 
over a softened gumma, giv- 
ing exit to disintegrated and 
sloughing tissue : these open- 
ings may unite, forming a 
single gummatous ulcer, or 
remain distinct (Fig. 68). 
The ulcer is at first smaller 
than the cavity and surround- 
ing infiltration : its edges are 
thickened, bluish-red, and 
undermined, its base being 
made up of the degenerated 
tissue of the gumma. The 
ulcer remains open until all 
the affected tissue has been 
softened and expelled. The 
reparative process is slow, 
and may be complicated and 
delayed by infection of the surrounding skin, gangrene, phagedena, etc. 
The ulceration may furthermore extend deeply, involving the underlying 
muscles and bones. Necrosis of the tibia, skull, and other bones follows 
at times a chronic gummatous ulceration. Deformity and contraction 
may result from deep destruction of tissue about the joints, the lip, or 
the eyelids. A thickening of the lower extremities, face, and elsewhere, 
allied to elephantiasis, has followed the destructive process. 
The subcutaneous gumma is generally a single growth : a group of 
half a dozen or more may be seen, however, which forms a characteristic 
picture when the stage of ulceration begins. The cicatrices are depressed, 
circular, white, with a pigmented margin, and may be adherent to the 
bone or subcutaneous tissue. A group of such scars would suggest the 
nature of the affection which produced them, while a single cicatrix 
might not be at all characteristic. 
Gummata are the most important syphilitic neoplasms from a surgical 
standpoint, as they frequently occur without other symptoms of syphilis 
and closely simulate other conditions. They have been mistaken for 
abscesses, sarcomata, lipomata of the subcutaneous tissue, for malignant 
disease of the tongue, the muscles, the breast, etc., and for tuberculosis 
of the bones, testicle, and other organs. Deep-seated nodules of the 
subcutaneous tissue are sometimes seen in scrofulous subjects, which 
Fig. 68. 
An ulcerating gumma of the leg. 204 
SURGICAL DISEASES. 
adhere to the skin, ulcerate, and present almost identical features with 
the syphilitic affection. They are usually symmetrical and heal with 
scarring, or, if atrophy takes place without ulceration, the loss of tissue 
may not be pronounced. 
These scrofulous gummaici, or erytheme indure des scrofuleux, occur 
most frequently in young girls. In a case recently under my observa- 
tion the administration cf the iodides caused the nodules to break down 
more rapidly and the ulceration to extend. They healed under local 
antiseptic applications and cod-liver oil internally. 
The chronic ulcer of the leg in subjects with varicose veins differs 
from the gummatous ulcer in its more frequent localization on the lower 
part of the leg, its chronic course, and in the absence of any feature 
suggesting syphilis. Syphilitic ulcers occurring in such patients at times 
lose all their surrounding infiltration and are converted into simple 
ulcers. 
Ulcers following localized gangrene due to obliterative endarteritis, 
gangrene of the extremities necessitating amputation, and the symmet- 
rical form of gangrene of the extremities—Raynaud’s disease—have 
been observed to develop during the course of syphilis. 
Pathological Anatomy of the Syphilitic Inflammation.— 
An implication of the blood-vessels is met with in all stages of the 
disease. The connective-tissue elements of the vessel, as well as the 
intima, are the seat of a proliferative inflammation which often leads to 
its occlusion. 
Fig. 69 (a photograph of a section from a secondary papule) shows a fibrosis 
and leucocytic infiltration of the vessel’s coats. The inflammatory cells which are 
at first confined to the immediate vicinity of the blood-vessel soon become general- 
ized. These cells usually undergo necrosis and are absorbed. The degeneration 
begins in the oldest part or centre of the lesion, while an active cell-growth takes 
place at the periphery. This method of involution and evolution of the infiltra- 
tion explains the ringed and serpiginous outlines which many eruptions assume. 
Fig. 69. 
Fig. 70. 
Thickening and infiltration of the walls of a 
vessel in a secondary papule: a thrombus 
has formed in the lumen of the vessel 
(X 400). 
From a syphilitic orchitis, showing the devel- 
opment of connective tissue between the 
dilated tubules: the tubules are destroyed 
in other parts of the testicle (X 200). 
The necrosis of the cells is more pronounced in certain types of eruption than 
in others. In the pustular lesions it takes place so rapidly that frequently a typical SYPHILIS. 
205 
papule does not form. In both the initial lesion and in the non-suppurative syph- 
ilide the cell-degeneration can be distinctly seen in the microscopic sections. In 
these lesions, as well as in syphilis in general, there is little tendency on the part 
of the newly-formed cells to organize into permanent connective tissue. 
An exception to this rule is found in certain visceral affections due to syphilis 
where connective-tissue growth occurs, either as a result of the vascular changes 
in the parts or directly from the action on the cells of the specific virus. 
It follows, too, on gummatous deposits in the liver, the lungs, the testicle (Fig. 
70), and other organs, causing pressure on and destruction of the implicated tissue. 
The fibrous tissue which surrounds gummata of the skin and subcutaneous tissue 
does not show the same tendency to spread as a similar condition in the viscera or 
nervous system. 
In congenital syphilis both the liver and spleen are very often enlarged from an 
infiltrating growth of connective tissue. The first changes consist of a small-celled 
deposit about the branches of the hepatic artery or portal canals, which becomes 
later more generalized and organizes into connective tissue or degenerates into 
miliary gummata. As the greater part of the arterial blood in the foetal circula- 
tion passes directly through the liver, it can be easily understood that when this 
blood is charged with the toxines or bacteria of syphilis the first and most pro- 
nounced effect may be manifested on this organ. 
Histology of the Gumma.—These neoplasms begin as small 
round-celled infiltrations in the connective tissue with a tendency to 
peripheral extension. Giant cells may be found in the advancing mar- 
gin. The centre of the gumma undergoes a necrosis which involves 
not only the recent infiltration, but the connective tissue of the part as 
well, leading to a permanent destruction of the implicated tissue. 
Fig. 71. 
Fra. 72. 
Section through a miliary gumma of the 
skin, showing central necrosis in an 
early stage ( X 80). 
Gumma of the subcutaneous tissue: 
advanced stage of necrosis (X 80). 
Fig. 71 illustrates an early stage of a miliary gumma of the skin. 
In the centre of the photograph an amorphous mass of connective tissue 
is shown, containing a few nuclei and leucocytes. Surrounding the 
degenerated centre a marked cell-infiltration is present which extends 
for some distance into the surrounding tissue. In other cases the line 
of demarcation is more sharply defined. With greater amplification the 
blood-vessels in the necrotic area are found to be occluded, and those in 
the surrounding tissue are involved in a manner similar to the vessels 
in the earlier syphilides. 206 
SURGICAL DISEASES. 
The blood-vessels of the gumma are not so numerous, nor do they 
play so important a role, a sin the early processes. The characteristic 
pathological feature of the gumma consists in a degeneration of the con- 
nective tissue, of a hyaline and fatty character, which may be expelled 
or dry into a cheesy mass. 
In Fig. 72 a later stage of gumma of the subcutaneous tissue is 
shown, in which the cellular tissue has been converted into an amorph- 
ous mass containing granular matter intermingled with leucocytes and 
small round cells. Necrosis in the gumma begins in the connective 
tissue, in the sclerosis, and, in the early lesions, in the newly-formed cells. 
In the viscera the contraction of a cavity resulting from a disinte- 
grated gumma results in considerable deformity of the implicated organ ; 
and in the central nervous system, where loss of tissue is of vastly more 
importance than in the skin, it may produce consequences which are 
irreparable. 
Syphilis of the Mucous Membranes.—Most of the eruptions 
which are seen on the skin may be found on the mucous surfaces, their 
appearances being altered by the local heat, moisture, and irritation to 
which they are subjected. A sharply-defined erythema of the fauces 
and soft palate usually accompanies the macular eruption. A syphilitic 
vaginitis and urethritis have been noted. It is quite probable that 
other mucous membranes, which cannot be inspected, are also the seat 
of similar catarrhal inflammations. 
Mucous patches or plaques, which represent the cutaneous papule, 
frequently occur on the genitals of women before the outbreak of the 
eruption on the skin, their development being favored by local heat and 
moisture. In this locality and where similar conditions are present, as 
about the anus, beneath the breast, at the angle of the mouth, etc., the 
papule becomes abraded, hypertrophied, or is covered by a grayish- 
white membrane, and at times ulcerates. These vegetating hypertrophic 
and other abraded papules in such places are called condylomata lata, to 
distinguish them from the pointed warts, or condylomata acuminata, 
which are not syphilitic. They secrete a thin, watery fluid and are a 
potent source of contagion. At the angle of the mouth they may be 
fissured and painful from the movement of the parts. 
Mucous plaques in the mouth arise from the modified papule, and 
exist in the papulo-erosive, the papulo-hypertrophic, and the papulo- 
ulcerative forms. The epithelial covering of the lesions is macerated 
and assumes a grayish-white or opaline appearance. The patches may 
vary in size, from a line or two to half an inch or more in diameter, and 
are slightly elevated above the surface. The edge of the tongue and 
inner side of the lip are favorite sites for them. They show a marked 
tendency to recur after healing, especially in smokers, and are often 
seen after other evidences of the disease have passed away. 
These late and recurring lesions lose their moist character, become 
quite smooth, shiny, of a bluish-white color, and may mark the begin- 
ning of the condition known as leukokeratosis. This affection of the 
mucous membrane of the tongue and buccal cavity not infrequently 
follows local syphilitic lesions which have been subjected to chronic 
irritation. It also occurs in individuals who have never had syphilis 
and are not smokers. It is not influenced by antisyphilitic remedies, SYPHILIS. 
207 
and must be regarded as the result of the disease rather than as syphil- 
itic per se. 
Leucokeratosis appears as circumscribed or diffuse smooth patches 
of a bluish-gray color over the tongue and on the mucous membrane of 
the cheek, extending backward in radiating lines or bands from the angle 
of the mouth. The epithelium covering the patches becomes thickened, 
fissured, and may be the seat of an epithelioma. Its surgical interest 
depends on the frequency with which it is followed by this malignant 
growth. 
Ulcerative lesions of the tongue or any part of the buccal cavity 
may follow disintegration of the papule, the nodular, or gummatous 
deposits. Such ulcerations sometimes spread at their margins, and may 
assume the outlines of the corresponding cutaneous eruptions. 
Gummata of the tongue begin as single or multiple, deep-seated, 
pea-sized, or larger tumors, over which the mucous membrane may be 
quite normal. These gummata develop slowly, without pain, and may 
reach the size of a pigeon’s egg before undergoing resolution or break- 
ing down. When they ulcerate a small opening appears over their 
central portion, which rapidly enlarges to an abscess-cavity. 
The differential diagnosis between epithelioma and ulcerating gumma 
is not always easy. In general terms, it may be stated that cancer is 
usually single, while the syphilitic neoplasm is often multiple. The 
ulceration in cancer is superficial, painful, bleeds easily, discharges 
freely, and is often the seat of papillary outgrowths ; its edges are more 
elevated and the induration about the ulcer more pronounced. 
The communicating lymph-nodes are soon implicated in the cancer- 
ous disease, while they are absent after the late specific neoplasm. An 
epithelioma may develop on a gummatous ulceration. In such a case a 
differential diagnosis is at times only possible after a microscopic exam- 
ination. 
Interstitial Glossitis.—In late syphilis, as a result of an interstitial 
sclerosis involving the muscular structure, a part or the whole of the 
tongue becomes greatly hypertrophied. Later, from contraction of the 
fibrous tissue, the tongue grows smaller, its mucous membrane becomes 
smooth, deep furrows form over the tongue which cannot be effaced by 
stretching, and the organ is harder and less movable than normal. A 
permanent deformity of the tongue results which is little influenced by 
treatment. 
Hereditary Syphilis. 
Syphilis may be transmitted by the mother through the infected ovum ; 
by the father, through the infected spermatozoon ; or by both parents. A 
mother who acquires syphilis after impregnation has taken place may 
transmit the disease to the foetus through the utero-placental circulation. 
The later such infection takes place after conception the less probability 
is there that the child will be affected. When transmission takes place 
under the last condition—utero-placental infection—the placenta is found 
to be diseased, and no longer acts as a filter to retain the hypothetical 
microbe. A child born from a mother who is infected with syphilis in 
the late months of her pregnancy may be healthy, but is immune to sub- 
sequent infection, as are other healthy children of syphilitic parents 208 
SURGICAL DISEASES. 
(Profeta’s law). Such a child may be delicate, ansemic, and have little 
resisting power to other infectious diseases, or may develop a late hered- 
itary syphilis. A healthy mother who gives birth to a syphilitic child 
from the father may be infected with the disease through the utero-pla- 
cental circulation : she may acquire a modified form of the disease, which 
manifests itself in cachexia, impairment of the general health, or by late 
syphilitic lesions; she may remain healthy with an acquired immunity 
to subsequent infection (Colles-Baumes’ law). When pregnancy occurs 
with recent syphilis in one or both parents, it results in the death and pre- 
mature delivery of the foetus ; the birth at term of a dead child ; a living 
child with the disease in an active stage; or of one in which the disease 
does not manifest itself for several weeks to two or three months after 
birth. Either parent may, in exceptional instances, transmit the disease 
after healthy children have been born. The longer the time between 
infection and impregnation, however, the less chance there is of transmit- 
ting the disease by inheritance, and the milder the disease when so con- 
veyed. The infectiousness of the virus is generally weakened by treat- 
ment and time, but no one can say when it ceases. 
The character of the mother’s infection from a syphilitic foetus, and of the child’s 
infection when the mother acquires the disease after impregnation, probably depends 
on the occurrence of pathological changes in the placenta. If the placenta is dis- 
eased and its power of filtration destroyed, the micro-organisms themselves may 
pass from child to mother and from mother to child, giving rise in both cases to 
active syphilis. If the placenta is not diseased, it permits the passage of the 
soluble toxines alone, and a modified form of the disease or a partial or complete 
immunity to subsequent infection results (Finger, Yon During). 
As the microbic origin of syphilis has not been established, these statements 
are largely theoretical, but they explain in a satisfactory manner the phenomena 
of hereditary and placental syphilis. 
The prognosis in congenital syphilis is much more grave than in 
acquired. The greater number of children born with the active disease 
die soon after birth. When its symptoms are delayed until the first or 
second month, if the nutrition is not bad, recovery generally takes place 
under proper treatment. From one-third to one-half of all cases die 
before reaching adult life. 
Symptoms.—The early symptoms of congenital syphilis appear in 
the majority of cases within the first three months, never later than the 
fifth month. Nearly half the cases present some sign of the disease 
within the first month. If no evidence of the disease is present during 
the first six months, the child, as a rule, remains well, or at most develops 
a form of late hereditary syphilis. 
Syphilitic children are poorly nourished, and remain deficient in both 
their physical and mental development. They have little resisting power 
to other disease, and not infrequently acquire tuberculosis, rachitis, or 
other disorders of nutrition. 
Nasal catarrh—snuffles—from a specific affection of the mucous membrane of the 
nose, is one of the most common of the first symptoms of the disease: this is fol- 
lowed or accompanied by a modified erythematous rash, of a patchy character, 
over the abdomen, about the anus or thighs—by mucous patches and fissures at the 
angles of the mouth or about other apertures. A generalized erythematous, pap- 
ular, or a mixed eruption is at times present. On the palmar and plantar surfaces, 
occasionally on other parts of the integument, the eruption assumes a bullous or 
pustular character. This so-called pemphigus syphiliticus develops because of the SYPHILIS. 
209 
delicate character of the epidermis over the specific infiltration. The papules 
about the anus and mouth readily break down and form superficial ulcers. 
Papulosquamous eruptions may be found localized on the face, the extremities, 
the trunk, or generalized. Later in life the nodular or gummatous syphilide may 
be met with, which presents the same appearance as in the acquired disease. 
A frequent and characteristic affection of the long bones, known as 
osteochondritis syphilitica, in some cases closely resembling rachitis, occurs 
early in hereditary syphilis. A swelling takes place at the junction of 
the epiphysis and diaphysis which may resolve under treatment, or in 
severe cases ulcerate with extrusion of the diseased epiphysis. Bony 
union may take place between the epiphysis and diaphysis, or abnormal 
ossification follow, which can result in shortening or deformity. Par- 
rot’s opinion that rickets was always due to hereditary syphilis is not 
now accepted. 
Circumscribed or diffuse thickenings of the bones of the skull, espe- 
cially the frontal and parietal bones, combined with atrophy of the bone- 
substance in places, is common in congenital syphilis. 
An osteitis and periostitis of the phalanges—dactylitis syphilitica— 
occurs in both hereditary and acquired syphilis. 
In addition to the interstitial changes in the liver and spleen, the lungs 
may be the seat of multiple gummata or of connective-tissue growths 
which may involve a part or the entire lung. This white hepatization is 
harder than normal lung-tissue and contains no air. It may develop 
after the cutaneous lesions have passed away and yield to treatment, or 
be combined in later years with tuberculosis. 
Hutchinson first called attention to a deformity of the upper central 
incisor teeth of the second set which he looked upon as diagnostic of hered- 
itary syphilis. When cut, these teeth are short, narrow, and thin. After 
a time a notch is formed by the breaking away of a crescentic portion 
from their edges, which is permanent for some years. The appearance 
described is often absent in syphilitic patients, or may result from other 
causes. 
Sudden deafness without pain or purulent discharge in a young per- 
son points to hereditary syphilis (Hutchinson). When deafness, inter- 
stitial keratitis, and the notched teeth are present in the same patient, the 
diagnosis of congenital syphilis is looked upon as positive. 
Treatment.—Syphilis in healthy individuals of early adult life is, 
in the majority of cases, a benign affection, often disappearing without 
treatment, and producing little if any impairment of the general health. 
Unfortunately, we have no certain means of determining when the dis- 
ease is cured, or of foretelling the cases that will prove mild and of 
short duration, and those that may involve important organs and 
endanger the future health, or even the life, of the patient. 
It is, therefore, of the greatest importance to explain to one suffering 
with the disease the necessity of systematic and prolonged treatment, 
not only during an active outbreak of symptoms, but during the latent 
periods as well. 
When any doubt exists regarding the character of the primary sore, 
treatment should not be begun until the appearance of the first cutaneous 
eruption. The future course of the affection is probably not at all 
influenced by such delay, and both the surgeon and patient are assured 210 
SURGICAL DISEASES. 
of the certain existence of syphilis, and both are more active in carry- 
ing out a prolonged treatment than if a doubt exists regarding the 
diagnosis. 
The presence of a sclerosis on extragenital parts or the early occur- 
rence of severe general symptoms during the second incubation-period 
may be indications for the use of mercury before the characteristic rash 
has developed. Many surgeons who have had a wide experience with 
the disease do not hesitate to begin the use of mercury when a character- 
istic chancre and its accompanying adenopathy are present. 
Before the use of mercury is begun the patient should consult a dentist and 
have the teeth put in good condition. If all cavities are filled and the tartar 
removed from the teeth, larger doses of mercury can he taken with less liability to 
salivation. 
Alcohol in all forms should be 'prohibited unless some special indica- 
tion may arise for its use. Smoking should not be allowed, as it is apt 
to irritate mucous patches in the mouth or throat and to determine suc- 
cessive outbreaks of such lesions. Syphilitic mucous patches irritated 
by tobacco-smoke terminate at times in leucokeratosis and epithelioma. 
Attention to the ordinary laws of hygiene should be insisted on, and 
every means employed to preserve the patient’s health. Iron, tonics, 
cod-liver-oil, etc. may at times be indicated in conditions which arise 
from syphilis, as well as from other causes. They possess no specific 
action on the syphilitic virus, however, and are sometimes employed for 
an anaemia which mercury or the iodides can only control. 
The contagious character of the syphilitic secretions and discharges 
and the necessity of great care in the family and other intercourse 
should be explained in detail to the patient. 
If marriage takes place during the contagious stage of the affection, 
or if the disease develops after marriage, the patient must be informed 
of the danger to the wife and offspring which will follow the advent of 
pregnancy. 
The two specific remedies which we possess are mercury and iodine, 
the latter usually given as potassium iodide. Certain vegetable reme- 
dies, like sarsaparilla and guaiacum, are occasionally used as auxiliaries. 
Mercury exerts a pronounced specific influence over the local and consti- 
tutional manifestations of the primary and secondary stages, and it is 
not without curative effect in the later stages. 
The potassium iodide causes the rapid disappearance of local lesions 
and general symptoms in the tertiary stage. It is useful in combination 
with mercury when early pustular and ulcerative lesions occur, and in 
the late secondary and intermediate stages of the disease. 
Mercury alone is the remedy with which to begin the treatment of 
syphilis. It may be given by the stomach, by inunction, by hypodermic 
injection, or by fumigation. The most convenient and generally employed 
method is by the stomach, and in the majority of eases it is not neces- 
sary to resort to other means of introducing it into the system. It 
should be given in sufficient doses to exert a prompt effect on the dis- 
ease, and yet care must be observed to avoid salivation and diarrhoea. 
A persistent diarrhoea weakens the patient, impairs the appetite, and causes a 
too rapid elimination of the drug, so that the specific influence on the disease is SYPHILIS. 
211 
prevented. Salivation is injurious, necessitates an interruption of the treatment, 
and is apt to recur when once allowed to become severe. 
There is little uniformity in text-books regarding the best preparation of mer- 
cury or the length of time it should he given. It is well to have in mind a number 
of preparations, as individuals differ in their susceptibility to the various mercu- 
rials. Pil. hydrarg. in doses of 2 to 4 grains, t. i. d., or hydrarg. cum creta in the 
same doses, may be given continuously for from four to six months. If diarrhoea 
and pain result, small doses of opium (gr. J-J) may be added to one or two of the 
daily doses of mercury for a short time or until the tendency to diarrhoea ceases. 
At the same time, the use of fruits and acids should be limited or prohibited; 
later on, their use may be resumed. 
The condition of the mouth must be carefully watched, and as soon 
as the gums become tender and swollen or show a disposition to bleed 
the administration of mercury must be stopped for a few days, or, better, 
the number of doses or the quantity given reduced. 
A wash of alum and potassium chlorate, ad. 3j, to a pint of water, should be 
frequently used to prevent and relieve this condition of the mouth. Saline laxa- 
tives, administered during the existence of a mercurial sore month, hasten its cure 
by eliminating the drug more rapidly through the bowels. 
In pronounced ptyalism, with swollen and spongy gums and superficial abra- 
sions of the mouth, mercury should be promptly discontinued. The flow of saliva 
in such cases is limited by atropine, in doses of -gjjjj of a grain every four hours. 
The mercurial stomatitis may be quickly relieved by carefully painting the gums 
with a 2 to 5 per cent, watery solution of chromic acid once a day, in addition to 
the other measures mentioned, care being taken that the mouth is thoroughly 
rinsed with water thereafter. 
The protoiodide of mercury, in pill or tablet form, given in doses of 
gr. to gr. 1, t. i. d., has had a wide popularity and is largely used as a 
routine treatment of secondary syphilis. It is not as efficient as the 
other preparations mentioned, and is apt to give rise to gastro-intestinal 
irritation when used in larger doses. 
The tannate of mercury, in doses of from to 1 grain, t. i. d., is an 
active drug, and is said to produce less stomach and bowel disturbance 
than the protoiodide. 
For the relapsing eruptions of the late secondary stage it is some- 
times of advantage to give the biniodide of mercury in doses of to 
of a grain dissolved in an excess of iodide of potassium. The following 
formula may be employed : 
Id. Hydrarg. biniodid., gr. j-ij ; 
Potass, ioclid., 3ss; 
Aquae dest., 3iij.—M. 
Sig. 3j, well diluted, an hour after eating. 
When early pustular and ulcerative lesions are slow in healing the 
quantity of the iodide in the last prescription may be increased. 
During the first six months the use of one or another of the prepara- 
tions mentioned should be kept up pretty constantly. At the end of 
this time, if no symptoms of the disease are present, medication may be 
discontinued for a month or six weeks, and then resumed for three or 
four months. A longer period of rest may then be permitted, followed 
by a third course of mercury or mercury combined with the iodide. 
If the patient’s health keep good and no indications arise against its 
use, a fourth or fifth mercurial course may be advised. 212 
SURGICAL DISEASES. 
Inunction Treatment.—This method has the great advantage of 
not so readily disturbing the digestion, and when, for any reason, the 
internal use of mercury is not well borne inunctions should be advised. 
It is the most efficient and rapid method in causing the symptoms to 
disappear. It is disagreeable, uncleanly, cannot readily be concealed, 
and requires considerable time to be properly carried out. 
At health-resorts, like Hot Springs in Arkansas or Aachen in Ger- 
many, where experienced rubbers can be employed, it is the method 
which is almost exclusively used in early syphilis. 
The patient should be directed to rub one drachm of the unguentnm 
hydrargyri each day, for a period of twenty to thirty minutes, over a 
limited portion of the integument until the body has been completely 
covered. The legs may be chosen for the first day, the thighs the second, 
the back the third, the arms the fourth, and the chest and abdomen for 
the fifth day. At the end of this time the same course should be 
repeated. From thirty to fifty inunctions may be given, followed by a 
period of rest for a month or six weeks. At the end of this time 
another inunction-treatment should be employed or mercury given by 
the stomach. 
In syphilis of the viscera or nervous system the inunctions can be 
advantageously combined with the administration of the iodides. 
Hypodermic Treatment.—Of the many soluble and unsoluble salts 
of mercury which have been advocated for hypodermic and intramus- 
cular injections, corrosive sublimate is probably the most efficient and 
least dangerous. The following formula and method are given by 
Cooper1 for its employment: 
It. Hydrarg. bichlor., gr. xxxij ; 
Ammonii chlor., gr. xvj ; 
Aquae desk, ffij.—M. 
Sig. Ten minims to be used for one injection. 
The injection should be given through a platino-iridium needle pre- 
viously sterilized. The gluteal region is the most convenient site to be 
chosen. The point of the needle is inserted into the gluteus maximus 
muscle and the solution slowly injected. One injection a week is given 
for six or seven weeks, and then at longer intervals. By means of these 
intramuscular injections a sure and rapid mercurialization of the patient 
is effected, and in certain emergencies they are to be recommended. As 
a routine method of treatment, however, they cannot be advised, and 
few patients will submit to them. 
Local treatment is often necessary for certain lesions of the secondary 
and tertiary stages. For the condylomata lata about the genitals, anus, 
and other regions the free use of calomel is the most efficient agent. 
Mucous patches on the lips and mouth should be cauterized with the 
nitrate-of-silver pencil or a chromic-acid solution (gr. xx—xxx to aq. sj). 
Ulcerations in the throat maybe sprayed with a solution of bichloride 
of mercury (gr. ss—j to aq. sj). 
Localized, eruptions disappear more rapidly after the application of an ointment 
containing mercury. When on the face, a dilute ammoniated mercury or calomel 
1 Syphilis, Alfred Cooper, 2d ed., 1895. SYPHILIS. 
213 
ointment should be employed to avoid the stain left by the blue ointment. Specific 
infiltrations of the tertiary stage are favorably affected by the local use of mercu- 
rial ointments or plasters. Mercury is contraindicated in syphilis when tuberculosis 
exists, in nephritis not due to syphilis, and in pronounced anaemia from other 
causes. Pregnancy is an indication for its vigorous employment. 
Congenital syphilis should be treated by hydrarg. cum creta, gr. j, 
t. i. d., or, better, by the use of inunctions of blue ointment, gr. xx, 
once a day, thoroughly rubbed into the body. The ointment should be 
diluted with vaselin, to prevent its irritant effect on the delicate skin 
of the infant. 
Indications for the Use of the Iodides.—The iodides are frequently 
given between courses of mercury or after the completion of the mer- 
curial treatment, for the purpose of rendering soluble and eliminating 
the mercury which may remain in the tissues. Their most striking effects 
are produced in the late stages of the disease in causing the rapid disap- 
pearance of gummata, and other specific infiltrations, and in the healing 
of syphilitic ulceration of the skin and mucous membranes. No other 
therapeutic agent can produce so marked and rapid effects as the iodides 
in late syphilitic neoplasms. 
Iodide of potassium is the preparation generally used. It is well to prescribe 
it in the following manner: 
Jti. Potass, iodidi, .yj ; 
Aquae, 3 ij.—M. 
SlG. Take twenty drops in a tumbler of water after each meal. To be gradually 
increased. The initial dose need not be larger than 10 grains, three times 
a day; it may be increased by adding two drops to each dose until the daily 
quantity taken amounts to 100 grains or more. When the symptoms begin 
to yield it is not necessary to increase the dose. 
In gummatous ulcerations of the mucous membranes and in visceral syphilis, 
where a rapid effect is desired, the initial dose may be larger than that indicated, 
and the quantity increased more rapidly. 
Certain persons are very sensitive to the iodides, small doses pro- 
ducing catarrhal symptoms in the nose, throat, and bronchial tubes. 
Tolerance of the drug in such patients may generally be acquired bv 
beginning with minute doses and slowly increasing the amount taken. 
Papular, pustulous, bulbous, erythematous, nodular, and purpuric erup- 
tions are at times produced by the ingestion of the iodides. Certain of 
these eruptions may be confounded with syphilitic lesions. 
It is generally stated that the iodides only relieve the symptoms in 
late syphilis, and have no direct curative effect. On this account a 
course of the iodides is followed by the prolonged use of mercury. 
We have no proof that such is the case. 
In certain chronic ulcerations of the skin and mucous membranes in cachectic 
subjects who prove rebellious to the iodides and mercury large doses of the decoc- 
tion of sarsaparilla or Zittman’s decoction sometimes exert a beneficial influence 
in starting the healing process. The tissues may become habituated to the pro- 
longed use of mercury and the iodides, and fail to respond in a prompt manner to 
their use. 
Cachectic subjects of syphilis, who do not do well at home, are sometimes 
promptly benefited by a visit to Hot Springs in Arkansas or Aachen, Germany. 
The use of the hot tub- and vapor-baths employed in these places increases tissue- 
change, enhances the effect of the remedies, and improves the general health. CHAPTER XI. 
GONORRHOEA AND ITS SEQUELA!. 
By W. T. Belfield, M. D. 
Etiology.— Gonorrhoea is an infection of human tissues by a specific 
bacterium, the micrococcus or gonococcus of Neisser, reinforced by one or 
more varieties of the common pus-bacteria; practically, it is therefore a 
mixed infection. 
The gonococcus is not only an obligate parasite—never found except 
in animal tissues—but it is also a parasite of human tissues only, other 
animals, so far as known, being an unfavorable soil for its growth. 
Hence it is acquired only by con- 
tact, direct or indirect, with a suf- 
ferer from the disease. The com- 
monest seat of the infection is the 
genito-urinary tract of male and fe- 
male, and it is hence usually trans- 
mitted by sexual contact. Yet cer- 
tain other mucous membranes are 
susceptible to the infection, and it is 
occasionally carried indirectly—by 
soiled fingers, towels, and syringes, 
or by unnatural intercourse—to the 
mucous membrane of the eye and 
rectum, even of the mouth and nose. 
While all accessible mucous mem- 
branes may be infested by the gonococ- 
cus, yet those lined with cylindrical epi- 
thelium seem to afford more favorable 
conditions for the parasite than do the 
flat-celled membranes; and the disease persists more obstinately in the former 
than in the latter—in the uterine cervix, for example, longer than in the vagina. 
While the infection always begins on a mucous surface, it does not 
always remain limited to these: it may spread by continuity to the sub- 
mucous tissues, by the lymph-stream to the nearest lymph-nodes; it 
may enter the blood-current and produce metastatic infections in distant 
structures—serous membranes and fibrous tissues of joints, bursae, ten- 
don- and muscle-sheaths, pleura, peritoneum, meninges, peri- and en- 
docardium—constituting a veritable pyaemia analogous to that which 
follows wound-infections. 
Mon rid Anatomy.—The gonococci implanted during intercourse 
within the meatus multiply rapidly, and penetrate the epithelium and 
the subepithelial structures, their presence and products causing that 
reaction of the tissues which is called inflammation, and is manifested by 
Fig. 73. 
Gonococci in fresh gonorrhoeal pus; X 1000 
(Frankel and Pfeiffer). GONORRHCEA AND ITS SEQUELS. 
215 
swelling, reddening, and desquamation of the urethra. Through the 
gap in the protecting epithelium thus made by the gonococci the pus- 
microbes—which easily gain access from without, and are indeed often 
present in the normal urethra—find a favorable soil and reinforce the 
specific bacteria. The rapidly-multiplying parasites spread along the 
mucous membrane and submucous lymph-spaces. 
The extent of the invasion varies: in a minority of cases it is limited to the 
penile urethra; in a decided majority it continues through the deep urethra; 
in a large number it proceeds farther, by way of the ejaculatory ducts, into the 
dilated extremity of the vas deferens—the ampulla—and into the seminal vesicle; 
in a considerable number it is further propagated along the vas deferens to the 
epididymis, thus involving the entire genital canal. 
The urinary channel proper—that is, above the union with the seminal canals— 
commonly escapes, the infection ceasing at or about the urethro-vesical orifice. 
Sometimes, however, the trigone becomes involved, and occasionally the bacterial 
invasion and consequent inflammation ascend the ureters to the kidney-pelvis and 
even to the renal tubules. 
In the female also the extent of invasion varies: the vulva and urethra may 
alone be infected, though usually the cervix uteri is included j the vagina, paved 
with squamous epithelium, seems a less favorable soil, though inevitably contami- 
nated by the discharge from vulva and uterus. The infection often traverses the 
uterine body to the Fallopian tubes, and through these to the ovaries and sur- 
rounding peritoneum. 
The many follicles and pockets which line the genital canal of either 
sex are naturally included in the bacterial invasion: in the male, the 
numerous lacunae of the urethra, Cowper’s glands, the prostatic utricle 
and glands; in the female, the lacunae of the urethra and urethro-vag- 
inal septum and the vulvo-vaginal glands. 
This is a fact of great clinical importance, for long after the general 
surface has recovered its normal condition and the patient is apparently 
well, the gonorrhoeal infection may persist in some of the hidden pock- 
ets in quantity sufficient to infect a partner in the sexual act, and even, 
when favored by alcoholic or sexual excess, to reinfect the genital 
canal of the individual himself. 
The serous and fibrous structures which may become the seat of 
metastatic infection through the blood-current exhibit all grades of 
reaction, from serous hypersemia to purulent inflammation, the effect 
depending, in part at least, upon the varieties of bacteria concerned in 
the process. 
Diagnosis.—Until the discovery of the gonococcus in 1879 there 
was no distinctive feature by which a gonorrhoeal infection could be dis- 
tinguished from other purulent inflammation of the genital tract; hence 
there occurred many errors in diagnosis, and by consequence many false 
conclusions as to therapeutics. 
For years after Neisser’s discovery it was generally assumed that the gonococ- 
cus constituted an absolute diagnostic feature; that it was never found except in 
cases of infection; and that its presence even in small numbers constituted abso- 
lute evidence of such infection. In later years, however, it has been proven that 
a diplococcus, indistinguishable by any laboratory test from the gonococcus, is 
occasionally found in the normal urethra and vagina, as well as in certain purulent 
discharges, such as the vulvo-vaginitis of children, where gonorrhoeal infection is 
at least improbable. Whether this non-pathogenic organism is a distinct species 
of bacterium—a pseudo-gonococcus—or whether it is the gonococcus exhibiting, like 
the Klebs-Loffler bacillus of diphtheria, a wide range of virulence, are questions 
for the future to answer. But with our present knowledge we must admit that a 216 
SURGICAL DISEASES. 
diplococcus indistinguishable from that of Neisser may be present in small num- 
bers in discharges which are not gonorrhoeal, and hence that the microscope can- 
not in every case distinguish between gonorrhoeal and non-gonorrhoeal infections. 
When, however, a profuse purulent discharge presents large num- 
bers of gonococci enclosed in both pus and epithelial cells, we are war- 
ranted in a diagnosis of gonorrhoeal infection. In practice, it is only 
the slight, chronic gonorrhoeal discharges, containing but few gonococci, 
which can be confounded with the non-gonorrhoeal discharge containing 
the pseudo-gonococci; and since cases of chronic gonorrhoea or gleet are 
exceedingly numerous, and cases of non-gonorrhoeal urethritis exhibiting 
the pseudo-gonococci are quite rare, the detection of the characteristic dip- 
lococcus furnishes a very strong presumption of gonorrhoeal infection, 
even when the discharge is slight and the cocci few. 
The clinical distinction between gonorrhoea and other purulent inflammations 
of the genital tract is even less trustworthy: it is true that an acute urethritis, 
beginning from three to seven days after suspicious connection in one who has for 
a long time had no urethral disease may safely be pronounced gonorrhoea; but 
there are numerous cases of urethritis which do not conform to these conditions, 
and in which the clinical diagnosis can be only a probability. 
In practice, the differentiation of the gonorrhoeal from other purulent 
inflammations of the genital tract must often rest upon both clinical and 
microscopical evidence. We may divide all such inflammations in the 
male into four classes : 
1. Gonorrhoeal infection from without, marked clinically by an 
incubation of three to seven days (usually),, and a severe inflammatory 
reaction in a patient previously free from urethritis: the microscope 
shows an abundance of gonococci contained in both pus and epithelial 
cells. 
2. Gonorrhoeal infection from within (auto-infection, the “ bastard 
clapv of the older authors), marked clinically bv an incubation of six to 
twenty-four hours, and slight or no pain, in a patient with a history of 
uncured urethritis, as shown by slight gleety discharge, gumming of the 
meatus, or merely pus-threads in the urine ; the microscope shows gono- 
cocci, but less numerous than in the first class of cases. 
These two classes include over 90 per cent, of all cases of purulent 
urethritis in the male. 
3. Non-gonorrhceal infection from without, beginning within 
twenty-four hours after connection, with slight inflammatory reaction, 
in a patient previously free from urethritis: the microscope shows no 
gonococci, or at most a few, with an abundance of pus-bacteria. Such 
cases occur especially after excesses in alcohol and venery with a woman 
suffering from leucorrhoea, notably when at or near her menstrual 
period. 
4. Non-g-onorrhceal infection from within.—This may be an 
extension to the anterior urethra of an inflammation in the bladder or 
prostate due to vesical calculus, enlarged prostate, gout, or other cause. 
It is not rare in elderly men suffering from these complaints, and is of 
mild degree ; no gonococci are visible. 
In this category one must classify cases of urethritis from injury, 
as by urethral instruments ; from caustic injections for the prevention of 
gonorrhoea, etc., in which the history plainly indicates the cause. The GOXORRIICEA AND ITS SEQUELS. 
217 
possibility that a mild urethritis following connection may be due to an 
urethral chancre should never be forgotten ; the diagnosis is made by 
inspecting the fossa navicularis. 
Conditions favoring- Infection.—It is certain that not every sexual 
act with an infected woman conveys the infection, for it is repeatedly 
observed that of several men who cohabit with the same woman in the 
same night, one will acquire, another escape, the disease. To this result 
doubtless several factors contribute : the natural susceptibility of different 
urethras must vary, some having greater natural immunity, some having 
acquired such immunity bv repeated infections with the gonococcus. 
M oreover, influences which depress the vitality of the urethral tissues, 
such as excessive drinking, favor infection ; and prolonged sexual excite- 
ment, by which the naturally acid fluids of the urethra are rendered alka- 
line, must have the same effect, because the gonococcus grows well in 
alkaline, poorly in acid, media. A profuse and acrid leucorrhoea of the 
female, especially when heightened by the congestion incident to men- 
struation, must similarly favor the transfer of infectious material. 
The prevention of g-onorrhceal infection after exposure is impos- 
sible. Thorough washing of the parts and immediate urination doubt- 
less contribute to that end, but are often ineffectual. 
The use of caustic injections after the act is to be condemned: they may be 
relied upon not to remove nor destroy the infectious material, but to irritate the 
epithelial lining of the urethra, and thus pave the way for bacterial growth. 
The popular belief that a true gonorrhoea can be acquired from a non-gonor- 
rhoeal leucorrhoea or menstrual discharge, or from a “strain,” is erroneous; while 
it is doubtless true that a simple and brief urethritis can be so acquired. Gonor- 
rhoea in a patient proves the pre-existence of the disease in another person and the 
transfer of infected matter. 
The disease is occasionally transferred without sexual contact, by means 
of infected towels, syringes, urethral instruments, etc. The patient 
should be warned to protect his own eyes, as well as the persons of others, 
from such accident; and the physician should be most careful to sterilize 
all urethral and vaginal instruments after each use of them, particularly 
upon a case of even suspected gonorrhoea. 
Dr. Wishard personally observed the following instance of innocently-acquired 
gonorrhoea in a virgin: A lady, having contracted the disease from her husband, 
used a syringe for vaginal injections; an unmarried sister, living in the house, used 
the same syringe on her own person for the relief of constipation, and thus infected 
the rectum with gonorrhoea; the purulent discharge from the anus infected the 
vulva, vagina, and urethra. 
Clinical History.—During a period of incubation varying from 
two to fourteen (usually three to five) days after exposure no evidence 
of disease attracts the patient’s attention: then an itching sensation, a 
swelling, reddening, and gumming of the meatus, and a smarting pain 
during urination, are observed, soon followed by the appearance of thick 
pus ; these features become rapidly intensified, until in a few days the 
severe inflammation extending along the penile urethra is manifested by 
great swelling of the meatus, oedema of the prepuce, redness, often 
excoriation of the glans, heat and soreness of the entire penis, and a 
constant discharge of thick yellow or greenish pus. During this period 
the passage of urine causes acute pain; the stream issuing from the 
meatus is small, twisted, or scattering. As the inflamed tissues sur- 218 
SURGICAL DISEASES. 
rounding the urethra are less distensible than normal, erections—which 
are apt to be frequent—are exceedingly painful and often distorted, the 
penis presenting a more or less sharp curve whose concavity is usually 
downward, sometimes also laterally : this is the condition called chordee. 
There is usually a slight rise of the body-temperature. Seminal emis- 
sions during sleep are increased in frequency. 
This condition persists, if untreated, for ten to fifteen days, when the 
symptoms gradually subside : the purulent discharge may persist for 
several weeks after pain and soreness have ceased. 
Such is the clinical history of gonorrhoea when limited to the penile 
urethra. Yet in a decided majority of cases the disease is not so limited, 
and other important clinical features are added. These have been gen- 
erally described as complications of gonorrhoea, but are really essential 
features of the disease, though no one occurs in every case, and some are 
seen in only a minority of cases. But it is an error—though formerly a 
prevalent one—to consider gonorrhoea a disease of the penile urethra, 
and its natural extension to deeper parts as complications. 
These extensions are designated bv the name of the tissue or organ 
invaded : the infection may attack the entire genital canal, the urinary 
tract, the peritoneum where contiguous to these, and the blood-current 
itself. These will be considered in natural sequence. 
Balanitis, an extension of the infection to the plans penis, often 
occurs in slight degree. In exceptional cases, especially where cleanli- 
ness is neglected or impossible because of phimosis, a severe infection 
of the glans and corona occurs, causing extensive erosions, even ulcera- 
tions. 
Folliculitis, extension of the infection to the lacunae and follicles 
branching off from the urethral canal, always occurs; but so long as 
the pus produced in these follicles is freely discharged into the urethra 
no distinct clinical phenomena are induced. If, however, the orifice 
becomes occluded, the follicle becomes distended with pus : when located 
near the fossa navicularis these distended follicles protrude on the exter- 
nal surface, on one or both sides of the frenum, as hard, tender nodules 
as large as buckshot. In a few days these usually soften, discharge 
externally, and heal spontaneously: sometimes they discharge internally 
into the urethra, and exceptionally in both directions, making a urinary 
fistula that it may be difficult to close. 
Periurethral Inflammation.—When, however, these inflamed and 
distended follicles are located behind the fossa, the course of events is 
not always so simple : while the follicle may discharge externally with- 
out complications, yet the inflammation may involve the periurethral 
tissues, making a hard, distinct tumor as large as a hazelnut. This may 
remain unchanged for months, or it may become the seat of a rapidlv- 
spreading suppuration: the pus sometimes empties into the urethral 
canal, sometimes rapidly infiltrates the spongy or cavernous bodies. In 
either case the urine may escape into the periurethral tissues, causing the 
so-called urinary infiltration: abscess and fistula, septic phlebitis, em- 
bolism, and pyaemia, are all possible unless incision and drainage of the 
infiltrated tissues be promptly made. 
These processes destroy more or less of the normal periurethral 
tissues: the cicatrix by which they are ultimately replaced may later GONORRHCEA AND ITS SEQUELS. 
219 
constitute a stubborn stricture, and even occasion a notable deflection of 
the penis from its normal straightness during erection. 
The clinical signs of diffuse periurethral inflammation are those of septic infec- 
tion in general: pain at the site of the inflamed follicle, at first dull, then acute 
and aggravated during urination and erection: diffuse suppuration and urinary- 
extravasation (the latter usually follows soon upon the former) cause throbbing 
pain, a dark-red oedema, chills, and high fever. 
Cowperitis is the designation given to the same process occurring in 
the two large follicles (glands of Cowper or Mery) which are situated 
between the layers of the triangular ligament in the perineum and open 
into the membranous urethra. It occurs after the tenth day of the dis- 
ease, and occasions a tense, painful swelling in the perineum, noticed 
especially by the patient when sitting. In all respects, except the 
anatomical surroundings, it is identical with folliculitis of the anterior 
urethra. 
Prostatitis.—The prostatic urethra is provided with thirty or more 
glands or follicles, besides the relatively large follicle termed the utricle, 
or masculine uterus. When the gonorrhoeal infection invades this portion 
of the urethra (causing the so-called deep urethritis), these numerous fol- 
licles are invaded by the gonococcus; and there may result a peri- 
urethral inflammation and suppuration, just as in the anterior urethra. 
This process is in this locality called prostatitis. Periurethral suppura- 
tion and infiltration of urine may occur, the pus and urine burrowing 
into the pelvic connective tissue or the perineum, and the abscess point- 
ing into the rectum, suprapubic space, or perineum. 
Septic infection from the prostatic urethra is especially prone to cause phle- 
bitis, peritonitis, and pyaemia. Fortunately, folliculitis of the deep urethra or 
prostatitis usually terminates by spontaneous evacuation of the pus into the 
urethral canal. 
Deep Urethritis.—In a majority of cases of gonorrhoea the infection 
extends in the second or third week through the membranous and pros- 
tatic urethra to the bladder. This extension is usually indicated by 
distinct symptoms which proceed from the irritation of the prostatic 
urethra. Normally, this portion of the urethra exhibits a triple func- 
tion: in it originates the impulse .to urinate; it is intimately concerned 
in erection and seminal ejaculation; and it is a sphincter of the bladder. 
Hence the disturbance of its tissues by the gonorrhoeal infection causes 
three notable symptoms : (1) increased frequency in the desire to urinate; 
(2) prolonged erections and frequent emissions ; and (3) marked difficulty 
in expelling the urine, sometimes amounting to complete retention, com- 
pelling the use of the catheter. A dull pain, a sense of heat and weight 
in the perineum, rectum, and suprapubic region, and a sharp pain at 
the end of urination and referred to the glans penis, accompany all 
but the mildest cases. The last urine evacuated is apt to be mixed with 
blood, varying in quantity from a few drops to a light hemorrhage. 
Ampullitis and Vesiculitis.—The extension of the inflammation to 
the dilated extremity of the vas deferens (ampulla) and the seminal 
vesicle occurs in a percentage of cases as yet imperfectly determined, 
but probably almost as often as deep urethritis; for the clinical distinc- 
tion between the latter and vesiculitis has not always been made. The 
chief symptoms marking the extension from the prostatic urethra to the 220 
S UR CICA L DISEA SES. 
seminal tubes are the pronounced heat and pain in the rectum and the 
large admixture of blood and pus with the seminal discharge. The 
examiner’s finger, introduced into the rectum, easily recognizes the 
swollen, tense, and tender vesicles above the prostate. 
Epididymitis and Orchitis.—The further extension of the gonor- 
rhoeal infection along the vas deferens finally involves the epididymis, 
and sometimes the tubides of the adjacent testicle itself. Epididymitis 
occurs in from 5 to 20 per cent, of cases of gonorrhoea, rarely appearing 
before the third week. The first symptoms noticed may be increased 
frequency of urination, then pain and tenderness either in the testicle 
or at the external inguinal ring. Sometimes a chill and fever usher in 
the local swelling; in a day or two the epididymis has become swollen, 
tender, and exceedingly painful, the skin covering it dark-red and 
cedematous : the testicle usually participates in the swelling and pain. 
All these symptoms begin to recede in four or five days, and subside in two 
weeks, except that hard, sensitive nodules may remain in the epididymis for many 
weeks, even months. In exceptional cases suppuration and local necrosis occur in 
the epididymis and testicle. 
Cystitis of gonorrhoeal origin is usually limited to the vicinity of 
the vesico-urethral orifice: many cases so called because of the frequency 
and pain in urination, are really instances of prostatitis and deep 
urethritis. 
Ureteritis, pyelitis, and suppurative nephritis are infrequent 
extensions of the gonorrhoeal infection : they are marked by chills, 
fever, and pain, referred to the region of the kidney, the course of the 
ureter, the testicle, and the thigh. An enlargement of the kidney is often 
perceptible. The pus passed with the urine is greatly augmented, and 
there is more albumen than the pus accounts for. 
Lymphangitis and Adenitis.—The lymphatics surrounding the 
urethra are always invaded by the gonorrhoeal bacteria, and some of the 
inguinal nodes are usually slightly swollen and sensitive; in the severer 
cases a lymphatic vessel along the dorsum of the penis is perceptible as 
a hard, sensitive cord leading to the inguinal nodes, which are distinctly 
swollen, and in exceptional instances suppurate {suppurating gonor- 
rhoeal bubo). 
CEdema of the prepuce is frequent in the first week of the urethri- 
tis, subsiding as the more acute symptoms lapse : sometimes the oedema 
is so great as to constitute a veritable phimosis, or, if the patient retracts 
the swollen foreskin, he may be unable to return it, presenting the con- 
dition called paraphimosis. The latter is an unpleasant complication, 
because the narrow orifice of the retracted prepuce so constricts the 
penis as to cause great oedema of the glans, and in occasional instances 
—fortunately, rare—extensive necrosis and sloughing in front of the 
constricting ring. Usually, however, this ring itself sloughs away, the 
strangulation of the glans is relieved, and the swelling gradually sub- 
sides. 
Post-gonorrhoeal arthritis, often miscalled gonorrhoeal rheuma- 
tism, occurs in only 2 or 3 per cent, of cases of gonorrhoea, and is 
caused by the infection of various tissues by means of the blood-current. 
It begins at any time, from three days to three months after urethral 
infection, many cases starting in the first month. It affects especially GONOBRHCEA AND ITS SEQUELS. 
221 
fibrous structures and serous membranes, and exhibits an acute variety— 
beginning with chill, fever, and local swelling—and a chronic form, 
which may be primary or a continuation of the acute. It attacks most 
frequently the knee-, ankle-, hip-, shoulder-, and elbow-joints and those 
of the fingers and toes; sometimes only one joint is affected, sometimes 
several are simultaneously or successively involved. The local inflam- 
mation lasts in acute cases two to three months, in chronic cases several 
years. 
Besides the joints, bursa and tendon-sheaths are often attacked, especially those 
of the legs, feet, and hands; the muscles of the neck, the conjunctiva, and iris 
also become the seat of the infection. The meninges, peri- and endocardium some- 
times participate in the disease, which is then apt to terminate fatally. 
The morbid anatomy presents nothing distinctive from lesions of the same 
structures due to other causes, except that the gonococcus is sometimes found in 
the inflammatory exudate, especially on serous surfaces. 
Pyaemia.—As the gonorrhoeal infection includes the pus-microbes as 
well as the gonococcus, we can understand that a real pyaemia, differing 
in no respect from that proceeding from a septic wound, may follow a 
gonorrhoeal urethritis. Such is really the case, though, fortunately, in 
rare instances. 
Treatment.—The rational treatment of gonorrhoea—the destruc- 
tion of the invading bacteria—is as yet undiscovered : it should be dis- 
tinctly understood that our treatment of the disease is only palliative, 
and that the infection may steadily advance and long persist in spite of 
any treatment. 
An enumeration of the numerous remedies and methods which have been from 
time to time recommended, and of the many specifics and sure-cures even now 
current, would fill this volume: only the measures sanctioned by large experience 
will be here mentioned. 
Anterior Urethritis.—The patient presenting himself with a recent 
gonorrhoea should be first carefully instructed as follows: He should 
scrupulously avoid constipation, bodily activity, alcohol, and sexual 
excitement; he should destroy or sterilize by boiling all clothes and 
handkerchiefs soiled by the discharge, and should wash his hands im- 
mediately after every contact with the infected parts or dressings; he 
should not protect his linen by inserting a wad of cotton under the fore- 
skin (as most Gentiles do), because the cotton dams up the pus in the 
urethra and spreads it over the glans penis ; he should indulge sparingly 
in meats, coffee, and tobacco, and should keep the horizontal position as 
much as possible. He should procure a gonorrhoea-bag—a cloth or 
rubber sack which encloses the penis and is secured by tapes around the 
waist—or make a substitute by sewing tapes to the toe of a stocking, 
and place some absorbent cotton in the bottom ; in this way the linen 
is protected, while the pus drains freely from the urethra. 
Medicinal treatment is internal and local; the former consists 
of—(1) Laxatives, especially calomel and salines; these are beneficial in 
all cases, and imperative when there is a tendency to constipation, which 
must be carefully avoided ; 
2. Balsams excreted by the kidneys, such as santal oil, freshly 
powdered cubebs, and copaiba. Of these pure santal oil is decidedly 
the most valuable. 222 
SURGICAL DISEASES. 
The oil of the shops is usually adulterated (costing two dollars a pound, while 
the pure oil costs eight dollars), and often disturbs both stomach and kidneys, as 
is shown by the gastric distress and belching on the one hand, and pain in the 
loins on the other—symptoms seldom caused by the best qualities of the oil. Good 
santal oil may be given in ten-minim capsules, beginning with six and increasing 
to sixteen per day within a week: the dose should be diminished or the remedy 
discontinued if gastric or renal distress becomes manifest. 
Freshly powdered cubebs, a teaspoonful every two to four hours, 
markedly lessens the amount of discharge, though frequently disturbing 
the stomach ; the oleoresin of copaiba, a ten-minim capsule six times a 
day, has a slighter influence upon the discharge, but a greater effect 
upon the stomach, and occasionally produces an annoying scarlet rash. 
Internal antiseptics, so called, such as salol, which when given by the mouth 
are excreted by the kidneys as carbolic and salicylic acids, etc., have failed to pro- 
duce the beneficial effect hoped from them, and have been abandoned, though 
there is still a lingering belief that boric acid, in doses of three to five grains four 
times daily, does exert a good influence. 
3. Diuretics.—Water, milk, potassium acetate and bitartrate are use- 
ful to dilute the urine and thereby diminish the irritation of the inflamed 
urethra by contact of this fluid. 
Internal medication may therefore be outlined as follows: calomel in 
quarter-grain doses, three to six a day for one or two days; for the 
next six days a half teaspoonful of potassium bitartrate and five grains 
of sodium phosphate in a glass of hot water, night and morning; after 
which the calomel may be repeated. Naturally, the size and frequency 
of these doses must be determined by the effect produced. 
Twenty minims of good santal oil or a teaspoonful of fresh cubebs 
may be given from four to eight times daily as the stomach permits. 
The local treatment of gonorrhoeal urethritis is exceedingly important: 
the ancient prejudice against it, based upon the ill effects of severe and 
caustic injections, does not hold against the later methods. 
Of all local remedies, hot water holds the first place, and cannot be 
used too freely nor too often : it should be applied to both the exterior 
and interior of the penis. This organ should be immersed, as often and 
as long as circumstances permit, in a glassful of water whose tempera- 
ture may be at first 100° F., and is gradually raised by the addition of 
hotter water to 105°, 110°, or 115° F. At intervals injections of the 
same water should be thrown into the urethra. The addition of boric 
acid to the water, a teaspoonful to the pint, enhances the moral, and 
possibly the physical effect of the water. 
Injections into the urethra should be made with a hard-rubber syringe holding 
half an ounce and terminating in a blunt tip without nozzle; and it is wise 
for the physician to instruct the patient how to inject, both verbally and by 
administering an injection, and causing the patient to repeat the process in the 
doctor’s presence. Before an injection the patient should empty the bladder: the 
syringe, filled with hot water (100° F. or more), is held in the right hand, the tip 
placed carefully between the lips of the meatus, which are then gently compressed 
laterally by the thumb and fingers of the left hand; by the right hand the piston 
is pressed slowly and gently home until the urethra feels distended. The syringe 
is then removed, the escape of the water being prevented by compression of the 
meatus. After a half minute the water is allowed to escape, and a second injection 
of hotter water (105° to 110°) is made. After this one of the following solutions 
is injected: hydrastin muriate, saturated solution, or zinc permanganate, 1 : 4000 
(1 grain to 8 ounces of water). GONORRHOEA AND ITS SEQUELS. 
223 
The hydrastin solution only is used during the acute stage—that is, the first 
week: thereafter the zinc solution is used first, and then the hydrastin. 
It is understood that the hot-water injections are continued. The 
hydrastin is not irritating, and presents only one disadvantage—the yel- 
low color, which, however, is easily removed by water. These injections 
should be made from six to ten times per day. 
Under such treatment the acute symptoms commonly subside in a 
week, and in two weeks the discharge becomes slight in quantity and 
resembles thin milk. When this occurs the hot-water immersions are 
discontinued and zinc-chloride solution, one-half grain to six ounces, sub- 
stituted for the permanganate. 
If the patient can be seen daily, there may be added to the above treatment, at 
any stage of the disease, even the most acute, a measure recommended by Guiteras 
—namely, a single daily injection of silver-nitrate solution. This should be made 
by the physician, who injects the first day one to two drachms of a solution contain- 
ing one grain of silver nitrate to the ounce of water ; the second day the solution 
used contains two grains of the nitrate to the ounce, the third day three, and is 
thus increased until on the tenth and last day it contains ten grains to the ounce. 
Occasionally this treatment must be discontinued because of the severe reaction 
produced. 
Various plans have been practised for the purpose of aborting a 
gonorrhoea : these may all be dismissed as certainly useless and often 
dangerous. 
Under such treatment as has been outlined perhaps one-tliird of the 
cases of acute gonorrhoea are apparently cured in from three to six weeks ; 
but it should be impressed upon the patient that the cessation of free 
discharge from the meatus does not prove that he has recovered; for 
long after this stoppage of the flow there may persist various evidences 
of disease, such as a gumming together of the lips of the meatus, espe- 
cially during the night; the appearance of a milky drop at the meatus 
in the morning; and the constant presence in the urine of thick white 
threads (clap-threads) of pus, which soon sink to the bottom of the 
vessel (these are commonly called by the German name, tripper-fdden). 
The persistence of any of these phenomena indicates the presence of 
one or more infected areas in some portion of the genital canal, and the 
■case must be considered one of chronic gonorrhoea. 
Chordee is not frequent under the hot-water treatment: if it occur, 
an attempt to prevent it may be made by the administration at bedtime 
of thirty grains of sodium bromide or two grains of camphor monobromide 
with a grain of codeia. When awakened by the painful erection, the 
patient should empty the bladder and apply cold water or a cold metallic 
object to the penis and perineum. Constipation favors chordee. 
Balanitis may be controlled by hot applications of boric-acid solution, 
followed by vaseline inunctions. 
Phimosis is reduced by immersions in hot water and injections of 
the same under the foreskin. 
Paraphimosis needs no treatment but hot water, unless the swelling 
of the glans seems to threaten necrosis of tissue: in this case the end 
of a probe-pointed bistoury should be inserted under the constricting 
band, which is then divided, the incision being dressed with iodoform or 
aristol. 
Folliculitis in the penis needs no special attention unless symptoms 224 
S UR G re A L DI SEA SES. 
of periurethral suppuration become apparent—local redness, tenderness, 
and boggy swelling: in such case incision and perfect drainage should 
be promptly made, followed by hot-water immersions of the septic 
tissues. 
Periurethral suppuration, occurring in any portion of the tract from 
meatus to bladder, must be recognized early and treated promptly, for 
it is apt to be followed by urinary infiltration and the severest forms of 
septic infection. When discovered, whether in penis, perineum, or pros- 
tate, the pus should be promptly evacuated from the nearest cutaneous 
surface. 
Deep urethritis occurs in the majority of cases of gonorrhoea, and 
often requires no especial treatment; indeed, it is often unnoticed by 
both patient and physician. In more severe cases, when frequent and 
difficult urination, pain in perineum and rectum, and some fever attract 
attention, the patient should remain in bed, take frequent hot-water 
fomentations, hip-baths, and enemata; the perineum should be irritated 
by mustard plasters or even blistered by cantharidal collodion ; and the 
pain and straining to urinate, often agonizing, quieted by morphine ; 
complete retention of urine, requiring the use of the catheter, is not 
unusual. Not infrequently these severe symptoms are suddenly relieved 
by a discharge of pus from the prostatic follicles into the urethra; but 
occasionally the pus burrows into the perineum, vesico-rectal or supra- 
pubic tissue, requiring prompt evacuation. 
Vesiculitis and ampullitis often follow closely upon deep urethritis, 
from which they can be distinguished by the finger in the rectum, reveal- 
ing an oblong, tender swelling on one or both sides above the prostate. 
Rest in bed, hot hip-baths, and enemata, and morphine should be used 
until the more acute symptoms subside ; then with a finger in the rectum 
gentle pressure toward the prostate should be made. Sometimes this 
manipulation is rewarded by a gush of foul pus through the urethra and 
meatus, and rapid subsidence of both swelling and symptoms. If, how- 
ever, the effect fails and the symptoms increase in severity, an incision 
should be made into the sac from the rectum, the cavity washed out and 
lightly packed with gauze. 
Epididymitis can usually be aborted by painting the skin along the 
cord and epididymis with guaiacol, using fifteen to thirty minims for each 
application, and making three applications in the first twenty-four hours, 
and two each day thereafter for a few days. The skin is usually peeled 
by the guaiacol, and the excoriations should be dressed with vaselin. 
Both testicles should be held up against the symphysis in the following manner: 
The entire scrotum is enveloped in a thick layer of cotton, which is covered with 
oiled silk or sheet rubber, surrounded by a gauze bandage, and the whole raised 
and supported against the symphysis by a jockey-strap or a silk handkerchief 
pinned to the underwear. The cotton should be changed every day. By the early 
use of guiacol and this bandage confinement to bed can usually be avoided: under 
other treatment a week’s rest in bed is commonly inevitable. 
Orchitis.—A certain amount of orchitis usually accompanies epidid- 
ymitis, and is relieved by the treatment for the latter: the local appli- 
cation of guaiacol may be extended over the testicle if this organ is 
swollen. 
If neglected, suppuration may occur in the testicle, indicated by chills, fever, and 225 
GONORRHCEA AND ITS SEQUELS. 
local softening: this should be treated by prompt incision and drainage. There is 
usually some protrusion of the testicle-substance through such an incision (hernia 
testis), which, however, is spontaneously reduced as the swelling subsides. Gan- 
grene of a portion of the testicle is an occasional event, often indicated by sudden 
subsidence of pain, and requiring ultimate removal of the necrotic tissue by the 
knife. 
Post-gonorrhoeal arthritis, or gonorrhoeal rheumatism, has until 
recently been unaffected by any of the numerous remedies tried upon it: 
treatment has consisted of wrapping the inflamed joints in cotton and 
oiled silk, placing the patient upon a water-bed and administering ano- 
dynes. Inunction of the inflamed joints and tissues with guaiacol (not 
more than two drachms being applied per day) promises better than any 
medication hitherto advised. 
Chronic Gonorrhoea; Gleet. 
By common consent, a gonorrhoeal infection of the genital tract in 
the male which persists more than eight weeks is termed a chronic gon- 
orrhoea, and the discharge from the meatus, when present, is called a 
gleet. 
It has been customary to consider chronic gonorrhoea and gleet syn- 
onymous terms, but this is one of the many errors which have descended 
to us from the earlier surgeons ; for by a gleet we understand a discharge 
from the meatus, but the gonorrhoeal infection often persists in the pros- 
tatic urethra and seminal tubes long after the anterior urethra is prac- 
tically well and without any discharge from the meatus; for the pus 
produced in the deeper parts may be prevented from reaching the ante- 
rior urethra by the cut-off muscle. Hence a chronic gonorrhoea may 
long exist without a gleet—an important clinical distinction. 
Gleet is the continuation of a gonorrhoeal discharge from the meatus, 
and may vary from a profuse milky to a slight watery flow. Sometimes 
there will during the day be no distinct discharge, but only a gumming 
of the meatus; but in the morning, with or without milking the penis, a 
drop or two of milky fluid appears, the so-called morning drop, or, as 
the French call it, the military drop. 
While a gleet proceeds directly from the anterior urethra, the source 
of the discharge may lie behind the cut-off muscle. Failure to recognize 
this fact is the explanation of many failures to stop the discharge : the 
patient uses one medicine after another, one injection after another, with- 
out relief. Or the discharge stops while an injection is constantly used, 
but reappears when it is discontinued. 
The first step toward the intelligent treatment of gleet is therefore 
the discovery of the infected area, which may be found anywhere from 
the meatus to the vas deferens. For practical diagnosis and treatment 
the genital surfaces may be divided into three portions : (1) the anterior 
urethra (to the bulbo-membranous junction); (2) the deep urethra (from 
bulb to bladder); and (3) the prostate, ampullce, and seminal vesicles. 
The simplest means for determining which of these three portions is the source 
of a gleet is called the “ three-glass test,” which is thus made: The patient, having 
retained his urine two hours or more, first submits to a thorough irrigation of the 
anterior urethra through a catheter passed as far as the bulb, whereby all pus 
anterior to this point is removed; he then passes about an ounce of urine into the 
first glass (it is best to use small glasses), whereby the pus is washed from the deep 226 
SURGICAL DISEASES. 
urethra; the physician’s finger is then introduced into the rectum and gently 
presses the prostate and seminal vesicles; the patient then passes another ounce 
of urine into the second vessel and the remainder into the third. A comparison 
of the amount of pus in the respective glasses affords a fair inference as to the 
source of the pus. (A drop or two of nitric acid in each glass will remove any 
cloudiness due to phosphates, while not affecting pus.) 
It is chiefly important to know whether the pus-production is limited 
to the anterior urethra or extends also to the deep urethra: in the latter 
case some involvement of the prostate and seminal tubes may be 
expected. 
Persistence of suppuration is due to the existence of diseased areas, 
which are of three classes: (1) plastic exudate in the submucous tissue, 
causing a catarrh of the surface and developing into stricture ; (2) pre- 
existing stricture; (3) imperfect drainage, as in the prostatic follicles and 
seminal vesicles. 
The anterior urethra is explored by—(1) bulbous sounds and (2) 
the urethroscope (endoscope). 
The bulbous sound (Fig. 74) is so shaped as to detect a lack of normal disten- 
sibility of the canal; that is, a stricture. This natural distensibility (calibre) varies 
in different portions of the urethra, being greatest in the bulb and the prostate and 
Fig. 74. 
Bulbous sound. 
least at the meatus, the scrotal and membranous portions. The calibre also varies 
in different individuals, maintaining a fairly constant ratio (about four-tenths) to 
the circumference of the flaccid penis : in general it ranges from 30 to 36 of the 
French scale. By means of the bulbous sounds any strictures worthy of note ca,n 
be detected, provided the meatus will admit a bulb of full size. If, as often hap- 
pens, the natural contraction of the meatus prevents a satisfactory exploration by 
these instruments, the surgeon must either divide the meatus to 35 Fr. or employ 
an Otis (or similar) urethrometer. Division of the meatus should never be per- 
formed if that orifice admits a 22 Fr. bulb; for, while the operation is trivial, the 
result is a gaping deformity of the natural nozzle-shaped orifice, whereby the 
expulsion of urine and semen is unfavorably influenced, and the patient’s liability 
to gonorrhoea and urethral chancre undoubtedly increased. 
Instead of cutting a normal meatus, the surgeon should use the urethrometer 
of Otis (Fig. 75), an ingenious instrument constructed on the umbrella principle: 
Fjg. 75. 
Urethrometer. 
introduced when closed, it is dilated by a screw at the handle to the desired size 
(33 Fr. or more), and then drawn forward, the variations in calibre necessary for 
its passage being indicated on the dial. 
Neither bulbous sounds nor urethrometer should be passed into the 
muscular portion of the urethra beyond the bulb : the distensibility of 
this portion of the canal is tested by cylindrical sounds. 
The prostatic urethra is practically never the site of contractions (stric- 
tures) as the result of gonorrhoea. GONORRHCEA AND ITS SEQUELJE. 
227 
Inspection of the entire urethral surface can be made through one of the many 
urethroscopes in use : by it the surgeon may detect diseased areas by the unnatural 
redness and granular appearance of the surface. While urethroscopic inspection 
is always desirable in cases of gleet, it is not always essential. 
Digital examination per rectum should never be neglected in deter- 
mining the source of a gleety discharge, even though the anterior urethra 
is found to be strictured or otherwise diseased; for the prostate and 
seminal vesicles are often the seat of persistent infection and contribute 
to the discharge. 
To determine the condition of these parts the surgeon’s fore finger— 
best enclosed in a rubber condom which is anointed with glycerin—is 
introduced into the rectum of the patient, who may either lie upon his 
back or stand with the feet apart and body bent forward. The finger 
first determines whether the prostate is sivollen, asymmetrical, or unduly 
sensitive; then the finger-tip is made to “milk” the prostatic follicles by 
gentle pressure on the organ from above downward (toward the anus) : 
the prostatic utricle, which lies between the lateral lobes of the organ, 
and is often distended with pus, should be included in the milking pro- 
cess. The appearance of a purulent discharge at the meatus during this 
manipulation shows that the prostatic follicles are diseased. 
The finger should then be inserted farther into the rectum, so as to 
compress or “ milk ” the seminal tube and vesicle on each side : the escape 
of pus and catarrhal products in notable quantity indicates that these 
tubes are implicated in the chronic infection. 
Treatment of Chronic Gonorrhcea and Gleet.—The treat- 
ment of gleet should always be preceded by a determination of the seat 
of the disease, as already outlined: a routine prescription of injections 
or use of sounds, while curing a certain number, will fail to relieve 
many that are amenable to intelligent treatment. 
Certain general measures are applicable to all cases of gleet: they 
should carefully avoid constipation, alcohol, and sexual excitement. 
It may be here remarked that instances are not rare in which an obstinate 
gleet has stopped suddenly and permanently after indulgence in beer or wine by a 
patient who has long abstained, or after sexual intercourse by a man who has long 
been continent. 
Patients afflicted with gleet should drink plenty of good water and 
avoid the excessive use of tobacco and coffee. 
The special measures required are—(1) sounds ; (2) injections—ante- 
rior and deep urethra; (3) milking of 'prostate and seminal tubes; (4) 
medicines internally and locally; (5) local applications to diseased patches 
through the endoscope. 
Fig. 76. 
G. TIEMANN & 00. 
(1) Sounds.—A stricture should be treated by gradual dilatation car- 
Otis’ dilating urethotome. 228 
SURGICAL DISEASES. 
ried to the full calibre of the urethra, 32 to 36 Fr. If a narrow meatus 
prevents the use of large sounds, the surgeon should choose between 
enlargement of the meatus (advisable in exceptional cases only) and 
dilatation by means of special instruments, the dilators of Otis, Tuttle, 
Oberlander, etc. Even when no decided stricture is detected, the passage 
of large sounds through the deep as well as the anterior urethra is an 
advisable accessory to other treatment. The surgeon who possesses one 
of the special dilators should gradually overstretch (by 2 or 3 mm.) any 
contracted ring. 
(2) Injections.—Of the multitude of injections recommended for 
gleet of the anterior urethra the following are useful: hot water (100° to 
115° E.) alone and containing in solution hydrastin muriate (saturated) 
or picric acid, zinc permanganate, nitrate of silver, one grain to eight 
ounces : alcohol is an old and valuable remedy, beginning with one part 
in twenty of water, and gradually increasing to one part in live. 
Deep Injections.—Liquids injected from the meatus do not ordi- 
narily reach the deep urethra, because arrested by the “ cut-off” muscle. 
Injections into the deep urethra are therefore usually made through a 
tube introduced beyond the bulbo-membranous junction. 
Special syringes for this purpose have been designed by Guyon, Ultzmann, 
Keyes, and others (Fig. 77), whereby an exact number ofminims of a given strong 
Fia. 77. 
STOViUAMW.V* KKBX.W&. 
Deep urethral syringe. 
solution can be deposited in the deep urethra—a process often called instilla- 
tion. A better practice is irrigation of the deep urethra with a larger quantity of 
a Aveaker solution. For this purpose a small soft catheter (sterilized) is introduced 
until the urine flows, then AA’ithdraAvn about an inch and a half; a five-ounce rub- 
ber syringe or small fountain syringe (hung Ioav) is then attached. The solution 
passes into the deep urethra, and thence into the bladder, the cut-off muscle pre- 
Arenting its escape through the penis; the catheter is then withdrawn and the 
patient empties the bladder, thus passing the solution a second time over the deep 
urethra. 
The solution used should be hot (100° F.), and may consist of nitrate of silver, 
one part to ten thousand of Avater, bichloride of mercury, one to tAventv thousand, 
or permanganate of potassium, one to five thousand, employed every tAvo or three 
days. 
Many patients can with practice inject the bladder without a catheter: 
this is, when practicable, preferable to the injection by catheter, and is 
accomplished by placing the patient in a reclining position, with thighs 
flexed upon the body. A fluid gently injected by means of a five-ounce 
syringe may, after slight delay at the cut-off muscle, flow into the blad- 
der. Elderly men are especially favorable subjects for such injection. 
(3) Milking- the prostate and seminal vesicles is always required 
when these parts are obviously diseased, and, like the passage of sounds, 
is sometimes useful even when no infection of these parts is detected. GONORRHOEA AND ITS SEQUELS. 
229 
This manipulation should be performed at first very gently and for only 
two or three minutes at a time : the pressure used and the time expended 
may be gradually increased, and the intervals between sittings reduced 
from six days to three. If the pain caused persists for several hours, 
the next application should be more moderate, as violent pressure may 
cause an extension of the infection along the vas deferens to the 
epididymis. 
(4) Medicines administered by the mouth cannot be relied upon to 
influence a gleet: the best effects are obtained from turpentine oil in 
three- to five-drop doses, scmtal oil in ten-minim doses, and tincture can- 
tharides in three-drop doses, four to six times daily. 
Iron and other tonics are beneficial to a patient showing any signs of anaemia, 
and sometimes are quite essential to a cure. 
In the suppository form drugs are applied directly to the prostate and vesicles 
with benefit when these parts are involved: ichthyol, two grains, ext. belladonnse 
or hyoscyami one-quarter grain, may be thus administered three times daily. 
Syphilitics should take mercury or iodine, and scrofulous subjects guaiacol: in 
malarial districts quinine may have a decided effect in checking a gleet. 
(5) Local applications to diseased areas through the urethroscope 
are sometimes necessary: the diseased surface is brought into the field, 
cleansed with cotton, and touched with a stick of copper sulphate or a 
strong (10 to 20 per cent.) solution of silver nitrate, the application 
being repeated every few days as the course of events indicates. 
The treatment of chronic gonorrhoea and gleet may be thus 
summarized: In addition to the hygienic measures necessary for all, 
and the tonic treatment required by some, direct measures should be 
adapted to the part of the genital tract involved: for the anterior 
urethra, sounds, injections, applications through the endoscope; for the 
deep urethra, irrigations, large sounds; for the prostate and seminal 
tubes, the treatment for the deep urethra combined with the milking 
process and suppositories. 
When does a chronic gonorrhoea cease to be contagious ? is a 
frequent and most important question, to which we can give no definite 
answer. Theoretically, the contagion ceases when the gonococci dis- 
appear absolutely from the body, but, practically, we cannot determine 
when this happy event occurs in a given case. So long as we find these 
bacteria in a free discharge or even scattered through the pus-threads 
(tripper-faden), which are passed with the urine long after free discharge 
has ceased, we believe the individual capable of conveying the infection ; 
but we know that the gonococci may lurk in crypts and follicles of the 
genital canal even when a careful search fails to detect them in the pus- 
threads. Under the excitement of intercourse a rapid multiplication 
of these organisms may occur, resulting in the infection of the woman 
and the reinfection of the patient’s own urethra. This is especially apt 
to occur in the frequent and prolonged sexual indulgence of recent 
marriage. Gonococci have been found in the pus-threads three and 
four years after the last infection. CHAPTER XII. 
SHOCK AND COLLAPSE. 
Roswell Park, M. D. 
Under these two terms, which are nearly interchangeable, is de- 
scribed a condition of reflex depression which occurs often after severe 
injuries or accidents, and often as the result of mental emotions from 
apparently trivial causes. If one is to distinguish between shock and 
collapse, one should reserve the former term for cases which follow 
injury or accident, and the latter for those cases occurring spontaneously 
or from mental or intrinsic causes not connected with physical violence. 
Shock may be of all degrees, from the most temporary faintness from 
which one recovers within a few moments, up to a condition of vital 
depression which terminates fatally, there being no reaction in spite of 
all efforts to produce it. 
The consideration of shock is more or less inseparable from that of concussion, 
for instance; and the condition so often alluded to in surgical literature as concus- 
sion of the brain is but little, if at all, distinguishable from true shock. When we 
attempt to isolate and define its peculiar features, we find but little more than 
inhibition of nerve-activity and reflex paralysis. The feebleness and inactivity of 
the heart are apparently due to reflex irritation of the pneumogastric, or else to 
reflex vasomotor paralyses, especially of the abdominal vessels. The theory of the 
causation of shock is a matter of great interest, but one which can scarcely be 
profitably discussed here. Whether the heart be in large degree paralyzed, or 
whether the vascular tonus be inhibited so that the vessels expand to their fullest 
and contain the blood which ought to be passed through the heart—these being 
the two now generally received explanations; or whether, as is more likely, shock 
be essentially a combination of these two conditions,—the symptoms are classical 
and easily recognized. 
Symptoms.—These at least can be referred almost solely to vaso- 
motor paralysis, obviously of reflex origin from the peripheral (i. e. the 
sensory) nerves. They consist of an expressionless face, of pallor of 
the skin and visible mucous membrane, with corresponding coldness of 
the same (i. e. reduction of surface-circulation and heat); of dilated 
pupils, reacting slowly to light; irregularity of the heart’s action, with 
a weak, irregular, thready, or imperceptible pulse ; irregular respiration, 
breathing being irregular both in rate and depth ; mental inactivity and 
apathy ; loss of voluntary muscle-movement; impairment of superficial 
sensibility; actual reduction of body-temperature; occasionally nausea 
or actual vomiting. These at least constitute the symptoms in the 
majority of cases, and form what may called the apathetic or torpid type 
of shock. 
Again, we may have shock of the so-called erethistic type (Travers), 
in which patients are restless and excited, uncontrollable, and yet with 
230 SHOCK AND COLLAPSE. 
231 
irregular pulse and breathing, often with dilated pupils. Finally, we 
have a third type, described by Travers as the delayed, in which the 
symptoms are as above detailed, but come on only some hours after that 
which has produced them, but which may be only an expression of con- 
cealed (internal) hemorrhage. The delayed type is often seen in those 
who escape serious accident with a minimum of physical harm. 
As shock becomes more pronounced, mental depression deepens into 
coma, or mental excitement subsides into it; the surface becomes colder 
and bathed with perspiration ; and death follows. These symptoms are 
those generally noted, whether following injury to the head and denot- 
ing so-called concussion of the brain, or loss of blood, or wound of the 
abdomen with injury to the viscera, blows upon the testicles, gunshot 
wounds, or other accidents which are notorious causes of shock. They 
follow also after perforation of the bowel, as in typhoid fever or appen- 
dicitis, or fatal cases of empyema, or the depression following the receipt 
of bad news, or fright, etc.; in other words, the physical condition is 
practically the same no matter what the exciting cause. 
The general subject of shock is one of keen interest to the surgeon, 
because he is often called to patients whom he finds in this condition, 
when the question at once arises, Is the necessary operation to be per- 
formed at once, or must one wait for a certain degree of reaction ? It 
is of interest also because of the danger in many extreme cases that the 
necessary operation, so plainly indicated, maybe followed by a degree of 
shock from which the patient may not be revived. 
Diagnosis.—Shock has practically only to be diagnosed from fat- 
embolism, or possibly from a general and more or less permanent condi- 
tion of physical depression. From the latter it is usually easily disso- 
ciated ; differentiation from the former is not always easy, and it is 
unquestionable that many patients have died of fat-embolism in whom 
the actual cause of death has not been appreciated, yet has been ascribed 
to shock. (See Fat-embolism, Chapter II.) 
Shock is sometimes scarcely to be distinguished from other conse- 
quences of exhaustive hemorrhage, such as acute reduction of the normal 
amount of haemoglobin, save by careful estimation of the latter. ( Vide 
Chapter II.) 
Treatment.—The treatment of shock consists in those measures by 
which reaction may be safely brought about. At the very outset one 
must bear in mind two or three cautions that may not safely be neg- 
lected. One is, that it is injudicious to establish reaction too quickly, 
lest it be succeeded by over-action with attendant disasters in the shape 
of secondary hemorrhages, etc. Another is, that, volition being so 
largely destroyed, these patients cannot swallow nor act as they would 
under other circumstances. It is a mistake, then, to expect a patient 
suffering from shock to drink strong liquors, for instance, as would one 
when not so suffering, since a little of the irritating fluid may escape 
into the larynx and set up a violent coughing-fit which, of itself, might 
prove fatal. The same is true of inhalations of strong volatile stimu- 
lants, like ammonia, etc. These measures, therefore, should all be 
resorted to with care and discretion. Cerebral anosmia is evidently a 
part of the condition of shock, and should therefore be combated by a 
dependent position of the head. Hence the patient should be laid flat, 232 
SURGICAL DISEASES. 
or even with the head lower than the rest of the body—i. e. the feet and 
extremities raised. It is a good plan occasionally to bandage the extrem- 
ities from their tips toward the body, in order that the blood which they 
would naturally contain may be pressed into needed service in the vital 
organs. Should, however, cyanosis be noticed, it may be held that the 
depression of the head is being overdone. Warm stimulating drinks, if 
they can be swallowed, are always of avail; and whiskey, brandy, etc. 
should be given dilute and warm rather than strong and cold. External 
heat is evidently indicated, and in many cases can be well applied by 
immersing the patient in a bath-tub of warm water, taking pains only to 
keep the face out of water. When this be not at hand, bottles and other 
receptacles for warm water may be applied about the patient, care being 
exercised not to burn him. Enthusiastic application of too much heat 
under these circumstances has often been the cause of serious burns with 
great resulting discomfort. Artificial respiration may be resorted to, or 
the diaphragm may be stimulated to activity by the Faradic current, 
applied with one pole over the phrenic nerve, the other over the dia- 
phragm. When the stomach does not retain, or when the patient cannot 
swallow stimulating drinks, almost as much benefit can be gained by 
resorting to enemata of hot black coffee with brandy, with ammonium 
carbonate, etc. Nitrite of amyl will frequently bring a flush to the face, 
and will relieve vasomotor spasm of the cerebral capillaries and of the 
body surface, thus helping to equalize the circulation. It will be found 
sometimes of great value. The principal remedies by which to stimulate 
the activity of the heart are strychnia and tincture of digitalis, both of 
which should be administered subcutaneously and in comparatively large 
doses. A flagging respiration may also be stimulated and sustained by 
atropia, given in the same way. Under these circumstances, when these 
drugs are called for, it would be well to give in one hypodermic injec- 
tion 1 c.c. of tincture of digitalis with of a grain of strychnia and 
To O’ of a grain of atropia. This may be repeated in half an hour or an 
hour if necessary, while the digitalis alone may perhaps be given at more 
frequent intervals. 
The erethistic or extremely restless type of shock may always be 
profitably treated by small, at all events sufficient, doses of opium, pref- 
erably by morphia, to grain subcutaneously, and repeated p. r. n. 
Such a case as this requires most careful and constant watching and judicious 
stimulation, in order that one may stop abruptly when reaction becomes too marked 
or comes on too suddenly. 
When shock is due, in large measure at least, to loss of blood, either by acci- 
dent or operation, the infusion of a saline solution, consisting of sterilized water 
1000, ammonium carbonate 1, common salt 6, may be practised, this fluid being 
slowly introduced through a hollow needle into one of the superficial veins where- 
ever it may be most easily reached. It should not be introduced rapidly, but 
may be employed very gradually to the extent of 500, 1000, or possibly even 2000, 
c. c. of this fluid. It serves to equalize the circulation and to give to the endocar- 
dium the stimulus which it must get from a certain volume of fluid of normal 
specific gravity in order to excite cardiac motions. A fluid thus prepared and 
used is probably just as efficacious as blood or milk, is much more easily obtained, 
and serves in every respect as well. 
Finally, the question of immediate operation has often to be most 
carefully considered. There can be no question but that shock is often 
alleviated by prompt removal of mutilated limbs or parts whose frag- SHOCK AND COLLAPSE. 
233 
ments, when still connected with the trunk, seem rather to perpetuate 
the condition. So, too, prompt surgical attention to severe compound 
fractures, as of the skull or of the limbs when bone-ends are much dis- 
placed or are projecting, seems to be a most important measure and an 
essential part of the treatment of shock. CHAPTER XIII. 
SCURVY AND RICKETS. 
Roswell Park, M. D. 
Scurvy. 
Scurvy is an affection by general consent placed among the so- 
called surgical diseases, manifesting, at all events, many distinctly sur- 
gical features and possibly of parasitic character, although this feature 
of its existence has not as yet been incontrovertibly established. It is 
in large degree a starvation disease, its principal characteristic being 
that of mat-assimilation, accompanied by more or less profound anaemia. 
It has certain points of resemblance to that condition of multiple 
neuritis met with in warm climates and known usually as beri-beri. The 
former is apparently due to the absence of a vegetable regimen, while 
beriberi is largely due to the absence of an animal regimen, nature hav- 
ing intended that man’s diet should be mixed, and having ordained that 
suffering and disease practically always follow confinement to one or the 
other. 
As met with in the United States, scurvy is essentially due to the absence, 
from the dietary of the patient, of meats which have not been salted or preserved 
and of fresh vegetables and fruit. This condition obtains par excellence among 
sailors upon long voyages. But scurvy is misjudged when it is supposed to be 
solely a disease of those who follow the sea. One meets with well-marked instances 
of it in overcrowded parts of great cities and among the very poor, while famine 
always and everywhere has been characterized by typical expressions of the same 
condition. Distinctly scorbutic manifestations have also been seen in individuals 
far removed from want, in whom they appear to have been produced by simple 
mal-assimilation. Close confinement also figures as a predisposing cause, and 
scurvy is noted in prisons and asylums. Physical and mental misery always pre- 
dispose, and nostalgia, coupled with hunger, seems to precipitate, its attacks. 
Pathology.—The pathology of scurvy is very obscure. The con- 
dition is certainly dependent upon chemical alterations in the blood, 
without, however, morphological changes which are distinct or pathog- 
nomonic. The ease with which hemorrhagic effusions occur, the 
degeneration of muscles and other tissues, the frequent detachment of 
cartilages, can, in a general way, be accounted for by conditions thus 
summarized; for which, however, we have no minute explanation. 
Moreover, scurvy may so complicate various other diseases, and usually 
does when occurring in large bodies of men—as in armies, prisons, 
among convicts, etc.—that it is hard to dissociate morbid phenomena 
and assign to each its proper place. 
Symptoms.—The disease begins by a condition of more or less 
generalized prostration, with an icteric tint of the skin, malaise, mental 
torpor, loss of appetite, insomnia, etc. The first recognizable or dis- 
234 235 
SC UR VY AND RICKETS. 
tinctive local appearances occur about the margins of the gums. Here, 
in the intervals between the teeth, the gums become livid, friable, and 
bleed easily, while the breath assumes a characteristic fetid odor. These 
appearances are followed by local pains, diversified and sometimes ex- 
cessive, and extravasations of blood in the skin and under the visible 
mucous membranes, causing small ecchymoses, which by themselves 
would be considered as simple purpura heemorrhagica. These pass 
through the usual phases of extravasations, while it is made evident by 
pain, nodular masses, etc. and by post-mortem examination that similar 
hemorrhages occur in the deeper tissues, especially in the muscles, even 
in the bones and epiphyses. So easily, in advanced stages, do hemor- 
rhages occur that there is often external bleeding, particularly from the 
gums and mucous membranes, while from points thus involved pyogenic 
infection may proceed internally; and at last one sees a picture of, as 
it were, an animated corpse, with surface discolored and mottled, often 
appearing terribly bruised, with ulcerations where extravasations have 
failed to resolve, and where infection has occurred, possibly with epiph- 
yses loosened, and. if time permit, necrosis of bones of the extremities. 
In such cases death results from marasmus and sepsis. 
Treatment.—So long as the patient be not in the desperate condi- 
tion last described the prognosis and promise of treatment is very good, 
since all the milder manifestations of scurvy can be completely dis- 
sipated by suitable feeding and medication. Loss of teeth and cica- 
trices of ulcers, of course, leave permanent traces, but function can be 
completely restored. So far as the purpura is concerned, it is simply 
one expression of the scorbutic condition. Nearly all cases of scurvy 
will present purpuric manifestations, but by no means all cases of pur- 
pura are necessarily scorbutic. The canons of treatment may be 
summed up in proper diet and in the administration of certain drugs. 
Proper diet should be issued at once, but administered, especially in 
severe cases, with extreme caution. The food selected should be given 
in small quantities, but frequently. It will consist in large measure of 
fresh fruits and vegetables, while cranberries and lime-juice figure 
largely among the former. Buttermilk is excellent, and cider may be 
allowed ; lemonade is also highly commended if it contain not too much 
sugar. 
For the local condition in the mouth an antiseptic mouth-wash con- 
taining a fair proportion of hydrogen dioxide is most advisable. Alco- 
holic stimulants are called for, at least up to a certain point. Strychnia 
and cinchona preparations will give force to the heart’s action and the 
horizontal position, for a time at least, will prevent sudden heart- 
failure. The compound syrup of hypophospliites, with the newer meat 
preparations, will supply lacking material, while the hemorrhagic mani- 
festations are best controlled by the fluid extract of ergot and aromatic 
sulphuric acid, separately or combined. 
Of the importance of fresh air, cleanliness, etc. one need scarcely 
speak in this place. 
Rickets. 
Rickets, or rachitis, is another of the diathetic conditions, in this 
instance not yet considered of parasitic origin, met with most commonly 236 
SURGICAL DISEASES. 
in infancy and early childhood, although its resulting lesions may per- 
sist throughout life. It is characterized by nutritional disturbances and 
organic irregularities. 
Like scurvy, rickets is a disease of mal-assimilation, but due for the most part 
to widely different causes. It is by no means necessarily a disease of the poorer 
classes, but instances of it among the wealthy and fashionable abound. These are 
largely due to the absurd restrictions which society imposes upon fashionable 
mothers during pregnancy or lactation, the result being that children are brought 
into the world born of those whose nutrition is bad, inheriting inability to assimilate, 
and perhaps after birth being condemned to artificial foods because the mothers 
cannot or will not nurse them. The result is a puny physical development and an 
utterly inadequate supply of those elements which especially go to form the bony 
skeleton. Thus, while the conditions predisposing to rickets abound among the 
poor, they are met with as well among the rich. One may say perhaps that 
chemically the disease is largely characterized by absence of calcium salts. While 
probably the most characteristic evidences of rickets are seen in the bony skeleton, 
they are by no means confined to it; for which reason rickets is considered here 
rather than in the Chapter on Diseases of the Osseous System. Another theory to 
account for rickets is excess of lactic acid, but this perhaps is not easily separable 
from the other, which accounts for it by absence of calcium salts, the one not 
being present to neutralize the other. Rickets is prevalent in every country, but 
it is perhaps seen most often in Europe, particularly often in Italy and Great 
Britain. The negro race is notably rachitic. 
Pathology.—Rickets is spoken of as “ foetal ” or “ congenital ” 
according to whether the infant presents characteristic markings at birth 
or whether they develop later. So far as one can see, the most marked 
constitutional defect is in the supply of calcium salt, which leads appa- 
rently to formation of bone which has not enough of compact tissue to 
make it strong. Especially along the line of junction between bone and 
cartilage do we see the most marked expressions of rachitic lesions. 
Here the cartilage is evidently actively growing, while the bone-forma- 
tion proceeds with difficulty, and the proportion of vascular tissue is 
excessive. The result is prolongations of soft vascular into the carti- 
Fig. 78. 
Rachitic rib, showing characteristic changes. 
laginous tissue, by which the latter becomes more or less absorbed and 
ossification is essentially interfered with. In fact, in severe cases it may PLATE X 
Congenital Pseudo-Rachitis, showing Aplasia of Cartilage; a, Osteo-Periosteum ; b, Quiescent Cartilage 
c, Periosteum penetrating between Bone and Cartilage. (Klebs.) SCURVY AND RICKETS. 
237 
be entirely lacking. In consequence, at epiphyseal lines one may have 
a layer of osteoid tissue which is not cartilage and will not become bone. 
Because of its yielding nature, then, it warps under the mechanical 
strain to which the bones of the extremities in young children are con- 
stantly subjected. 
The osseous lesions of rickets differ from those seen in osteomalacia 
in that in the latter the softened tissue is practically decalcified bone, 
while in the former case most of the affected tissue has never got so far 
as genuine bone-formation, but is arrested in its perverted state. 
The result of rickety changes in the skeleton is a thickening of the 
shafts of long bones, of the outer table of flat ones, of the epiphyseal 
extremities of shafts and frequently a stunting of their development, so 
that they do not attain their normal length. The periosteum, having 
much to do with the development of bone, is also affected in rickets, 
with the result that when the changes occur, mostly subperiosteally, we 
get warpings and carvings of the bone-shafts, while so long as the dis- 
turbance is epiphyseal more or less abrupt curvatures and angular 
deformities will be produced as the result of muscle-action. So marked 
are the changes in some instances that it has been stated that bones may 
even lose three-fourths of the calcium salts which they ought to con- 
tain. When, as is the case, rachitic bones are so soft as to be easily cut 
with a knife, it is not strange that marked deformities occur as the 
result of muscular activity. {Vide Plate X.) 
Thus, in the extremities we get bow-legs, knock-knees, clubbing of the ends of the 
long bones, bending of the neck of the femur, flat-foot, club-foot, etc.; while the 
clubbing of the bone-ends may be also well marked in the bones of the upper 
extremity, where, however, marked deformity is less common, because the upper 
extremity does not bear the weight of the growing body. In the skull the bones 
remain soft and yielding to pressure, with a tendency to return to their original 
membranous condition, and this is the condition comprised under the term cranio- 
tabes rachitica. The fontanelles always remain open for an undue time; the sutures 
are broad and membranous. The bones of the face grow less rapidly, giving to the 
face a disproportionately small size; dentition is delayed and the teeth decay very 
easily. The upper incisors often project far over the lower. 
In the thorax we get enlargements of the sternal ends of the ribs, causing a row 
of nodules spoken of as the rachitic rosary. The ribs tend to sink in, the sternum 
to be protruded forward, and the deformity known as pigeon-breast becomes often 
pronounced. Curvatures of the spinal column, especially kyphosis, are common, 
and distinct degrees of lateral curvature are frequently begun as a rachitic 
deformity, to be magnified by perverted muscle-action as the child grows older. 
In the pelvis the innominate bones approach each other, causing the pelvic cavity 
to become contracted, or the sacral promontory projects too far, or in various other 
ways the normal pelvic diameters are so far compromised that rachitic deformities 
of the pelvis constitute the most common and most serious obstacles to normal labor 
in adult women, and are the most frequent cause of major obstetric operations. 
While the rachitic changes in the osseous system are the most distinctive and 
easily recognized, numerous other organs and tissues of the body are more or less 
seriously compromised. Ventricular dilatation, leading to chronic hydrocephalus, is 
one of the common results of rachitis of the skull, which may be followed by con- 
vulsions and may terminate fatally. So, again, we get porencephalon and cerebral 
sclerosis. Disturbances of digestion are common in rickety children: the liver is 
sometimes decreased, sometimes much enlarged; the spleen, particularly, often 
enlarges, and sometimes to enormous dimensions. In various other parts of the 
body we get the same expressions of malnutrition as are met with in tubercular 
disease. Rickety children perspire easily, particularly at night, when the head will 
often be found bathed in perspiration. They are fretful and irritable as a rule, and 
difficult to control. A child with protuberant belly, due to enlargement of liver 238 
SURGICAL DISEASES. 
and spleen, as well as to crowding up of pelvic organs, with relaxation of abdom- 
inal walls, with a contracted and distorted thorax, with the skull flattened on 
the top, with clubbed bone-ends, with a history of resting badly at night and 
sweating profusely, constitutes a clinical picture of rachitis so marked that it can 
be recognized at a glance. Between this picture in its worst forms and the 
slightest deviation from the ideal type one may meet with all degrees in manifesta- 
tions of rickets in the children of the rich or the poor, while in adults one may 
often see evidences of that which had obtained during early childhood. In order 
that all these features may be made out the children should be stripped and 
examined from head to foot. 
While rickets may be a very acute disease, it is, as a rule, chronic, 
and children dying essentially from this disease die rather from cerebral 
or other manifestations which may be regarded as in some degree acci- 
dental. Scurvy and other nutritive disturbances may be associated with 
rickets. 
Treatment.—The treatment for the condition consists mainly in 
proper nutrition. Mother’s milk is certainly preferable to any other, 
and should be insisted upon if possible. If feeding must be artificial, 
it should be in accordance with the very best precepts of modern thera- 
peutics. Cod-liver-oil emulsions are of advantage ; compound syrup of 
the hypophosphites is a remedy of great virtue. Very minute doses of 
phosphorus seem to be of value—1 milligramme pro die. It is a mis- 
take to let rickety children begin to walk, or even to creep, too early. 
They should be kept, so far as possible, in cribs or upon the back. 
The deformities due to rickets are so numerous as to constitute a 
large part of those to which special or orthopaedic surgery is addressed. 
The mechanical and operative treatment of these cases will be referred 
to in other and appropriate parts of this work. CHAPTER XIV. 
SURGICAL ASPECTS AND SEQUELAE OF OTHER INFECTIONS 
AND DISEASES. 
Roswell Park, M. D. 
As the result perhaps of the conditions which, two centuries ago and 
more, so distinctly separated the barber-surgeons from the practitioners 
of medicine, there has been evolved, partly from tradition and partly 
from custom, an artificial and unfortunate separation of surgery from 
so-called internal medicine. The consequence has been a more or less 
deep-rooted feeling, in the minds of young practitioners especially, that 
medical cases were to be treated exclusively by non-operative measures, 
and that surgical cases could scarcely be expected to present any per- 
plexities that were not to be solved by an operating surgeon. It has 
been no small part of the benefit resulting from modern teachings that 
these imaginary boundaries and limitations have been swept away; and 
one of the lessons which this text-book is intended to inculcate is that 
broad principles underlie disease conditions, and that one must appreci- 
ate their bearings thoroughly in order to practise either medicine or 
surgery successfully. In order better to inculcate this teaching I have 
deemed it wise to insert a chapter with the above general heading, 
in order to impress, so far as one may, the statement that some 
learn too late, that any of the co-called internal diseases may present 
at almost any time indications, sometimes urgent, for distinctly surgical 
interference. Some of the surgical sequelae of the exanthematous and 
continued fevers are well known and commonly recognized : for exam- 
ple, orchitis following mumps, suppurative inflammation of the middle ear 
after scarlatina, and bed-sores after typhus and typhoid. These are, of 
course, easily recognized, but concerning many others the text-books are 
singularly silent. 
The majority of these surgical lesions are expressions, in one form or another, 
of mixed or secondary infections, to which reference has been already made, and 
of these the majority assume the suppurative type. Of the various tissues or 
organs involved in these expressions of disease, the most commonly affected per- 
haps are the joints, the bones, and the lymphatic tissues, although no tissue nor 
organ may always escape. In time past too many of these sequelae have been 
roughly grouped, as by Bonnet, for instance, among the consecutive rheumatisms, 
which he carefully warned us are not to be confounded with genuine rheumatisms. 
How often the surgeon of to-day has had to open up collections of pus in cases 
which were formerly almost always, and are yet too often regarded as rheumatism, 
the various museums and hospital records will eloquently testify. Rheumatism, 
as such, is one of the affections which is never followed by suppuration until some 
purely distinct infection occurs ; and the part which suppurates is not one which 
has been recently involved in the true rheumatic attack. How many errors of 
diagnosis the vague term “ rheumatism ” is made to cover no one knows : let us hope 
that in the future such errors may be far less common than they have been in the 
239 240 
SURGICAL DISEASES. 
past. Since the renaissance of surgery which bacteriological study has brought 
about, we have at last the explanation of that for which in time past many and 
often absurd theories wrere invoked. Of the so-called non-surgical diseases which 
may yet be followed by distinctly surgical sequelae I will not venture a careful list, 
but will simply call attention especially, as illustrative examples, to the following : 
Dysentery. 
Joint-complications in this disease have been recognized from the 
earliest times. One hundred and fifty years ago Strack expressed him- 
self thus : “ If the dysenteric poison affect only the chest, it causes 
asthma; if the limbs, it produces arthritis; if both, abscess.” Joint- 
pains and swellings, with other suppurations, have been noted in several 
of the epidemics of this disease which have ravaged various parts of the 
world at different times. Post-dysenteric arthritis may assume notice- 
able and even pysemic aspects, and is occasionally fatal. The bones and 
joints may become involved in painful and even suppurative swellings, 
not alone during the active stage of the disease, but during the period 
of convalescence ; while mildness of the primary attack does not neces- 
sarily provide immunity from later complications. Here, too, as in 
many other instances, thrombosis of large veins or thrombo-phlebitis is 
also observed. When the joints are involved, it is usually in irregular 
order and not simultaneously. Joint-lesion does not necessarily proceed 
to suppuration, perhaps only to the point of oedema and fluid exudation 
or hydrops. 
Dysenteric amoebae have been found by Kartulis in an osteomyelitic focus in the 
lower jaw of an Arab. 
Cholera. 
Cholera is usually too rapid and too violent in its course to be fol- 
lowed by secondary infections. Nevertheless, Poulet reports from Yal- 
de-Grace several instances of articular and osseous lesions, some of 
these characterized by mere effusion of fluid which was sometimes very 
thick and resembled balsam, while at other times pus was present. 
Pneumonia. 
Pneumonia having now taken its place as a distinct germ-disease, 
and the micrococcus of Frankel and the capsule coccus of Friedlander 
being now well established as the active agents in the two principal 
forms of this disease, we need not be surprised at finding collections of 
pus in various other parts of the body. For the most part, the surgical 
sequelae of pneumonia occur as a post-pneumonic pyarthrosis, which in 
time past was also considered as a rheumatic affection. These lesions 
are probably of embolic or, strictly speaking, of metastatic origin. 
Pysemic manifestations are noted occasionally after pneumonia, and patients 
even die essentially of post-pneumonic pyaemia or of terminal infections, rather 
than of pneumonia alone. Deep and painful bone-lesions, essentially of the type 
of acute infectious osteomyelitis, have also been noted; and in some of the joints 
involved in post-pneumonic pyarthrosis resection lias been necessary because of 
the extensive destruction of joint disease. Abscess in the brain has also been 
observed, as well as a double-sided parotitis and various other lesions of this gen- 
eral character, while the frequency with which empyema follows pneumonia is a 
matter of general acceptance. SURGICAL SEQUELAE. 
241 
Tuberculosis. 
So much has already been said about the general aspects of tuber- 
cular disease that it will be enough to simply recall here that in the 
course of pulmonary tuberculosis surgical expressions of the same infec- 
tion may be found in various parts of the body. 
Influenza, or G-rippe. 
Within the past few years this disease has assumed great prominence 
in medical literature, and not a few instances have been reported of 
surgical sequelae—abscesses, purulent ear disease, pyarthrosis, bone- 
lesions, etc. Even necrosis has been repeatedly observed. 
Although here, as in other instances, the surgical lesions by themselves do not 
have a peculiar type as does the original disease, nevertheless it must be borne in 
mind that the case of uncomplicated grippe of to-day may, a month hence, be in 
the hands of the surgeon for serious operation. I have had, for instance, to evac- 
uate a litre of pus from a large subfascial abscess which made its appearance while 
the patient was recovering from the acute stage of this disease, while no other 
explanation could be afforded than a secondary pyogenic infection because of the 
lowered tissue-resistance produced by the primary disease. It has been also 
observed that patients who when attacked by grippe are in the stage of recovery 
from operation are much more prone to suffer from complications, often serious, 
than others. They manifest also a remarkable slowness in the processes of repair 
and cicatrization. The eye, the ear, the pleura, the pericardium, the salivary 
glands, and the testes do not escape in such instances as these. 
Measles and Scarlatina. 
The frequency with which these exanthems are followed by surgical 
complications has been noted by many authors. Inasmuch as the infec- 
tious agent is not yet recognized, we must probably consider their sur- 
gical sequelae as due to secondary pyogenic infections, which are relatively 
very common. 
Remembering what has already been said upon the principal ports of entry for 
disease-germs, in connection with the notable lesions of the mucous membranes 
and the lymphadenoid tissue of the nasopharynx which are characteristic of these 
two diseases, it will be readily appreciated how pyogenic organisms may secure an 
entrance permitting their distribution to various parts of the body, while the 
lowered resistance of these patients permits the pernicious activity of these germs 
to make itself felt when otherwise it would not be. It is notorious that surgical 
tuberculosis appears often as a sequel of the exanthemata, and it is in no degree 
straining after effect when one explains the entrance of these germs in the way above 
described. Consequently, in the lymphatics, in the periosteum, bones, and joint- 
cavities especially, and in and about the eye and ear, we very frequently find mani- 
festations of suppurative disease. It is generally believed that these sequelae are 
more likely to appear when the eruption has been incomplete. The fact that 
hyperplastic thickening of periosteum and neuralgic pains of the affected parts are 
often met with without suppuration has given, in time past, some reason for the 
rheumatic character which Bonnet and others have ascribed to these manifestations. 
While the absence of pus takes these out of the category of pyogenic 
infections, it nevertheless leaves them still as surgical complications 
which have often to be dealt with by mechanical measures, such as 
orthopaedic apparatus, etc.; while too frequently more or less formidable 
operations, as for relief of ankylosis, etc., have to be performed. Post- 
scarlatinal arthralgia may be explained as a local ischaemia; so may 
acute swelling or chronic thickening. But pus is always an expression 242 
SURGICAL DISEASES. 
of infection, and cannot be otherwise regarded. Joint-distention with 
fluid which is not pus may even take place to the degree of producing a 
dislocation, and I have seen luxation of the hip from this cause. Twice 
I have also seen spurious ankylosis of the knees in bad position as the 
result of tissue-changes consecutive to scarlatina. On the other hand, 
the pysemic features of such affections may be excedingly rapid. Trous- 
seau has related the case of a girl whose wrist was already swollen and 
painful on the second day after an outbreak of scarlatina, while the child 
died upon the fifth day, all her joints being filed with greenish pus. 
That streptococci have much to do with scarlatina has been established 
by numerous investigators, though we are not yet in position to say posi- 
tively that the disease is a streptococcus invasion. Nevertheless, these 
organisms will easily account for the pus met with in these cases, and I 
have repeatedly found them in post-scarlatinal lesions. Retropharyn- 
geal abscesses and a peculiar necrosis of the alveolar process of the jaws, 
particularly described by Salter, are among the various serious surgical 
complications of scarlatina. Epiphyseal separations and purulent 
destruction of ribs have also been noted. 
Typhoid. 
Although in elaborate treatises, as by Liebermeister and Murchison, 
bone- and joint-complications find no mention as sequels of typhoid, 
they have nevertheless long been recognized by surgeons. Post-typhoid 
hip-dislocations have been reported by several German surgeons. Boyer 
observed spontaneous dislocation of both thighs after what he called 
“ essential fever,” and the general topic of spontaneous luxations sub- 
sequent to typhoid has been seriously discussed by the German Congress 
of Surgeons. 
Those affections of joints which used to be considered rheumatic occur much 
less often after typhoid than after dysentery. Nevertheless, post-typhoidal arthral- 
gia and myodynia have been recognized by several French writers. Probably not 
a few times patients with affected joints, supposed to be rheumatic, have later 
been discovered to be suffering from genuine typhoid fever, and it has been after- 
ward recognized that the joint-lesion was merely a bizarre expression of the 
typhoid poisoning. The works on general practice call attention to the frequent 
complications of the pleural and pericardial serous membranes in this disease. 
They say little, however, about the implications of the articular serous membranes, 
though one is as easy to explain as the other. Post-typhoidal polyarticular serous 
arthritis has been described by more than one writer. Multiple joint-abscesses 
have been more rarely seen. Pus has also been known to collect, not only in the 
joints, but in the tendon-sheaths and bursae. The lymph-nodes are also frequently 
affected, and cervical, axillary, and inguinal abscesses are not rare. Post-typhoidal 
pyarthrosis, as leading to spontaneous luxation, has had even a medico-legal 
interest, since luxation has been known to occur while raising or lifting a patient, 
the question of violence being subsequently brought into court. When the joint 
disease assumes the monoarticular form it is likely to terminate in suppuration ; 
when polyarticular, pyarthrosis is much less common. In the pus from many 
of these abscesses typhoid bacilli may be recognized, but by no means in all. I 
have found them in a case of abscess in the abdominal wall occurring during con- 
valescence from typhoid in a young woman. A non-suppurative but extremely 
painful form of periostitis is occasionally met with; and I never have seen more 
exquisite tenderness nor expressions of greater suffering than I met with in a case 
of this kind in a young lad in whom the bones of both lower extremities, of the 
pelvis, and the lower spine were all involved. The slightest jar upon the floor 
called out a cry of pain, and to minister to his ordinary wants was a most distress- SURGICAL SEQUELS. 
243 
ing task. He eventually recovered without any pus-formation. Deep suppura- 
tions in bone are less often met with, but occasionally occur; even necrosis with 
separation of sequestra has been noted. 
Thrombosis and thrombo-phlebitis are also well-known sequels of 
typhoid, which may lead to most unpleasant complications. Typhoid 
fever appears to bear a peculiar relation to the growth of bones, since it 
has been noticed that during its course, or during convalescence, they 
show an extraordinarily rapid growth in length, even to the extent of 
1 mm. a day. This is probably caused by the irritation of the typhoid 
toxine upon the osteogenic tissue, since hypersemic areas have, by numer- 
ous observers, been found in the bone-marrow of those dying of the 
disease, and bone-pains are a frequent accompaniment of the disease. 
Typhoid bacilli have the power of remaining latent in the tissues for 
considerable lengths of time after cessation of all active symptoms, and 
they have been found alive and capable of active growth so long as 
seven months after cessation of the fever. Remembering the multiple 
ulcers of the lymphoid tissue which characterize the intestinal lesions of 
typhoid, one will not find it hard to explain pyogenic or other septic 
infection by absorption through these open ports of entry ; and the 
typhoid bacilli themselves, entering the circulation through these paths, 
may be carried to all parts of the body, and have been found in the pia 
—in fact, everywhere. 
Diphtheria. 
This also belongs to the diseases frequently complicated by lesions, 
aside from those of laryngeal obstruction, calling for surgical relief. 
Abscess occurs so frequently as to scarcely call for comment. Here, as 
in the cases of scarlatina, the location of the throat-lesions and the 
absorbing powers of the lymphadenoid tissue so completely involved 
will readily account for all septic or pyogenic manifestations at a dis- 
tance. Multiple abscesses have been found, for instance, in the liver, 
the spleen, and lungs, in and around the bones—everywhere, in fact, 
where abscesses can form—betokening thereby a pysemic manifestation. 
Infectious nephritis is also common. It is also notorious that patients 
recovering from diphtheria have a lowered susceptibility, as against other 
infections, of indefinite but considerable duration; consequently, post- 
diphtheritic tubercular invasions are common. Nevertheless, post- 
diphtheritic multiple pyarthrosis of ordinary pyogenic type has been 
repeatedly noted, numerous joints being involved, even the temporo- 
maxillary and the costo-sternal. 
Other forms of septic angina, pseudo-diphtheritic, etc. are also liable to be fol- 
lowed by evidences of septic infection at a distance, the tonsils and any decayed 
teeth which may be present probably serving as paths of infection. I have seen, 
for instance, a case of most serious tonsillitis, where for hours we stood ready to 
make tracheotomy for relief of threatened suffocation, in which extensive abscesses 
developed about one knee and the lower part of the other leg. 
Mumps. 
The infectious character of this disease is not questioned to-day, 
although not definitely established. Orchitis, ovaritis, stomatitis, 
enlargement of the tonsils and spleen, and albuminuria are frequent 244 
SURGICAL DISEASES. 
accompaniments of the disease, while articular and periarticular compli- 
cations have been noted by several writers. Bursal abscesses and pyar- 
throses have also been reported. In time past these surgical complica- 
tions have been spoken of as rheumatoid or rheumatic, their essential 
significance not being recognized until comparatively recently. 
Variola. 
The writers of the earlier part of this century allude frequently to 
the rheumatoid complications of smallpox, among which pyarthrosis 
seemed perhaps the most common, as certainly the most serious. The 
various arthropathies are the most interesting of the surgical complica- 
tions of this disease. That joints become swollen, red, and painful is 
not infrequently noted, and that one joint after another is involved is 
also the usual programme. 
Some have held that because the periosteum, and even the endocardium, 
become inflamed, this must be a rheumatism, but this will not be claimed to-day in 
the light of our knowledge of the infectious diseases. Necrosis with spontaneous 
elimination of sequestra has also been noted. Trousseau mentions that joint- 
inflammations following smallpox very easily take on a purulent character, but 
unmistakable pyaemia appears to be a rare complication. The occurrence of acute 
abscesses in bones has also been noted. Considering the nature of the pustules 
characteristic of variola, and their multiplicity, it is a source of surprise that sup- 
purative internal comjflications do not occur very much oftener than appears to be 
the case. 
Cerebrospinal, Meningitis. 
It is now well established that this disease, certainly in its epidemic 
form, is of microbic origin. This being the case, we need not be sur- 
prised to find evidences of secondary infection, providing only that 
patients live long enough to develop them. Too often death occurs 
with such rapidity that time for secondary symptoms is scarcely offered. 
Nevertheless, the studies of such authors as Grisolle, Lave ran, and 
others show that we have occasionally articular complications between 
the fifth and eleventh days, should life persist so long, and that these 
not infrequently assume the suppurative type. The larger joints are 
those commonly attacked, including probably those of the vertebral 
column. 
If suppuration may occur at all in this disease, as is well known it may, there 
is no reason why the meningeal cavity should not be treated as is the peritoneum 
or any other serous cavity when involved in an acute pyogenic infection—i. e. 
opened and drained. To be sure, this is a more serious operation, because of its 
honv covering, than it is to open most of the other serous cavities. Nevertheless, 
it is as plainly indicated, and success has followed the procedure in a fair propor- 
tion of the few instances in which it has been tried. It at least is as promising 
as non-operative treatment, and often more so. (For a further discussion of this 
the reader is referred to Chapter I., Volume II.) 
Infectious Endocarditis. 
The individuality of this condition has been recognized only within 
the last thirty years, and accurately only within ten. That it deserves 
the characterization of “ malignant” often given to it is well known. It 
is, in fact, an infectious disease with a special localization in the heart, 
the term cardiac typhus, given to it by some, being very expressive. SURGICAL SEQUELAE. 
245 
Although so apparently spontaneous, it is itself, in fact, usually a sec- 
ondary lesion, perhaps sometimes a primary infection. When we con- 
sider the peculiar location of the disease, we shall have no difficulty in 
appreciating the readiness with which metastatic complications may 
arise. The arthritic manifestations, too, often assume a pysemic cha- 
racter, and even at the beginning of the affection, as Trousseau pointed 
out, there are frequently severe joint-pains. Abscesses may form very 
rapidly, while around the joints there occurs oftentimes diffuse oedema, 
which is simply another expression of the intensity of the disturbance. 
The infectious character of these complications should be kept distinct 
from the category of multiple hemorrhages and articular effusions of 
purely serous character which accompany the so-called non-septic form 
of endocarditis—kept distinct, at least, until there is more argument for 
its infectious character than we now have. 
Nearly one hundred species of micro-organisms from the mouth 
have been studied and identified by W. D. Miller, who has clearly 
established that dental caries is due to the specific action of some of 
these parasites, which, gaining entrance into the dental tubules, deter- 
mine fermentation and acid-production, with erosion of the dental struc- 
ture of the teeth and an increase in softening and destruction. In this way 
the teeth, as already indicated in Chapter III., become wide-open paths 
of infection for germs which may travel but a short distance, causing 
only local disturbance, or which may be carried to other points about 
the head, producing disturbance in the antrum, in the neighboring bones, 
in the middle ear, and not infrequently in the brain. Abscess in the 
brain has been distinctly traced to caries of the teeth. Tubercular in- 
fection is also common through this channel, and its most common ex- 
pression is probably the invasion of the cervical lymphatics, superficial 
and deep, constituting those lymphatic tumors of the neck formerly 
known as scrofulous, with their disastrous train of adhesions, suppura- 
tion, erosion, etc. 
Dental Caries. 
Syphilis and Gonorrhoea. 
These are surgical affections whose secondary complications in the 
way of abscesses, infarcts, tumors, etc. will be dealt with in other parts 
of this work. It will simply be well to group all of these infections— 
those just mentioned—along with anthrax, glanders, etc. into a class of 
infections which may be followed by tardy or very late surgical sequelae 
which may call for more or less radical operation. In the case of gon- 
orrhoea this is seen best, perhaps, in the so-called pus-tubes of the female 
pelvis, which often call for operations years after the date of the pri- 
mary invasion. 
The Puerperal State. 
This is seldom followed by surgical sequelae, save in the instance of 
mechanical lacerations demanding plastic repair, or of septic infections, 
which, when life is saved, sometimes lead to disastrous, though remote, 246 
SURGICAL DISEASES. 
consequences. Puerperal septicaemia is in no respect different, path- 
ologically speaking, from septicaemia due to any other presumably strep- 
tococcus invasion; and the predilection which streptococci manifest for 
serous membranes, and especially joints, is well known. Consequently, 
after puerperal fever one may meet with articular or periarticular ab- 
scesses, affections of tendon-sheaths, lymphatics, etc., or the complica- 
tion may assume a different type, the veins and their contents being 
mainly involved, with thrombosis, infarct, etc. for its immediate results. 
The possible outcome of these various lesions will be appreciated if one 
simply reflect upon the known course of the blood and bear in mind the 
facts stated in Chapter II. 
As stated at the outset, it was intended to make this chapter sug- 
gestive rather than complete. In summarizing it would be well, prob- 
ably, to say that there is probably no disease of known or suspected 
germ-origin which may not be followed by disastrous or unexpected 
surgical complications, while even those degenerative changes for which 
as yet no theory of parasitism has been invoked are followed by con- 
ditions, often painful in the extreme and crippling, which may call for 
most serious surgical measures. In other words, the surgical complica- 
tions of any so-called non-surgical disease may loom up at any moment 
in any case, and may even tax to the utmost the resources of a surgeon, who 
should he promptly summoned in the unwillingness of the general practi- 
tioner to act as such. Surgical sequelae are always unfortunate, but are 
always most so when unfortunate delay in their recognition or in sum- 
moning special help has been permitted to occur. CHAPTER XV. 
POISONING BY ANIMALS AND PLANTS. 
Roswell Park, M. D. 
Certain poisons or deleterious substances are introduced in various 
ways into the human system from without, some of which produce only 
symptoms of moderate intensity, while others are quickly fatal. Thus, 
it is authentically stated that in India many thousands of individuals 
lose their lives every year as the result of the bites of poisonous snakes. 
Nothing approaching such injuries in frequency or intensity can be found 
in any other part of the world. Animal poisons may be introduced by 
animals of many species. The poison of hydrophobia has been already 
sufficiently described. The bites of the mammalia may be serious and 
may be followed by septic symptoms, but they are not regarded as due to 
any special toxine secreted by the animal. A number of reptiles, how- 
ever, possess special poison-glands which, for the most part, are con- 
nected with a tooth on either side of the upper jaw which is canal- 
iculated and serves as a duct through which the poison is injected when 
the animal inflicts its bite. 
The principal poisonous serpents in North America are the rattlesnakes—of 
which there are several species, usually placed at eighteen—the copperheads, the 
moccasins and the vipers. Some of these have movable poison-fangs, some fixed. 
In other parts of the world others equally or even more poisonous are known. 
The poison-gland is analogous to the parotid in location and structure. The 
duct which runs through it is so dilated as to contain a small amount of the pecu- 
liar poison. The amount of poison contained in these reservoirs varies from eight 
to twelve minims, and is secreted somewhat slowly. It seems to be, in some cases 
at least, a glucoside; in others, a toxalbumen. It is capable of being preserved 
either dry or in alcohol or glycerin. The active poisonous principle seems to per- 
tain to a globulin or to a peptone. Almost all of these venoms are innocuous if 
swallowed, and like septic infections seem inoculable only through the tissues and 
the circulating fluids. According to Mitchell, the venom of the rattlesnake 
renders the blood incoagulable, paralyzes the wralls of the capillaries, and facili- 
tates escape of leucocytes into the tissues, thus making actual hemorrhagic swelling 
occur easily; while the red corpuscles rapidly lose shape and fuse together into 
irregular masses and their haemoglobin is dissolved or disappears. This poison 
seems to paralyze both the respiratory centre and the heart. Cobra-poison, not 
containing globulin, at least to such extent, does not produce the rapid changes of 
rattlesnake poison. 
Symptoms.—A snake-bite is like a hypodermic injection of a deadly 
poison, and symptoms set in usually very promptly. These are both 
local and general. There is more or less local pain, with swelling and 
discoloration, these being due to effusion of blood. They increase in 
intensity, and are followed by vesication and necrosis of tissues—i. e. 
gangrene—if the patient survive long enough. Constitutional symp- 
247 248 
SURGICAL DISEAS US. 
toms are not long delayed, and are characterized by severe prostration, 
including cold, clammy sweat, feeble and rapid pulse, irregular respira- 
tion, etc. When patients die, they die usually in collapse. The patho- 
logical changes are not sufficiently well marked or characteristic to 
detain us here. 
Treatment.—Treatment of snake-bite must be most prompt if it is 
to be successful. It should consist of the promptest possible incision 
and drainage of blood from the part, with application of a tight ligature 
or tourniquet above the bite, in order to prevent diffusion into the rest 
of the body by means of the returning blood and lymph. Bleeding 
should be facilitated by cups or by sucking of the wound. If there be 
any known antidote to snake-poison, it consists of potassium perman- 
ganate or calcium hypochlorite (chloride of lime), which may be applied 
locally in solutions, the former strong enough to have a very marked 
color and capable of producing local irritation (1 per cent.). Along 
with these local measures, constitutional stimulation should be most 
active by means of both volatile and other stimulants. There is a 
popular fallacy in favor of inducing alcoholic intoxication. To do 
this is undoubtedly a mistake. Nevertheless, alcohol may be given 
freely, dosage being limited not by amount, but by effect. Strychnia, 
digitalis, atropia, etc. will often prove serviceable. The tourniquet 
should be after two or three hours very gradually released, while one 
should be ready to antidote the poison which may thus enter the system 
with the necessary doses of stimulants above mentioned. Even so much 
strychnia as half a grain may be administered in divided doses with 
happy effect, it being apparently, in large measure, a true antidote to the 
snake-venom. There is much reason from recent experimentation to 
expect benefit from a serum-therapy—i. e. by injection of serum from 
immunized animals who have been fortified by increasing doses of the 
snake-poison. In this country such treatment, however, will be called 
for so seldom that there is not the hopeful outlook for the serum-therapy 
of snake-bite that there is in India. 
A large lizard found in the southwestern part of this country and in 
Northern Mexico, known as the Gila monster (Helodenna suspectum), 
is generally credited with being a poisonous animal. The probability 
is that the bite is fatal to some of the lower animals and may produce 
more or less serious disturbance in man. Nevertheless, there is little 
real evidence that this is to be considered in the same category with the 
venomous serpents above mentioned. 
Certain species of spiders are venomous, the tarantula being the 
best known. Certain scorpions also inflict poisonous stings, and centi- 
pedes and other animals occasion at least serious local disturbance by 
bites or stings. These insects and animals seldom attack unless irritated 
or disturbed. Tarantula-bites are occasionally inflicted in the Northern 
States by spiders which have concealed themselves in shipments of fruit, 
bunches of bananas being especially likely to be their hiding-places. 
The injuries inflicted by these animal organisms cause local pain, con- 
siderable swelling, with remote effects on the nervous system, prostra- 
tion, restlessness, etc. They are seldom fatal, but may cause exceeding 
great annoyance and even serious disturbance. These cases are to be 
treated in the same way as bites of poisonous serpents, adapting the POISONING BY ANIMALS AND PLANTS. 
249 
measures and the energy of the treatment to the severity of the symp- 
toms. 
Wasps, hornets, and bees are capable of inflicting severe stings, 
while smaller and more domestic insects, like mosquitoes, bedbugs, etc., 
inflict minute injuries, which, nevertheless, sometimes occasion excessive 
annoyance. Their sting is followed by pain, burning sensation, some- 
times intense itching, and more or less swelling. Enough poison is 
deposited to produce local vasomotor paralysis, as the result of which 
wheals resembling those of urticaria, or more extensive swellings, quickly 
result. If the sting of an insect has been broken off' in ridding one’s 
self of it, it may remain and intensify the disturbance. Two or three 
injuries of this kind create at most local disturbance, but there are 
numerous instances on record where men and animals have been stung 
to death when attacked by swarms of these little enemies of our race, 
death apparently being due to intensification of effect owing to increased 
dosage of poison. If a sting occur upon loose tissues, like the eyelid, or 
upon the tongue or lips, swelling and suffering may be extreme. If 
symptoms of depression present, they must be combated by stimulants, 
diffusible or other, and by hypodermic medication pro re natci. Local 
discomfort may be alleviated by ice, by menthol, by chloral-camphor, etc.1 
The arrow-poison of various Indian and savage tribes is a compo- 
sition of very variable and usually unknown nature. It is compounded, 
for the most part, from vegetable substances, and, if one may judge from 
the specimens of curare sold by importing houses, their strength must 
be most unreliable. 
While some of these preparations are made by the natives from species of 
Strychnos growing in the northern part of South America, this tree certainly is 
not in universal use for this purpose: in the East Indies they are made from a 
species of Upas (the deadly Upas of song and story). Some of the poisoned arrows 
of certain tribes are dipped in putrefying blood. A wound made by these is not 
necessarily promptly fatal, but would tend to kill by setting up septic disturbance. 
The vegetable poisons have, for the most part, the property of paralyzing the 
motor nerves and the circulation, to such an extent even that death may occur 
within a few moments after injury. All of these poisons are innocuous when 
swallowed, and game killed by their agency may be eaten with impunity. Arrow- 
poison of the vegetable variety which is not fatal within a few hours may be 
recovered from if only stimulation be vigorous enough. Artificial respiration is a 
factor of very great importance in keeping such patients alive. 
Many of the lower forms of marine animals are capable of inflicting 
stings by their rays, or minute injuries in other ways, which give rise to 
great temporary annoyance. The stinging nettle, etc. are instances of 
this kind. The lesions produced in this way partake of the nature of 
a more or less acute dermatitis. 
In the vegetable kingdom there is one species of plant which is 
capable in certain instances of producing the most intense dermatitis. 
I refer here to the so-called poison-ivy (Rhus toxicodendron, etc.). Not 
all individuals are susceptible to this poison—least so those of thick 
skin and dark hair. It is rather those of blond type and thin skin who 
seem most liable to its irritation. 
1 Oil of lavender is a pleasant means of local protection against mosqnitoes, etc. Oil 
of tar is also in common use. A mixture of equal parts of camphor and chloral, with 
menthol dissolved in the mixture (camphor and chloral when mixed without other 
ingredients quickly form a dense fluid like glycerin), gives great local relief from the 
itching and pain of insect-bites. 250 
SURGICAL DISEASES. 
The active agent is toxicodendric acid, and it is capable of setting up the most 
intense irritation of the eczematous type, with a large amount of hypersemia and 
oedema, especially of soft tissues. Thus, when the face is involved the eyelids 
become so puffed as to make it almost impossible to separate them for purposes 
of vision. Ivy-poisoning comes practically always from contact with the plant, 
which grows in various parts of the country, and with which one may come 
in contact in most unexpected places. Symptoms supervene usually within 
twenty-four hours, probably much less, and in well-marked cases do not subside 
for three or four days. The itching is almost intolerable, and is best combated by 
strong alkaline solutions or brine. A very dilute bromine solution is also of very 
great benefit, but is not always ready at hand in instances of ivy-poisoning in the 
woods. Salt and soda, however, are nearly ahvays at hand, and can be used with 
great relief in pretty strong solutions. Vigorous catharsis will also help, and 
hypodermic injections may be necessary for the enjoyment of sleep. 
Certain other species of sumach will also produce similar symptoms, usually 
less severe, in a comparatively small proportion of susceptible individuals. This 
is true in milder degree of certain species of the genus Cypripedium. CHAPTER XVI. 
ACUTE INTOXICATIONS, INCLUDING DELIRIUM TREMENS. 
Roswell Park, M. D. 
Delirium tremens as an expression of acute or subacute alcoholic 
poisoning is in no essential degree a surgical condition. Nevertheless, 
it so notably and often so disastrously complicates surgical cases that it 
is necessary to take it into account in this place. This form of toxic 
delirium may occur while the individual is still drinking hard, or not 
until several days have elapsed after active drinking has ceased. It is 
precipitated in many cases, where otherwise it would simply remain 
imminent, by surgical injuries and operations. In an individual in whom 
it is feared, we should become apprehensive in proportion as the muscu- 
lar system becomes unsteady and tremulous, the mind disturbed, and 
the individual sleepless. It conies on usually with anxiety of counte- 
nance, with more or less hallucination, which is often of a frightful 
nature, with fright at trifling incidents, with restlessness, and with curi- 
ous perversions of sensation, the patient hearing imaginary noises, see- 
ing visions of everything that is disagreeable, and tortured by sensa- 
tions of insects, reptiles, etc. upon his person. Insomnia deepens per- 
haps into absolute terror, and there is refusal to take food. Patients 
become rapidly reduced in strength, and are absolutely irresponsible for 
their actions, with respiration irregular, surface bathed in perspiration, 
urine scanty, bowels sluggish, tongue tremulous and furred, and often 
such disturbance of the stomach that there is rejection of all kinds of 
food. Should the case go on from bad to worse, prostration increases, 
tormenting hallucinations may increase, the patient remains either 
furious or stupid, agitation and muscular tremor are constant, the urine 
becomes nearly completely suppressed, and death, perhaps preceded by 
convulsions, finally terminates the case. Should the case not prove so 
serious, there is usually abatement of illusions and hallucinations; the 
patient begins to sleep restfully, although perhaps only for a short time ; 
gastric irritability subsides; nutrition is resumed; pulse and respiration 
become more regular; reason returns to the disturbed mind; and ame- 
lioration follows in every respect. 
Patients in a well-marked condition of delirium tremens become 
often so uncontrollable and so lost to sensation of pain that it may be 
practically impossible to enforce the physiological rest which their sur- 
gical condition demands. The restraining sheet will answer for general 
purposes, but the strait-jacket, and even the most carefully applied 
plaster splint or mechanical restraint, will not always be sufficient to 
carry out the indication. Ingenuity may be taxed beyond its limit to 252 
SURGICAL DISEASES. 
enforce the needed rest, for patients will tear off bandages and injure 
themselves in various ways. 
Treatment.—The local indications, as just expressed, are in the 
direction of physiological rest if it can possibly be enforced. Constitu- 
tionally, the indications are in two directions : First, to keep up nutrition 
and excretion; secondly, to properly medicate. Nutrition is difficnlt 
unless excretion be maintained. Hot-air baths, laxative enemata, pref- 
erably of cold water, when necessary, and administration of a fluid and 
easily assimilable diet are measures of the utmost importance. Should 
the case present features of an acute alcoholic gastritis, stomach-feeding 
may be altogether abandoned and the rectum utilized for this purpose. 
Medication must consist mostly of stimulants, with such sedatives, laxa- 
tives, diuretics, etc. as may be necessary. Whatever may be the general 
wisdom of the course, it is probable that in surgical cases it is not wise 
to abruptly deprive these patients of the alcohol which they have so 
abused. Consequently, it is well in many instances to continue a mild 
degree of alcoholic stimulation, at least for a time, letting them down, 
as it were, by the easiest possible stages. Two stimulants rank higher 
than all others put together as substitutes for alcohol, and in some 
degree antidotes to its effect. These are strychnia and digitalis. The 
former should be given preferably subcutaneously; the latter by the 
stomach if tolerated; otherwise, by the rectum or beneath the skin. 
My own preference for the use of digitalis is in the direction of large 
and few doses. I have not hesitated in many instances to give 15 c.c. 
of ordinary tincture, repeated once or twice at intervals of a few hours, 
and then to discontinue it. The effect is both to brace up the heart and 
to equalize the circulation, while at the same time it acts as a most 
efficient diuretic; and I never have had occasion to regret such doses; 
on the other hand, I have often seen them do great good. 
Of the sedatives, bromides, chloral, and remedies of that class are those most 
often resorted to, and must be given in doses sufficient to meet the indication. One 
should remember, however, that they are all more or less depressant, and that 
stimulation by strychnia, etc. is necessary even while they are being administered, 
in spite of the apparent physiological antagonism between them. Occasionally 
nothing will take the place of opium, best given in the shape of morphia intro- 
duced beneath the skin. Whatever may be one’s tastes or preferences for drugs 
under ordinary circumstances, he can but feel that in serious surgical cases com- 
plicated by delirium tremens the first indication is toward the surgical lesion, and 
preferences, past methods, etc. must all be secondary to enforcing such quietude 
as shall permit repair of injury. The first indication, then, in most of these 
instances is in the direction of ensuring rest and sleep, even at the expense of 
inconvenience or misfortune in other directions. I write this with a full realizing 
sense of its significance, yet with positive conviction as to its truth. 
Entirely distinct from the forms of poisoning and of toxaemia already 
considered, and yet sufficiently allied to the caption of this chapter to 
require mention here, are certain other forms of toxaemia whose brief 
consideration is indispensable at this time and place. Of these I will 
first speak of— 
Traumatic or Post-operative Mania. 
Tliis it would be difficult to distinguish from a form of mania uni- 
versally recognized and known as puerperal mania, the two conditions ACUTE INTOXICATIONS, INCLUDING DELIRIUM TREMENS. 
253 
being, I take it, essentially similar. Regarding these cases from a 
surgeon’s standpoint, and carefully avoiding any attempt at minute 
explanation of the phenomena, I would only say that such cases are 
met with in the practice of operating surgeons, as in the experience of 
obstetricians, presenting themselves either as mild forms of harmless 
mental aberration, or assuming almost any of the types of insanity as 
made out and classified by experts in that subject. From the mildest 
mental alienation, then, up to furious and even homicidal or suicidal 
mania, one may meet with all degrees of departure from the normal 
standard. 
I think it is generally conceded that these cases are to be viewed as indicating 
a toxaemic condition whose special manifestations concern the brain and mental 
activities of the patient. They are of vital importance to the surgeon, however, 
because sometimes in these conditions his most earnest and intelligent efforts are 
interrupted or rendered futile by the still greater emergency which may exist 
of controlling a patient and keeping him even from committing suicide. 
Undoubtedly, in some cases these toxic conditions are due to drugs which have 
been used, among which iodoform is best known to produce such effects. The alco- 
holic forms have already been spoken of under Delirium Tremens, while yet other 
disturbed mental conditions are the immediate or remote consequence of adminis- 
tration of such drugs as chloral, opium, etc. Nevertheless, the fact remains that 
in certain instances the symptoms cannot be referred to any drug save possibly 
the ancesthetic which may have been administered for the performance of a severe 
operation. In my own experience, leaving out of consideration patients who were 
more or less addicted to alcohol, I have seen traumatic mania in more or less 
mild form more often in women after breast-amputations than in any other class 
of cases. Usually here it has assumed a melancholic type, and has called for little 
or no attempt at repression or restraint. I have been led to regard these cases, 
when not due to drugs, as apparently due to interference with the natural metab- 
olism of the tissues of the body, probably because of interference with excretion; 
and I have noted that these cases occur most often in individuals whose excretion 
is habitually poor. This should be regarded as another reason for careful prepara- 
tion of patients by the means already considered in Chapter VI., on Auto-infec- 
tions. But when a patient shortly after a severe operation develops a mania of 
this form and becomes violent or intractable, then almost every other considera- 
tion must yield to the necessity for restraint and, so far as may be, ensuring 
physiological rest, for which purpose I hold it wise and life-saving to subordinate 
every other consideration save nutrition and excretion to this purpose, and to 
give whatever strong anodyne or hypnotic may be called for, in order to achieve 
this primary purpose. It is often found, however, that a vigorous purgative or a 
series of hot-air baths, or other means by which elimination is furthered, will give 
a better ultimate soothing effect than will any of the “ drugs which enslave.” 
With little children who become more or less delirious, especially during sleep, 
after even trilling accidents, a mild manifestation of this condition need excite 
but little surprise. It is rather with adults in the later decades of life, with more 
or less sclerosed arteries and faulty excretion, that one feels most apprehension; 
and some of these cases are those which call even for stimulants rather than for 
sedatives. No succinct directions can be given which shall be universally 
applicable, but every such case must be treated upon its merits. 
Toxic Antiseptics. 
As stated above, it is generally recognized that in people perhaps of 
peculiar idiosyncrasies the administration of certain drugs ordinarily 
considered harmless is followed by more or less toxic symptoms. 
Obviously, if this were universally the case, or even in the majority of 
instances, the use of these drugs would speedily be abandoned. As it 
is, it is well to at least have in mind the consequences which are 254 
SURGICAL DISEASES. 
occasionally known to ensue, and perhaps to weigh in every case the 
chances as to whether it be worth while to use a given substance of 
known occasional toxic power as against another which is not known to 
possess it. 
Of the less active antiseptic agents, there is, for example, boric acid, 
ordinarily considered absolutely innocuous, yet which is known rarely 
to cause intestinal disturbance, while in at least one instance serious 
toxic effects followed its use. Naphthalin also, ordinarily considered 
as harmless, will sometimes produce vertigo or vasomotor symptoms, 
especially when administered internally. So many of the antiseptic 
materials used are more or less irritating to the skin that such local ex- 
pressions as eczema, etc. provoke very little comment except on the part 
of the patients, whose comfort is sometimes temporarily very much dis- 
turbed by their action. Yet, inasmuch as it is the patients’ welfare which 
we ordinarily seek, we must remember that the drug-eczema produced 
by corrosive sublimate, much more rarely by other antiseptics, which 
may so disturb a patient as to prevent sleep and make him irritable 
and particularly restless, is undoing very much of the good which we 
have sought to do him, because it is interfering with one of the first 
essentials of ideal wound-healing—i. e. physiological rest. 
Iodine, by itself or in certain combinations, is a drug whose activity 
should never be forgotten. Applied upon the surface, it ordinarily tans 
the skin, and, aside from being objectionable, does no good. Injected 
in solutions of varying strength, as it has been in times past more than 
at present, into serous cavities (for example, hydroceles, etc.), it 
occasionally gives rise to symptoms which may even be alarming. 
Fatal poisoning following its injection into an ovarian cyst has been 
reported, and I have seen alarming symptoms produced by injection of 
the ordinary solution into a hydrocele sac. Much of the virtue or- 
dinarily ascribed to iodoform is supposititiously credited to the libera- 
tion of free iodine by its decomposition. Whether or not this be true, 
it is certain that iodoform is one of the most frequently toxic of the 
antiseptic agents in ordinary nse. In mild cases it produces headache, 
restlessness, wakefulness, and often a distinct taste of iodoform in the 
mouth. In more pronounced degrees of poisoning there is fever, with 
often mental derangement which may amount to delirium or even to 
acute mania, and may cause well-founded suspicion of meningitis. 
Death has repeatedly occurred, from syncope or in coma, after its use. 
Carbolic acid produces unpleasant effects, both upon patient and 
operator, or with whomsoever it may come in contact. Aside from 
its local effect upon the skin, which is most unpleasant, but which 
usually passes away within a few hours, it seems to affect especially the 
kidneys, causing often temporary albuminuria with discolored urine, 
deranged secretion, aiid sometimes much more acute forms of disturb- 
ance, similar to those met with after its internal use. Carbolic poison- 
ing was met with most frequently during the era when Lister’s original 
directions were scrupulously followed, and at a time before we learned 
that it is much better to remove dirt than to try to antagonize its action. 
Certain eminent operating surgeons were even compelled to discontinue 
its use because of its unpleasant effect upon themselves as well as upon 
their patients. ACUTE INTOXICATIONS, INCLUDING DELIRIUM TREMENS. 
255 
Finally, of all the powerful antiseptic agents in common use, the 
most active are the soluble preparations of mercury, ordinarily corro- 
sive sublimate, in solutions of varying strength, which are used for 
irrigation, douching, etc. and for preparation of dressings. Aside from 
an intense and even serious eczema which may follow its local use, one 
may meet with any or all of the expressions of mercurial poisoning 
after using it, particularly on certain individuals of peculiar suscepti- 
bility to this drug. Salivation, intestinal irritation, and all other well- 
known phenomena of mercurial poisoning have been occasionally pro- 
duced, with the result that the solutions and preparations of corrosive 
sublimate now used are much weaker than those which were used at 
first, and that in many instances where it is desired to avail one’s self 
of its properties we at the same time protect the area involved against 
toxic activities by dusting with some standard sterilized powder or by 
anointing it with some sterilized ointment which shall protect the skin, 
while at the same time permitting the dressings to be applied where 
they may best absorb wound-discharges. PART III. 
SURGICAL PRINCIPLES AND METHODS AND 
MINOR PROCEDURES. 
CHAPTER XVII. 
CONTROL OF HEMORRHAGE; ABSTRACTION OF BLOOD; 
PARACENTESIS; COUNTER-IRRITATION. 
John Parmenter, M. D. 
Control of Hemorrhage. 
The methods of controlling- hemorrhag-e are many, and vary 
according to the nature of the hemorrhage, the situation of the vessels 
concerned, etc. The subject will be considered in a general sense only 
in this place. We may divide our measures for the control of hem- 
orrhage into Temporary and Permanent. 
I. Temporary Measures.—Among the recognized temporary expe- 
dients are (a) Digital compression, which implies the use of the finger or 
thumb applied over the bleeding point or over the vessel at some acces- 
sible place in its continuity. The amount of force required for all 
vessels, provided they are situated superficially, is surprisingly little. 
(More force is required for arteries than veins, of course, and also 
where a large muscle-covering exists without underlying bone against 
which to press the vessel.) Alien the vessels lie deeply, however, this 
Fig. 79. 
C.TIEMAWB. 
&. CO. 
method is too tiring and inexact to be depended upon. Furthermore, 
long-continued pressure may endanger the vitality of the adjacent tis- 
sues. This danger and that of the conversion of an open into a con- 
Haemostatic forceps. 
257 258 
SURGICAL PROCEDURES. 
cealed hemorrhage constitute two sequelae resulting from injudicious 
pressure which should always be avoided. 
(h) Hcemostatie Forceps.—These serve a double use—to crush the 
vessel (in case of arteries) and to differentiate it from the adjacent tis- 
sues prior to torsion or the application of a ligature. It has bluntly 
serrated ends which easily catch and crush the vessel. Forceps are of 
various forms and sizes. For brain and intestinal work the haemostatic 
used in Johns Hopkins Hospital and shown in Fig. 79 is especially 
useful because of its delicate but firm ends. For small arteries forceps 
usually effect permanent closure after a few minutes’ application. Even 
the largest vessels may be closed if the pressure continues sufficiently 
long. In using haemostatic forceps great care should be employed not 
to include any tissue excepting the vessel itself. Local necrosis is often 
caused by the too prolonged application to too much tissue, and doubt- 
less frequently leads indirectly, if not directly, to suppuration in other- 
wise aseptic wounds. In removing the forceps it should not be made to 
drag upon the vessel, and should be slowly removed in order not to dis- 
turb the clot already formed. 
(c) Tourniquets.—Of these the commonest, cheapest, and most gen- 
erally useful is the Esmarch tourniquet, which is a piece of f-inch 
rubber tubing about If to 2 feet long, 
with a hook at each end. A sim- 
ple rubber bandage does equally well. 
Where neither is obtainable a hand- 
kerchief may be bound around the 
part and tightly twisted with any kind 
of stick (cane, umbrella, etc.). As a 
means of controlling hemorrhage tour- 
niquets possess certain elements of dan- 
ger. If applied too long, at injudicious 
places, such results as paralysis of im- 
portant nerves, sloughing, great oozing 
of serum from the wound, and much 
after-pain may result. They are there- 
fore to be used with caution, and dis- 
pensed witli as soon as the vessel can 
be isolated and closed. 
(d) Forced Flexion.—In suitable 
cases pressure can be made by putting 
a joint, such as the knee or elbow, in 
a position of forced flexion with immobilization, as shown in Fig. 80. 
II. Permanent Measures.—(a) Ligation.—This is done by tying the 
vessel with some form of ligature (catgut, silk, kangaroo-tendon, etc.). 
The ligature may be applied at the open end of a vessel or in its con- 
tinuity. Applied with moderate force, the middle and inner coats are 
cut through and curl up, although this is not necessary for the oblitera- 
tion of the vessel. 
Fjg. 80. 
; : r;,:> ' " i 
Illustrating forced flexion for control of 
hemorrhage. 
The only object in using force sufficient to destroy the inner coats is to ensure 
so firm a hold upon the vessel as to prevent its slipping off. An internal clot 
forms, which reaches usually to the next highest branch, organization begins, and 
the ligated parts become a mass of cicatricial tissue. All in all, ligation is the CONTROL OF HEMORRHAGE, ETC. 
259 
simplest, safest, and best method of controlling hemorrhage. Some substitutes for 
ligation may be mentioned here: they are torsion and deep suturing. 
Torsion is effected in two ways: In small vessels it suffices to catch the end with 
a haemostatic forceps and twist it around several times, stopping short of severing 
the twisted from the main portion. When dealing with larger vessels it is better 
to seize them near the end (one-third of an inch), with one haemostatic forceps 
applied at right angles to the axis, and, having secured this firmly, to then twist 
the distal portion as above described (four or five complete turns usually suffice). 
This method is applicable to vessels as large as the femoral, and has the advantage 
Fig. 81. 
Obliteration of artery following ligation. 
of enabling us to dispense with ligatures. The method is peculiarity valuable in 
plastic surgery and where scar is to be avoided. 
Deep suturing (ligature en masse) consists in passing a ligature through the 
tissues around a vessel by means of a needle whose points of entrance and emerg- 
ence are near to each other. The method is indicated in cases where the end of 
the vessel cannot be caught up, as occurs in certain wounds or in dense, unyielding 
tissues. 
(b) Pressure.—-This may be effected by long-continued digital pres- 
sure or by leaving a haemostatic forceps clamped upon the vessel for a 
period of from twelve to forty-eight hours according to its size and tone, 
and by the use of gauze or other form of dressing. It is most applicable 
in regions where other means for arresting hemorrhage cannot readily be 
employed; that is, in the rectum, vagina, nose, medullary canal, socket 
of a tooth, wounds of the deep palmar or plantar arch, etc. The coap- 
tation of the edges of a wound by sutures is another method of apply- 
ing pressure, and is especially useful where the skin is vascular, as in 
the scalp and scrotum. 
(e) Styptics.—These are chemical agents which arrest hemorrhage by 
inducing coagulation of the blood. Chief among these are persulphate 
and perchloride of iron, powdered alum, tannin, gallic acid, nitrate of 
silver, vinegar, cocaine, chloroform and water (one drachm to the pint), 
turpentine, antipyrine (5 to 20 per cent, solution), Park’s mixture of 
antipyrine and tannin, solutions of each, of 15 per cent, strength, 
mixed. If too strong, styptics easily cause necrosis and sloughing of 
the tissues, and thus prevent primary union. 260 
SURGICAL PROCEDURES. 
Styptic cotton is a convenient and useful form in which to induce haemostasis. 
It is simply cotton dipped in a solution of the perchloride of iron. To get the 
best results from styptics, the wound should be carefully dried and the agent 
employed applied immediately to the bleeding point with sufficient pressure to 
control the hemorrhage. This should be kept up for two or three minutes. 
Styptics are often inefficient from non-observance of the above rules, the clot 
being too small and non-adherent to the walls about the opening to prevent its 
being washed away by the current of blood. 
(d) Heat.—This may be applied in the form of water at the tem- 
perature of 120° to 150° F. or by means of the actual cautery. Hot- 
water irrigation is of great value upon extensive raw surfaces or in 
cavities which ooze. The actual cautery, of which the Paquelin is the 
best and most commonly employed, should be used at a dull-red heat 
and applied for a few moments to the bleeding point. It is a powerful 
haemostatic. It checks hemorrhage, either by forming an aseptic eschar 
at the end of the vessel or causing the end to curl up and invert, thus 
finally closing the vessel. A bright-red or white heat is not haemostatic 
in action. An iron heated to dull red or the galvano-cautery may be 
used in place of the Paquelin. 
(e) Cold.—In the form of exposure to air, ice-water, or ice cold has 
long been used for checking hemorrhage. It causes contraction of the 
muscular coat, and therefore acts more promptly and effectually in 
arterial than in venous bleeding. The exposure of an amputation-stump 
to air set in motion by a fan quickly causes the surface to become dry 
and glazed over. 
(/) Elevation.—If the upper or lower limb be Held in a vertical posi- 
tion for sixty to ninety seconds and a tourniquet applied, we find that 
we have rendered the part almost bloodless; so also when hemorrhage 
is occurring elevation quickly lessens or stops the oozing from veins and 
capillaries. This is so well recognized that elevation of an amputated 
stump for the first few hours after operation is almost a routine practice. 
(g) Acupressure, acufilopressure, and acutorsion are now rarely 
employed. Occasionally the one or the other method may be useful. 
Acupressure consists in passing a long needle through the soft parts in 
such a manner as to compress the vessel beneath it. When, in addition, 
we bind a ligature about the projecting ends of the needle, the procedure 
is called acufilopressure. Acutorsion consists in drawing out and trans- 
fixing with a needle the end of the vessel. The needle is then given a 
half or complete turn, when clot-formation occurs and hemorrhage is 
checked. 
Abstraction of Blood. 
Blood may be withdrawn from the body in various ways. In what- 
ever form accomplished, there can be no doubt of the value of such a 
therapeutic agency in properly-selected cases (vide, e. g., Chapter V.), 
and it is to be regretted that such simple and direct measures should 
have been supplanted by much less effective and more depressing medi- 
cinal means. The methods by which blood may be abstracted include 
venesection, arteriotomy, scarification, cupping, and leeches. 
(1) Venesection, or Phlebotomy.—This consists in opening a vein, 
preferably the median basilic, although the median cephalic may be 
selected, and, where cerebral inflammation or apoplexy exists, the 
external jugular is often chosen. It should be borne in mind that the CONTROL OF HEMORRHAGE, ETC. 
261 
median basilic vein crosses the brachial artery, being separated from it 
at this point by the thin aponeurosis of the biceps. In fat persons, 
where an excessive amount of fat covers the veins, venesection may be 
difficult. A bright light or reflector may be advantageously employed 
in such cases, the veins revealing their situation by their shadow. The 
opening into the vein should be made either above or below this point, 
the artery having been first identified by its pulsations. 
Venesection is usually done as follows: The elbow having been previously 
rendered aseptic, a bandage is applied about the middle of the humerus sufficiently 
tight to retard the venous return, but to leave the radial pulse quite perceptible. 
The arm is allowed to hang down and the fingers given some object like a roller 
bandage to grasp, to better fill the vein. In a few seconds the vein becomes quite 
prominent, when an oblique incision maybe made through the skin and wall of the 
vein, or, what is better, a bistoury may be thrust under the vein and a cut made 
outward. The opening in the skin should be generous to avoid subsequent infil- 
tration. The blood should be allowed to flow until the pulse becomes soft and 
slow. The amount necessary to produce this effect varies with the individual, but 
in general it averages between eight and twenty ounces. Should the flow become 
too slow before the desired effect has been produced, it may be hastened by having 
the patient alternately close and open his hand and tightly squeezing whatever 
object he may be holding. The muscular contraction induced increases the flow. 
When sufficient blood has been abstracted, the encircling bandage should be 
removed and antiseptic dressings applied with moderate pressure. The antiseptic 
management of venesection is highly important, as bent-arm, due to suppurative 
cellulitis and suppurative thrombosis, followed by fatal pyaemia, has occurred not 
infrequently. 
(2) Arteriotomy.—This procedure may be used where rapidity is 
necessary. The temporal artery is usually chosen because of its super- 
ficial situation, convenient size, and the ease with which the bleeding 
from it can be controlled by pressure. Its exact position may be deter- 
mined by its pulsation, which can be readily felt, and in some indi- 
viduals seen. The artery should not be entirely cut through to secure 
the best flow, although complete division is sufficiently effective. If 
only partial section of the artery has been made, when the bleeding has 
been completed the vessel should be cut entirely through and firm anti- 
septic dressings applied. 
(3) Scarification.—This is performed by making several small cuts or 
punctures in the affected part, through which the blood will exude more 
or less vigorously according to circumstances. Where applicable, heat to 
the part and the dependent position will promote exudation of blood. 
The method is safe and of genuine value, and in cases of threatening abscess, 
especially of the tonsils, gums, etc., and in acute inflammation of the tongue and 
epiglottis, it always produces a happy effect. After the blood has ceased flowing 
the scarified surface may be further utilized for the application of antiseptic and 
antiphlogistic ointments, which are much more readily absorbed from such a sur- 
face than through the intact skin. 
(4) Cupping.—This may be either dry or wet. In dry cupping the 
blood is simply drawn to the surface, and thus, in the strict sense of the 
word, is not abstracted. It is, however, taken from the congested part, 
its effect upon which is virtually the same as though the blood was 
removed from the body. 
Dry cupping is effected by using a cupping-glass or tumbler, the interior of 
which has been previously heated with an alcohol lamp or a piece of burning 
paper, or, better still, by rinsing one or two teaspoonfuls of alcohol around the 262 
SURGICAL PROCEDURES. 
sides of a glass, which is then inverted to allow the excess of alcohol to escape: 
the edges of the glass are wiped free of alcohol and the remaining film within the 
glass ignited. The glass is then applied to the affected area. The skin becomes 
congested and rises in the glass. By far the best, most rapid, and accurate cupping 
apparatus is the Allen surgical pump, which is shown in Fig. 82. The degree of 
suction can be regulated to a nicety and any number of cups applied in quick 
succession. 
Fig. 82. 
Allen pump, employed in lavage, illustrating its range of utility 
Wet cupping implies the abstraction of blood from the body. 
Formerly it was done with a complicated instrument containing ten or 
twelve sharp knives working in a half-circle through slits in a metal 
plate fixed to a frame. The instrument is rarely or never used to-day. 
The complicated mechanism made it difficult to render it aseptic and to 
keep in order. A better way is to scarify the part with a tenotome or 
bistoury and apply the cupping-glass as before described. The amount 
of blood withdrawn will depend upon the degree of suction and the 
depth of the cuts. The cupping ended, an antiseptic dressing should be 
applied. 
(5) Leeches.—These are not often used at the present time. There 
are two varieties, the American, which can abstract about a teaspoonful 
of blood, and the Swedish, which draws about three or four teaspoonfuls. 
The latter is most commonly used. 
Leeches may be applied as follows: The skin of the region selected is washed 
and, if necessary, shaved; it is then smeared with milk or blood. The leeches are 
taken from their receptacle and allowed to swim in a basin of fresh water for two 
or three minutes, after which they are urged to crawl over a clean towel for a 
similar period. Each leech is then taken up in a test-tube or small glass, and this 
is inverted over the spot chosen, when the leech usually fastens upon the skin. 
Sometimes considerable time elapses before it will attach itself. When it has 
drawn sufficient blood a little salt or snuff will make it relax or drop off. The 
wound may then be dressed with some antiseptic gauze. When the bleeding con- 
tinues too long, pressure, styptic cotton, or solid nitrate of silver may be applied 
to the point. Haycraft ascribes the continued bleeding sometimes met with to the 
anticoagulating substance secreted from the pharnyx of the leech. If the bleeding CONTROL OF HEMORRHAGE, ETC. 
263 
be insufficient, it may be encouraged with heat in the form of poultices or fomen- 
tations. 
Care must be exercised in the application of leeches. They should 
never be applied over loose cellular tissue, such as the scrotum, penis, 
or eyelid, nor over superficial veins, arteries, or nerves. When applied 
to the neighborhood or interior of cavities they should be prevented 
from going too far, either by stuffing the continuation of the cavity with 
cotton or gauze or by securing the leech. 
The mechanical leech is a device consisting of a scarificator-cup and exhausting 
syringe. After scarifying the part the cup is applied, a vacuum produced, and the 
blood slowly withdrawn. It is in no way comparable to the Allen pump, which 
possesses other advantages as well. 
Paracentesis. 
Paracentesis may be performed in one of three ways—viz. aspira- 
tion, tapping, or incision. 
Aspiration is the withdrawal of fluid from a closed cavity without 
the admission of air by means of an instrument with which a vacuum is 
produced and an outward flow of the fluid induced. There are many 
kinds of aspirator, from the piston trocar to the more elaborate bottle- 
aspirator of Potain, which is the one most commonly used. It consists 
of a suction-pump connected with a bottle by rubber tubing and pro- 
vided with stopcocks; the bottle is, in turn, connected in a similar way 
with the needle. 
Fig. 83. 
The bottle is first exhausted of air, when the needle is inserted into the cavity- 
containing the fluid, the stopcock is turned, and the fluid flows into the bottle. 
Should this become full, the stopcock is turned off, the bottle emptied, and the 
process repeated until the desired amount of fluid has been withdrawn. The area 
about the point to be aspirated should be thoroughly aseptic, as should the instru- 
ment in all its parts, especially the needle or trocar. 
Aspiration of shoulder-joint. 
The place of puncture may be made anaesthetic with ice, rhigolene 
spray, or, what is usually more convenient, by touching it with a drop 
of carbolic acid, which is both antiseptic and anaesthetic. Aspiration is 
more commonly employed to remove effusions within the pleural, peri- 
cardial, ventricular, and subarachnoidian cavities, encysted collections 
within the abdomen, and fluid in the joints, especially the knee. 264 
SURGICAL PROCEDURES. 
Tapping is effected by means of the trocar and cannula. (See Fig. 
84.) The same preparation of the instrument and parts should be made 
as in aspiration. The instrument should be plunged quickly and firmly 
into the cavity and the trocar withdrawn. If the trocar be a large one, 
it is better to first incise the skin with a scalpel to prevent the opening 
in the skin from remaining patulous. Where a large collection is to be 
removed it is well to attach a piece of rubber tubing to the cannula to 
carry the fluid into some receptacle, and thus avoid wetting the patient’s 
clothing and immediate surroundings. Tapping is usually applied in 
Fig. 84. 
Trocar and cannula. 
dropsy, and when neither an aspirator nor trocar can be obtained the 
valvular incision may be employed. The skin having been drawn well 
aside from the line selected, an incision is made down through the skin 
and underlying tissues until the cavity is reached, and when drained 
sufficiently the skin is allowed to slip back to its original position. This 
puts the incision through the skin well to the side of that through the 
tissues beneath, and gives to the whole the action of a valve. The 
method has been successfully used in pleural and joint effusions, in spina 
bifida, and in cold abscesses. 
The technique of these procedures in special cases will be given in their 
proper place in this work. 
Counter-irritation. 
Like abstraction of blood, counter-irritation, except in the milder and 
less effective forms, has dropped out of fashion. So pronounced is the 
writer’s conviction upon the value of this procedure as accomplished by 
the actual cautery that he regards the Paquelin thermo-cauterv as an 
almost indispensable part of a surgeon’s armamentarium. Counter- 
irritation is of especial value in the treatment of chronic inflammation 
(so called) the result of chronic congestion and tissue new formation, 
in which condition it both relieves pain and promotes the absorption of 
existing exudates. 
Of the modus operandi, it is uncertain whether the good effects are due to the 
withdrawal of blood from the congested part or to the irritation of the terminal 
nerves, thus producing changes in the innervation of the diseased part. The 
degree of counter-irritation employed will depend upon circumstances, and may 
vary from mild reddening of the skin to actual destruction of the same, together 
with the adjacent underlying tissues. 
The various means of producing counter-irritation include rubefa- 
cients, vesicants, the seton, and the actual cautery. To these may be 
added issues and acupuncture, which, however, are rarely ever used at 
the present time. 
(1) Rubefacients.—In this list are found hot water, turpentine, mus- 265 
CONTROL OF HEMORRHAGE, ETC. 
tard, ammonia, capsicum, chloroform, and others, most of which, if 
applied sufficiently long, produce a vesicant action. Speaking broadly, 
the effect of rubefacients is not of signal value in most surgical conditions 
requiring counter-irritation, and, inasmuch as their method of applica- 
tion is so generally understood, we may pass them by without further 
consideration. 
(2) Vesicants cause an effusion of serum and lymph under the skin. 
Chief among these are mustard, cantharides, chloroform, and ammonia. 
Mustard is usually employed as a plaster made by mixing equal parts of the 
flour with wheat or flaxseed meal, to which enough lukewarm water has been 
added to make a paste. (It should be remembered that boiling water, by altering 
the active principle, renders mustard valueless as a vesicant.) It may also be con- 
veniently used in the form of the mustard leaf, which is first dipped in warm 
water and applied. In either form the plaster should be left in situ for half an 
hour or more, and applied directly to the skin without intervening gauze or oint- 
ment, as is done where the rubefacient effect alone is desired. Although always 
at hand, and therefore convenient, mustard is not to be commended as a vesicant, 
because it is more painful than others to be mentioned and the resulting ulcers 
are often very slow in healing. 
Cantharis is used in two forms—the cerate and cantharidal collodion. 
The cerate may be spread upon adhesive plaster, leaving a margin suf- 
ficient for adhesion to the skin in order that the cerate may be held in 
place. It should be removed in from six to ten hours and followed by 
a poultice. Cantharidal collodion is an admirable form in which to use 
this drug, its advantages being that it is not easily displaced and can be 
applied to irregular surfaces. It is painted on the selected surface with 
a brush, several layers being applied. Chloroform and ammonia are 
both used in a similar way. A few drops are applied upon the skin and 
covered with a watch-cover, or absorbent cotton saturated with them 
may be applied and covered with oiled silk, greased brown paper, or 
some impervious material. Within half an hour vesication has been 
usually produced. The use of these agents is open to the same objec- 
tions as in the case of mustard—viz. pain and slow-healing ulcers. 
Silver nitrate, in strong solution, or the solid stick applied to the skin, 
produces vesication. 
General Rules for Use of Blisters.—1. The region to be blistered should be thor- 
oughly cleansed with soap and brush to remove natural oil, and, if hairy, should 
be shaved. 
2. Poultices aid in the formation of a blister and diminish pain. 
3. In using vesicants care should be taken not to bring the hands in contact 
with the eye. 
4. Where the first effect alone is desired the bleb may be drained by inserting 
a common sewing-needle through the unaffected skin about an eighth of an inch 
from the margin of the bleb. This is usually painless. 
5. Where the counter-irritant effect is to be prolonged, the raised cuticle hav- 
ing first been removed, savin ointment in full strength or diluted with vaseline, 
according to circumstances, or, better still, mercurial ointment, may be applied. 
This latter produces a powerful counter-irritant effect. Repetition of the blister 
may be resorted to also; indeed, a single blister is rarely sufficiently effective, three 
or four being usually necessary, in which case the succeeding blister is applied just 
after the sore from the one preceding has healed. 
6. A large area should not be blistered at one time. A number of smaller 
blisters is safer and equally effective. 
7. The use of blisters in children and persons with delicate skin requires espe- 
cial caution. 266 
SURGICAL PROCEDURES. 
8. The effect of cantliaris in producing renal congestion and inflammation is 
to be remembered. 
9. Blisters should be placed a little remotely from the inflamed area (unless this 
is deep-seated) and over the cutaneous nerves which are in relation with those 
going to the diseased area. 
10. The use of blisters directly over diseased areas lying near the skin may 
aggravate the disease. If the inflammation, however, has passed away, blisters may 
promote absorption. 
(3) The Seton.—This consists of a subcutaneous sinus with two open- 
ings, through which some foreign body, usually silk, is passed. 
This is easily made by thrusting a needle having a generous eye and armed 
with large silk through the desired place, the ends of the silk being tied together. 
After two or three days the wound is dressed and the silk drawn back and forth 
through the wound a few times, this being subsequently repeated daily. The irri- 
tant effect may be increased by smearing savin or mercurial ointment upon the silk. 
The writer has employed the seton in post-cervical pain with marked benefit. 
(4) The Actual Cautery.—In point of view of wide range of appli- 
cability, efficiency, and speedy action the actual cautery ranks first among 
counter-irritants. The old cautery-irons, the red- or white-hot poker, 
and other crude forms have been superseded by the Paquelin thermo- 
cauteryshown in Fig. 85. 
Fig. 85. 
Use of the actual cautery as a counter-irritant. 
Its principle depends upon the power of benzine to render heated spongy plat- 
inum incandescent. Having heated the tip in an alcohol flame, the rubber bulb 
connected with the benzine receiver is compressed and the benzine vapor is forced 
into the spongy platinum, which becomes heated to any degree up to white heat, 
according to the pressure upon the bulb. 
When ready for use the following precautions should be observed: 
The part to be cauterized should be thoroughly cleansed and shaved. 
The cautery, having been brought to a white heat, should be touched 
upon the part in spots half an inch distant from each other, or in the 
form of streaks parallel or crossing each other. The amount of pressure 
and the duration of contact upon the skin will determine the depth of 
the burn, which it is better to limit to partial rather than to entire 
destruction of the cuticle. 
The counter-irritant effect in the former condition is greater because 
of the exposure of the terminal ends of the sensory nerves. After cau- CONTROL OF HEMORRHAGE, ETC. 
267 
terization has been produced the part may be dressed with ice-water, 
poultices, with or without some anodyne or an ointment containing 10 per 
cent, of iodoform. Where it is desired to keep up the effect the ulcer 
may be dressed with savin or mercurial ointment, as previously men- 
tioned when speaking of blisters. It is proper to mention here that the 
thermo-cautery may be used to produce a rubefacient effect. This is 
done by heating the largest tip to a white heat and holding it within a 
quarter or half an inch of the surface until the pain causes the patient 
to exclaim or the skin is seen to redden, when it should slowly be shifted 
an inch or so. The writer has found this of great sedative value in 
tympany following laparotomy after synovitis and other analogous 
conditions. 
Ignipuncture—i. e. puncture with a fine cautery-point, made by plung- 
ing it into the skin and underlying tissues in a number of places— 
produces admirable counter-irritation in deep-seated congestions or 
inflammations. CHAPTER XVIII. 
MINOR SURGERY AND BANDAGING. 
John Parmenter, M. D. 
Knots. 
The knots in common use by the surgeon include the reef or square 
knot, the surgeon’s knot, the granny, the Staffordshire knot, and the 
clove hitch. 
(а) The reef knot is formed by passing one end of the ligature over and around 
the other, drawing the single knot thus formed sufficiently tight, when the process 
is repeated, using the same end that was first employed. 
(б) The surgeon’s knot differs from the reef knot only in the first stage of its 
formation, where the one end is carried over and around the other twice. This 
makes the knot more secure by preventing the slipping of the single knot while 
the second is being made—an accident which easily occurs where great tension is 
Fig. 86. 
Fig. 87. 
Fig. 88. 
Reef knot. 
Fig. 89. 
Granny knot. 
Fig. 90. 
Clove hitch. 
Staffordshire knot. 
necessary or slippery ligature materials are used. The surgeon’s knot requires 
more force to produce the same amount of tension. 
268 MINOR SURGERY AND BANDAGING. 
269 
(c) The granny differs from the reef knot in that in the second stage of its 
formation the end first employed is passed under and around its fellow. It is a 
good knot, easily made and thoroughly secure, some authorities notwithstanding. 
(d) The Staffordshire knot is especially useful for securing pedicles. It is made 
by transfixing the pedicle with a double-threaded transfixing needle, slipping the 
loop over the stump, and pushing it down to the point of entrance of the ligatures 
(the needle having been withdrawn), when one ligature is placed over and the 
other remains under the loop : each is pulled tightly and secured by a square knot. 
The Staffordshire knot thus secures each half of the pedicle, and is a safe and 
reliable knot when properly made. When carelessly made it is highly dangerous. 
(e) The clove hitch may be properly considered in this place, although not em- 
ployed in the class of cases in which the knots just described are used. It is 
easy to make and does not slip. In fact, the more it is pulled upon the more 
secure becomes its grasp. Its formation is best conveyed by observing Figs. 88, 89. 
Sutures. 
Sutures are employed in various forms according to the necessity of 
the individual case or the preference of the operator. Those in most 
frequent use are : 
Fig. 91 
Fig. 92. 
Fig. 93. 
Continuous suture. 
Interrupted suture. 
Modified plate suture, 
using gauze instead, 
Fig. 94. 
Fig. 95. 
Fig. 96. 
Modified quill suture, using gauze 
Billroth’s chain-stitch. 
Transfixion suture. 
(a) The continuous suture (Fig. 91) is made by passing the needle in at one side 
of the wound and out through the other at an opposite point, when the suture is 270 
SURGICAL PROCEDURES. 
tied : the needle is again inserted into the side first penetrated and brought out 
upon the opposite side. This process is repeated until the wound is closed, when 
the double thread is tied with single thread into a square knot. This suture can 
be quickly placed, and if done with due care leaves a good scar. It is easy to 
strangulate the lips of the wound if more than moderate force be employed. 
Furthermore, unless the wound be quite dry the continuous suture requires that 
drainage be coincidently employed, as wounds thus closed are too tight to permit 
much escape of fluid from underneath. In long wounds it is well to tie the suture 
at varying intervals to avoid giving way of the entire suture should a part fail. 
(6) The interrupted suture is the form most commonly employed. It is made 
by passing the needle through the tissues from one side to the other at an opposite 
point; the suture is then tied with an appropriate knot and cut off. The process 
is repeated as often as necessary, the sutures being from one-quarter to one-half an 
inch apart according to the tension. 
(c) The plate, transfixion, and quill sutures are shown in Figs. 93, 94, 96, and 
require no special description. They are all useful where tension is to be overcome 
or close approximation is required. Gauze makes an admirable substitute for the 
plate or quill. 
(d) The Lembert suture is used in intestinal surgery. It includes all the coats 
of the intestine except the mucous. When the sutures are tied the serous surfaces 
are approximated. The sutures should be placed about one-eighth of an inch 
apart. 
(e) The Czerny suture brings the edges of the wound directly into apposition, 
but is employed only in intestinal suture, which see in Yol. II. 
Secondary sutures are used in cases where from hemorrhage or 
expected suppuration the surgeon has been compelled to pack the cavity 
with gauze. The sutures (of non-absorbable material) are placed, but 
not drawn so as to coapt the edges of the wound. After a few days the 
packing is removed and the sutures tied, so as to bring the lips of the 
wound into apposition. 
Removal of Sutures.—Sutures are usually left in place from four to 
nine days: the time varies with the vascularity of the region and the 
tension. The knot should be seized with dressing-forceps and pulled 
upward and to one side, when the suture will show the part previously 
just underneath the skin and easily recognizable by its bleached appear- 
ance and moist condition. This is divided with appropriate scissors in 
the moist part, and the suture removed with the forceps previously 
applied to the knot. This detail of cutting through the moist part of 
the suture should be observed, as by dragging a dried part of the suture 
through the wound the latter may be easily infected. 
Transfusion and Infusion. 
The object of these procedures is to give bulk to the blood in the 
vessels from which it has been in part withdrawn through hemorrhage, 
to add nutriment, and to furnish red blood-corpuscles to the blood. 
That the two latter etfects are ever produced is very doubtful. The 
giving of additional bulk is of unquestioned efficacy. 
The transfusion of blood, either directly or indirectly, from an 
animal or a human being into an exsanguinated person is to be men- 
tioned only to be condemned. It has been proven beyond doubt that the 
injection of defibrinated blood into the circulation is a dangerous pro- 
cedure. After a few days the red corpuscles injected die, haemoglobin 
is set free, and quickly causes destruction of the white blood-corpuscles, 
with formation and accumulation of fibrin-ferment, and not infrequently 
death of the individual. MINOR SURGERY AND BANDAGING. 
271 
Direct transfusion is much less dangerous, but impracticable, as it is 
commonly difficult to find one ready to donate the blood. Furthermore, 
the blood may coagulate in the conducting tube, and under any circum- 
stances it is doubtful whether the red corpuscles thus injected retain 
their vitality. 
It seems, therefore, needless to describe the technique of transfusion, 
which is attended with so many dangers, and for which the infusion of 
a normal 0.6 of 1 per cent, saline solution may be more safely and 
advantageously substituted. A good formula is aq. destil. 1000, sodii 
chloridi 6.0, sodii carb. 1.0. This should be sterilized, warmed to 39° C., 
and rendered alkaline by the addition of one drop of sodium hydrate 
(sat. sol.) to every half-litre of the solution. Ludwig suggests the 
addition of from 3 to 5 per cent, of sugar to the alkaline solution, 
claiming that the addition of the sugar adds nutritive value, increases 
endosmotic action, whereby the blood absorbs the parenchymatous fluids 
more readily, and furthermore preserves the red blood-corpuscles from 
destruction better than the plain solution. The apparatus required con- 
sists of a glass funnel with rubber tube attached, which, in turn, is con- 
nected with a glass cannula. In order that the pressure exerted by the 
infused solution should not exceed that in the large veins the flask 
should be held a few inches above the level of the opening in the vein. 
Eighty or ninety cubic centimetres should be injected each minute until 
from 5 to 1500 c.c. have been used, according to the individual case. 
The quality of the pulse will indicate when sufficient has been injected. 
Kneading of the abdomen favors the diffusion of the solution. 
An admirable and efficient substitute for the above-described method is the 
subcutaneous infusion of the same solution, which is prepared, sterilized, and 
warmed as previously mentioned. This is then injected under the skin with an 
appropriate needle in amounts varying in all from 500 to 1000 c.c. 
The anterior abdominal wall and the thighs are good regions in which to inject 
the solution. Massage helps the absorption of the fluid. In the absence of the 
normal saline solution pure warm water may be used, but is not so readily absorbed. 
Milk also has been recommended, but the best authorities agree that it is a danger- 
ous agent and should not be used for this purpose. 
Catheterization. 
Catheters are used chiefly to withdraw urine from and to wash out 
the bladder. Three kinds are in common use—viz. the metal, gum, and 
flexible—each of which has its distinctive advantages. In addition there 
are special forms, such as the prostatic, the elbowed (catheter Coude), 
and the olivary. 
The technique of catheterization varies with the form employed and 
the condition of the urethra. In the following brief description a normal 
urethra and a stiff catheter are presupposed : Having placed the patient 
preferably in the recumbent position, and having selected a good- 
sized catheter (No. 24 French) which has been previously made aseptic, 
well warmed, and thoroughly oiled, the operator holds the same between 
the thumb and forefinger of his right hand. Resting the little finger of 
the same hand upon the patient’s abdomen at or just beneath the umbil- 
icus, the catheter is inserted into the meatus, when the penis is slipped 
over the catheter as far as it can be made to go. (This procedure has 
the advantage of rendering the urethra smooth by obliterating the folds 272 
SURGICAL PROCEDURES. 
of the mucous membrane.) The catheter is then carried from its hori- 
zontal to a vertical position, when by pressing slightly downward and 
at the same time depressing the shaft between the thighs of the patient 
the instrument will usually glide into the bladder. 
Cleansing- of Catheters.—Catheters should be kept in a strictly 
aseptic condition, otherwise inflammatory troubles, such as urethritis 
and cystitis, are prone to occur. After using, the catheter should be 
thoroughly rinsed in clean water, care being taken to remove all clots 
or debris from the bore of the instrument. (That portion of the cathe- 
ter between the eye and the tip is most liable to be insufficiently 
cleansed.) If running water be not at hand, water may be forced 
through the catheter with a syringe, and considerable pressure should be 
used to ensure dislodging of the material contained within. This done, 
it should be followed with some antiseptic solution, such as carbolic-acid 
solution, 1 : 20, Condy’s fluid, etc. 
Metal and glass catheters have the advantage that they may be sterilized by 
boiling. Other catheters after lying for twenty minutes in the antiseptic solution 
may be carefully dried and laid away for future use, wrapped in some impervious 
material like rubber tissue, oil silk, and the like. Glass catheters may be kept 
in the antiseptic solution permanently. 
Normal Obstacles to Catheterization.—The novice may encounter 
several points along the normal urethra which tend to prevent the 
further passage of the instrument : 
1st. The catheter may catch in the fossa navicularis, an accident 
which may be easily avoided by keeping the tip close to the floor of the 
urethra during the first part of its passage. 
2d. It may be stopped at the triangular ligament. When this occurs 
the catheter should be withdrawn a little and the tip made to hug the 
roof of the urethra. 
3d. False passages, previously made by using misdirected and excess- 
ive force. These are often difficult to avoid, but can usually be circum- 
vented by keeping the tip of the catheter close to the side of the urethra 
opposite the opening of the false passage. 
4th. The neck of the bladder may form an obstacle, under which cir- 
cumstances withdrawing the stylet a little, and thus tipping up the end 
of the catheter, will usually cause it to ride over the urethral floor into 
the bladder. 
Untoward Effects sometimes following- Catheterization.—These 
are both local and constitutional. Chief among the local effects we 
have— 
1st. Fain.—This is usually severe in nervous persons upon whom 
the catheter is passed for the first time. It may be mitigated by exer- 
cising gentleness and thoroughly oiling the instrument. A 4 per cent, 
solution of cocaine may be previously injected if deemed necessary or 
advisable. 
2d. Hemorrhage.—When this occurs it is rarely serious, and ceases 
soon after withdrawal of the instrument. If ordinary care has been 
used and hemorrhage follows, it usually denotes a pathological condition 
of the urethral mucous membrane. 
3d. False Passages.—As before said, these are usually due to mis- 
directed and excessive force, but may occur from very slight pressure MINOR SURGERY AND BANDAGING. 
273 
when the mucous membrane has been congested for a long time from 
previous disease. Their occurrence may be recognized by the sudden 
giving way of previous resistance, sudden pain, followed by a sensation 
of grating appreciable alike to patient and operator. Further confirma- 
tion may be gained by noting any deviation of the handle of the catheter 
from the median line, bv feeling the tip out of the middle line upon 
rectal palpation, and by the fact that no urine escapes. False passages 
may be avoided only by exercising the greatest gentleness and intelli- 
gence in manipulation. 
4th. Extravasation of Urine.—This occurs in connection with false 
passages alluded to, and the prevention of the latter implies avoidance 
of the former. 
5th. Inflammatory conditions, such as abscess, urethritis, prostatitis, 
and cystitis, not infrequently result from the use of unclean catheters, 
mere mention of the cause, uncleanliness, indicating how best to avoid 
the condition. 
Constitutional Conditions.—The more common constitutional 
conditions may be traced to the effects of catheterization upon the ner- 
vous centres or to sepsis. Of the former we have, chiefly— 
1st. Syncope, Retention, and Suppression of Urine.—The use of 
cocaine and the recumbent position, combined with the greatest gentle- 
ness during the passage of the catheter, will do most to prevent or 
mitigate these unpleasant and sometimes dangerous effects. 
2d. Urethral Fever.—This is believed by some to be of nervous 
origin, by others to be due to the absorption of toxic alkaloids. The 
use of measures similar to those employed in the case of syncope are 
usually of pronounced value. 
3d. Pyaemia.—This may occur even with the formation of meta- 
static abscesses, and is usually due to infection from without. The 
writer has seen one case of purulent synovitis of the knee-joint result 
from the use of an unclean catheter; at least this seemed to be the only 
solution of the origin of the trouble, inasmuch as commoner causes of 
this affection could be pretty safely excluded. 
Artificial Respiration. 
There are various methods of producing artificial respiration, some 
of which accomplish the result through pressure upon the thorax, others 
by means of direct inflation of the lungs. Of the former methods, those 
in most common use are Sylvester’s, Marshall Hall’s, and Howard’s. 
Of these, Sylvester’s is the simplest and easiest of execution. This method 
makes use of the arms as levers to expand the chest through the medium of the 
muscles which pass from the arms to the chest-wall, the origin and insertion of 
these muscles interchanging at each step. The patient is laid upon his back with 
the shoulders somewhat elevated by a pillow or cushion placed under them, the 
neck extended, and the head thrown back. The tongue may be drawn forward 
by an assistant if necessary. Foreign bodies, including water, must be removed 
from the pharynx. The surgeon should then seize the forearms just below the 
elbows and carry them over the patient’s head as far as they can go. This action 
expands the thorax. A little extra jerk when the arms are at their highest point 
increases the efficiency of the movement. The arms having been thus held about 
two seconds, they should be brought down to the sides of the thorax and pressed 
firmly against the same for two seconds, when they are again elevated, and the 274 
SURGICAL PROCEDURES. 
entire procedure repeated until no longer necessary. Pressure against the liver 
upward assists in emptying the lungs of their contents. The number of complete 
movements in a minute should equal that of normal respiration (sixteen to eigh- 
teen). If the patient be small, it is important that the feet be firmly held to 
prevent the body being pulled forward when the arms are carried upward. Should 
this occur, the efficiency of the procedure in expanding the thorax will be much 
diminished. 
Marshall Hall’s method is practised as follows: The patient is rolled from the 
position on his back to that on his side; the uppermost arm is pulled forward and 
pressure made directly upon the side of the thorax to expel the air from the lungs. 
The body is then rolled over on to the back, which movement causes respiration. 
The process is repeated as often as sixteen or eighteen times per minute. The 
method is not as efficient as that of Sylvester. 
Howard’s method is best described in the words of its author: 1. Instantly turn 
patient downward, with a large firm roll of clothing under stomach and chest. 
Place one of his arms under his forehead, so as to keep his mouth off the ground. 
Press with all your weight two or three times, for four or five seconds each time, 
upon patient’s back, so that the water is pressed out of lungs and stomach and 
drains freely out of mouth. Then, 2, quickly turn patient, face upward, with roll 
of clothing under back just below shoulder-blades, and make the head hang back 
as low as possible. Place patient’s hands above his head. Kneel with patient’s 
hips between your knees and fix your elbows firmly against your hips. Now, 
grasping the lower part of patient’s naked chest, squeeze his two sides together, 
pressing gradually forward with all your weight for about three seconds, until 
your mouth is nearly over mouth of patient; then with a push suddenly jerk your- 
self back. Rest about three seconds; then begin again, repeating these bellows- 
blowing movements with perfect regularity, so that foul air may be pressed out 
and pure air be drawn into lungs, about eight or ten times a minute for at least 
one hour or until patient breathes naturally. 
The above directions must be followed on the spot the instant patient is taken 
from the water. A moment’s delay and success may be hopeless. Prevent crowd- 
ing around patient; plenty of fresh air is important. Be careful not to interrupt 
the first short natural breaths. If they be long apart, carefully continue between 
them the bellows-blowing movements as before. After the breathing is regular 
let patient be rubbed dry, wrapped in warm blankets, take hot spirits and water 
in small, occasional doses, and then be left to rest and sleep. 
The procedures based on direct inflation of the lungs include mouth- 
to-mouth inflation and forced respiration. 
Mouth-to-mouth inflation is practised in the following way: The tongue hav- 
ing been drawn forward, the operator applies his mouth directly to the mouth of 
Fig. 97. 
Fell’s apparatus for forced or artificial respiration. 
the patient, at the same time closing the nostrils. The operator then blows into 
the mouth of the patient, following this action with forcible pressure upon the MINOR SURGERY AND BANDAGING. 
275 
walls of the thorax. This process should be repeated fourteen times in a minute. 
A good modification is to blow through a catheter which has been previously 
passed through the larynx, or to pass an intubation-tube to which has been 
attached a rubber tube through which air can be easily forced. 
Forced respiration is effected by means of a bellows, the best form 
being that elaborated by Dr. George E. Fell of Buffalo. With it air 
can be forced into the lungs, either directly through the mouth and 
larynx or through a tracheotomy-tube. The writer lias had occasion to 
test the efficacy of this apparatus a number of times, and cannot exag- 
gerate its usefulness. 
Whatever form of artificial respiration be made use of, such adjuvants 
as warmth, stimulation, and rubbing of the body in the direction of the 
venous circulation are not to be forgotten. 
Corns. 
Corns belong to the papillomata, and may be defined as an nndue 
development of the cuticle attended with increased vascularity of the 
underlying cutis and more or less enlargement of its papillae. They are 
caused by intermittent or occasional pressure. There are two varieties— 
the hard and the soft—the former situated upon exposed parts like the 
little toe or the back of the toes, the latter being found between the toes 
and deriving their character from the moisture usually existing in this 
place. For the same reason a soft corn grows more rapidly than a hard 
one. 
Corns are usually flattened and circular in shape externally, and extend 
beneath the skin in a conicular wedge-shaped manner. It is to this latter circum- 
stance, whereby the apex of the cone or wedge presses upon the sensitive papillae 
underneath, that corns owe their painful character. Old corns frequently have a 
bursa develop underneath them. This may become inflamed and even suppurate, 
a process usually very painful and occasionally terminating in ulceration, which 
may perforate deeply into the tissues, even to the bone. 
Treatment.—The treatment should combine prevention of recur- 
rence with destruction of the corn. When new and small, corns will 
commonly disappear on removing the pressure of tight or ill-fitting 
shoes and placing around the corn a felt ring (U-shape), whose edges 
shall take the pressure of the shoe from the corn. When it has existed 
for a long time a hard corn should be thoroughly softened with warm 
water, after which a solution containing salicylic acid 1 drachm, ext. 
henbane 4 grains, flexible collodion 1 ounce, may be painted upon the 
part once or twice a day. Iodine, potassium chromate, silver nitrate, and 
other similar agents have been recommended. Inflamed corns should 
be treated by elevation and rest of the part, together with antiseptic 
fomentations. If pus forms, it should be evacuated, great and almost 
immediate relief usually following. (Vide also Chapter XXVII.) 
Bunions. 
A bunion is an enlarged normal bursa or one produced adventitiously 
by the pressure of an ill-fitting shoe. Bunions are usually found on the 
inner side of the great toe at the metatarso-phalangeal joint. When the 
shoe has its inner border slanting outward, as in very pointed shoes, or 276 
SURGICAL PROCEDURES. 
it is too short and narrow, the best conditions are present for producing 
a bunion. Another cause is prolonged continuous standing upon a weak 
tarsus, which produces flat-foot and the oblique outward direction of 
the great toe which accompanies the condition. It may become much 
enlarged and inflamed, and not infrequently terminate in suppuration. 
Very commonly, too, the joint becomes prominent on its inner side from 
enlargement of the head of the metatarsal bone. In extreme cases the 
great toe may lie at almost a right angle to the long axis of the foot and 
over or under the adjacent toe. In such cases the deformity is pro- 
nounced and the interference with walking quite marked. 
Treatment.—This is preventive or curative. Remembering the 
etiology of bunions, it is apparent that proper shoes are necessary. The 
inner side of the shoe should be almost straight, there should be suf- 
ficient width to permit the foot to spread normally, and the shoe should 
be sufficiently long. When inflamed the foot should be elevated and 
put at rest. Incision is indicated when pus is present. In the old and 
inveterate forms, without much or any inflammation, a blister may be 
applied, and its counter-irritant effect maintained by rubbing in an oint- 
ment of biniodide of mercury, 10 grains to the ounce of lard. Where 
the head of the metatarsal bone is unduly enlarged and the deformity 
great, excision of a wedge-shaped piece of bone, followed by fixation of 
the toe in a normal position, is indicated. Except in very old and feeble 
subjects amputation is rarely called for. 
Ingrown Toe-nail. 
Two causes operate to produce ingrown toe-nails : one is the pressure 
of a shoe or tight stocking which is too narrow; the other is the over- 
growing of the cuticle adjacent to the edge of the nail. This latter is a 
very common cause, which is frequently aided by the bad practice of 
rounding otf corners when cutting the nail. In the milder grades of 
the trouble there is little to be seen on inspection except the overhang- 
ing cuticle. When, however, ulceration has occurred, the side of the 
nail may be covered with foul granulations which exude pus. The pain 
and inability to walk may be very great when the inflammation is pro- 
nounced. In some severe cases widespread cellulitis may be present. 
The therapeutic indications are to remove pressure either of the shoe 
or cuticle and to substitute healthy for unhealthy granulations. Patients 
with ingrown toe-nails should wear well-fitting shoes and stockings. 
When the cuticle overhangs it may be pushed back into normal place by 
inserting a small roll of cotton under the edge of the nail and along the 
border of the same. Adhesive plaster applied so as to draw the cuticle 
from the edge of the nail has proved of signal value in the writer’s 
hands. In the more severe cases the granulations should be touched 
with silver nitrate or copper sulphate, or, better still, they should be 
curetted away and the remaining surface thoroughly disinfected and 
cauterized. Others, again, may only yield when to the above treat- 
ment is added continuous pressure and some astringent powder. This 
may be done by dipping a small hard roll of absorbent cotton into pow- 
dered lead nitrate and binding it over the granulating surface with 
adhesive plaster. Sometimes removal of the contiguous portion of the MINOR SURGERY AND BANDAGING. 
277 
nail is indicated, but this procedure is rarely necessary if both patient 
and surgeon will exercise a little patience and employ treatment along 
the lines above indicated. 
Skin-grafting. 
The two recognized methods of skin-grafting include that of (a) 
Hamilton or Reverdin ; (6) of Thiersch. 
(а) The Hamilton or Reverdin Method.—This consists in spreading 
upon the granulating surface minute portions of the epidermis which 
have been shaved off from some convenient region (callus in the palm 
of the hand is useful). These are placed about one-quarter of an inch 
from each other. They adhere to the underlying granulations, upon 
which they spread until they coalesce with neighboring spots. Ulcers 
treated in this way heal rapidly, but when extensive are apt to be fol- 
lowed by a weak scar and considerable contraction. 
(б) The Thiersch Method.—In this method about half the thick- 
ness of the skin is used. It is removed by putting the skin on the 
stretch either with broad sharp retractors or by grasping the part so as to 
accomplish the same effect, when, with a keen razor previously wet with 
a sterile normal (.6-1.0 per cent.) solution of common salt, strips anywhere 
from one to twelve inches long are removed. These are transferred to 
the wound upon the razor-blade or a spatula, and spread evenly and 
closely upon the surface with probes. The preparation of the granu- 
lating surface for the reception of the grafts is of vital importance to 
success. It should have been made aseptic and healthy. When granu- 
lations are deep red or “ raw beef” in color, with little or no pus, and 
cicatrization has already begun, we have the best surface for grafting. 
It is not necessary, however, to wait until this condition is present. 
Provided the surface be aseptic, the superficial granulations may be cur- 
retted off, a very light touch being sufficient to do this. It has been 
recommended to remove any line of cicatrization which may be already 
formed, as experience has shown that subsequently ulceration frequently 
occurs in just this place. All hemorrhage is to be thoroughly checked 
before the grafts are put in position. The after-dressing consists in first 
placing a layer of sterilized green protective or rubber tissue sufficiently 
large to cover the entire surface and overlap the edges a little. This is 
to be laid on evenly, and over this are applied gauze compresses satu- 
rated in the normal saline solution and absorbent cotton, all firmly held 
in place with a bandage. Gold- or tin-foil may be used in place of the 
protective or rubber tissue, and sterilized oil may be substitued for the 
saline solution. 
The oil dressing is certainly more convenient than the solution, with which 
the dressings must be kept constantly saturated to ensure success. Any dressing 
which sticks is apt to dislodge the grafts, their adhesion to the underlying surface 
in the first few days being very slight. No antiseptic solutions should come in con- 
tact with the grafts. The dressing should not be changed under four or five days, 
and should then be removed with the greatest care lest the grafts be disturbed. A 
similar dressing should replace the first, and not be discontinued under two weeks, 
after which some ointment may be used. The advantages of the Thiersch method 
are the rapidity of healing of extensive defects and the relative non-contractility 
of the new skin thus formed. 278 
SURGICAL PROCEDURES. 
Extraction of Teeth. 
There is, perhaps, no minor surgical procedure which requires for its 
proper completion a more thorough application of anatomical knowledge 
and more manual dexterity than the extraction of teeth. When one con- 
siders the frequency with which the average practitioner is called upon 
to perform the operation, it is apparent that he should possess sufficient 
knowledge to appreciate the dangers arising from the application of 
immoderate and misdirected force. 
Conditions demanding Extraction.—There are various conditions 
which demand the extraction of teeth. Chief among these are the 
various inflammatory conditions resulting in abscess of the alveolus of 
the root or the destruction of the crown from caries; old stumps and 
teeth with sharp or ragged edges which may irritate the inside of the 
cheek or the tongue, producing ulcers and even epithelioma; irregular, 
impacted, and overcrowded teeth; various operations upon the jaws, 
such as resection, tapping the antrum of Highmore, etc.; and, finally, 
incessant toothache not remediable by any other means. 
Instruments Required.—The instruments required are forceps and 
the elevator. There should be at least five pairs of forceps, and, better, 
seven. (The more experienced, however, the operator the fewer the 
forceps needed.) The forceps have various shapes to meet the require- 
ments. The elevator is of use where the forceps cannot be applied, as, 
for instance, in troublesome stumps lying beneath the alveolar border. 
Method of Extraction.—To extract teeth properly the operator 
should bear in mind certain anatomical points. The teeth are arranged 
in the form of an arch in which each tooth is a keystone, it being nar- 
rower at the inner alveolar border than at the outer. It can therefore 
be dislodged most easily by force acting in a direction outward—i. e. 
toward the cheek. Furthermore, the alveolar border is much thinner 
upon the outer than upon its inner side. (An exception must be made 
at the site of the third molar (wisdom) tooth.) The tooth should be 
seized with appropriate force upon the fang well beyond the crown. 
Pressure outward is then made, this frequently splitting the socket on 
the outer side and coincidently rupturing the periosteum on the inner 
side of the tooth. The pressure is then reversed and the tooth brought 
back into its original place, this motion causing the periosteum on the 
outer side to break. By quickly repeating these rocking movements the 
periosteum is entirely torn through and the socket sufficiently bent or 
split to leave the tooth free, when by adding a direct pull the tooth is 
extracted. Naturally, the technique varies somewhat with the tooth 
extracted and its situation, whether in the upper or lower jaw. In the 
upper jaw direct pressure upward permits the forceps to be easily 
applied to the fang. In the lower jaw the operator adjusts the forceps 
to the neck of the tooth and presses it down with the thumb of his left 
hand placed over it in the mouth, the fingers of this hand grasping the 
lower jaw firmly from below. 
Accidents from Extraction.—(a) Hemorrhage.—This may be 
severe enough to threaten life in those having a hemorrhagic diathesis. 
Ordinarily it is not of moment. 
The socket having been thoroughly cleared of clot, ice or ice-water may be put MINOR SURGERY AND BANDAGING. 
279 
into it, followed, if necessary, by a cotton plug soaked in some astringent, such as 
persulphate or perchloride of iron, tannin, alum, and the like. This plug should 
be pressed firmly into the socket and reach its uppermost part, otherwise the pres- 
sure of the blood will quickly dislodge it: should plugging prove inadequate, the 
fine point of a Paquelin cautery may be used with advantage. Where the tooth 
that has just been extracted is at hand, it may be placed in the socket and pressed 
firmly in. This often succeeds admirably. 
(b) Dislocation or Fracture of the Lower Jaw.—These injuries should 
receive immediate treatment, the details of which will be found else- 
where. 
(c) Fracture of Opposing Teeth.—This results from slipping of the 
forceps or their sudden and unanticipated release from breaking of the 
crown, etc., whereby the forceps hit the teeth above or below, as the 
case may be. 
(d) Fracture of the Tooth Extracted.—When this occurs all pieces 
should be removed with appropriate forceps. Should the removal of the 
remainder of the fang require much bruising or breaking of the alveolus, 
it is better to postpone its removal until it has risen nearer the alveolar 
border. 
(e) Extraction of Healthy Teeth.—This may happen through mis- 
take, or a healthy tooth may be pulled coincidently with one diseased. 
The socket should be cleansed and the tooth washed in warm water and 
replaced. After pressing it firmly into place, it may be retained by 
closing the teeth and maintaining this apposition with an appropriate 
bandage. 
(/) Forcing a Tooth into the Antrum of Highmore.—This accident is 
due to pressing too firmly in the effort to grasp the fang. The tooth should 
be removed and the parts thoroughly cleansed to avoid inflammation and 
suppuration within the antrum. 
(g) Tearing of the Alveolar Border.—Careless application of the for- 
ceps is the usual cause. When slight the gum may be pressed into place. 
If more extensive, one or more stitches may be required. 
(A) Injury to the Inferior Dental Nerve.—This may occur as the result 
of dislocation of the lower jaw or from fracture. Perfect reposition of 
the parts is the treatment indicated. 
(i) Dropping of a Tooth or of Pieces of Instruments into the Larynx.— 
The result may be immediate suffocation, or, if the foreign body escape 
through the vocal cords, a septic pneumonia is apt to occur. To avoid 
this complication the operator should invariably make sure that the for- 
ceps have released the tooth previously drawn before again introducing 
them into the mouth. When the accident has occurred removal of the 
foreign body is imperative, and may be accomplished by appropriate 
measures. 
Hypodermatic Medication. 
Except where a drug is being constantly used it is better kept in the 
form of tablets than in solution, which latter easily deteriorates from 
keeping too long. Administration is made by means of a hypodermic 
syringe, of which there are various forms, all constructed, however, upon 
a common principle. It usually contains about thirty minims, and is 
graduated either upon the barrel or upon the shaft of the piston, that so 
a given number of drops may be injected. 280 
SURGICAL PROCEDURES. 
Points of Election for Injection.—Injections are best given in places 
where there is sufficient subcutaneous tissue to permit the skin to be 
pinched up, and also where there are no perceptible veins. (Where it is 
desired to produce a local as well as a constitutional effect the injection 
may be made at the affected site.) Speaking generally, however, the 
outer side of the upper or lower extremities will be found the safest and 
best places for injection. 
Method of Administration.—The surface selected having been thor- 
oughly cleansed with alcohol or ether, the solution, just brought to the 
boiling-point in a spoon placed over a gas-jet or lamp, is drawn into the 
syringe. (The advantages of boiling are sterilization, readier absorp- 
tion, and diminution of pain.) The needle having been adjusted, the 
syringe is then turned with the needle-point upward and all air expelled. 
The skin is pinched up between the finger and thumb of the left hand 
and the needle inserted with a quick thrust. Done properly, the entrance 
of the needle will be barely felt by the patient. When the needle has 
been inserted to almost its full length, the fluid should be slowly ex- 
pressed, the needle being gradually withdrawn at the same time. This 
procedure helps to avoid the accident of injecting directly into a vein 
by constantly shifting the point of the needle. The injection completed, 
the needle is wholly withdrawn and the fluid further dissipated by gentle 
friction with the fore finger over the injected area. Where the skin is 
unduly sensitive a cloth wet in cold water should now be applied for 
fifteen or twenty minutes to allay irritation and congestion and possible 
inflammation. 
Accidents.—(a) Injection Directly into a Vein.—This produces fre- 
quently very alarming symtoms. The patient becomes suddenly dizzy; 
the face, first pale, quickly becomes suffused ; the temporal arteries may 
be seen throbbing vigorously; buzzing noises in the ears are heard. 
These phenomena are succeeded by a more or less violent congestive 
headache which may persist for several hours. 
Severe as are the symptoms, the condition passes off, as a rule, without further 
detriment to the patient. In the writer’s experience this accident is most apt to 
occur to those addicted to the use of the syringe. It is possible that in such per- 
sons the repeated injections have produced contraction in the connective tissue 
under the skin, as a result of which certain small veins have been made patulous 
by having their walls pulled upon from each side and their diameter increased. 
(6) Injury to a Nerve.—This is sometimes severe enough to produce 
neuritis and pain which may persist for a long time. In this connection 
the writer has seen two cases in which almost immediately following an 
injection the skin of the whole arm became raised into irregular wheals 
of varying size and attended with severe itching and burning. Under 
cool applications the condition speedily disappeared. 
(c) Sepsis.—Now and then cellulitis or a local abscess develops after 
injection. It can almost invariably be attributed to lack of cleanliness. 
Sometimes, however, it occurs in certain depraved constitutional states 
where direct infection can be fairly well excluded. 
Care of the Syringe.—Much difficulty is often experienced in keep- 
ing the syringe in good condition. Either the needle becomes blunted 
or stopped up or the piston becomes dry and does not exert sufficient 
suction. By filling the syringe before attaching the needle the chief MINOR SURGERY AND BANDAGING. 
281 
cause of blunting—viz. striking the needle-point against the spoon— 
will be obviated. 
After using, the needle should be blown through to remove all remaining 
moisture from the bore, or it may be well heated over the gas or lamp. Finally, 
by putting a drop of oil now and then between the washers of the piston the suc- 
tion-power will be maintained. The screw caps accompanying syringes are of lit- 
tle or no use in preventing drying, as air readily enters along the shaft of the 
piston. 
Bandaging. 
The tendency in bandaging to-day is toward simplicity, and this is 
due in part to modern ideas of antiseptic and aseptic surgery and in part 
to the materials employed. 
The need for elaborate descriptions of the various methods of band- 
Fig. 98. 
Figure-of-8 bandage of leg. 
aging different parts of the body does not seem to exist, and therefore 
diagrams instead of verbal descriptions will be employed, the latter 
Fig. 99. 
Fig. 100. 
Velpeau’s bandage. 
Ascending spica bandage of the groin. 
being too complicated and indefinite to justify the space they occupy in 
the average text-book of surgery. 282 
SURGICAL PROCEDURES. 
Among the materials used in bandaging may be included cotton, 
cheese-cloth, crinoline, gauze, flannel, rubber, and materials which have 
been impregnated with plaster of Paris, starch, silicate of sodium, etc. 
In selecting a bandage one must have in mind the part to be bandagedy 
Fig. 101. 
Fig. 102. 
Head-and-neck bandage 
the amount of restraint and support required, the length of time the latter 
is to be maintained, the effect upon the skin, the circulation of the part, 
and such other considerations as may be indicated in individual cases. 
For instance, crinoline is easily impregnated with plaster of Paris, 
Fig. 103. 
Fig. 104. 
Spica bandage of shoulder. 
starch, or other stiffening material, and when so used lias peculiar 
advantages in giving firmness to the dressing. Where moderate firm- 
ness with some elasticity is desirable cotton is a good agent. We employ 
bandages to give rest and support to affected parts, to retain splints and 
dressings, to prevent or reduce swelling, and to check hemorrhage. MINOR SURGERY AND BANDAGING. 
283 
Bandages may be divided into three general classes—the roller, tri- 
angular or scarf, and special bandages. The roller bandage varies 
in width and length according to the requirements in individual cases. 
It is employed as the single or double roller, the former being the one in 
Fig. 105. 
Fig. 106. 
Third roller of Desault’s bandage. 
common use. It is usually employed upon the head and extremities, 
although applicable to other situations. 
Roller bandages are made in various sizes, the average being 2f to 
3 inches by 7 to 8 yards. They may be made into rolls for use, either 
by hand or with appropriate apparatus found in instrument-stores. 
Fig. 107. 
Fig. 108. 
T-bandage. 
Kelly’s bandage with perineal straps. 
The method of applying a roller bandage varies with the region to 
be bandaged. Its application to an extremity, however, is sufficiently 
illustrative of its use in general, and may he briefly described as follows : 284 
SURGICAL PROCEDURES. 
Bearing in mind the amount of firmness and support required, and that 
the pressure must be evenly distributed over the part, the roller is 
seized with the right hand, the free end being detached with the thumb 
and fore finger of the left hand, the bandage unrolled for some three or 
four inches; the free end is then placed upon the inner side of the limb, 
and the roller carried around it again and again, 
each time overlapping the one preceded by 
about half its width. Where the extremity 
is cone-shaped the reverse must be employed, 
this being done by turning the bandage on 
itself. This process is repeated until the part 
again becomes cylindrical or until the region 
is sufficiently covered. When the bandage has 
been applied the remaining free end is pinned 
to the underlying layers. 
The triangular or scarf bandage is sim- 
ple, efficient, and of wide applicability : it has 
proven of great value in emergencies upon 
the battle-field and elsewhere. 
Special bandages include the many-tailed 
H and T bandages, all of which are found use- 
ful in certain regions of the body, a few typ- 
ical examples being shown in Figs. 107, 108. 
Fig. 109. 
Barton's head bandage as em- 
ployed for suspension in apply- 
ing plaster-of-Paris bandage." CHAPTER XIX. 
ANESTHESIA AND ANESTHETICS, 
H. A. Hare, M. D. 
The word anaesthetic was first suggested, as a suitable term for a drug which 
removed the sense of pain, by Oliver Wendell Holmes in November, 1846, the 
discovery of this property of ether or ethyl oxide having been put to practical 
application by Dr. Morton, a dentist of Boston, on September 30, 1846. The first 
public use of ether for surgical purposes was made by Warren on the 16th day of 
October, 1846, in the Massachusetts General Hospital. Although Long of Georgia 
caused anaesthesia by ether as early as 1842, and Jackson of Boston asserted that 
it was he who made the discovery, and not Morton, it has been decided by com- 
petent judges that the latter (Morton) really deserves the credit for the general 
introduction of ether as an anaesthetic for surgical purposes. In November, 1847, 
just one year after Morton’s discovery, Simpson of Edinburgh first noted the 
anaesthetic power of chloroform, on himself and some friends. Since this time no 
other substance designed to produce general surgical anaesthesia has been intro- 
duced which approaches the usefulness of these two drugs, and they remain the 
almost universal anaesthetics of the day, if we except nitrous-oxide gas, the appli- 
cations of which are very limited. 
Before discussing the action and uses of ether and chloroform it is 
proper to consider several general facts concerning both of them and the 
use of anaesthetics in general. The first fact to be borne in mind by the 
surgeon is that these drugs are not to be used except when really needed, 
and when employed are to be chosen with distinct ideas as to their indi- 
vidual peculiarities and indications in each case. A patient under the 
effect of so powerful a drug that consciousness is destroyed is nearer 
death than the ordinary human being, since the primary depressing influ- 
ence upon the high nervous centres may speedily pass to the lower vital 
centres in the medulla oblongata. 
Again, the day is fast approaching, if not already here, when the sur- 
geon must choose the anaesthetic to be used in each individual, just as 
he directs one or another cardiac stimulant in circulatory failure accord- 
ing to the end to be obtained. No one should use ether exclusively or 
chloroform exclusively, for there are, as we shall point out later on, indi- 
cations and contraindications governing the use of both. 
Another point to be remembered is that the skill of the anaesthetizer 
does not consist so much in getting his patient under in a short time as it 
does in producing surgical anaesthesia gently, easily, and tenderly, so that 
the heart and mind will not be disturbed by suffocation, fright, strug- 
gling, or overdosing with the drug. Many anaesthetizers think that their 
responsibility ceases as soon as the patient returns to consciousness, but 
nothing is more erroneous, for much of the post-anaesthetic distress, the 
vomiting, the bronchitis, the pulmonary congestion, and the condition of 
anuria may be avoided by properly giving the drugs we are discussing. 
285 286 
SURGICAL PROCEDURES. 
It is quite as much a duty to avoid excessive drugging under these circum- 
stances as it is to avoid overdosing when digitalis or any other powerful drug is 
used, for the skill of the physician consists not only in knowing w'hat to give, but 
in knowing when enough has been used to produce the results sought for. The 
dose of the anaesthetic is to be governed by the response of the individual, and the 
physician who drowns his patient with chloroform or ether is producing poisoning 
and not therapeutic anaesthesia. 
Every person to whom an anaesthetic is to be given should be 
examined to determine the condition of the heart and blood-vessels, and, 
if time permits, the urine should be examined repeatedly for several 
days prior to the operation to determine the condition of the kidneys, 
since the danger of artificial anaesthesia is greatly increased by the pres- 
ence of disease of the heart, blood-vessels, or kidneys. Immediately 
before the drug is given careful inquiry should be made to discover 
whether the patient has some foreign body in the mouth, such as false 
teeth, tobacco, pins, or, as is frequently the case to-day, chewing-gum, 
which if not removed may cause grave difficulties by falling to the back 
of the mouth and so obstructing the air-passages. The patient also should 
be asked whether lie or she has ever taken an anaesthetic before, and 
if so whether it had any untoward effect. In this manner idiosyncrasies 
may be discovered which will enable the physician to be on the lookout 
for accidents. 
An anaesthetic should never be given without the consent of the patient or his 
friends if it be possible to obtain it, but in an emergency case, should no friends be 
at hand and the patient incompetent to decide for himself, then the surgeon may 
fearlessly take the responsibility of giving the drug he deems safest. Care should 
always be taken when a woman is to be anaesthetized that a reliable assistant, pref- 
erably a female nurse, is present, both for the comfort of the patient and for pro- 
tection of the physician, since cases are on record where the patient has accused 
her medical attendant of assault while he had her under the effects of the drug, 
either for the purpose of blackmail or because in the anaesthetic sleep she has 
experienced an orgasm of which the anaesthetizer has appeared to be the cause. 
Leaving for later on the discussion of the relative safety of the minor 
anaesthetics, we come to a study of the safety of ether and chloroform. 
There has been much difference of opinion as to the relative safety of 
these drugs, but at present the profession is practically a unit in recog- 
nizing that ether is the less dangerous by far, although a large number 
of eminent men still employ chloroform to the exclusion of ether, on 
the ground that when given with care accidents are almost unheard of. 
When we remember that in many cases the giving of the anaesthetic is 
entrusted to the least experienced professional man present or to a nurse, 
the relative danger of ether and chloroform is a factor of importance. 
Deaths have occurred in only too many instances while patients have been 
under the influence of either drug, but it is a noteworthy fact that in nearly every 
instance wrhere death has occurred as the direct result of the use of ether some 
abnormal condition of the patient precipitated the catastrophe. On the other 
hand, death due to chloroform has occurred frequently in those in the best of health 
in whom no trace of disease could be discovered. 
Published statistics as to the relative safety of ether and chloroform 
during anaesthesia are open to many objections and vary with startling 
discrepancies, so that even the largest collections of figures are to some 
extent at fault. The chief fault is that in none of the statistics are the 
deaths really resulting from the direct action of the drugs separated ANAESTHESIA AND ANESTHETICS. 
287 
from those in which it has only needed the action of a powerful sub- 
stance to upset the balance of function in some diseased organ and so 
produce a fatal ending. 
The following table shows the approximate death-rate from ether and chloro- 
form, and the variations in statistics according to different collectors: 
Andrews, 
Julliard, 
ETHER. 
1 death in 23,204 cases. 
1 death in 16,542 cases. 
(314,738 cases), 1 death 
in 
CHLOROFORM. 
1 death in 5860. 
(524,507 cases), 1 death in 
Ormsby, 
14,987 cases. 
1 death in 23,204 cases. 
3258. 
1 death in 2873. 
Roger Williams, 
(14,581 cases), 1 death 
in 
(12,368 cases), 1 death in 1236. 
Lee, 
Medical News collection, 
4860 cases. 
1 death in 23,204 cases. 
1 death in 16,677 cases. 
1 death in 3749. 
Coles, 
1 death in 23,204 cases. 
1 death in 2873. 
Gurlt, 
(42,141 cases), 1 death 
in 
(201,224 cases), 1 death in 
Richardson, 
Ziegler, Vogel, Korte, 
and Esmarch, 
6020 cases. 
no death in 2900 cases. 
2286. 
1 death in 3000. 
In studying this table the fact must be constantly borne in mind that 
one or two cases of heart disease or advanced renal disease, causing 
“ death from the anaesthetic,” so called, may seriously alter the percent- 
age, but the preponderance in favor of ether is so great as to settle the 
question of relative safety for ever. 
It is only fair to state, in addition to these figures, that Ollier has collected 
40,000 etherizations without a death, Poncet 15,000, Tillier 6500, and Chabot 730. 
Similarly, McGuire of Virginia claims 28,000 chloroformizations without a death, 
Von Nussbaum 40,000, and Lawrie of India about 30,000. 
Having discussed the relative frequency of death from ether and 
chloroform, we pass to the consideration of the general effects produced 
by their use, and under these separate headings will be discussed the 
minor untoward effects caused by them. As ether is most largely used 
in America, we will speak of it first. 
Ether, 
Sulphuric ether is made by the action of sulphuric acid upon ethylic alcohol. 
When it is used for inhalation purposes the greatest care should be exercised to 
see that it is pure and concentrated. At 77° F. its specific gravity should be 0.714 
to 0.717, and it should leave absolutely no residue on evaporation. Ether should 
boil at 98.6° F. if placed in a test-tube containing some broken glass, and if 10 c. c. 
of it are poured on blotting-paper, no odor should be left upon the paper after the 
ether is evaporated. 
When ether is first inhaled, even when well diluted with air, it is apt 
to cause a sensation of oppression or even of suffocation, which can be 
overcome by gradually increasing the strength of the vapor and by the 
aid of the patient, who, if intelligent, will often voluntarily overcome 
his shallow breathing and take deep inspirations of air laden with the 
vapor. 
This primary sensation of suffocation, with that which often comes on just as 
the patient is about to pass into unconsciousness, can nearly always be avoided, at 
least in part, by not giving the drug too freely, or rather by allowing enough air 
to enter with the vapor of the ether to prevent cyanosis. 288 
SURGICAL PROCED URES. 
Only in the most hurried cases is it proper to pour the ether on the 
inhaler and then hold it tightly over the patient’s face at the very begin- 
ning of the administration. Not only is such a method harsh and 
calculated to frighten the timid, but it is capable of straining the heart 
through congestion arising from the struggles of the patient, and, if any 
weakness of the blood-vessels is present, may cause their rupture by the 
rise of arterial pressure produced by the drug, the struggling, and the 
partial asphyxia. 
The direct cause of the primary arrest of respiration when ether is given has 
been proved to be irritation of the peripheral filaments of the trifacial nerve, which 
reflexly causes spasm of the glottis (Kretzschmar), and irritation of the peripheral 
vagi in the lungs, which inhibits respiratory movement and momentarily impedes 
the action of the heart (Hare). Probably there is also a spasm of the muscular 
fibres of the smaller bronchial tubes induced by the irritant vapor of the ether. 
Very commonly there follows after this period of reflex irritation a 
few long-drawn breaths, and then fixation and immobility of the chest 
ensues, so that for thirty seconds or a minute it would seem as if the 
patient was forgetting to breathe, and then a deep respiration like a long- 
drawn sigh ensues, followed by a rapid, deep breathing, which, by reason 
of the large amount of ether inhaled, either renders the patient partially 
anaesthetic and ready for a minor and brief operation or more commonly 
it initiates what is known as the stage of excitement, during which the 
patient shouts, sings, cries, swears, or fights, according to his tempera- 
ment and previous condition. This stage rarely lasts for more than a 
few minutes, and then the patient actually passes into the complete 
anaesthetic condition and is ready for the surgeon’s method. The pulse 
from the first under ether is accelerated, although in some cases, where 
because of fright or other reason the pulse has been very rapid, it may 
be slowed by the steadying or stimulant effect of the drug. The respi- 
rations when once the patient is anaesthetized are more rapid and deeper 
than in health, and the skin is dry and warm, though often flushed, 
particularly about the face and neck. 
As the etherization proceeds the respirations return to the normal rate or fall 
a little below it, and if the effects of the drug are excessively marked, they become 
slower and more shallow than in health, while the face, heretofore flushed, may 
become exceedingly pale, or if the ether is given in too large amount and with 
too little air the patient may become cyanotic. 
With the development of well-marked muscular relaxation snoring 
or stertorous breathing comes on, and the increased secretion of mucus 
and saliva due to the irritant effects of the ether increases the noisiness 
of the respiratory cycle. If the ether be pushed beyond all therapeutic 
bounds, the pallor of the surface changes to a deathly lividity, while 
the skin becomes cold and perhaps relaxed and moist, the pulse fails; 
the respiration is gradually extinguished from intoxication of the res- 
piratory centre, so that death ensues from this cause. The muscular 
system is totally relaxed and flabby, but the heart continues to beat 
feebly for some moments after the breathing ceases. In producing its 
effects ether depresses first the perceptive and intellectual cerebral centres, 
next the sensory side of the spinal cord, next the motor side of the cord, 
then the sensory and motor portions of the medulla oblongata ; and with 
this depression death ensues. ANAESTHESIA AND ANESTHETICS. 
289 
Turning from the general effects produced by ether to its therapeutic 
application, we find that it has certain advantages and disadvantages. 
The chief advantage connected with its use is that it is by far the 
safest anaesthetic substance so far discovered for the production of 
anaesthesia during prolonged surgical operations. The patient passes 
under its effect, as a rule, quite rapidly, and once anaesthetized needs 
but a small additional quantity to keep him under its influence. 
Besides the lethal effects of ether we have still before us a considera- 
tion of the non-fatal accidents which may occur under its influence and 
the sequelae which follow its use. The accidents which occur during the 
use of ether are rarely very alarming, and consist chiefly in arrest of 
respiration through depression of the respiratory centre by the excessive 
action of the drug, or stoppage of breathing caused by an accumulation 
of mucus or some foreign body in the air-passages. The appearance of 
the face must be the guide under such circumstances as to the methods 
of relief to be employed. If the face is, as usual, very much flushed or 
dusky or cyanotic, artificial respiration is to be resorted to by the 
general methods described later in this article under the treatment of 
anaesthetic accidents. If it is very pale, thereby indicating cardiac as 
well as respiratory failure, then the artificial respiration should be aided 
by inversion of the patient and the injection of stimulants. 
The sequelae following etherization are chiefly pulmonary and renal, 
and it is probable that a certain number of deaths result from these 
secondary manifestations of the action of this drug. As will be pointed 
out when discussing the choice of an anaesthetic, bronchitis, pulmonary 
congestion, and catarrhal pneumonia often seem to be produced by it. 
Very rarely, even croupous pneumonia has ensued. 
Renal disorders from the use of ether rarely arise in persons with 
primarily healthy kidneys, and consist in varying degrees of irritability 
and inflammation up to that which results in the condition of anuria, 
which is the most serious and fatal complication which can arise, because 
death is nearly always assured by this symptom, and because it is prac- 
tically irremediable. 
The question as to whether ether really does irritate the kidneys has been 
studied both clinically and experimentally, and it seems certain that if the drug is 
continuously given for a long period of time, it may develop cloudy swelling of 
the cells in the normal kidney and actual incompetency in kidneys already dis- 
eased. In Weir’s studies on this subject it was proved that albuminuria might be 
produced in kidneys previously perfectly sound by inhalation of ether for surgical 
purposes, but that this was rarely the case. Similar testimony as to the fact that 
ordinary uses of ether do not irritate the perfectly healthy kidney is to be found 
in the studies of Reuter, Garr6, Butter, and Kdrte, but there is plenty of evidence 
that in the presence of renal disease it causes in many cases serious disorders. 
Further than this, nearly all surgeons in looking up this question have regarded 
the presence or absence of albuminaria as the crucial test of renal integrity, 
whereas we now know that a much more accurate guide is an estimation of the 
amount of urea excreted. Until this estimation is made in a large number of 
cases this point cannot be positively decided, for, in opposition to the statements 
made above, Deaver found evidences of renal irritation quite constantly, and Blake 
states that in 36 cases out of 50 ether either produced albuminuria or augmented it. 
The use of ether in the case of diabetics is dangerous, and Becker 
has found in 188 cases of etherization acetonuria in no less than two- 
thirds. Baxter has reported a deatli from ether given to a diabetic, 
who passed into coma from the anaesthetic state. 290 
SURGICAL PROCEDURES. 
An important fact in this connection with the development of catar- 
rhal complications after ether is that surgeons, as a rule, are careless of 
the maintenance of the body-temperature during an operation. In a series 
of studies made by the writer some years since it was found that even 
under brief operations the temperature might fall from 1° to 4° F., 
this fall being due in part to the evaporation of the ether and to the 
depression of the vital processes. Naturally, irritation of the respiratory 
mucous membrane plus exposure to cold will predispose to pulmonary 
complications, and the chilling of the surface produces pulmonary and 
renal congestion. 
Vomiting following the use of ether is unfortunately very commonly 
seen, and is practically a constant sequel in those who have inhaled the 
drug upon a full stomach. It is supposed to be due to irritation of the 
vomiting centre and to the swallowing of saliva and mucus. It is to 
be avoided to some extent by giving the drug on an empty stomach. 
Once developed, the vomiting is to be treated by counter-irritation in 
the form of a mustard plaster over the epigastrium, by the use of one- 
grain doses of acetanilide every hour,1 or by rectal injections of bromide 
of sodium and laudanum in starch-water. Sometimes washing out the 
stomach with a stomach-tube gives relief. For persistent singultus 
drachm-doses of Hoffman’s anodyne are very effective. 
Chloroform. 
This drug was discovered practically simultaneously by Guthrie in America 
and Soubeirau in France. It is a colorless, transparent, volatile fluid of a hot 
sweetish taste and rather pleasant odor, having a specific gravity of 1.491 at 60° F. 
It is liable to decomposition in the presence of sunlight, and generally contains 
about 1 per cent, by weight of alcohol to retard this change. A pure chloroform 
has been made by a freezing process by Pictet, which is said to he less liable to 
decomposition than that made by the ordinary method. Great importance is to 
be attached to the use of pure chloroform, as many of the fatal accidents are 
believed to be due to the use of a poor article. It should be absolutely neutral, 
and when evaporated in a watch-glass should leave no residue of any kind or any 
strong odor. 
When chloroform is inhaled by the healthy man there may be for a 
moment a slowing of the pulse and a rise of arterial pressure, due in 
part to the cerebral excitement of the patient and to the irritation of 
the respiratory mucous membrane produced by the anaesthetic vapor, 
which may also reflexiy cause cardiac inhibition. This condition is, 
however, very fleeting, and is replaced by a pulse more rapid than nor- 
mal and one which is less powerful. The arterial tension is generally 
decreased. The respiration may for a very brief period be partially 
arrested, but this symptom is often entirely absent, and never so marked 
as when ether is given. 
The pupils are primarily a little dilated, but permanently contracted 
during full anaesthesia. If they suddenly dilate during the ancesthetic pe- 
riod, death is imminent. In other words, relaxation of the iris under 
chloroform is a part of the relaxation of death. 
1A very useful formula in this connection is one composed of 1 grain of acetanilide, 
1 grain of monobromated camphor, and 1 grain of citrated caffeine, given every hour for 
six or eight doses. ANESTHESIA AND ANAESTHETICS. 
291 
Should the patient struggle violently, the drug must not be pushed, 
and it is to be borne in mind that the use of the drug is more apt to 
cause sudden death if the patient be an athlete or a drunkard. 
The action of the chloroform in producing anaesthesia is identical with that 
of ether, acting first on the perceptive centres, then on the intellectual centres, and 
then on the motor centres. Care should also be taken while it is being used that 
the bodily heat does not fall. 
The effect of chloroform on man and lower animals has been studied with 
extraordinary care all over the world, and much conflicting testimony exists con- 
cerning it. The writer has embodied his views as to its safety in his report to the 
Governor of Hyderabad, India, and believes that the medium ground there taken 
is the correct one; and it is an interesting fact that Randall and Cerna of Galves- 
ton undertook a series of studies designed to contradict these conclusions, but in 
the end endorsed them. 
The writer very positively asserts that chloroform practically always 
kills by failure of respiration when administered by inhalation up to the 
point of producing poisoning, provided—and this provision is most 
important—that the heart of the anaesthetized is healthy and has not 
been rendered functionally incompetent by fright or violent struggles, 
or, again, by marked asphyxia. There can be no doubt that chloroform 
always impairs the circulation by causing a fall of blood-pressure by its 
depressant etfect on the vasomotor system and upon the heart, and for 
this reason any idiosyncrasy or disease might readily result in a cardiac 
death from it. 
In other words, supposing that the amount of depression from very full doses 
of chloroform equals 25 units, this amounts to little in the normal heart; but if 
the heart be depressed 25 additional units by disease, the depression of 50 units 
may be fatal, particularly if to this 50 is added 25 units more of depression 
through fright and cardiac engorgement arising through disordered respiration 
or struggling. That true depression of the heart-muscle may take place under 
chloroform seems most undoubted, for there is always a decrease in cardiac power 
manifested by the decrease in the force of the individual pulse-beat under its 
influence. 
The accidents which may result during the use of chloroform will 
be discussed under the head of the Treatment of Accidents under Anaes- 
thetics. We shall now speak of the sequelae which may follow the use 
of chloroform. The most important of these is renal disorder, for pul- 
monary complications are very rare indeed. 
In a recent series of clinical investigations Wunderlich has thrown doubt upon 
the advisability of using chloroform for patients with renal disease, claiming that it 
is capable of causing disastrous congestion and irritation of the renal structures. 
Still more recently Alessandri has stated that, while the effects of chloroform upon 
healthy kidneys are practically nil, in patients with renal affections this condition 
of perfect safety cannot be said to exist, and he believes, further, that chloroform 
under these circumstances is to be avoided if possible, and that prolonged or 
repeated anaesthesias by it in such cases are unjustifiable. 
The truth of the matter seems to be that both ether and chloroform 
possess the power of distinctly irritating the kidneys, but it also seems 
to be undoubtedly true that, as chloroform acts as an anaesthetic in very 
small quantities, it is always to be the anaesthetic of election where ope- 
rative procedures are demanded in the face of renal complications. 
Vomiting following the use of chloroform is comparatively rarely 
seen, although nausea may be present in susceptible persons. 292 
SURGICAL 1'ROCKI) URLS. 
The position of bromide of ethyl as an anaesthetic is still undecided. 
Originally introduced with much promise, it soon fell into disrepute 
because of several deaths which took place under its use, but within the 
the last few years it has been more largely employed, notably by Mont- 
gomery of Philadelphia. 
Ethyl Bromide. 
In cases where enough of it is given to produce death in one of the lower 
animals the fatal result depends upon respiratory failure. In man we have no 
reliable records as to its method of causing death, but there seems to be little 
doubt that the heart maybe seriously disturbed in its action by the drug, although 
the writer believes that the respiratory function is the one most affected. 
The advantages possessed by ethyl bromide are its speedy action, the 
patient becoming anaesthetic in a very few moments, and the equally 
rapid passing away of its effects, the patient returning to consciousness 
almost at once when the drug is removed. Other advantages are that it 
produces no disagreeable after-effects. Generally the patient is able to 
walk perfectly in a very few minutes without much vertigo or nausea. 
Sometimes during its inhalation tonic spasm of the muscles with rigidity 
develops. 
The proper manner of using bromide of ethyl is to pour two or three 
drachms on a well-made ether cone, and then to give as pure vapor of 
the drug as possible, with little air. If much air enters, the anaesthesia 
is imperfect and the operation of the drug unsatisfactory. Sometimes, 
even if the drug be well given, a temporary tonic contraction of the 
muscles conies on and is more or less persistent. 
There are several points of great importance to be borne in mind about this 
drug. The first is that it is only suitable for brief operations lasting a few min- 
utes, like opening an abscess or curetting the uterus. The second point is that it 
must be absolutely pure. Poured over the hand and allowed to evaporate, it should 
leave no oily smell, and it must be kept in dark tightly-stoppered or hermetically- 
sealed bottles. It is best to buy it in small glass vials which have been closed by 
melting the glass and which contain about enough for one operation. If exposed 
to light or air, it decomposes and becomes dangerous. 
Bromide of ethyl is not to be confused with bromide of ethylene, which is very 
poisonous. 
A. 0. E. Mixture. 
Various mixtures of chloroform and ether have been made and used 
for the production of anaesthesia. The most commonly used of these is 
the so-called “ A. C. E. mixture,” composed of alcohol, chloroform, and 
ether. It was thought that, as alcohol and ether stimulated the heart 
and chloroform depressed it, a combination of the three drugs would 
antagonize each other on these vital points while acting to produce anaes- 
thesia. Unfortunately for this theory, the drugs differ so in volatility 
that they are not absorbed simultaneously in equal amount, and the 
alcohol tends to produce bronchial irritation and prolonged intoxication. 
The mixture is not to be commended. 
Nitrous-oxide Gas. 
This gas is the safest and most rapid general anaesthetic that we pos- 
sess. As. its anaesthetic influence does not last more than a minute, and ANESTHESIA AND ANESTHETICS. 
293 
in many persons not more than fifteen to thirty seconds, it can only be 
used for very brief minor operations, and as a matter of fact is seldom 
used except by dentists for the production of anaesthesia during the 
extraction of teeth. 
When the gas is given to man there may be a momentary increase in sensitive- 
ness, followed by analgesia, during which time little feeling exists, although the 
patient generally knows what is being done. Immediately after this he becomes 
absolutely unconscious and jerking or twitching of the muscles may occur. The 
superficial reflexes’are abolished, but the knee-jerk is pi’esent and ankle-clonus is 
often present. Often the bladder and rectum are emptied, but vomiting rarely 
occurs. The subsequent symptoms are tinnitus aurium, headache, and dimness of 
sight. 
Sometimes nitrous oxide is used to anaesthetize a patient when the 
surgeon is in a hurry, unconsciousness being then preserved by the addi- 
tional use of chloroform and ether. 
Nitrous oxide ought not to be given to persons with fatty heart or athe- 
romatous vessels. 
The Choice of an Anaesthetic. 
As already stated, ether and chloroform are still the anaesthetics of 
election for all general purposes. Nitrons oxide is only suited to minor 
and brief operations, and is difficult of use because of the bulk of its 
containers : the other anaesthetic substances are either dangerous or, like 
ethyl bromide, only suited for the production of rapid passing effects. 
(1) On general principles ether is to be preferred to chloroform, 
whenever no contraindication to its use exists, because of its greater 
safety. This is particularly the case where an inexperienced person is 
to give the anaesthetic. It is, however, inferior to chloroform in very 
young children and in persons who have bronchitis, because of its irritant 
effect on the respiratory mucous membrane. Renal disease also renders 
ether a dangerous anaesthetic, because the kidneys are irritated by it, 
and, again, marked atheroma or aneurism contraindicates its use, since 
it greatly increases arterial pressure and so tends to produce arterial 
rupture. 
Similarly, it will be found best not to attempt the use of ether in hot 
climates, because of its volatility, nor on the battlefield, where rapidity 
of action is essential and where its bulk is so great as to make its use 
difficult. 
Ether should never be given in the presence of a naked flame, unless 
the flame be high above the cone, as the vapor is inflammable. The 
vapor of ether being heavier than air, gravity causes it to sink to the 
floor. 
(2) Chloroform is not as safe as ether for the average case, but is to 
be preferred, where ether cannot be used, to any similar drug. It is to 
be preferred in hot climates (where ether is inapplicable), and here a 
free circulation of air increases the safety of the patient. It may also 
be selected whenever a large number of persons are to be rapidly anaes- 
thetized, so that the surgeon may pass on to others and save a majority 
of lives, even if the drug endangers a few, as on the battlefield, where 
only a small bulk of anaesthetic can be carried. 
(3) Its employment is indicated in cases of Bright's disease requiring 294 
SURGICAL PROCEDURES. 
the surgeon’s attention, owing to the fact that anaesthesia may be obtained 
with so little chloroform that the kidneys are not irritated, whereas ether, 
because of the large quantity necessarily used, would irritate these 
organs. Quantity for quantity, ether is of course the less irritant of the 
two. 
(4) In cases of aneurism or pronounced atheroma of the blood-vessels, 
where the shock of an operation without anaesthesia would be a greater 
danger than the use of an anaesthetic, chloroform is to be employed, 
since the greater struggles caused by ether and the stimulating effect 
which it has on the circulation and blood-pressure might cause vascular 
rupture. 
(5) In children or adults who already have bronchitis, or who are 
known to bear ether badly—or, in other words, have an idiosyncrasy to 
that drug—chloroform may be employed. 
(6) Persons who struggle violently and who are robust and strong 
are in greater danger from the use of chloroform than the sickly and 
weak, probably because the struggles strain the heart and tend to dilate 
its walls. 
In operations upon the nose or throat chloroform is the best drug to 
employ, as by its use vomiting is avoided, only small quantities are 
needed to keep the patient under its influence, and the operator can 
readily examine the area of his operative procedures. Similarly, in 
some cases where vomiting following upon thoracic or abdominal opera- 
tions is greatly to be feared chloroform is to be preferred to ether. 
Because of its rapidity of action chloroform is largely used to the 
exclusion of ether during labor. 
From the time at which chloroform was first introduced into medicine as an 
anaesthetic until to-day it has been universally recognized that parturient women 
seem to possess an immunity to its poisonous properties; and it is one of the curi- 
osities of medical literature that while the journals fairly teem with reports of 
chloroform deaths when the anaesthetic has been given for ordinary operations, 
death from this drug in parturient women is almost unknown. Various explana- 
tions have been put forward by obstetricians and others as to the reason of this 
apparent immunity. 
It seems to us that the correct explanation of the ability of parturient women 
to take full amounts of chloroform without accident arises in the well-known 
influence which is exercised by pain upon the vasomotor centres. Whatever may 
be the differences of opinion in regard to the influence of chloroform upon the 
heart, every investigator so far has admitted that its primary influence is upon the 
vasomotor centre, and every physiologist knows that complete vasomotor paralysis 
is capable of producing death if at the same time the respiration and heart be 
somewhat depressed. 
In the physiological laboratory it is customary to irritate a sensitive nerve 
whenever it is desired to decide as to the integrity of the vasomotor centre; or, in 
other words, pain produces a rise of arterial pressure by stimulation of this centre. 
We believe that the immunity of parturient women to chloroform depends upon 
the fact that frequently repeated labor-pains continually stimulate the vasomotor 
centre, and so antagonize the depressant influence which is exercised by chloroform 
upon this important portion of the nervous system. Certainly it would seem very 
probable that this explanation is the correct one, and wre are confident that if the 
physician will feel the radial pulse of the patient at the time of the onset of any 
severe pain, he will find that arterial pressure is greatly increased. 
As typical examples of the effect which pain produces in the human being in 
this respect we may cite the hard, corded pulse of acute peritonitis or the equally 
high-tension pulse of lead, renal, or hepatic colic. ANAESTHESIA AND ANAESTHETICS. 
295 
Administration. 
We have already referred to the necessity of giving anaesthetics gently 
and in not too concentrated form. Ether is best given by means of one 
of two inhalers. 
The first is that of Allis, which is designed to give the patient plenty 
of air heavily laden with ether vapor. It consists of a wide collar- 
shaped piece of leather with a fenestrated metal lining, through the 
openings of which is passed from side to side a wide roller bandage. 
The ether is poured on these diaphragms, and the air passes over them, 
becoming heavily charged with the evaporating ether. (See Fig. 110.) 
Fig. 110. 
Fig. 111. 
Allis’s inhaler (from Lentz). 
Lawrie’s inhaler, consisting of four bamboo sticks, sup- 
porting unbleached muslin. 
A simple and readily-made inhaler for ether is made by shaping a 
towel, containing between its folds a stiff piece of paper, into a cone or 
cornucopia, in the apex of which is placed some absorbent cotton or a 
small sponge. Upon this cotton is poured the ether, and the large open 
end of the cone is placed over the patient’s face. If well made, this is 
a very satisfactory inhaler which can be hastily prepared for each case. 
Other ether-inhalers exist by the score, but nothing is gained by 
using them. 
Ether should be so freely given that the air is only present in about 
5 per cent, while the patient is struggling, thereby differing from chloro- 
form, which ought always to be given with about 95 per cent, of air. 
For the inhalation of chloroform the safest method of administration 
is by Lawrie’s or Esmarch’s inhaler, because these provide free circula- 
tion of air and do not distract the attention of the amesthetizer from the 
respiratory movement by complicated apparatus. Apparatus much like 
these in allowing a free amount of air are the Hyderabad chloroform- 296 
SURGICAL PROCED URES. 
inhaler or open-ended cone, with Krohne and Seseman’s respiration- 
in<licator attachment. 
The Junker inhaler, even with its modifications, is too complicated 
Fig. 112. 
Fig. 113. 
Krohne and Seseman’s modi- 
fication of Lawrie’s inhaler, 
with respiration-indicator at- 
tached. The inner lining is 
white felt, the outer case is 
leather. It can be used directly 
or by the air-pump attached to 
the top. 
Esmarch’s inhaler and chloroform bottle. The inhaler con- 
sists of a wire frame covered by a thin piece of flannel. 
and cumbersome, and, while less chloroform is wasted in administering 
the drug, it must all be thrown out of the bottle afterward. If used at 
all, it should be used with the increased air-supply and respiration-indi- 
cator of Krohne and Seseman. 
Fig. 114. 
Krohne and Seseman’s modification of Junker’s inhaier, with respiration-indicator. 
A very useful addition to our methods of producing anaesthesia by 
ether and chloroform is the administration of oxygen gas by inhalation 
with the anaesthetic vapor. By this means cyanosis is less likely to 
come on, accidents are more rare, and it is claimed that vomiting is 
often entirely avoided. It lias been suggested that the mixture of oxy- 
gen with the vapor of these drugs may produce some chemical changes, ANESTHESIA AND ANAESTHETICS. 
297 
but this view is incorrect. The mixture of ether vapor and oxygen 
simply forms a high explosive mixture. If ozonized ether is conducted 
into anhydrous ether, it forms a thick liquid which explodes if heated. 
Fig. 115. 
Oxygen apparatus for use in producing chloroform or ether anaesthesia. The oxygen gas passes 
through the anaesthetic in the bottle, and so becomes laden with the vapor. 
It is probably ethyl peroxide. Chloroform when mixed with oxygen 
undergoes no change. 
If one of these inhalers is not employed, the chloroform is to be 
given by letting it fall drop by drop on a folded napkin held far enough 
away from the face to permit the inhalation of 95 per cent, of air with 5 
per cent, of chloroform vapor. This free supply of air is important, 
whether we believe death to be imminent front cardiac or respiratory 
failure; but this supply of air matters little to the patient if he does 
not breathe freely, nor does the dose of chloroform amount to aught if 
it is not drawn into the chest. The dose of chloroform is not the 
amount on the inhaler, but the amount taken into the chest, and, finally, 
the amount absorbed by the blood-vessels. We agree so heartily with 
Lawrie’s personal conclusions as to the manner in which chloroform is 
to be used that we print them below: 
1. Chloroform should be given on absorbent cotton stitched in an open cone or 
cap. 
2. To ensure regular breathing, the patient lying down, with everything loose 
about the neck, heart, and abdomen, should be made to blow into the cone held at 
a little distance from the face. The right distance throughout the inhalation is the 
nearest which does not cause struggling or choking or holding of the breath. 
Provided no choking or holding of the breath occurs, the cap should gradually be 
brought nearer to, and eventually may be held closer over the mouth and nose as 
insensibility deepens. 
3. The administrator’s sole object while producing anaesthesia is to keep the 
breathing regular. As long as the breathing is regular and the patient is not com- 
pelled to gasp in chloroform at an abnormal rate, there is absolutely no danger 
whatever in pushing the anaesthetic till full anaesthesia is produced. 
4. Irregularity of the breathing is generally caused by insufficient air, which 
makes the patient struggle or choke or hold his breath. There is little or no tend- 
ency to either of these untoward events if sufficient air is given with the chloro- 298 
SURGICAL PROCEDURES. 
form. If they do occur, the cap must be removed and the patient must be allowed 
to take a breath of fresh air before the administration is proceeded with. 
5. Full anaesthesia is estimated by insensitiveness of the cornea: it is also 
indicated by stertorous breathing or by complete relaxation of the muscles. 
Directly the cornea becomes insensitive or the breathing becomes stertorous the 
inhalations should be stopped. The breathing may become stertorous while the 
cornea is still sensitive. The rule to stop the inhalation should, notwithstand- 
ing, be rigidly enforced, and it will be found that the cornea always becomes 
insensitive within a few seconds afterward. 
It is only necessary to add that the patient should be so dressed for 
an operation that his respiratory movements can be easily seen by the 
ehloroformist. 
The use of chloroform requires that it shall be used only in the 
purest form, as medical literature shows that impure chloroform is very 
dangerous to life. Care should be taken that chloroform is not given in 
a room where there is a burning gas-jet unless there be good ventilation, 
as it is decomposed by the flame, setting free irritant fumes of chlorine, 
and thereby causing respiratory inflammation. 
Accidents from Anaesthetics. 
There still remain to be considered the methods which we are to 
resort to in accidents under anaesthetics. First, let us discuss the treat- 
ment of arrested respiration. This should be treated by the use of the 
Fig. 116. 
Cut showing how proper traction on the tongue pulls on the epiglottis. ANAESTHESIA AND ANAESTHETICS. 
299 
Sylvester method, as by this means a greater amount of air enters the 
chest than by any other. For the free entrance of air we must so place 
the head that the epiglottis and tongue will not obstruct breathing. 
As long ago as 1889, Howard of London published a very interesting paper on 
this topic, which has since been widely quoted. While recognizing the value of 
his studies, a series of studies made by Martin and the writer have led us to reach 
somewhat different conclusions in regard to the posture of the head and its 
influence on the patulousness of the windpipe. Howard’s statements in regard to 
the r61e of the epiglottis in cases of arrested respiration in anaesthesia are as 
follows: 
1. The epiglottis falls backward in apncea and closes the glottis ; therefore the 
first thing in order and importance is the elevation of the epiglottis. 
2. Traction upon the tongue, however, whatever the force employed, does not 
and cannot raise the epiglottis, as supposed. 
3. The epiglottis can only be raised by the extension of the head and neck. 
Fig. 117. 
Cut showing how dragging the tongue over the teeth fails to pull on the epiglottis. 
The question which naturally arises first is, Is Howard correct in regarding 
the epiglottis as the cause of the obstruction ? Personally, we believe he is wrong, 
because in the great majority of cases the air-passages are at once cleared of 
obstruction simply by drawing the tongue forward—a method resorted to by all 
of us, yet one which, as Howard himself states and as we have proved, has 
absolutely no effect on the epiglottis unless the traction is applied well back on 
the dorsum of the tongue by a tenaculum, or it is pulled forward and upward. 
We may conclude, therefore, that the epiglottis is not the chief cause of the ob- 
struction, and that the tongue is more frequently at fault; but as any obstruction 
is undesirable, and as the epiglottis does sometimes certainly close the windpipe, 300 
SURGICAL PROCED URES. 
what shall be done to govern its position ? Howard states that this may be accom- 
plished solely by the posture of the head. The method which he recommends is 
as follows: 
“ Having, by bringing the patient to the edge of the table or bed or by eleva- 
Fig. 118. 
The head should be held as in this cut, extended, and pushed forward in the posture in relation 
to the trunk of that assumed by a runner. 
tion of the chest, provided that the head may swing quite free, with one hand 
under the chin and the other on the vertex steadily but firmly carry the head 
backward and downward: the neck will share the motion, which must be con- 
Fig. 119. 
Showing the inversion of the patient as adopted by Kelly, and the method of performing artificial 
respiration simultaneously. 
tinued till the utmost possible extension of both head and neck is obtained. 
Sometimes a slight elevation and extension of the chin will at once check the 
stertor or irregularity of breathing; but, understand, the extension, which can in ANAESTHESIA AND ANAESTHETICS. 
301 
no case do harm, should always be rather more than appears necessary. It should 
never be forgotten, however, that the full effects of extension as above described 
can be secured with certainty only by making the extension complete as directed.” 
Once more, the studies which we have made of this subject have convinced us 
that Howard’s advice is not practically valuable. Although there can be no 
doubt that the changes described are produced, so far as the position of the epi- 
glottis is concerned, on the other hand such a position of the head and neck as he 
directs has the effect of strapping the soft palate over the dorsum of the tongue, 
thereby cutting off the entrance of air through the mouth and rendering the nos- 
trils the only path for its entrance. As the nasal cavities are in many persons 
obstructed by exostoses, hypertrophies, or polyps, the nostrils do not afford a 
sufficiently certain entrance-space for air, and the removal of glottic closure by 
this posture may cut off the air higher up. 
If, on the other hand, the head is extended and simultaneously projected for- 
ward, both the tongue and epiglottis are raised, and the soft palate is so drawn as 
to permit of free breathing through the mouth as well as the nose. This is well 
shown in the accompanying cuts. 
Often in cases of circulatory failure during anaesthesia complete inversion of 
the patient may be practised with good effect, as seen in the accompanying cuts, 
taken from photographs of Dr. Kelly’s method (Figs. 119 and 120). 
Fig. 120. 
Same as Pig. 119. 
For the cardiac failure which comes on in cases of anaesthesia the 
best drug we can employ hypodermically is strychnine in full doses, at 
least f-Q grain, repeated in ten minutes if need be, and associated with 
grain of atropine sulphate, since it has been proved that strychnine 302 
SURGICAL PROCEDURES. 
is the best physiological stimulant to respiration and the heart that we 
have, while the atropine aids its influence on these functions and stimu- 
lates the vasomotor system. 
When an accident occurs under chloroform, this medication is par- 
ticularly necessary, for, as already pointed out, the influence of chloro- 
form on the blood-vessels is its primary and dominant effect. 
This influence the author believes to be very much more worthy of attention 
than is generally recognized. Every physiologist knows that the action of the 
heart and respiration is greatly influenced by vasomotor relaxation. The gasping 
respiration of sudden faintness is probably due more to sudden vascular dilatation 
than to direct failure of the heart, and the exceedingly rapid pulse of shock is seen 
in conjunction with the relaxed blood-vessels so characteristic of this state. The 
integrity of the vasomotor system is as necessary to life as the integrity of the 
heart, since it is under the government of this system that the cardiac mechanism 
is active and the vital interchanges take place throughout the body. Acting upon 
this belief, the writer has found, both in the laboratory and at the bedside, that 
atropine enables more chloroform to be given without circulatory depression than 
can be used if no atropine is administered, and there is good reason to believe that 
the use of atropine by surgeons for the purpose of stimulating the respiratory 
’functions or preventing cardiac inhibition by irritation of the vagus in reality 
prevents dangerous symptoms, chiefly by its vasomotor influence. 
Of the methods of artificial respiration, Sylvester’s is by far the best, 
as it drives more air into the chest, or, in cases where this cannot be done, 
we should not forget the very remarkable results to be obtained by prac- 
tising Laborde’s method of rhythmical traction on the tongue. The tip 
of the tongue being grasped, it is drawn out of the mouth regularly 
sixteen times a minute, and, probably by reflexly stimulating the respi- 
ratory centre, reneivs respiratory movements in apparently hopeless cases. 
The application of electricity in the presence of circulatory or respiratory failure 
during anesthetization rests entirely upon its power to produce irritation of the 
peripheral sensory nerves, thereby reflexly causing respiratory effort. The idea 
that placing one pole over the phrenic nerve in the neck and another over the 
diaphragm will cause this muscle to carry out the respiratory movement is incorrect. 
As a matter of fact, Martin and the writer have proved that this effect is never 
produced, but, on the other hand, that it is possible to produce so much irritation 
of the vagus that temporary inhibition of the heart may result—a serious condition 
if that organ is already depressed. If electricity is used for the purpose of pro- 
ducing resuscitation, the poles should be swept over the skin to cause pain and 
reflex stimulation. 
Local Anaesthesia. 
The production of local anaesthesia is sought for either through the 
influence of cold, which benumbs the nerve-endings or trunks, or by the 
use of cocaine or carbolic acid, which paralyzes peripheral sensory nerves 
when it is brought in contact with them. 
The advantages of local anaesthesia in minor operations are manifest. 
When cold is used, we can employ a small piece of ice dipped in salt, or 
a spray of chloride of ethyl or chloride of methyl or rhigolene. The 
chlorides of ethyl and methyl as commonly employed are contained in 
glass bulbs the ends of which taper to a point. This point having been 
broken off, the heat of the hand forces a fine spray of the liquid out of 
the glass, which as it strikes the skin becomes volatilized and simul- 
taneously freezes the surface. The skin becomes blanched, then shriv- 
elled and hard to the touch. After the anaesthesia, which lasts for a ANESTHESIA AND ANESTHETICS. 
303 
few moments, is over, the part becomes pink and remains congested in 
appearance for some hours. Rhigolene or ether may be used in an ordi- 
nary fine atomizer. 
Aside from cold, we most commonly use cocaine for local anaesthetic 
effects. As this drug cannot penetrate the skin, it can be applied only 
to mucous membranes, unless we introduce it under the skin by means 
of a hypodermic needle. The strength of solution of cocaine for 
mucous membranes varies with the membrane to which it is to be 
applied. Thus in the eye a 2 per cent, solution is often strong enough. 
In the nose from 2 to 4 per cent, solutions may be used, whereas for the 
proper anesthetization of such dense membranes as are found in the 
vagina and rectum 10 per cent, solutions may be needed. The applica- 
tion of cocaine to the ocular, vaginal, and rectal mucous membranes is 
almost never followed by untoward symptoms, but when applied to the 
nasal or urethral mucous membrane it may be rapidly absorbed and 
produce profound collapse. The application of cocaine to the urethral 
mucous membrane is peculiarly dangerous, sudden death having followed 
its use in this area. Very weak solutions should be employed in small 
amounts in the urethra for this reason. 
When anaesthesia of parts protected by the skin is to be obtained, 
the drug in 4 per cent, solution may be injected under the skin very 
gently. Schleich has lately introduced a method of using a solution of 
2 parts cocaine muriate, \ part morphia muriate, 2 parts sodium chloride, 
in 1000 parts of sterilized water, which is deposited in many beads or 
separate drops, the tissues being infiltrated or distended, with the fluid. 
By using a sufficient quantity of the solution (even a weaker one being 
useful) extensive operations can be done without pain and without 
danger. 
Local anaesthesia of the skin for minor operations may be obtained 
by drawing a camel-hair pencil wet with carbolic acid over the line in 
which the incision is to be made. CHAPTER XX. 
SURGICAL DIAGNOSIS. 
Chauncey P. Smith, M. D. 
The chief reason for the practice of surgery is its purpose to relieve 
or cure disease. To obtain this end a recognition of the morbid process 
is always desirable and oftentimes more important than the treatment. 
With diagnosis comes more of the science and less of the art of sur- 
gery. 
The lives of patients lie more in the hands of the general practitioners 
than in the hands of the surgeons, and there is no surgeon who has not 
seen many cases brought by family physicians with some unrecognized 
disease, far—perhaps too far—advanced for operative treatment, while 
if some operative procedure is to be done, it is with greater danger to 
life and at the expense of some mutilation or loss of some function. 
Too many women die yearly from carcinoma of the breast which goes 
unrecognized until too late for any hope for thorough removal. Too 
many children are crippled through ignorance and lack of systematic 
examination by physicians who call pain in the knee front hip disease 
“growing pain.” Many students and younger medical men have a 
chance to make a diagnosis, but few to remove a jaw, yet their credit as 
regards the ultimate result should equal that of the operating surgeon. 
It is well for the student to make a systematic, thorough, and method- 
ical examination of every patient. He will have a knowledge of that 
case which will give him a better insight into its treatment, while he 
will gradually learn what is normal, and hence speak with some weight 
on what is abnormal or diseased. He will thus become familiar with 
joints, chests, malformations, diatheses, and many diseased conditions 
foreign to that one for which the patient conies. It will train him for 
close observation, and, furthermore, many times enable him to bring 
into play preventive medicine—i. e. the treatment of the future. 
Much may be learned of the patient—his habits, his strength, mal- 
formations, diseases, etc.—from inspection. To be thorough, one notes 
the expression, whether of pain, apathy, or paralysis, and one may often 
judge of the patient’s occupation and general condition. 
Exteknal Examination.—When the patient is seen, observe his 
general appearance, whether robust or feeble. Note the color of the 
face—e. g. the florid face of plethora, the green of chlorosis, the pale- 
ness from anaemia, whether constitutional or due to hemorrhage, the 
sallow or yellow hue seen in septicaemia and hepatic disorders, the waxy 
skin of Bright’s, the cyanosis due to obstructive respiratory or circula- 
tory disease, the crimson flush of pneumonia and erysipelas. The color 
of the conjunctiva is as important—c. g. the paleness seen in anaemia, 
304 SURGICAL DIA GNOSIS. 
305 
the yellow of jaundice, the watery eye of the alcoholic, the glassy eye of 
cachexia. It should be observed particularly for hemorrhage when there 
is a history of injury, which, if subconjunctival, denotes serious intra- 
cranial mischief. In females note the presence or absence of cloasma, 
which occurs in pregnancy and during the menstrual periods. 
The Bye.—General protuberance or exophthalmos is seen in tumors 
involving the antrum and brain. If this symptom be coupled with 
enlargement of the thyroid and irregular heart, the diagnosis of Base- 
dow’s disease is simple. Conjugate deviation is seen in apoplexy. The 
pupil is contracted to a pin-point in opium-poisoning; inequality is 
observed in brain-tumors, fracture of the skull, or some interference 
with the sympathetic nerve, such as carotid aneurism. A bright eye is 
seen in fever, coma-vigil in the typhoid state; the presence of the arcus 
senilis denotes arterio-capillary fibrosis. Puffiness is seen about the eye- 
lids in nephritis, in inflammations near by, and in chronic alcoholics. 
The Head and Pace.—Baldness, usually partial, of the eyebrows, 
moustache, or hair is common in lues. It is also seen at the back of the 
head and in rickets, and is then due to restlessness. Scars about the face 
denote some previous injury or disease. Their presence is important 
in epilepsy : if about the angle of jaw, tuberculosis is usually the cause ; 
if on the lip, syphilis, although the primary lesion of lues may be found 
at the alse of the nose and inside the mouth, particularly on the tonsil 
and soft palate; if suspected, examine the contiguous lymphatic nodes. 
Sweating is a symptom in pyaemia, in rickety children—particularly at 
night—and in uraemia. In the latter the sweat has a urinous odor. The 
real age may be judged by the face, as well as the apparent age. By 
this is meant the real age from the life led, whether of overwork, anx- 
iety, or dissipation. Observe the general contour of the head and face, 
the symmetry or asymmetry. Myxoedema gives a moon-face ; acromeg- 
aly, prognathism of the lower jaw with overgrowth of the superciliary 
ridges. Rickets causes a box-shaped head. A general bulging of the 
face is seen in neoplasms of the antrum, a unilateral swelling in infec- 
tive processes of the jaw. 
The Neck.—Enlargement of the lymphatic nodes of the neck is of great 
assistance in diagnosis. Bilateral enlargements are found in lues, the 
nodes being small, hard, shot-like, and movable; in tuberculosis, either 
of the nodes themselves or secondary to a similar process in the lung; 
they are usually large, adherent, often fluctuating or soft, and increase 
progressively in size as one approaches the primary lesion; as, for 
instance, if due to infection through the tonsil, the largest node lies 
near the angle of the jaw, while from that point each node decreases in 
size until the supraclavicular lymphatics may be noted only with dif- 
ficulty. Bilateral enlargement is seen in Hodgkin’s disease, the nodes 
standing out in great bunches and the enlargement continuing into the 
axilla. 
Unilateral enlargement is secondary to infective processes of the jaw, 
to faulty dentition, to malignant growth of tonsils, tongue, salivary 
glands, lips, or to tuberculosis. Occasionally it is seen in carcinoma of 
the breast and pylorus. The mouth should be examined as to the state 
of the tongue, the presence or absence of malignant disease or chancres; 
the gingival border, for the blue line of lead- or green line of copper- 306 
SURGICAL PROCED URES. 
poisoning. The state of the teeth is of importance, particularly in lym- 
phatic enlargement of the neck, in alveolar abscess, and as a possible 
source of infection in meningitis and antral abscess. Sordes are seen 
upon the teeth in low fevers. The breath has a sweet odor in pyaemia, 
a penetrating putrid odor in gangrene of lung, and a characteristic foul 
smell in epithelioma of the tongue or tonsil. Erysipelas usually starts 
from the angles of the mouth or eyes or a he of the nose and spreads 
therefrom. It rarely crosses the middle line. 
Tumors of the thyroid body rise and fall with deglutition. They may 
be unilateral or bilateral, fusiform or globular, and are common in 
women : the growth is often coincident with pregnancy, and can readily 
be distinguished from aneurism of the carotid by the foregoing symp- 
tom and by pressure-effects in the latter, and by the tact that aneurisms 
follow the line of the great vessels. 
The ear should be examined for the presence or absence of a dis- 
charge, whether of pus, denoting middle-ear and possibly mastoid dis- 
ease, or of blood, which with history of injury points to fracture of the 
skull, in which case the blood is soon replaced by a serous discharge of 
cerebro-spinal fluid. 
Expansile pulsation is seen often in the suprasternal notch in aneur- 
ism of aorta. 
Upper Extremity.—The general contour of the shoulder should be 
observed, particularly where there is a history of injury. Too much 
stress cannot be laid upon the importance of observing not only the 
injured but also the sound shoulder. Great stress is laid upon this 
point, which it is necessary to follow not only about the shoulder, but 
also at the elbow, the wrist, the hip, or the ankle. In other words, 
compare the injured with the sound part: by doing this not only may 
the pathological condition be discovered, but also often much time and 
expense may be saved in court. 
One general proposition should be laid down which not only covers the upper 
extremity, but also the lower, and takes in every joint of the body; and that is, 
any swelling in or about a joint which follows the general contour of the joint is 
due to some lesion within it. Whether this lesion be diagnosed as due to blood, 
pus, or serum depends entirely upon the skill of the observer. And, on the other 
hand, any fusiform swelling about a joint when the demarcation of the capsule 
which marks the limit of the normal joint cannot be made out is due either to 
effusion, which may be purulent, or to malignant growth. 
Dropping of the shoulder is seen in fracture of the clavicle; marked 
prominence of the acromion in subglenoid dislocation. The fusiform 
swelling which follows the foregoing rule is limited by the capsular lig- 
ament in joint diseases, which must be differentiated from the more fusi- 
form and less well-defined swelling due to sarcoma. 
Flatness of the shoulder is seen in atrophy of the deltoid muscle, 
which may be caused by injury or disease of the circumflex nerve, and 
in fracture of the humerus. If, following injury, a large swelling, fill- 
ing the axillary fossa, which may or may not have expansile pulsation, 
appear, with absence of the radial pulse, it would indicate traumatic 
aneurism of the subclavian or axillary artery. 
In elderly people pulsation is often observed at the inner side of the 
elbow, and is due to arterio-venous aneurism of the brachial artery and 
cephalic veins. It often results from careless bleeding. SURGICAL DIAGNOSIS. 
307 
The arm is swollen and oedematous in infective processes ; e. (j. if the 
hand be involved in a cellulitis or a malignant oedema. This swelling 
is accompanied by a brawny feeling and by constitutional symptoms, 
which are absent when it is secondary to incomplete extirpation of the 
mammary gland and lymphatic nodes. In this latter condition the 
marble-like oedema is due to obstruction to the venous return caused by 
the scar. 
The axillary lymphatics are enlarged in carcinoma and infective pro- 
cesses in the mammary gland, in inflammation of the hand or arm, in 
tuberculosis of the lymphatic nodes of neck, in lues, and occasionally 
in irritation of the female breast. The epitrochlear node is enlarged in 
infections of the hand and in syphilis. Great importance is put upon 
its enlargement in the diagnosis of the latter condition. 
The Elbow-joint.—When the elbow is extended the inner condyle, 
olecranon, and external condyle will be on the same transverse line. 
This is very important, as when there is any dislocation these three 
bony points will be out of line, while, on the other hand, in a fracture 
which does not involve the joint they will still remain in their normal 
position. Inspect the forearm for atrophy of muscle-groups which may 
be due to injury or disease of their respective nerves. Local enlarge- 
ments of the bones of the forearm are common : those with a tender, 
brawny surface are seen in inflammations, either subcutaneous, subperi- 
osteal, or of the osseous tissue itself. Toward the distal extremity, par- 
ticularly if there be a history of injury, look for the silver-fork deform- 
ity of Codes’ fracture and for the shorter and more abrupt deformity 
seen in a backward dislocation of the carpus. Severe infections of the 
hand are accompanied by brownish-red streaks running up the arm to 
the lymphatic nodes—i. e. lymphangitis—or else by the purple lines of 
phlebitis. 
Much may be learned as regards'the general condition of the patient from the 
hands, as the claw-hands of pseudo-muscular atrophy, the general flexion of fin- 
gers and hand seen in severe palmar or digital inflammation, the general over- 
growth of fingers of acromegaly, the spade-like hand of myxoedema, the clubbed 
fingers of phthisis, the cyanosis seen under the nails, indicating poor circulation, 
and hence often observed in conjunction with the clubbed fingers of phthisis, or 
the small round ulcers or scars occurring on the tips of the fingers observed in 
Revnaud’s disease. A small fusiform, semi-fluctuating swelling in the line of a 
metacarpal bone or phalanx is diagnostic of spina ventosa. The fingers of gout 
and of rheumatoid arthritis are excellent indices of the patient’s condition. Wast- 
ing of the interosseous muscles is seen in progressive muscular atrophy and in 
leprosy. Athetosis due to intracranial lesions, or glassy skin, with absence of 
hair, seen after nerve-section, should not escape observation. 
The Chest.—Observe the shape: in emphysema it is barrel-shaped; 
in rickets the sternum is pushed forward (the so-called pigeon breast) 
and is associated with that enlargement of the costal cartilages known 
as the “ rickety rosary.” A long, flat, narrow chest indicates a tendency 
to tuberculosis of the lung. 
Unilateral enlargement is found in pleural effusion, whether of pus, 
blood, or serum. The fifth interspace to the left may bulge, and is the 
favorite pointing-place for a purulent pleurisy. Protrusion of the sternum 
is a common symptom of aortic aneurism and mediastinal tumors, while 
in these conditions there is a prominence of the cutaneous veins of the 308 
SURGICAL PROCEDURES. 
chest due to deep obstruction. The scapula is prominent in lateral cur- 
vature of the spine, whether the scoliosis be primary in the vertebral 
column or secondary to unequal lengths of the legs. In fracture of the 
clavicle the winged scapula is common, as the fracture itself allows the 
shoulder to drop forward. The accessory muscles of respiration are 
brought into play when there is obstruction to respiration, whether the 
obstruction be in the larynx as a foreign body or a membrane, or 
whether in the lung itself, as in fat-embolism. Cheyne-Stokes’ respira- 
tion is met with in fatty degeneration of the heart, tubercular menin- 
gitis, uraemia, and apoplexy. Unilateral immobilization is significant of 
pneumonia, pleurisy, and fractured rib. 
The Breast.— Observe the general contour, the condition of the 
nipple and its areola. It is enlarged in lactation, sarcoma, chondroma, 
and abscess; its size is decreased after the menopause and in atrophic 
scirrhus. The presence of cloasma denotes pregnancy or uterine dis- 
orders. The nipple is only retracted in carcinoma. Oftentimes the 
areola may have a bacony, waxy, or lardaceous appearance—Paget’s 
disease—which precedes mammary cancer from one to three years. The 
breast has a general protuberance in sarcoma and retromammary abscess. 
Primary syphilitic lesions are not infrequent about the nipple, due to an 
infected nursing child. Oftentimes from the nipple, in women who 
have passed the menopause, a thick, purulent-looking fluid can be 
squeezed: it may be mistaken for pus, but its true nature may be 
diagnosed by the microscope. 
Carcinoma, the most frequent malignant mammary neoplasm, is 
usually situated to one side of the nipple. The tumor is the size of a 
walnut, is hard, adherent to surrounding structures, hence not sharply 
defined, and the overlying skin is coarse and has been likened to pig- 
skin. The nipple may or may not be retracted. The axillary lymph- 
nodes are enlarged. Sarcoma invades the whole breast, which is much 
increased in size, presents no distinct border, and is of unequal consist- 
ence ; overlying veins are prominent; there is no axillary involvement 
unless ulceration has commenced. 
In retromammary abscess the whole breast is protruded; there are 
axillary involvement and associated symptoms of inflammation. 
Occasionally a small hard tumor is found with associated axillary 
involvement in a middle-aged woman, which may be mistaken for 
carcinoma. It is a retention-cyst, and may be distinguished by its depth 
in the gland, its lack of infiltration and of skin-changes. 
For the recognition of any tumor of the breast the palm, of the hand should be 
used. Any one, if he feels with his fingers, can find a tumor in a normal breast, 
which is simply mammary-gland tissue. If the palm of the hand be taken, the 
mammary gland spreads itself out against the ribs, but any tumor by means of this 
procedure will readily be distinguished. In examining for adhesions the arm 
should be abducted to make the great pectoral muscle tense; if the muscle is 
relaxed, false diagnosis is easy. 
If an ulcerating breast present for diagnosis, attention should be given to the 
character of the secretion: blood is common in sarcoma; a thin, sanious watery 
secretion and occasionally scabs are seen in carcinoma. Small blue circumscribed 
spots upon the anterior surface of the chest—taches bleu&tres—are caused by 
pediculi either of the pubes or axilla. 
Abdomen.—From the general appearance of the abdomen much SURGICAL DIAGNOSIS. 
309 
may be learned. Rigidity and oftentimes rigid retraction are seen in 
dyspnoea when the respiratory muscles, particularly those of the belly, 
are brought into play. Rigidity of the right side, particularly of the 
rectus muscle, is seen in peritonitis or appendicitis. The manner of 
observing this should be as follows: With the thumbs of both hands 
pressure should be made upon each rectus, beginning at the symphysis 
pubis and following the line of Poupart’s ligament. Starting again 
from the symphysis pubis, both recti muscles should be palpated up to 
and beyond the umbilicus. In examination of the belly the hand should 
be warm, as a cold hand will often cause, particularly in women, a 
momentary contraction of the muscles which may mask any diseased 
condition beneath. Observe whether the patient or the belly itself 
shrink at the approach of the examining hand. This is of great diag- 
nostic value, particularly in deep-seated pain. Often the stomach may 
be partly outlined, particularly in thin subjects, and its size may be 
noted, as, for instance, in increase due to pyloric obstruction. A sausage- 
shaped tumor in the right inguinal region, chiefly seen in infants, is due 
to intussusception of the bowel. 
The general contour of the belly should be observed. The pouting of the navel 
in anasarca, the lack of this in ovarian tumors, the ball-shape of ascites, the 
general distention of the peritoneal cavity observed not only in the foregoing 
disease, but also in cancer of the peritoneum itself or of the colon or liver, often 
a symptom of hydatid cyst,—these are all of importance. Marbling of the belly, 
due to obstruction of the venous flow, is seen in pregnancy, liver diseases, ascites, 
and tumors pressing on the deep veins. 
Enlargement of the spleen, which can be easily distinguished, may be 
due to malignant disease, to leukaemia, or to malaria. In local enlarge- 
ments between the costal borders and below the xiphoid cartilage, if 
hard, cancer of the stomach, usually pyloric, is thought of, but when 
soft, pulsating, and expansile, they are caused by aneurism. General 
protuberance of the bowels is often a most characteristic symptom of 
tumors of the kidney, which push the bowel forward; hence one should 
not be deceived by tympany on percussion. Tumors of the right hypo- 
chondrium, are usually of the liver and gall-bladder; of the left hvpo- 
chondrium of the spleen or a distended stomach; renal tumors may be 
found on either side. In the right iliac region tumors may be caused 
by disease of the caecum and appendix, by pelvic abscesses, fecal 
accumulations, or cysts of the ovary and broad ligament; in the left 
iliac, by tumors and cysts of the ovary, pelvic abscess, or volvulus. In 
the umbilical region we may find tuberculosis of the mesentery, and 
tumors may present themselves here which spring from other regions. 
In the hypogastric region the most common tumors are pregnant uteri, 
distended bladders, and fibroids. Lumbar tumors spring from the 
kidneys, or are cysts, peri nephritic abscesses, or occasionally perityph- 
litic abscesses. 
When peristaltic motion is observed from without it is often due 
to obstruction of the bowels. Board-like rigidity with distention is 
seen in tubercular peritonitis. 
One may meet with the pelvic enlargement of ovarian tumors, the general 
bloating or distention of peritonitis and intestinal obstruction; the doughy, 
brawny swelling, spreading from the pubis, of extravasated urine; also with scars 310 
SURGICAL PROCEDURES. 
along the side, indicating previous pregnancies or the results of great abdominal 
distention. Occasionally one sees, particularly at the navel, a persistent omphalo- 
mesenteric duct which may discharge a purulent material or even intestinal con- 
tents. A discharge at this point may be from a persistent urachus. In these 
latter conditions there will be more or less excoriation around the umbilicus. 
Observe the middle line particularly for old scars of previous operations, for 
hernia at the umbilicus, or separated recti muscles, and particularly, in the 
inguinal region, the condition of the inguinal rings. Pulsating swellings may be 
observed which if in the longitudinal axis of the body might indicate aortic 
aneurism, although aneurisms of the superior mesenteric artery are not infrequent. 
A flask-shaped tumor arising in the middle line from the pelvis, which often may 
reach the umbilicus or even beyond, and which fluctuates and is elastic, is prob- 
ably a distended bladder, which may be mistaken for a more serious condition. A 
tumor in either flank about the size of one’s fist, which possibly can be grasped by 
the hand, with the history of movement, change in position, sharp colicky pain, 
and a lessened secretion of urine, usually indicates a floating kidney. This is 
Earticularlv true of the right side. An elastic, flask-shaped tumor of the right 
ypochondrium may be a dilated gall-bladder or a hydatid cyst. Swellings in the 
ileo-costal space almost always originate from the kidney or surrounding structures. 
For instance, a dense, brawny infiltration on one side, with other characteristic 
indications of pus, would show the presence of perinephritic abscess, in which 
fluctuation is rarely detected. The diagnosis is made upon its pitting, the indura- 
tion, and the history. Tumors here with unchanged skin, particularly in the 
young, almost always spring from the kidney proper, and, if in the very young, 
of rapid growth, and of large size, with the other associated symptoms, are chiefly 
due to sarcoma, although cysts are not infrequent. 
The spine should be examined for any local enlargement, beginning 
at the atlas and going down to the coccyx ; as to its general contour, 
whether there be kyphosis, lordosis, or scoliosis; and as to its mobility, 
as shown by movement. An undue rigidity of the spine is brought out 
by asking the patient to pick up an object on the floor. The influence 
of extension in the correction of deformity should be tried in all curva- 
tures, and in lateral curvatures measurements should be made of the 
legs for inequality. Cold abscesses lie always to one side of the spine 
and below the affected region. 
In the very young certain tumors present themselves, particularly around the 
sacrum, the lumbar region, and the coccyx, which are placed centrally, which are 
deeply connected, may or may not fluctuate, are oftentimes transparent and usually 
congenital; as, for instance, spina bifida and the sacro-coccygeal tumors and der- 
moids. In many patients at the lower portion of the sacrum a small sinus, one to 
twro millimetres in diameter, is found, with an intermittent discharge of unpleasant 
odor—called the pilo-nidal sinus—which, while congenital, yet often does not begin 
to be annoying until early manhood. 
In the inguinal region many tumors present themselves for diag- 
nosis, and this is a common seat for error. 
A hernial protrusion, whether direct or indirect, of the inguinal 
variety always presents itself in this region, and the diagnosis should be 
easy by its reducibility or the presence of the characteristic impulse on 
coughing. A hernia may be confused with the shot-like nodes of 
syphilis, which are always bilateral, and with the large immovable 
swellings of Hodgkin’s disease or, if unilateral, with bubo from infec- 
tion from the foot or from the urethra, whether the latter be gonorrhceal 
or chancroidal. The nodes also enlarge in tuberculosis, epithelioma of 
penis or leg, etc. 
The Genitourinary Tract.—Kidney.—Constant pain in this 
region may be due to cancer or to tuberculosis; paroxysmal pain, to 
stone and foreign bodies. A tearing pain is felt in hydronephrosis and SURGICAL DIAGNOSIS. 
311 
pyelitis; a dragging pain which at times is paroxysmal, attended by 
nausea, is characteristic of floating kidney. Tumors of the kidney are 
not affected by respiration. In perinephritis the patient lies on his back 
turned toward the affected side, with his legs flexed. It simulates, on 
the right side, appendicitis. Sudden increase in the amount of urine 
passed, following suppressed urination, is pathognomonic of hydrone- 
phrosis. 
The penis should be observed for the presence or absence of scars— 
for discharges, which are very important, particularly when associated 
with a painful knee-joint. In elderly people, particularly after fifty- 
five years of age, a muco-purulent discharge is complained of, which 
they attribute to former disease, commonly seen a short time after 
defecation and simply due to enlarged prostate. The normal pros- 
tatic discharge is squeezed out by the act of defecation. The presence 
of a pin-point meatus or adherent foreskin in children may give valu- 
able aid in many conditions. 
Testicles.—In any abdominal tumor in the male the presence of tes- 
ticles should be sought for, as a retained testis is very liable to undergo 
sarcomatous change. The absence of one or both is important, particu- 
larly in painful swellings in the groin or about the rings. A nodular 
tumor of the epididymis in conjunction with a thickened vas is charac- 
teristic of tuberculosis. The testicle is uniformly large in sarcoma and 
luetic affections. 
The scrotum is always large, pear-shaped, and fluctuates (or if the 
tunica albuginea be greatly distended an elastic feel may be substituted 
for the fluctuation) in cases of hydrocele and hsematocele. A worm-like 
condition of the left side of the scrotum which subsides in the recum- 
bent posture, and which may be prevented from recurring when the 
patient is standing by pressure upon the external ring, is due to vari- 
cocele. This is only seen on the left side. 
Perineum.—The drawers of the patient should be examined in every 
case when pain is complained of in this region for the presence of pus 
and blood, which oftentimes are significant, though not noticed by 
the patient. If present, gonorrhoea, anal fissure, hemorrhoids, fistula 
in ano, and epithelioma may be the cause. Urinary fistulse are common 
in this region following stricture and urinary extravasation. A brawny, 
painful mass in the ischio-rectal fossa shows abscess. In this condition 
fluctuation cannot be detected. Hemorrhoidal tags denote past and 
possibly present hemorrhoids. 
The groin is the common seat of hernise, both inguinal and femoral, 
which are oftentimes difficult to differentiate. It may be said that if 
the finger be placed upon the spine of the pubis, any hernia which 
points externally to the finger is femoral—internal to it, inguinal. In 
fat people the spine of the pubis is found with difficulty, but may be 
easily reached if the leg be abducted and the finger run along the tendon 
of the abductor longus where it is inserted into this bony landmark. 
A large fluctuating swelling which may point above or below Poupart’s 
ligament, externally or internally to the femoral vessels, or between the 
tuberosity of the ischium and the great trochanter, with a history of 
long duration, is possibly a cold abscess, and is very suggestive of spinal 
or hip-joint tuberculosis. 312 
SURGICAL PROCEDURES. 
Enlarged, tender lymph-nodes follow infected wounds of the foot, epithelioma 
and infection of the penis. They may also be enlarged from tuberculosis. 
With the history of an injury in elderly people when fracture of the femoral neck 
is suspected, resistance felt in Scarpa’s triangle is very important as an aid in diag- 
nosis, particularly when there is flattening of the trochanter on the same side and 
a puckering above the patella, which latter is due to a shortening of the quadri- 
ceps extensor tendon. 
The Lower Extremity.—The knee is flexed and everted in tuber- 
culosis; flexed and fixed in shortening of the hamstrings; slightly flexed 
in every joint-effusion, as in this position the joint may be distended to 
a greater degree with less pain. In “joint-mice” and dislocation of 
the semilunar cartilages the knee is often flexed and locked. In hydrops 
articuli the joint is much swollen, but its contour is preserved and the 
lines of the capsular 'ligament are sharply defined. In all effusions in 
the knee-joint the patella is said to float, whether the effused fluid be 
blood, pus, or serum. Sinuses about the joint are commonly due to 
neighboring tuberculosis. They are small, often multiple, and present 
the characteristic granulations of this condition. All joints should be 
examined for muscle-spasm, which is characteristic of tuberculosis. 
The Leg-.—The anterior surface and shin are favorite seats for the 
tertiary lesions of lues. Tenderness on percussion and old scars have 
great diagnostic significance as to a previous active process. Varicos- 
ities, chiefly seen in women, are due to venous obstruction, whether 
just above the knee, pelvic, or thoracic, and follow the course of the 
internal saphenous vein, and often are associated with an obstinate pig- 
mented ulcer on the shin. 
The Foot.—Pain felt in the arch, with no perceptible injury, maybe 
due to flat-foot. Distention of the ankle-joint, whose normal structure 
will not admit of much fluid, is seen in tuberculosis; tenseness of the 
tendo Achilles in talipes equino-varus. 
The Diagnostic Significance of Pain. 
The writer is indebted to Dr. J. H. Musser for the following classifi- 
cation and paragraphs on Pain : 
Pain is primarily due to either functional or local causes, the func- 
tional being illustrated by the headaches of anaemia or the heel-pain of 
gout, while local causes may be due to hyperaemia, inflammation, or 
injury. 
Pain is shown (1) by facial expression ; (2) by posture. It is often 
pathognomonic, as, e. g., the doubling up in cramps; the bent knee of 
arthritis; the retracted head of meningitis; the straining attitude of 
dysuria; the support of the arm in clavicular fracture; flexion of the 
thighs in peritonitis; the ape-like posture with general tremor seen dur- 
ing micturition with vesical calculus; the sudden upright posture in 
angina pectoris; the support of the head in cervical caries; the eversion 
of the leg in fracture of the cervix femoris; the rigidity of the injured 
side in fracture of rib; the immobile side in pleurisy. (3) By reflex 
actions—as, e. g., stiffening of the belly-wall in peritoneal inflammations, 
especially upon palpation by examining hands ; the erections of urethral 
irritation and frequent urination of bladder disorders ; and the brassy 313 
SURGICAL DIAGNOSIS. 
cough of aortic aneurism. (4) By the associated phenomena of disease, 
injury, etc. 
According to Musser, pain should be studied for the following aspects : 
First, the mode of onset; second, duration; third, time of occurrence; 
fourth, character ; fifth, seat; sixth, whether affected by heat, cold, pres- 
sure, posture, or rest. 
(1) Mode of onset oftentimes gives clue to morbid processes. 
Sudden onset points toward inflammations of serous membranes, as in perito- 
nitis ; or to obstruction of some normal mucous canal, as in appendicitis, obstruct- 
ing gall-stones, or vesical calculi; or to rupture of an organ or part, as sudden pain 
in an aneurism or in perforation of the stomach and intestines : sudden pains are 
also observed in neuralgias, particularly in the branches of the fifth nerve. Slow 
pain usually betokens slow development, as, for instance, painful urination due to 
enlarged prostate. 
(2) Duration shows the acuteness or chronicity of the cause. 
Pain of long duration is always associated with a long-standing cause. It 
should be noted whether it is temporary or constant, as from this one may be able 
to judge of the disease: temporary pain may indicate either relief or a cessation 
of the disease, while constant pain points to a constant cause. As an example a 
temporary pain is felt in the passage of hard faeces, yet constant pain during the 
passage points to some organic lesion of the rectum, as fissure or hemorrhoids. 
The duration may indicate the prognosis, as when in a strangulated hernia the 
pain ceases gangrene may have occurred. Pain following shock shows that reac- 
tion has set in, and hence is a favorable sign. “ The abdominal surgeon should 
welcome its presence after operation” (Musser). 
Constant pain is seen particularly in organic lesions, in inflammations 
of all the tissues, particularly those of bone. It may be reflex in cha- 
racter, as the pain and uneasiness felt in the right shoulder which is more 
or less constant from gall-stones. Paroxysmal pain is usually associated 
with nerve-lesions or neuralgias, and also with obstruction to some canal 
by a foreign body. Periodical pains are chiefly due to malaria or syph- 
ilis or to some atmospheric influence, or are in relation to some physio- 
logical process. 
The Time of Occurrence of Pain.—Nocturnal pains are com- 
mon in lues, in all inflammations of bones, as seen in the night-cries of 
children with hip-joint disease. 
Pains in the day are oftentimes due to the position of the patient, such as pain 
in the instep due to flat-foot. The time and the relation to some function are often 
very important. Gastric pain coming on before meals means gastralgia; that 
occurring after meals is due to some organic lesion of the stomach, as cancer or 
ulcer, or at times to dyspepsia. A common example is the pain in cystitis which 
is felt before urination, and which is relieved by this act. This pain is due to the 
contact of the urine with the irritated and sensitive mucous membrane. Pain 
occurring during micturition points toward stone or inflammation of the urethra; 
pain occurring after it often is due to stone, when the bladder contracts upon its 
rough surfaces. This pain is usually relieved as the urine accumulates and lifts 
the bladder-wall away from the calculus. 
The Character of Pain.—Pain may be spoken of as being due to 
soreness, tenderness, aching, lancinating, or throbbing, and from each of 
these characteristics one is able to learn much of its cause. 
Soreness, particularly on movement, often indicates muscular or ligamentous 
origin. An aching pain is due to nerves or muscles. Aching pains may be gen- 
eral, and often usher in more serious general constitutional diseases, as the general 
pains in the bones preceding influenza. Throbbing pain is often an accompani- 314 
SURGICAL PROCEDURES. 
ment of acute inflammation, which, if it has been of several days’ duration, points 
many times toward abscess-formation. Sharp and lancinating pain is seen in 
obstruction to canals by some foreign bodies, particularly calculus, and also in 
inflammation of serous membranes. A dull pain, particularly in bones, betokens 
a chronic, slow’ inflammation. Pain accompanied with tenesmus is usually asso- 
ciated with foreign bodies, as blood and stone, and is noted chiefly in the rectum 
and the bladder. 
The character of the pain often indicates the structure involved—as, e. g., itch- 
ing, burning pain in skin and mucous membranes, while the soreness which is 
increased on movement and pressure is characteristic of muscles. A deep-seated, 
boring pain is characteristic of bone-lesions. A sharp, lancinating pain points 
toward nerves. A dull, constant, aching pain is often associated with disease of 
some viscera. If the lightest contact to any part elicit pains, it points toward 
affections of the cutaneous nerves. If the skin can be freely handled without 
causing pain, this source can be eliminated. If deeper pressure on the groups of 
muscles be made and soreness be complained of, it points toward muscles. If, on 
making deep palpation over the location of a bone deep-seated pain is elicited, 
w’hile the skin and muscles are free from pain, bone-lesions, chiefly of inflamma- 
tory nature, may be thought of. 
The location of pain may be said to point fairly accurately to the 
lesion, providing that the nerve-distribution is recalled; but one should 
always remember the possibility of referred pain. Examples of this 
are very common and frequently overlooked, hence the disease is not 
treated. Mention is made here of some of the commonly referred pains 
which are apt to mislead. 
Pain over the right shoulder is associated with gall-stones by means of the vagus 
and the third or fourth cervical nerves. Pain back of the ear may be due to 
mastoid disease, particularly if there be tenderness over this region ; but the mouth 
should always be examined for carcinoma of the tongue. Knee-pains often mean 
hip-joint disease. Pain in angina pectoris radiates down both arms. In renal 
disease it follows Poupart’s ligament or is felt in the bladder or the testis, or may 
radiate down the inner surface of the thighs. In vesical calculus pain is felt at 
the end of the penis. In diaphragmatic pleurisy it is located above the umbilicus 
and to the front. In Pott’s disease anywhere in the spine it is always referred to 
the anterior surface of the body. The high cervical Pott’s lesion will give pain in 
the throat, with irritation which is too commonly treated for a cold. In disease at 
the junction of the cervical and dorsal vertebrae pain is referred to the intercostal 
nerves and their distribution, and is often called “intercostal neuralgia;” mid- 
dorsal pain is referred about the belly, and in small children is frequently thought 
to be due to colic. In disease of the lumbar spine pain is referred down to the 
pelvis. 
Pain between the shoulders oftentimes is due to aneurism or to cancer of the 
oesophagus; pain in the neck may be transmitted by the phrenic nerve and be due 
to pericarditis or diaphragmatic pleurisy. So-called sciatica is often caused by a 
fissure of the anus, by cancer of the rectum, or by ulcer, and may be cured by 
treating these conditions. The pain of hip-joint disease may not only be felt in 
the knee, but may extend to the heel. Never make a diagnosis of “ rheumatic ” 
and “growing pains” in a child Avithout a thorough examination, looking par- 
ticularly for tubercular disease in some joint or joints. 
Pain Modified by Pressure and Movement—Pain increased bv 
pressure is due to inflammation; if relieved it is either neurotic or func- 
tional. Pain that is relieved by pressure, particularly around the belly, 
often is due to a reposition of some organ which has been dislocated : 
this is chiefly seen in the kidney, as when a patient himself can replace 
a movable kidney and thus relieve the characteristic sickening pain of 
this affection. 
Pain that is increased by pressure at “ nerve-points ” means neuralgia. If by 
pressing upon the head or by having the patient jar himself by his feet pain be SURGICAL I) I A GNOSIS. 
315 
elicited along the spine, it is characteristic of Pott’s disease. The influence of 
movement is very suggestive. The contraction of an inflamed muscle is painful. 
If it be found that certain active movements are painful, but that the movement 
can be made passively without causing pain, it may be put down as muscular. It 
is not the position of the limb which is painful, but the method of obtaining it. 
Ligamentous pain, whether active or passive, is elicited by any movement which 
stretches the ligament; hence in moving any joint, if it can be done passively to 
its normal degree without causing pain, the articular surface composing that joint 
may be said to be free from disease ; but the moment the joint and the ligaments 
about it are put upon the stretch and pain be elicited, it is ligamentous in origin. 
Pain in Special Regions.—Pain in the extremities, if bilateral, may 
may be due to disease of the spinal cord or to neuritis, toxaemia, or 
pressure; if unilateral, to injury, inflammation, or pressure, or to 
transmitted sensations. 
Pain in the foot is usually caused by flat-foot; in the heel, by gouty or rheu- 
matic conditions, although it may be caused by aneurism of the popliteal artery 
pressing on the popliteal nerve. Pain in the space between the third and fourth 
metatarsal bones is due to pressure on a small branch of the plantar nerve, which 
is nipped between the articular ends of the two contiguous bones. Pain is usually 
located in the shoulder when due to liver disease; in the back, when due to dis- 
orders of the stomach ; in the interscapular region, in ulcer of the stomach. Pain 
behind the sternum, common in gastric disorder, may also be due to aneurism, 
tumor, or angina pectoris. Pain in the sternum or ribs may be due to syphilis or 
periostitis. The pain in the loins, when acute, may be due to a dislocation of the 
kidney, to calculus, to uterine disorders; when chronic, to uterine and renal dis- 
orders and varicocele. 
Cough.—In aneurism of the carotid, and even of the aortic arch, a 
peculiar metallic, brassy cough and irritation of the throat are com- 
plained of. The dry, constant, hacking cough due to irritation, which 
by turn is caused by pressure, is often seen in women with thyroidal 
enlargements and in many tumors of the neck. The constant cough 
of irritation due to enlarged uvula, and a cough similar to that described 
above as due to pressure of tumors, may be found associated with car- 
cinoma of the oesophagus. Cough may be also caused by the presence 
of a foreign body in the auditory meatus. It is transmitted along the 
auriculo-temporal branch of the fifth nerve. In infants cough may be 
due to irritation of the stump of a tooth. CHAPTER XXI. 
THE METHODICAL REPORT OF A SURGICAL CASE. 
Edmond Souchon, M. D. 
The methodical report of a surgical case comprises the history of 
the patient, present condition, diagnosis, course and treatment, termina- 
tion and sequels, and, lastly, in case of death, the post-mortem exami- 
nation. 
History of the Patient.—First. Note the sex and age of the patient. 
Second. Note the race and nationality. 
Third. Note the family history—i. e. the age and the condition of health of 
the parents, if living; if any parent be in bad health, ascertain the name and 
nature of the disease and its course and duration, if possible; if dead, the age at 
which death occurred and the cause of death. This applies to the ascendants 
(father, mother, grandfather, grandmother, both on the paternal and the maternal 
sides), to the collaterals (uncles, aunts, cousins), to the descendants (children, 
grandchildren). Note the parent the patient resembles the most or takes after 
physically. 
Fourth. Note the place of birth; also the various places where the patient has 
lived; the duration of his stay in each place. 
Fifth. Note the effects, if any, of the various causes as ascribed above, includ- 
ing the cause to which the patient attributes his disease. 
Sixth. Note the condition of health previous to the attack ; also the date and 
mode of debut, the premonitory and prodromic symptoms (subjective, physical, 
functional, regional, and general). Note the order of succession of the symptoms, 
the duration of this period, the treatment undergone, and the effect; the course 
of the disease up to the date of the present record. 
Present State.—The description of the present state includes the 
mention of all the symptoms presented actually by the patient—subject- 
ive, physical, functional, regional, general. 
Diagnosis.—The diagnosis is now made in the following manner : 
First. Make a resum6 of the salient points or signs of the case derived from all 
sources—sex, age, race, nationality, place of birth, places where he has lived, 
effects of the various possible causes of the disease, course of the disease. 
Second. Note the diseases resembling the case. 
Third. Differentiate them. 
Fourth. Diagnose the stage and give the probable termination. 
Fifth. Diagnose the forms or varieties, the complications. 
Course and Treatment.—The course and treatment call for a record 
of the day and hour when any changes of consequence take place in the 
symptoms (subjective, physical, functional, regional, general) or in the 
treatment (hygienic, medical, surgical, etc.). Note relapses (date, causes, 
symptoms, etc.); also recurrences. 
Termination of the Disease.—The termination of the disease should 
be well noted; the sequels or consequences, if any, should be carefully 
mentioned. 
316 THE METHODICAL REPORT OF A SURGICAL CASE. 
317 
Post-mortem Examination.—The post-mortem examination should 
be conducted after the rules laid down in the best works; that is, the 
lesions of the main organ should be described first, then those of the 
region, then of the distant or general organs; the microscopic lesions 
should be also noted. 
Final Record.—The final record must be complete : it must include 
all the above; also the various charts (temperature, pulse, respiration, 
stethoscopic, plessimetric, sphygmographic); photographs, drawings, 
sketches, microscopic slides, if any, should accompany the record; the 
pathological specimen should be deposited in a museum with a distinct 
number for reference ; the label should explain the main features of the 
case. 
Rules to be Observed by the Recording Surgeon.—(1) Put the ques- 
tions with politeness and solicitude; kindness and gentleness will accomplish more 
than any other policy. (2) The phenomena should guide one toward the solution 
sought; do not shape the phenomena toward a desired solution. (3) The number 
of questions must not be too numerous nor be too few. (4) Use plain, simple 
words and expressions which the patient will understand. (5) Do not propound 
complex questions which bear on several points at the same time. (6) Put the 
questions in such a manner that the answers should be simply yes or no. (7) Do 
not allow the patient to indulge in too minute details ; however, patients must be 
allowed a free statement: when they digress too much from the main point bring 
them back to it, but gently and with care, otherwise they may become scared or 
nervous or sullen ; some resent it by wilfully giving false answers. (8) When the 
surgeon doubts the veracity of the patient, or when the answers lead to an extra- 
ordinary fact, the surgeon should change the terms and forms of the questions: he 
should cross-examine; he should return to this same point later in the examina- 
tion ; sometimes it is better to return to it the next or some other day: should 
the patient then give different answers on that same point, he should be reminded 
of his former answer; the version he finally adopts is usually the true one, or the 
fraud, if any, is more easily detected. (9) Put as few questions as possible in cases 
where quiet or silence is necessary (great pain, shock, etc.). (10) Proceed with 
gentleness in the physical examination, especially of the organs of generation and 
of the anus, particularly in the female. (11) Do not expose the patient any more 
than absolutely necessary, not only on account of modesty, but because exposure 
may cause cold. (12) Questions relative to syphilis must be put with care—never 
in the presence of the wife, or conversely, or of parties objectionable to the patient. 
(13) Avoid questions, words, movements, or facial expressions which might con- 
vey an unfavorable impression to the patient. (14) Take into consideration the 
social position and the character of patients in examining them, as some are more 
nervous and sensitive than others. 
Methods of Interrogation.—There are two methods of interrogat- 
ing a patient: 
The first method consists in beginning to review all the possible features of the 
case, following closely the order above described. This procedure is long and tedi- 
ous, because the local trouble is only discovered when the turn of the organ comes 
in the examination, but in obscure cases it is the safest and most preferable. 
The second method consists in well determining the debut, and letting the 
patient narrate what he feels and knows, so that he will himself guide the surgeon 
to the affected organ, which will then be thoroughly examined, and afterward the 
organs at large. 
Methods of Diagnosis.—The method, by hypothesis consists in taking 
up at once the disease which the symptoms suggest to the mind, and 
seeing if all the important signs fit it or not: if they do not correspond, 
then the next disease which suggests itself is considered, and so on until 
a disease is found that corresponds to all or most all the important signs. 318 
SURGICAL PROCEDURES. 
The method by exclusion consists in precising the salient signs of the 
history; in noting the diseases to which those signs may belong, thus 
eliminating at once all diseases where those signs are not usually ob- 
served ; in determining the diseases to which the signs do not correspond 
thoroughly, and eliminating them, one after the other, according as signs 
correspond less and less, so that in the end the only disease retained is 
the one to which the signs correspond best. 
Remarks—First. In cases where the data are insufficient all the regions and 
organs of the body must be examined, one after the other, before the diagnosis can 
be reached, as in cases of general injury with no special localization; or where the 
patient is incapable of precising in any way or gives contradictory or vague, worth- 
less answers with a view either to deceive the surgeon, or because of a lack of 
intelligence, or because of the absence of any predominating sensations; or when 
there is unconsciousness, delirium, intoxication, or coma. The diagnosis is reached 
only by the general result of such signs as have been gathered in this way. 
Second. The diagnosis of a disease may be difficult or impossible, at the outset or 
during all its course down to the termination, favorable or unfavorable, or, when 
the surgeon is called at the time of impending death, or when the patient simu- 
lates a disease or dissimulates the disease with which he is really affected. Third. 
In cases of disease presenting attacks or exacerbations it is important to see the 
patient at the time of the paroxysm. PART IV. 
INJURY AND REPAIR. 
CHAPTER XXII. 
WOUNDS. 
By Chas. B. Nancrede, M. D. 
Subcutaneous Injuries, Contusions, Lacerations, etc. 
Subcutaneous Injuries, Contusions, and Lacerations vary in 
severity from the pain and swelling of the skin, which promptly appear 
and as promptly disappear, for example, after a cut from a whip—i. e. a 
wheal—to complete disorganization of a limb, the skin alone remaining 
intact. The most common causes are blows from or falls upon blunt 
objects, the passage of wagon- or car-wheels, and entanglement of a 
limb in ropes or machine belting. The connective tissue with its vessels 
always suffers. When only a few vessels are ruptured an ecchymosis or 
bruise results, with pain, tenderness, swelling, and discoloration of the 
parts, the effused blood as it reaches the surface changing its purplish 
hue to a brownish, green, and yellow tint as it fades away. The effusion 
may either be evenly distributed throughout the damaged tissues—hem- 
orrhagic infiltration—or form circumscribed collections—ecchymoses or 
sugillations. In lax tissues, as the axilla, or where a limb has been 
traversed by a wagon-wheel, the major part of the skin may be stripped 
off’ from the deep fascia, and the cellular tissue and the intermuscular 
spaces be distended by such an enormous extravasation that death 
results from the sudden abstraction of blood from the circulation, or 
gangrene occurs because the pressure upon the small vessels is such that 
the collateral circulation cannot be set up. These accidents rarely occur 
except as a result of the giving way of a large vein—e. g. the axillary 
or external iliac. When the larger blood-collections become circum- 
scribed by condensation of the surrounding tissues, they are called hcema- 
tomata. Occurring in certain regions, a prefix or suffix is added to indi- 
cate the locality—cephal when occupying the scalp (cephalhcematomata); 
arthrosis when a joint is concerned (hcemarthrosis). The pressure exerted 
by the effused blood usually arrests the bleeding, and coagulation gen- 
erally sooner or later occurs. The clot eventually breaks down into a 
thick, reddish fluid which often assumes a brighter tint when exposed to 
the air. Repair takes place without true inflammation unless infection 
occurs. The coloring matters of the disintegrated clot diffuse into the 
surrounding tissues, and with the liquid portions are removed by the 
lymphatics. 
319 320 
INJURY AND REPAIR. 
Some of the peripheral leucocytes wander into the lymphatics, but the more 
central ones disintegrate and are absorbed. These processes sometimes fail or are 
incomplete; the surrounding tissue-cells, proliferating, circumscribe the effusion 
by a layer of granulations which develop into fibrous tissue, or sometimes into 
bone when related to bone. The broken-down contents, decolorized and included 
in the adventitious sac of fibrous tissue, now form a cyst, which may persist, or, 
after the liquid has been absorbed, leave only a subcutaneous scar, which in turn 
often gradually disappears. If the vitality of the tissues be seriously lowered by 
this injury or by previous ill-health, especially if the effusion be large, suppuration 
may occur. The germs gain access locally by (1) some abrasion of the epithelium 
over or near the injury; (2) the germs normally resident in the skin originate the 
trouble; or (3) those accidentally implanted. When the pressure of the effusion 
interferes with the vitality of the skin, already partially deprived of its blood- 
supply by stripping from the deeper tissues, blebs form, through which the infec- 
tion may occur. More rarely still the germs, gaining access to the circulation at 
some distant point, reach the injured tissues, where a slowed blood-current favors 
their accumulation and the impaired vitality of the tissues cannot inhibit or 
destroy them. Suppuration complicating subcutaneous injuries is common in cer- 
tain localities as the thoracic and abdominal walls, while it is said never to occur in 
cephallisematomata in infants. The varying conditions caused by complications, 
such as injuries of great vessels, nerves, lymphatics, bones, or joints, will be con- 
sidered elsewhere. 
Symptoms.—Pain, except when a nerve-trunk is damaged, is de- 
pendent upon and proportioned to the tension resulting from the 
swelling, which varies with the amount of effusion and the laxity of the 
tissues: when confined beneath tense, unyielding structures, as fascise, a 
small effusion may be productive of severe pain, while a large one in 
lax tissues, as the scrotum or eyelids, may cause nothing beyond slight 
discomfort. Discoloration shows promptly if the bruise is superficial, 
but may not appear for many days if the deeper parts are those injured 
or the effusion occurs beneath an unruptured fascia. At first of dark 
purple, the color changes to green, then to yellow, finally fading out. 
Constitutional reaction—“aseptic fever,” so called—is proportioned to 
the extravasation and laceration ; i. e. the amount of fibrin-ferment and 
nucleins available for absorption. When the injury is superficial the 
overlying skin presents the evidences of 'plastic exudation—viz. normal 
reparative processes—which soon disappears unless infection occurs. 
Treatment.—Rest must be secured for the part by splints, position, 
or both. Even where no appreciable lesion of the epithelium is dis- 
cernible, it is better to carefully sterilize the surface and employ subse- 
quently only aseptic applications, because portions of the skin may have 
been actually killed, and yet no evidence of this appear until later: 
these precautions are imperative if abrasions do exist, lest infection 
occur. Cold may be employed to check effusion by applying ice-bags, 
iced lotions, or aseptic lotions so disposed as to permit constant evapora- 
tion taking place, especially for the more superficial injuries. Alcohol- 
and-water is one of the best evaporating lotions, to which morphia may 
be added if desired. The value of lead-water is doubtful. Irrigation 
with cold sterilized water may sometimes prove useful in certain severe 
contusions, but all cases where any form of cold is used must be care- 
fully watched lest gangrene be precipitated. Massage has been recom- 
mended for slight contusions, because it favors rapid disappearance of 
the effused blood by distributing it over a greater area, but a judicious 
selection of cases must be made, lest more harm than good result. In 
the more severe injuries the effusion may be checked and absorption 321 
WOUNDS. 
hastened by gentle, elastic 'pressure, such as can be secured by the careful 
application of bandages over many layers of cotton, first having aseptic- 
ally emptied all blebs and protected them by proper dressings. If the 
tension comprises the integrity of the parts, aseptic aspiration, followed 
by gentle pressure to prevent fresh hemorrhage, usually suffices, although 
incision may be requisite to satisfactorily evacuate large collections if 
much clot be present. When coldness and oedema of the part show that 
the collateral circulation is seriously interfered with by the pressure of 
the effused blood, as this probably comes from a large vessel or ves- 
sels, aseptic incision, ligature, perhaps packing and proper drainage are 
indicated. 
Injuries of Vessels. 
Arteries.—Mere contusion, if the vessel be superficial, compression 
against a bone if deeper, or overstretching during the production or 
reduction of dislocations, may cause partial or complete rupture of an 
artery. In the former variety the internal or middle and internal coats 
yield, usually in such a manner that, curling upward and downward 
because of their normal elasticity, they partially or completely occlude 
the vessel, thrombosis soon rendering complete any partial blocking. 
Even when the incurved coats do not seriously interfere with the blood- 
current thrombosis often results. 
Precedent atheroma, calcification, or softening from inflammatory changes pre- 
dispose to these accidents. As a rule, occlusive thrombosis follows partial rupture 
of the inner coats of an artery, but sometimes a small, newly-formed, tortuous 
vessel may extend through the connective-tissue cord which represents the obliter- 
ated segment of vessel. When the thrombus gradually forms, with normal col- 
lateral vessels and a strong heart-action, the vitality of the distal parts is readily 
maintained, but with rigid collateral vessels and a feeble heart gangrene usually 
follows. When a limited rupture of the inner coats of an artery occurs, not 
affording the proper mechanical or vital conditions productive of obliterative 
thrombosis, reparative processes are set up which render the already weakened 
vessel more distensible. The remaining coat with the environing portion of the 
softened vessel either yields gradually to the intravascular pressure, forming a 
traumatic aneurism, or a few days or weeks later the rupture suddenly becomes 
complete, the blood escaping into the tissues. 
Symptoms.—Unless the incurved coats at once block the vessel, no- 
symptoms appear until thrombosis diminishes or cuts off the blood- 
supply, when the pulse in the distal segment of the artery either becomes 
feeble or is arrested, according to the rapidity of clot-formation : the 
part becomes numb, powerless, pale, and cold, with neither swelling nor 
extravasation to explain the condition. Sometimes severe pain is com- 
plained of. Later, if gangrene does not occur, enlarged collateral 
vessels may be detected. When, the rupture involves all the coats and 
the opening is large, if the surrounding tissues are lax, an enormous 
soft, fluctuating, imperfectly circumscribed swelling forms in a few 
moments, and the loss of blood from the circulation may be so great as 
to produce syncope. The distal portion of the limb becomes swollen, 
pale, and cedematous, and no pulsation can be detected in the vessels 
below the injury. Extreme pain is common. Pulsation is absent in the 
swelling or can only be detected over a small area : it is not expansile, 
nor is there usually bruit nor thrill. If a bruit be present, it is not 
conducted along the vessel. If the surrounding tissues are dense 322 
INJURY ANT) REPAIR. 
enough to resist the effusion, a small rent in even a large vessel may 
give rise, for a time only, to more or less vague symptoms of traumatic 
aneurism, and then, after some days, perhaps quite suddenly, the barrier 
yields and the blood spreads widely through the limb, forming a cha- 
racteristic arterial hcematoma. 
Diagnosis.—When immediately after injury a diffuse, fluctuating 
swelling, perhaps pulsating over a small area, with bruit and thrill, 
appears in the course of an artery, with cessation of the pulse below, 
the diagnosis is clear enough; but when the vessel is deep-seated and 
much inflammation exists, the condition closely simulates acute phleg- 
mon or even a rapidly-growing sarcoma. If neither thrill, bruit, pul- 
sation, nor alteration in the distal pulse can be detected, exploration 
with a grooved needle or aspirator must precede any active interference 
in doubtful cases. Traumatic aneurism, arising from yielding of the 
partially ruptured arterial wall, appears some time after injury and 
presents the ordinary symptoms of aneurism. 
Treatment.—When that surgical rarity, simple occlusion, results 
from contusion of a large vessel, carefully sterilize the skin, dress with 
abundance of sterilized cotton, place the limb in an elevated position, 
and wait to see if gangrene ensue. The gangrene, if it occur, may prove 
to be less extensive than at first appeared probable, one or more toes 
perishing instead of the extremity, so that before operating it is better, 
if possible, under aseptic dressings, to allow the line of demarcation to 
form and not amputate at the level of arterial occlusion. Traumatic 
aneurism must be treated as indicated by the locality and calibre of the 
vessel. When possessing a well-formed sac, compression or Hunterian 
ligation may succeed, as in rupture of the anterior tibial complicating 
fracture of the bones of the leg : in this particular case spontaneous 
cure often takes place by the time the fragments are consolidated. As 
the vessel is healthy close to the point of injury, there is no objection in 
appropriate cases, when the circulation can be effectually controlled, to 
cut down and tie the artery above and below the wound, and also any 
collateral branch opening into the portion included between the ligatures. 
An arterial haematoma—i. e. a diffused traumatic aneurism—requires 
prompt intervention. As the condition is really a wounded artery, it 
should be treated as such if the vessel be of any size. In addition to 
the danger from mere loss of blood, the effusion often interferes so seri- 
ously with the collateral circulation that gangrene will occur unless the 
pressure be relieved. Gentle compression has been recommended when 
the extravasation tends to cease spreading and the collateral circulation 
is fair. This is questionable practice, except for the smaller arteries. 
When the diagnosis is clear, ligation should be done as directed for 
traumatic (circumscribed) aneurism. The efficiency of modern methods 
for controlling hemorrhage, the immunity conferred by asepsis against 
secondary hemorrhage and septic inflammation, and the certainty of 
remedying the effects of the injury, all indicate that this is the proper 
course to pursue. Moreover, the necessary incisions will permit of the 
removal of so much of the effused blood as will materially relieve the 
collateral circulation. AVhile amputation at the level of the rupture is 
the only resource if gangrene of the segment of the limb actually occur, 
either before or after ligation, the emphatic warning must be repeated WOUNDS. 
323 
that with aseptic methods the surgeon can usually safely wait until no 
doubt exists as to the extent of the destructive process. 
Veins.—Contusion occasionally produces rupture of the internal 
coats, initiating a thrombosis which blocks the vein, but even when the 
main vein of a limb is concerned the free anastomosis prevents gangrene. 
The extent of extravasation in subcutaneous rupture of veins is rarely 
serious in itself, but if one of the main veins be ruptured or a branch 
be torn off close to the parent trunk, where the surrounding tissues are 
lax, as in the axilla, the amount withdrawn from the general circulation 
may threaten life or cause gangrene by interfering botli with the direct 
and collateral circulation. 
Treatment.—Elevation of the part, coupled with cold and equable 
pressure, usually suffices, but where the effusion causes so much com- 
pression as to threaten gangrene incision and suture with catgut for 
small wounds and ligation for transverse wounds should be done, after 
turning out all the clots. While pressure combined with elevation is 
often sufficient, suture or ligation is perfectly safe, and more reliable 
when the effusion tends to spread. 
Suture is preferred by many because, although thrombosis sometimes occurs, 
the vessel usually remains patent. Suture is only possible when the bleeding is 
thoroughly controlled during the whole procedure; hence it is usually better to 
ligate. 
Lymphatics.—In all contusions lymph is extravasated, and in 
some cases much of the effusion is composed of lymph. It may even 
form a fluctuating tumor containing yellowish or reddish fluid. These 
lymph-effusions most often residt from laceration of the lymphatics tra- 
versing the subcutaneous cellular tissues, and are therefore most apt to 
occur when the skin is extensively displaced from the subjacent parts. 
These tumors form rapidly at the outset, to soon become stationary 
(lymph-cysts). When they progressively increase, rupture with the for- 
mation of a lymph-fistula may result. 
Diagnosis.—This must depend upon the history of sudden appear- 
ance after traumatism and the exclusion of a haematoma or abscess by 
the appearances and the exploring needle. 
Treatment.—Compression should be tried. If this fail, the 
tumor should be laid open, any lymph-vessel which can be detected 
should be tied, and the interior of the cyst be cauterized with diluted 
carbolic acid : firm packing with iodoform gauze should be continued 
for some time. 
Injuries of Nerves. 
Experiment shows that slight blows inflicted upon nerves produce 
extravasations of blood into the neurilemma and between the nerve- 
fibres. The fibres are contracted at the point struck and irregularly 
enlarged above and below. In the more severe cases the Wallerian 
degeneration sets in within a few days, but where the hemorrhage is 
very slight and only a few fibres are torn, the paralysis rapidly disap- 
pearing, most of the fibres undergo, according to Mitchell, only a 
mechanical disturbance, and a restitutio ad integram rapidly occurs. 
Symptoms.—These vary with the severity of the injury. In the 324 
INJURY AND REPAIR. 
slighter cases pain will be felt at the point of injury, immediately fol- 
lowed by numbness and formication in the peripheral distribution of the 
nerve. A sensation of burning or heat is often experienced, and even 
actual flushing of the skin has been occasionally observed. All these 
sensations usually disappear in a few minutes, but the tingling may per- 
sist for several days. In more severe cases the parcesthesia and paresis 
continue, neuralgic pain appears, and a distinct chronic neuritis, tending 
to spread and resulting in various trophic lesions, occurs. After the 
most severe contusions immediate and complete paralysis of both motion 
and sensation ensues. This may pass away with great rapidity: 
improvement may not set in for weeks or months, or the paralysis may 
be permanent. 
It is well to note that the peripheral areas supplied by nerves may vary in 
different individuals, and that anastomoses occur with other nerves: ignorance of 
these facts has led, and again may lead, to the most erroneous conclusions. Com- 
plete rupture of a nerve is of course accompanied by initial pain and immediate 
sensory and motor paralysis in the area supplied by the severed nerve, the changes 
consequent upon nerve-section following later. 
Prognosis.—This is uncertain in the more severe cases, but neither 
patient nor surgeon need despair because many months elapse without 
evidence of improvement. If at the end of one to two weeks the 
faradic excitability of the muscles supplied by the damaged nerve per- 
sists, its continuity is not completely interrupted and rapid and com- 
plete recovery may be expected. In most cases faradic excitability rap- 
idly disappears, when the prognosis then becomes difficult. If some 
muscle or muscles supplied by the damaged nerve are not paralyzed, the- 
nerve is not wholly crushed and recovery is to be expected. If, how- 
ever, rapid muscular atrophy occur and the reaction of degeneration is 
present, complete solution of continuity of the nerve-fibres has taken 
place, although the nerve may not have been actually severed. Restor- 
ation of function under these circumstances is very doubtful, and, if it 
does occur, will require months or years. Usually, even in the worst 
cases, a gradual improvement is discernible, but one which stops far 
short of recovery. Again, an ascending neuritis may supervene, when 
the prognosis will depend upon its course as well as upon the original 
injury. 
Treatment.—When seen early an attempt should be made to limit 
the effusion of blood and the exudates of repair by perfect rest of the part: 
morphia is often demanded for the pain. Later, counter-irritation, 
blistering, massage, and galvanism are indicated. When a well-grounded 
suspicion exists that the nerve has been actually severed, and no 
improvement in the paralysis takes place in from eight to ten months— 
symptoms of neuritis being absent—an exploratory operation may be 
done, the nerve examined, and if found severed the ends must be fresh- 
ened and sutured together: if markedly reduced in size at the point of 
injury, in extreme cases, resection of the damaged portion and suture is 
indicated. If, despite of appropriate treatment addressed to the neuritis1 
when this occurs, the disease continues to extend, Bowlby suggests that 
the nerve should be exposed and stretched to free it from adhesions to 
and pressure by the surrounding inflamed tissues: nutritional changes 
1 See Chapter II. Vol. II., and consult neurological treatises. WOUNDS. 
325 
are also set up in the thickened nerve, tending to remove the compress- 
ing inflammatory exudate. 
Injuries of Muscles. 
Much pain, effusion of blood, and loss of power may result from 
contusion of muscles, but these symptoms are usually only temporary. 
Sometimes permanent atrophy follows. This may perhaps be due to 
serious interference with or deprivation of arterial blood by the pressure 
of the hemorrhagic effusion producing an ischaemic paralysis, but more 
probably results from myositis, causing coagulation-necrosis, fatty degen- 
eration, and destruction of the muscular fibres. External violence may 
rupture the sheath or a part or the whole of a muscle, or sever both 
muscle and sheath. 
Symptoms.—As just stated, contusion—i. e. more or less extensive 
laceration of a muscle—produces pain and loss of function lasting for a 
variable period, but complete division presents additional symptoms. 
Sudden, sharp pain is felt, followed by a dull aching and loss of power. 
The ends freely retract, and the interval can be felt to increase if 
attempts are made to contract the muscle. Much blood is effused 
between the ends of the muscle and into the surrounding tissues. In 
due time this is absorbed, and repair is effected by the formation of 
cicatricial tissue, unless the ends are too much separated, when atrophy 
usually results with loss of function. If but little separation has taken 
place, partial regeneration of the muscle-elements may occur, so that 
the scar is not wholly fibrous. Much of the original power is regained 
by the muscle, especially if only a small gap has to be filled by scar- 
tissue, but permanent atrophy or contracture may result. 
Treatment.—Mere contusion must be treated bv placing the part 
in such a position as will relax the muscle, and this must be maintained 
by splints and posture until healing occurs. If ruptured, two courses 
are open to the surgeon : The injury can be treated as just recommended 
for contusions, in addition maintaining quiet of the muscle by firm 
bandaging, which should be so applied as to approximate the separated 
ends and restrain further effusion of blood. Cold may also prove ser- 
viceable. When the restoration of the function of the injured muscle 
is of great importance, antiseptic incision and suturing should be done, 
care being exercised in passing the sutures to include, when possible, in 
some of the stitches the aponeurotic covering of the muscle, as other- 
wise the sutures too often cut out before union takes place. Even with 
considerable separation and a large scar the functional result is so often 
good that operation is seldom indicated. Electricity, massage, active 
and passive exercise will aid in restoring function. Secondary suturing 
where a large gap exists and the case is of some standing will usually 
fail. 
Hernia of a muscle, when following distinct traumatism, results 
from an unhealed rupture of a portion of the investing muscular 
aponeurosis. 
Symptoms and Diagnosis.—During the contraction of the muscle 
an elastic, almost fluctuating, mushroom-shaped protrusion occurs, 
which disappears as soon as the muscle relaxes. 326 
INJURY AND REPAIR. 
Treatment.—This may be palliative or curative. The former is 
carried out by a pad attached to an elastic belt or garter. If productive 
of serious inconvenience, aseptic incision, freshening of the margins of 
the fascial rent, and suturing should be done : as a precautionary meas- 
ure a pad and elastic girdle should be worn for a time. 
Tendons seldom suffer from contusions, but repeated injuries and 
strains sometimes lead to ossification, as in so-called rider’s bone. Rup- 
tures, especially of the quadriceps femoris tendon, sometimes occur from 
glancing blows, as by the end of a wagon-tongue. 
Symptoms.—They are similar to those of division of a muscle—viz. 
pain, sudden loss of power, a gap between the extremities of the tendon, 
and effusion of blood. 
Treatment.—This should be by suture if the tendon belong to an 
important muscle and the separation be great. If this cannot be done 
or is deemed inadvisable, the same treatment as was recommended for a 
ruptured muscle must be adopted, remembering that diminution, not 
complete loss of power, is the worst that will follow the lengthening of 
the tendon. Secondary suture may be tried if palliative treatment gives 
a poor functional result. 
Contusion of Bone. 
The blood may be poured out beneath the periosteum or into the can- 
cellous tissue, in the former position being usually only small in amount, 
except in children, in whom the periosteum is much more vascular and 
less firmly adherent to the bone than in adults. This is especially true 
of cephalhcematomata, where quite large accumulations form, which by 
subsequent changes closely simulate a depressed fracture because of par- 
tial ossification of the margin of the exudate. Absorption of the effused 
blood, after the manner already described, is the rule here as elsewhere, 
and suppuration is rare. 
Sometimes the effused blood becomes permeated with numerous plasma-cells 
and organization results in bone-formation; this termination occurs most fre- 
quently in syphilitics and rheumatics. Where osseous tissue itself is concerned in 
the injury, the hsemostatic thrombi may involve the afferent or efferent vessels of 
a given area, when, unless a collateral supply exists, quiet necrosis will result. Two 
terminations are here possible: either the dead bone, acting as a persistent irritant, 
causes a more or less extensive osseous thickening and sclerosis, or, pyogenic 
organisms reaching the damaged area, acute or chronic suppurative osteitis or 
osteomyelitis will result. 
The symptoms and treatment of these several results are considered in 
the chapter on Diseases of the Osseous System. CHAPTER XXIII. 
GUNSHOT WOUNDS. 
Charles B. Nancrede. 
In civil life small shot, pistol-balls, and, more rarely, rifle-bullets are 
the vulnerating bodies, but in military practice injuries inflicted by frag- 
ments of shell, cannon-balls, grape and canister shot, or splinters of 
wood or stone set in motion by large shot, are included under gunshot 
wounds. Injuries produced by flying pieces of caps and exploded gun- 
barrels are also spoken of as gunshot wounds. 
Missiles.—Shot ranges in size from dust, each pellet weighing of 
a grain, to buckshot, weighing 153 grains. Pistol-balls are of a calibre 
from .22 to .45 inch, and weigh from 25 to 250 grains. All modern 
missiles approach a conical form. They may be pure lead (compressed 
into shape, not cast) or be hardened by the addition of from 2.5 to 5 per 
cent, of tin. In addition, military projectiles are covered by a thin cover- 
ing (tjacket or mantle) of steel, nickel, copper, or alloys of copper and 
nickel, or copper, nickel, and zinc (Maillechort). 
Formerly of a calibre of .50 to .71 inch and weighing from 400 to 760 grains, 
the most recent missiles vary in length from 3.5 to 4 calibres and in weight from 
150 grains (calibre .256 inch) to 245 grains (calibre .315 inch), the former attaining 
a velocity of 2329 feet per second, the latter 1984. The old Springfield ball (calibre 
.45, weight 500 grains) of the U. S. service, with 70 grains of black powder attained 
a velocity of only 1300 feet, but the new weapon, recently adopted (calibre .30, 
weight 220 grains), propels a ball 2000 feet per second. 
Effects of Modern Bullets on the Tissues.—Great care must be 
exercised in drawing conclusions from the experimental results obtained 
with reduced charges at fixed distances (La Garde,1 Habart, Seydel) and 
on the cadaver. The differences between the velocity of rotation and 
angle of incidence with reduced charges at fixed distances and service 
charges at actual distances are marked. The tension of living muscles 
and fasciae as compared with dead tissues, and the physical change from 
the semi-liquid fat of adipose tissue and of medulla to a more solid con- 
dition by the loss of animal heat, influences the results. The velocity, 
form, size of ball, and time the injury is inflicted after leaving the weapon 
modify the tissue-damage. Elastic structures, as skin, may be merely 
split; less elastic ones, as fasciae, muscle, and bones, are more or less 
destroyed for a varying distance around the track of the ball. As Conner 
points out, the gross anatomical structure may limit the destruction, as 
in a muscle longitudinally traversed, when “ the track may be traced with 
great difficulty or not at all,” owing to the separation, not destruction, 
1 Report of Surg.-Gen. of the Army to Secretary of War, 1893, p. 73. 
327 328 
INJURY AND REPAIR. 
of the fibres. It has been confidently asserted that the old missiles pro- 
duced more primary and secondary destruction of tissue than the modern 
balls. With service charges—unless actual experience in warfare inval- 
idates the results of experiments upon human cadavers and living horses 
—the more “humane” effects of jacketed balls is doubtful. The zone 
of “ explosive action ” is increased, extending up to 500 yards,1 while for 
the skull, as has been shown by Demosthen,2 there is practically no dis- 
tance up to 1300 yards or more where “ explosive action ” is not marked : 
Fig. 121. 
Fig. 122. 
Wound inflicted at about 110 yards (from a 
recent foreign report).3 
Wound inflicted at 1300 yards by steel-mantled 
ball (from a recent foreign report). 
this is also in a measure true for the softer viscera and for the hollow 
viscera when containing much fluid. 
1 There is no such action exercised by pistol-balls. 
2 Etudes experimentales sur Vaction du projectile cuirasse du fusil Mannlicher, nouveau modcle 
Roumain de 615 m.m., p. 40 et p. 51. 
3 By request of the gentlemen to whom the author is indebted for permission to use 
these illustrations the exact source is not credited. G UNSHO T WO UNDS. 
329 
If no bony resistance is met with, or but little—as cancellous bone, between 
350 to 500 yards and 1500 yards—i. e. at the “middle distance”—the wounds are 
more apt to be perforations, without much comminution of bone and laceration of 
soft parts, than with the old balls. But if much resistance is encountered, the ball 
often does become deformed (see Fig. 123), and, while the bone-fragments may not 
be so widely displaced, there is no appreciable difference detectable between Fig. 
121, where the injury was inflicted at about 110 yards, and Fig. 122, where the ball 
struck at over 1300 yards. At 1800 yards and over—the “ zone of contusion ”— 
jacketed balls are not deformed, while the bone-comminution may be extensive with 
comparatively slight displacement of the fragments. Perforation rather than 
lodgement is the rule at all ranges, but this may occur if much bony resistance is 
encountered, although highly improbable for the cranium. Hemorrhage is apt to 
be more free than with the old balls, vessels and nerves being clean cut rather than 
lacerated or even pushed aside, although theoretically the larger size and greater 
deformation of the soft ball tended to endanger the vessels more than a small, 
unaltered missile. 
At least 10 per cent, of the German-silver jackets part entirely from 
their cores at ranges of from 100 to 2000 yards if bony resistance is 
met with. The steel jacket is less apt to strip, yet Fig. 123 (e, /, g, and 
Fig. 123. 
a, completely shattered after perforating a horse’s thigh-bone at 220 yards ; steel mantle stripped • 
b, ball with mantle torn otf and rolled up, core deformed, after shattering human tibia at 60 
yards; c, wholly disorganized ball, which destroyed middle metatarsal bone of horse at 660 yards, 
steel-mantled; a, ball which shattered a human femur at about 750 yards, steel-mantled * e 
remains of steel mantle and part of core lodged in human femur, wound inflicted at about 
1100 yards; /, g, fragments of mantle found near the orifice of the wound of exit at about 1100 
yards range, steel-mantled; h, piece of steel mantle split off by striking a dried horse’s met- 
atarsal at over 1300 yards; i, steel-mantled ball which perforated the internal femoral condvle 
and lodged beneath the skin at nearly 2200 yards. (Recent foreign report.) 
A) shows that at over 1100 yards great deformation and stripping may 
occur. Ball-wounds are usually contused wounds, although laceration 
may be added. Grazing of surfaces or contusion without skin-penetra- 
tion may occur with pistol-balls or even spent rifle-balls, but perfora- 
tion or penetration with lodgement is most common. The wound of exit 330 
INJURY AND REPAIR. 
with the old balls was apt to be larger and more irregular than that of 
entrance, but those made by the new balls, when they involve the soft 
parts alone, are about the size of the projectile, sometimes smaller, 
sometimes larger. Unless within the “zone of explosive action” the 
wound of exit is often not appreciably larger than that of entrance, 
even sometimes when a bone has been traversed. But within the 
“ explosive zone ” the difference is often very marked (Fig. 124). The 
Fig. 124. 
Wounds produced by steel-mantled ball at about 220 yards: 1, wound of entrance; 2, wound of 
exit (from a recent foreign report). 
wound of entrance lias often a contused, discolored margin, and is 
depressed, while that of exit is everted and “stellate, triangular, or 
linear.” Powder-staining, owing to differences in powder, varies, the 
distance of the muzzle from the part having been in reported cases from 
two to ten feet. Whether any analogous marking will occur with the 
new powders remains to be shown. Deflection of the modern conical 
pistol-ball is unusual as compared with the old round ball, and this is 
still more true of the mantled rifle-ball. Moreover, it must not be for- 
gotten that change of position of a part or the body after the reception 
of a wound may closely simulate deflection of the ball. One bullet may 
cause “from two to six or more wounds,” or, if lodging, “three, four, 
etc.”1 (Fig. 125). Splitting of the old, soft-lead ball sometimes caused 
two wounds of exit, but this will rarely occur with the hardened pistol 
or jacketed rifle projectile. The truth that “when a bullet has ceased to 
move it has ceased to do harm ” has but few exceptions. When lodged 
1 Conner, Dennis’s System of Surgery, vol. i. p. 448. I would here acknowledge my great 
indebtedness for much information and many valuable facts to Prof. P. S. Conner’s article 
on “Gunshot Wounds” in the work just quoted from. G UNSHOT WO UNDS. 
331 
in the brain it may primarily, or, by changing its position from gravity, 
secondarily, cause dangerous pressure-symptoms. Again, a ball may 
ulcerate its way into a hollow viscus or blood-vessel when in contact 
Fig. 125. 
Multiple shot-wounds of arms and back. The opening over the spine was produced by pressure, 
not by the ball (case in Cincinnati Hospital, 1881). (Conner, Dennis’s System of Surgery.) 
with one of these. Lodged in the soft parts, a bullet usually promptly 
becomes fixed by the development of a connective-tissue capsule, 
although sometimes a change of position is effected by gravity or mus- 
cular action. One wound usually indicates lodgement, but the missile 
may have passed out by a natural opening, as the mouth or rectum. 
Again, the old-fashioned round ball—still occasionally employed— 
sometimes carries ahead of it for a short distance into the tissues a 
pouch of clothing, upon the withdrawal of which the ball is extracted 
and may be overlooked. 
Determination of the Location of Balls.—Palpation and explora- 
tionwith the finger or probe—electric or simple—are the means to be 
employed, and the X-rays when time permits. The disinfected finger 
is the best probe if the track be large enough. Pistol-balls which cannot 
be detected by palpation would better be left without further search unless 
the brain or a hollow viscus have been wounded. The only warrant for 
the enlargement of a wound is the probable lodgement of a fragment of 
clothing, since the finger alone can distinguish any textile fabric from 
the soft tissues. 
A bullet-probe should be of metal and have as large an extremity as the ball- 
track will admit. Aluminum is light and useful for brain-wounds, but must not 
be placed in strong bichloride solutions. N6laton's porcelain-tipped probe may 332 
INJURY ANI) REPAIR. 
prove useful, but if a bone have been struck or traversed it may mislead, frag- 
ments of lead often adhering to the bone and marking the probe; moreover, a 
jacketed ball, unless approached from its butt end, cannot mark this probe, because 
no lead is elsewhere exposed. Girdner’s telephonic probe seems to be the best of 
the electrical devices, but its exact value has not yet been determined.1 Even 
when located it is not always advisable to remove balls. When their continued 
presence is likely to be more hazardous than their removal, operate: when this is 
in doubt and much damage will result from their extraction, let any missile alone. 
Extraction may be effected through the track of the ball or by a counter-opening, 
being guided by anatomical conditions and the superior facility of manipulation 
afforded by one method over the other. Fixation while being cut upon and free 
exposure are requisite when removing a ball by counter-incision. Many patterns 
of bullet-forceps have been invented, the U. S. A. patterns (Fig. 126) being the 
Fig. 126. 
Fig. 127. 
Bullet forceps, U. S. A. 
best, but except when extracting a ball through the wound-track an ordinary 
haemostatic forceps usually suffices; if imbedded in a bone, an elevator should be 
used. 
Hemorrhage.—This may be free, but is speedily arrested by natural 
processes unless a vessel of some magnitude is opened ; but a large pro- 
portion of deaths from gunshot wounds result from primary hemorrhage 
caused by wounds of the great vessels. It is surprising, in exceptional 
cases to see how such wounds as those of the jugular, carotid, vertebral,2 
subclavian, external and internal iliac, etc. may not prove fatal for 
hours or even days. Probably the new bullets will give rise to more 
severe primary hemorrhage, while asepsis will lessen the frequency of 
secondary hemorrhage, which is largely dependent upon sepsis. 
Pain.—This is variable, but unless a large nerve is struck it is dull 
or tingling, or like a smart cut with a cane. During great mental 
excitement no pain may be at first noticed. 
Shock.—Although ball-injuries involving the brain, spinal cord, 
abdomen (solar plexus)3 are usually attended with marked shock, this 
1 Park, “Some Considerations concerning Location and Detection of Missiles,” Medi- 
cine, June, 1895. 
2 The writer has seen one case where the jugular vein, carotid, and vertebral arteries 
were wounded, and successfully operated upon by a colleague more than two days after 
injury, death eventually resulting from cerebral softening. 
3 Injuries of the basal ganglia, cord above the phrenics, the medulla oblongata, and 
the solar plexus, especially with modern balls, are probably instantly or almost instantly 
fatal, so that after such wounds it may safely be affirmed that the individual had been 
incapable of inflicting harm upon himself or others—a point of medico-legal importance. GUNSHOT WOUNDS. 
333 
is not invariably true. The author lias seen marked symptoms from a 
comparatively trivial wound of an extremity, and after pistol-ball 
wounds of the brain or abdomen but little disturbance. 
Prognosis.—This depends upon the size of the missile, its velocity, 
the parts injured, and the degree of asepsis observed during the first 
examination and dressing, for, as Nussbaum justly observes, “the fate 
of a wounded man is in the hands of the surgeon who first attends him.” 
Cceteris paribus, a pistol-ball wound of the same structures will not be 
so dangerous as that inflicted by the bullet of a military rifle. The 
primary dangers of shock and hemorrhage being survived, sepsis with 
possible consequent secondary hemorrhage is alone to be feared; hence 
the early aseptic treatment possible in civil practice renders gunshot 
injuries less fatal than those received in war. The majority of 
bullets being aseptic, the wounds they inflict will usually remain so, 
unless fragments of clothing or an unclean Anger or instrument become 
a vehicle of infection. Theoretically, germs may reach a wound by 
way of the circulation, having gained access thereto by a distant infec- 
tion-atrium. In practice this can be ignored. Proper disinfection of 
the environment of the wound, with rigid exclusion of all infected 
instruments, hands, and sponges, must be enforced in civil, and so far 
as possible in military practice, since experience demonstrates how much 
gunshot mortality can thereby be diminished. 
Injuries by large shot or fragments of shell or objects set in motion by the impact 
of shot produce avulsions of limbs, extensive lacerations, or disorganization of a 
limb, leaving the skin almost or completely intact. These latter injuries usually 
result from the impact of so-called “spent shot.” Large fragments of shells, 
stone, the point of a sabre, or even cannon-balls, may be lodged in a limb and 
their presence be unsuspected.1 When such injuries are severe enough to demand 
amputation the limb must be removed well above the apparent limits of disor- 
ganization, otherwise sloughing will surely follow. 
Small-shot Wounds.—These include all those not produced by bul- 
lets proper, even “ buckshot.” At close range a charge of the smallest 
shot will act as a solid mass, making a large track through the soft 
parts and the bones. If the vascular supply is not too extensively 
destroyed by laceration of the soft parts, even with free comminution of 
bone, the part can often be saved, but when serious damage to vessels 
and nerves also exist it is a grave question whether the limb will be 
worth saving at the cost of great peril to life. Conservatism is more 
warrantable for injuries of the upper extremity than the lower, because 
a hand on a maimed arm is valuable, while a sound foot on a leg in- 
capable of bearing weight is only a useless incumbrance. 
Typical or atypical resection can often be substituted for amputation, especially 
for injuries of the elbow- and shoulder-joints. If the shot-charge is received 
at a greater distance than a few feet, the destruction is rarely such as demands 
operation other than removal, when possible, of shot, loosened fragments of bone, 
shreds of clothing, etc.-2 Of course eyes may be destroyed, the larynx wounded, 
the great cervical vessels be perforated, or even the spinal cord be severed by a 
single small shot fired at a distance. 
1 Larrey reports such a case where a five-pound ball was imbedded in the thigh. 
Larrey suspected its presence from the weight of the part. 
2 The author’s assistant in his presence and under his direction removed a large piece 
of newspaper and five hundred shot from the axilla of a patient, the charge being 
received at only about two feet distance, and yet no blood-vessels or important nerves 
were damaged. 334 
INJURY AND REPAIR. 
General Considerations as to Treatment.—Asepsis should be 
the one end in view after any hemorrhage has been temporarily arrested. 
Disinfection of the surrounding area must be carefully effected, after 
which any necessary exploration of the wound may be made, hemorrhage 
permanently arrested, and foreign bodies, including bullets, removed if 
deemed advisable. Disinfection of the ball-track should only be done 
when it has been explored or if it is an extensive one, as the wound of 
exit sometimes is within the “zone of explosive action.” Asepsis is 
favored by minimizing further damage to the tissues by securing rest 
for the parts by splints, etc. Patients wounded by modern pistol- and 
rifle-balls will usually recover if asepsis is maintained, unless some com- 
plication, as a serious visceral wound, coexists. Healing of the ball- 
track is usually said to commence in its central portion and proceed 
thence toward the wounds of entrance and exit, the former commonly 
healing last. When only the soft parts are compromised, aseptic healing 
often occurs or only a little pus is formed : this may even occur when 
bone lesions coexist. 
If symptoms of infective inflammation appear later, as this often results from 
lodgement of infected foreign bodies, such measures should be adopted as would be 
indicated for similar conditions originating otherwise than from ball-wounds. The 
surgeon will be guided as to amputation or resection or conservatism for extensive 
destructions of extremities by small shot, cannon-balls, fragments of shell, or 
“ explosive action of bullets ” by precisely the same indications as would govern 
his action in railroad or machinery accidents productive of the same extent of 
injury to bone and soft parts. The constitutional treatment must be that of any 
injury of the same magnitude. Undue oozing, not arising from vessels of a mag- 
nitude demanding ligation, can be checked by hot water, cold, or elevation and 
compression, these last two often availing even when a large vein is involved. 
Wounds of large vessels—vein or artery—must be treated by ligation at the point 
of injury. The question of amputation for wound of both artery and vein must 
be decided by the extent of concomitant laceration of soft parts and consequent 
risk of gangrene from destruction of the collateral vessels. In secondary hem- 
orrhage—usually the result of sepsis—the wounded vessel must, if possible, be 
tied in the wound above and below the lesion with any collateral vessel opening 
into the segment included between the ligatures: if this cannot be done, tie the 
vessel above, but as near the wound as possible. While compression, especially 
when the bleeding comes from the distal end of an artery or complete division of 
a partially divided artery, has sometimes succeeded, nothing short of ligation 
should satisfy the surgeon when this can be accomplished. If the first bleeding 
has been severe, interfere actively; if not, and the case can be under constant 
professional watching, in selected cases delay is advisable, because no further 
bleeding may occur. 
Injuries of Soft Parts.—The skin, struck at a proper angle, may 
be merely grazed, and if the ball be “spent” a mere linear contusion 
results; but if moving with more velocity or at a different angle, the 
ball may just penetrate the integument. An appearance simulating the 
linear bruise inflicted by a severe cut with a whip follows the passage 
of a ball between the skin and deeper structures. The subsequent 
destruction and separation bv sloughing of the tissues after such a 
wound will leave a depressed groove, and later a similar scar. Grazing 
by cannon-balls or large fragments of shells, or more commonly impact 
of a nearly “spent” large projectile, may leave the skin intact, but dis- 
organize all the other tissues of a limb, or the viscera if the walls of 
a cavity be concerned. With dry aseptic dressings skin-grazes or con- 
tusions, producing even sloughing of a portion or the whole thickness of G UNSHOT WO UN US. 
335 
the skin, will heal readily without suppuration. Deflections even of 
pistol-balls by fascice are now rare, and modern rifle-balls are never 
thus turned from their course. The openings made by perforations of 
fasciae being due to separation as well as division of fibres, partial 
closure takes place, rendering it difficult to follow the track of the ball 
and also interfering with drainage. Imperfect healing of fascial wounds 
may lead to hernia of muscle,1 but this will be much less likely to follow 
wounds inflicted by the modern small-calibre missiles than with the old 
large balls. Severe damage to muscles is only caused when balls strike 
at short range—i. e. within the zone of “ explosive action.”2 Wounds 
parallel to the course of muscular fibres often separate rather than divide 
them; hence the difficulty or impossibility of following such a track 
with a probe; but passing at right angles to the fibres, their division 
must take place. Large shot or fragments of shells produce much 
destruction and sloughing, often causing serious deformities by scar-trac- 
tion. The belly of a muscle may be ruptured by a bullet striking, but 
not penetrating, its tendon. Tendons may be perforated or divided or a 
segment may be removed. In the future bullets will rarely simply con- 
tuse vessels, but partial or complete division will be the rule. Secondary 
hemorrhage, the formation of an aneurism or an arterio-venous aneurism 
—when an adjoining artery and vein are injured—may follow slight 
vascular wounds. Nerves more commonly escape complete division than 
vessels, but partial division and contusion often lead to late trophic 
changes with partial or complete abolition of function. 
Injuries of bones and joints comprise nearly one-fourth of mili- 
tary gunshot wounds, but are much less common and severe in civil 
life, because usually inflicted by small pistol-balls moving with compar- 
atively low velocities. Pistol-balls and spent rifle-balls may simply 
contuse bones, the result depending upon whether merely subperiosteal 
effusion is produced or the vessels in the bone-tissue are ruptured. In 
the latter event necrosis may result, especially if infection occurs. 
Bone-contusions will probably be rare with modern projectiles, and 
under aseptic treatment should recover without local or general infec- 
tion, thickenings, or neuralgias, as was so common in the past.3 
Bones may be fissured, divided into two or more fragments, or may 
be partially or completely perforated. Slight Assuring is doubtless often 
overlooked, owing to the difficulty of diagnosis. The fissure may extend 
obliquely or transversely across a bone, even producing complete frac- 
ture without rupture of the periosteum. The fragments may never 
separate or attempts at walking may later displace them. Most ball- 
fractures are by penetration ; a portion of the osseous tissue, being driven 
in or more or less finely pulverized, is scattered along the ball-track 
(Fig. 128), lines of fracture usually radiating from the main focus. 
The comminution varies, being in inverse proportion to the velocity of the ball, 
but in a long bone does not usually extend through the epiphyseal ends. The 
fragments may be completely detached or partially adherent by periosteum. Pis- 
tol-balls may imbed themselves in bone, but this accident will be excessively rare 
with rifle projectiles. Except at short ranges modern balls comparatively clearly 
perforate long bones at or near their cancellous ends, with little or no Assuring 
(Figs. 129, 130). Flat bones are more apt to be perforated with extensive shatter- 
ing. Within the. “ explosive zone,” when a resistant bone is struck, there will be 
1 See Chap. XXII. 
2 See Figs. 124, 128. 
3 Conner, op. cit. 336 
INJURY AND REPAIR. 
great loss of bone-tissue, the fragments being driven in all directions, backward as 
well as onward and to either side, producing widespread purification of the soft 
parts (see Fig. 124). The wound of exit is really a bursting outward of the skin 
by the force acting from within, the track being conical, with the apex at the site 
of the fracture. Sometimes the wound exceeds six inches in length and four in 
Fig. 128. 
Shattering of humerus at long range with modern projectile; fusible metal cast showing extent 
and character of laceration of soft parts (from a recent foreign report). 
breadth, bone-fragments in addition occasionally piercing the skin outside the 
main laceration.1 At from 1200 to 1500 yards perforation with marked comminu- 
tion is apt to occur, but the fragments are not much displaced. Beyond these ranges, 
so long as the ball possesses momentum enough to fracture, comminution with dis- 
placement is the rule. A ball crossing a bony crest or at a tangent to a curved 
surface may cut a clean groove, but may in addition fissure. A soft-lead ball may 
split on a bony crest or even the convexity of the cranium. This accident will 
rarely occur with hardened pistol-balls, and will be still more improbable with 
jacketed rifle-balls. Fracture by penetration or perforation may be inferred if 
bone-fragments or dust be found in either wound, especially that of exit, and if 
this be decidedly larger, than that of entrance. Of course, if the ordinary symp- 
toms of fracture are detectable, the diagnosis is clear. When the direction pur- 
sued by the ball renders it nearly certain that fracture by penetration exists, it is 
safer to act upon this hypothesis, lest displacement with additional injury be pro- 
duced by manipulation. 
Treatment.—Render the wound-orifices and surrounding skin 
1 See Conner, op. cit. GUNSHOT WOUNDS. 
337 
aseptic, and then the accessible portion of the track; dress and immo- 
bilize the parts. 
More extensive bone-injuries require the same preliminaries, followed 
by aseptic removal of all completely detached fragments, moulding into 
place of attached fragments, disinfection, if deemed necessary drainage, 
careful fixation of the parts, and antiseptic dressings. When an 
Fig. 129 
Fig. 130. 
Wound of entrance at about 660 yards ; per- 
foration of cancellous bone with but little 
Assuring (from a recent foreign report). 
Wound of exit of specimen shown in Fig. 129 
(from a recent foreign report). 
impacted ball can be easily reached, it should be removed, but if much 
additional injury would result from its extraction, it had better be 
left, for although no heat sufficient to render a ball aseptic is devel- 
oped either during firing or by its passage through the tissues, yet the 
majority of projectiles “ are either sterile or free from septic germs.” 
Great destruction of bone and soft parts by balls wounding within the 
“ zone of explosion,” those by charges of small shot at short ranges, 
etc., must be treated as similar compound fractures otherwise induced. 
If the destruction of bone and soft parts is so great that the limb must 
prove useless if saved, or if the main vessel or vessels are divided, with 
such damage to the tissues through which the collateral circulation 
must be established that gangrene will occur or repair almost certainly 
fail, amputation should be done. When in doubt, especially in civil 
practice, tie all bleeding vessels, extract loose bone-fragments, replace 
attached ones, disinfect, drain by numerous counter-openings and tubes, 
and immobilize, amputating later if gangrene or infective osteomyelitis 338 
INJURY AND REPAIR. 
occur. These rules require modification in military practice because 
prompt and effective antisepsis with proper after-care of the wounded is 
so often impossible. 
Wounds of Joints.—Wounds of the soft parts over a joint may, 
if they become infected, secondarily set up intra-articular trouble. 
Wounds of bursae will lead to similar results if they communicate with a 
neighboring joint, as they so often do. If the wounds of entrance and 
exit indicate perforation of a joint by a modern conical ball, such an injury 
may be confidently affirmed. A ball traversing a joint usually perforates, 
crushes, splinters, or grooves one or all of the component bones, but the 
synovial membrane may alone be penetrated. Extra-articular bony 
fissures may tear the synovial membrane, or secondary penetration may 
result from septic ulceration extending from an infected fissure. 
Diagnosis.—With free destruction of soft parts, as by a fragment 
of shell, this is easy. Extensive bone-comminution near a joint, fol- 
lowed by rapid distention of the articulation from accumulation of blood, 
escape of bloody synovia, or the presence of bone-dust or fragments in 
the wound of exit, readily decide the question of joint-wound. In the 
absence of these symptoms the relative position of the wounds of en- 
trance and exit and the free escape of synovia must be depended upon. 
The probe should be avoided as a means of diagnosis. When doubt 
exists treat the case as one certainly involving the joint. 
Prognosis.—Death should rarely occur from an uncomplicated joint- 
wound in civil practice, but the prompt and successful employment of 
asepsis in military surgery is so often impossible that the mortality in the 
past has been as high as 12.9 per cent, for mere wrist-joint wounds. 
Modern methods will much diminish this mortality, as well as the fre- 
quency and extent of the ankylosis so common formerly when conserv- 
atism was attempted. 
Treatment.—This may be conservative; excision may be done or 
the limb be amputated. Conservatism means the removal of all foreign 
bodies, including the bullet if readily accessible, and all completely 
detached fragments of bone. If much blood fill the joint, free drainage 
must be provided, and voluminous antiseptic dressings applied, with 
fixation of the articulation. Formal excision as a primary measure has 
not given as good results as the conservative procedures just advocated. 
Primary amputation is only demanded when such extensive destruction of the 
hard and soft parts render it certain that the limb, if saved, will be only an 
incumbrance, or when both direct and collateral circulation has been practically 
destroyed by injury of the soft parts, because a main vessel can be ligated or an 
important nerve sutured if the collateral circulation is unimpaired. Suppurative 
arthritis requires free incisions, disinfection, drainage, and immobilization. If 
these measures fail, possibly excision or amputation may avail to save life. The 
different methods of treatment suggested are not equally applicable to similar 
injuries of all joints. The special indications for each articulation will be con- 
sidered in Chapter XXXIV. 
Wounds of the Head.—The scalp may alone be wounded, con- 
tusions, lacerations, or penetration, and lodgement resulting. Pistol- 
balls often lodge, especially in the temporal muscle, but rifle-balls rarely 
if ever. 
Treatment.—The probe or palpation will usually locate the ball. GUNSHOT WOUNDS. 
339 
When imbedded in the temporal muscle, pain on moving the jaw or upon 
pressure over the zygoma may guide the surgeon. 
Considerable hemorrhage may occur from wounds of the temporal or occipital 
arteries, or a cephalhsematoma may form, presenting some superficial resemblances 
to a depressed fracture. If absorption of these blood-effusions does not take place, 
antiseptic aspiration or incision is indicated. Unsuspected intracranial lesions 
produced by impact of the ball on the cranial vault may prove serious, but mere 
osseous contusion, treated antiseptically, should no longer give rise to the neural- 
gias, headaches, etc. so common in the past. 
Injuries of the Cranial Bones.—Contusions may be produced by 
nearly-spent balls or those striking at a tangent, but with the new bul- 
lets such lesions will be rare, fracture or grooving being nearly certain. 
If asepsis be maintained, usually only plastic exudate follows, although 
quiet necrosis may result. If infection occurs, osteomyelitis may cause 
necrosis of the external table alone or more rarely of the whole thick- 
Fig. 131. 
Complete shattering of a fresh head by a mantled ball, striking at about 55 yards ; scalp reflected 
(from a recent foreign report.) 
ness of the bone. Infective inflammation of the diploe is a not uncom- 
mon sequence of contusion. This may cause subcranial suppuration, 
septic encephalitis, or general pyaemia. Fracture of the internal table 
of the skull is also possible. ( Vide, also, Chapter I. Vol. II.) 
Diagnosis.—This may be made by inspection or the probe, but 
where the former is impossible it is safer to infer the lesion of the bone 
by the course of the ball, unless its removal or the arrest of hemorrhage 
demands exploration of the wound. 
Treatment.—Strict asepsis, if instituted early enough, will prevent 
any septic complications. If these arise, incisions, removal of infected 340 
INJURY AND REPAIR. 
bone, opening of cerebral abscesses, disinfection, and drainage are indi- 
cated. 
Penetrating gunshot injuries cause more serious intracranial lesions 
than follow other traumatisms, that which appears but a mere fissure 
having often been produced by marked temporary depression of both 
tables, as shown by a tuft of scalp-hairs imprisoned in the capillary 
crack or a fragment of a ball lodged within the cranium. 
Widespread shatterings, especially those involving the base, result 
from extension of fissures, conduction and amplification of vibrations 
by thickened bony ridges, and, owing to the semi-fluid structure of the 
brain, to hydrodynamic (hydraulic) pressure, so that the “ zone of 
explosive action ” for modern missiles exists at all ranges so far as the 
skull is concerned.1 The base is seldom fractured by hydraulic pressure, 
although the ethmoid and the orbital plates of the frontal may yield. 
Pistol-balls rarely develop this pressure, but these same plates are some- 
times thus broken. Sudden death, caused by disorganization or removal 
of large portions of the skull and brain by cannon-balls or charges of 
shot, etc., sometimes gives rise to traumatic cataleptic rigidity—i. e. post- 
mortem rigidity rapidly produced, which maintains the body in the posi- 
tion when struck. 
The skull may be grooved without other penetration than that by concomitant 
Assuring. Fracture of the external table alone is very rare. In adults—for in young 
children none exists—the anterior wall of the frontal sinus may be perforated by 
a pistol-ball which remains in the cavity, no penetration of the cranial cavity 
occurring. The inner table around the wound of entrance, when penetration 
occurs—i. e. on the side of extension—is more freely shattered, while at the wound 
of exit, the same law holding good, the external table suffers more. Pistol- or 
spent rifle-balls may sometimes produce depression of the external table with 
crushing of the diploe, the vitreous table being uninjured. Again, the inner table 
may be broken in this way or by the tangential impact of a ball. Very rarely frac- 
tures resembling those produced by the corner of a bolt-nut or a large board-nail 
are seen, where a limited portion of the external table and diploe are driven down, 
but the internal table is extensively shattered—a variety of punctured fracture, as 
Conner justly terms it.2 
Prognosis.—This is most serious, early death resulting in fully one- 
half from shock and hemorrhage. When the ball (pistol) was removed, 
according to Bradford, 33.33 per cent, recovered; when it was left, 46 
per cent. Expectancy gave in 25 cases a mortality of 52 per cent. 
Wounds involving only the frontal lobes with lodgement of the ball 
seem less dangerous than those of the more posterior portions of the 
brain. Cerebellar lesions are usually rapidly fatal. Transverse wounds, 
passing laterally through or near the ear, are more dangerous than 
antero-posterior ones. Infective intracranial inflammations, leading to 
localized (abscess) or diffused suppurations and hernia cerebri are the 
late causes of death : these are avoidable if asepsis be secured. Division 
of one or more of the cranial nerves and various late perversions of 
cerebral function, as epilepsy, headaches, and insanity, are possible se- 
quences, as after other head-injuries. Balls do not usually become 
encysted, but change their position in time by gravity. If while migrat- 
ing they encounter portions of the brain governing important functions, 
serious trouble is sure to arise, even many years after injury. 
1 See Demosthen, op. cit. 
2 Dennis’ System of Surgery. GUNSHOT WOUNDS. 
341 
Diagnosis.—This must be made by inspection, palpation, probing, 
or possibly by percussion. The aid of the X-rays may also be invoked. 
Treatment.—As infection is the sole lethal cause if primary hem- 
orrhage and shock do not cause death, disinfection and drainage are the 
indications. The wound or wounds should be protected by antiseptic 
compresses, and (preferably) the whole scalp carefully shaved and dis- 
infected ; finally the wound itself should be cleansed. Fracture or pene- 
tration having been determined by the proper means, a flap should be 
reflected and the damaged bone (probably infected) be removed, hemor- 
rhage be arrested by ligation, forcipressure,1 or possibly a gauze tampon. 
The wound of exit must be treated in the same manner. One drainage- 
tube, or two meeting in the centre of the track must be carefully intro- 
duced, and gentle irrigation with sterilized water employed. When the 
ball has lodged after the preliminaries described, it may be sought for 
by an aluminum probe or a medium-sized elastic bougie. 
The effect of gravity should be invoked to aid the progress of any probe, 
because a false passage is so readily made through the cerebral tissue. Probably 
the telephonic probe would here work to most advantage. If the probe passes 
readily to the opposite side of the skull, careful palpation may reveal the presence 
of the ball beneath the scalp, a fracture, or an ecchymosis if the head has been 
shaved. None of these three conditions being found, trephining should be done 
over the end of the probe and the ball sought within the cranium above, below, 
to one side or the other of the opening. After the failure of such an amount of 
search as can do no serious injury to the brain, it is better to desist from further 
manipulations beyond depositing a drainage-tube in the track and carefully irri- 
gating it. Localizing symptoms may indicate the course of a ball, but rarely its 
location, and unless detected very shortly after the reception of the injury are apt 
to be misleading, owing to slowly-extending hemorrhage. Even immediately after 
the wounding the localizing symptoms are often deceptive, owing to the wide- 
spread injury outside the actual ball-track. Voluminous dressings are usually 
requisite on account of the free escape of cerebro-spinal fluid. Fracture without 
penetration requires the treatment adapted to any compound fracture of equal 
severity. 
Secondary hemorrhage must be treated by ligature of any bleeding 
vessel or by tamponade if trivial; if severe, by ligature of the main 
vessel when the bleeding point is not accessible, securing the external 
carotid rather than the common if this will arrest the hemorrhage. 
Fractures implicating the base must be treated as when produced by 
other causes. 
Face.—Primary or secondary hemorrhage is the chief danger, al- 
though destruction of parts and extensive scarring may result, especially 
from small-shot wounds. Pistol-balls, except at short range, do not 
shatter the facial bones much, and probably the new rifle-bullets will 
not, at least in the middle ranges. Balls may pursue most erratic 
courses, penetrating the face to emerge by nostril or mouth, without 
doing any or but slight damage—traversing the orbit or mouth 
without injuring eye or tongue. Bullets travelling from before back- 
ward through the face often wound the brain, spinal cord, or great 
vessels. Transverse wounds, especially those involving the lower jaw, 
are often complicated by division of one or more of the larger vessels. 
1 Fine wire serres-fines, with attached ligatures, may be left in situ for days if liga- 
tures cannot be made to hold. Cerebral vessels being deficient in sheaths, it is difficult to 
ligate them ; only enough tension should be put upon the first half of the knot to occlude 
the lumen of the vessel. 342 
INJURY AND REPAIR. 
Pistol-balls often lodge in the orbit, nasal fossae, or antrum. Bullets 
passing through the back of the orbits may wound or divide one or botli 
optic nerves. Those injuries of the supraorbital regions leading to 
blindness, formerly attributed to damage to the supraorbital nerve, are 
generally due to a fissure traversing the optic foramen and destroying 
the nerve. Furrowing or perforation of the tongue is not uncommon. 
Fragments of, or whole, teeth are sometimes driven into the tongue ; 
more rarely the ball itself lodges. Although often productive of such 
swelling as to interfere with speech, deglutition, or even respiration, 
tongue-wounds are not usually dangerous unless the lingual artery be 
wounded. 
Treatment.—Ligate vessels; extract teeth, pieces of bone, or a 
ball imbedded in the tongue; remove neither attached bone-fragments 
nor contused soft parts; mould the hard parts into place; maintain all 
in situ by sutures, antiseptic compresses, or tampons, or by interdental 
splints. Secure all the asepsis possible by irrigation, non-poisonous 
mouth-washes, and sprays. 
Primary hemorrhage demands ligation in the wound when from a vessel of any 
magnitude; if not, antiseptic tamponade, deep suture—as in the tongue—or the 
cautery. When the wounded vessel is not accessible, tie the main trunk or trunks, 
as both linguals or facials, or even one or both external carotids. Secondary 
hemorrhage must be treated on the same lines, but, owing to the condition of the 
wound, ligation must usually be done at a distance. Dyspnoea, when serious, must 
be treated by free incisions into a swollen tongue; possibly laryngotomy might 
become requisite where the wound involves the base of the organ. Later, plastic 
and mechanical surgery are often demanded to relieve the deformities resulting 
from extensive loss of soft and hard parts. 
Neck.—Wounds in front of the sterno-mastoid muscles must, when 
deep, compromise important structures, as the trachea, oesophagus, great 
vessels, and nerves, with all their primary and remote dangers. Those 
posterior to these muscles, although possibly involving the spine, are 
usually only muscle-wounds. 
Prognosis.—Hemorrhage, often late, and suppuration, which unless 
early evacuated will extend, directed by the cellular planes into the 
thorax or axilla, are the chief dangers. 
Treatment.—Primary hemorrhage (rarely seen) must be treated by 
ligation in the wound, if possible, when arterial; by compression if 
venous, unless the deep jugular be wounded, when ligation should be 
done. Too often the vessel cannot be secured in the wound, when both 
carotids should be exposed, and if compression of the external arrests 
the bleeding it should be tied ; if not, the internal must be secured. 
Wound of the vertebral above the sixth cervical vertebra can better be 
controlled by efficient tamponade. Wounds of more than one vessel 
are not unusual, as carotid, jugular, and vertebral, and with a small 
external wound, as by a pistol-ball, such an injury of the great vessels 
has been found compatible with several days of life, a traumatic aneurism 
or arterio-venous aneurism forming. If a ball so lodge as to cause irri- 
tation or paralysis of nerves by pressure, its removal will probably 
ameliorate or relieve the trouble. The larynx or trachea may be merely 
contused by a bullet, causing pain, dyspnoea, and bloody expectoration, 
with cough. If penetrated, emphysema or the external escape of air is GUNSHOT WOUNDS. 
343 
superadded. When the oesophagus or pharynx is also opened, food is 
apt to escape from the wound, although this may be due not to an abnor- 
mal opening in the gullet, but to improper action of the epiglottis, so 
common after tracheotomy. Hemorrhage into the trachea, or, occurring 
later, oedema glottidis, may cause death. Dangerous pressure may also 
be exerted from without upon the trachea by blood or inflammatory 
exudate. After recovery impairment of the voice is apt to persist. 
Ligation, suturing, tamponade, or the actual cautery may become 
requisite to arrest bleeding if the thyroid body is wounded. 
Treatment.—Remove the ball if lodged, secure asepsis for the 
wound, and employ early intubation or tracheotomy if the respiration 
is seriously interfered with. Suture, or, if this is impossible, plugging, 
of any oesophageal or pharyngeal wound is necessary to prevent infec- 
tion, employing for the same reason the oesophageal tube for feeding. 
Later, necrosis of cartilage may occur, aerial fistula may persist, or more 
rarely stricture may form. 
Spinal Column.—The ball or fragment of shell may contuse a ver- 
tebra, fracture any portion of it (usually a spinous process), wound the 
meninges or cord, or be a complication of cervical, thoracic, abdominal, 
or pelvic perforation. 
Symptoms.—Shock is great. When the cord is damaged there is 
impairment or destruction of function according to the location and 
extent of the primary contusion or laceration or the secondary com- 
pression by blood and inflammatory exudate. Very rarely cerebro- 
spinal fluid escapes from the wound, proving that at least the membranes 
have been opened. Hemorrhage external to or within the membranes, 
and possibly within the substance of the cord, if slight may, after tem- 
porary pain and paralysis, end in complete recovery. Large effusions 
are apt to end in infectious myelitis, the chief danger in all spinal inju- 
ries. Evidences of severe and lasting damage to the cord when life is 
spared are most commonly due to bone-fragments, or, exceptionally, to 
lodgement of the ball. 
Prognosis.—Where the membranes have been opened, much worse 
perforated, some compression or laceration of the cord must result. In 
military surgery infective myelitis usually destroys life, but in civil prac- 
tice cases receive effective assistance so much sooner that the prognosis 
is somewhat better, although from the difficulty of securing asepsis 
unless the wound be below the cord proper—i. e. involving only the 
cauda equina—the outlook for life is most gloomy. 
Contusions of the membranes and cord, causing slight extra- or even intra- 
dural hemorrhages, are recoverable, but even when the osseous lesion is apparently 
limited to a spinous or transverse process “chronic inflammations and scleroses” 
may be expected to follow from slight concomitant lesions of the membranes or 
cord, which will result in neuralgias, impairment of function of the bladder, a 
limb, etc., but “ which may not perhaps be manifested for years.” 
Treatment.—Asepsis must be striven for and maintained, separated 
bone-fragments or the ball extracted, drainage be instituted, because 
asepsis is doubtful, and fixation of the spine should be effected. Where 
early symptoms'of pressure on the cord suggest the probability that the 
ball, bone-fragments, or blood-clot is causing the paralysis, or, later, 
that exudate or callus is destroying function, a more or less formal lami- 344 
INJURY AND REPAIR. 
nectomy is indicated in cases not complicated by serious lesions else- 
where. 
Thorax.—Thoracic wounds may be non-penetrating or penetrating. 
The latter may be complicated by fractures of the ribs, sternum, verte- 
brae, clavicle, or scapula, and by wounds of the axillary and scapular 
vessels, many of these last proving rapidly fatal. Any apparent deflec- 
tion of modern balls from a straight line is due to the difference between 
the position when the wound was inflicted and when it is examined. Con- 
tusion of the pleura or lung, evidenced by shock, temporary dyspnoea, 
and pain during respiration, is not uncommon. 
Owing to the great elasticity of the thorax, blows from fragments of shell, or 
contact with spent cannon-shot may produce lacerations of lungs, heart, or the 
great vessels without any fracture. Marked shock, collapse, and death, if the 
lacerations are extensive, follow such accidents. Associated bone-lesions add to 
the gravity, because of the greater risk of infection. Mere penetration without 
perforation is now very rare, even pistol-balls commonly traversing the thorax to 
lodge, perhaps, outside in the overlying muscles. If infection can be avoided, 
unless some necessarily fatal lesion has been inflicted by the ball, recovery is more 
apt to follow a perforating than a penetrating injury with lodgement of the missile, 
because no foreign body is left in the chest. 
Diagnosis.—From the small size of so many modern missiles, this 
is often difficult, neither protrusion of lung taking place nor inspiration 
and expiration of air occurring through the wound during the corre- 
sponding acts of respiration. Emphysema may occur in non-penetrating 
wounds from air insinuating itself among the tissues during the alter- 
nate expansions and contractions of the thoracic wall. If a line con- 
necting the wounds of entrance and exit would traverse a lung, such an 
injury may be confidently affirmed, as modern balls do not run for long 
distances beneath the thoracic soft parts. Pain, restriction of the free- 
dom of respiration, haemoptysis in varying amount, and cough accom- 
pany penetrating and perforating wounds of the lungs. Compression 
of the lung by accumulation of air or blood in the pleural cavity may be 
detected by the characteristic physical signs. Shock and collapse are 
usually greater that in non-penetrating wounds. External hemorrhage, 
when severe, comes from the cervical or axillary vessels. Internal 
bleeding comes from the intercostals, internal mammary, the large pul- 
monary vessels, the great vessels, or the heart. When from any of the 
three latter sources, the hemorrhage rapidly proves fatal. Bleeding 
from the lung-tissue is rarely of much moment. 
If a ball lodge—an unlikely accident in the future—it may remain harmlessly 
encapsulated for years, may ulcerate early or late into a bronchus and be coughed 
up, into the oesophagus and pass per anum, or pass into the pleural cavity. Even 
bone-fragments imbedded in the lung do not add materially to the danger, provided 
infection is prevented. 
Prognosis.—Asepsis should lessen the mortality of the past by 
diminishing the frequency of empyema, lung-abscess, and mediastinal 
abscesses which formerly caused the high death-rate. The not uncom- 
monly associated wounds of the abdomen markedly increase the mor- 
tality. Prolonged intrathoracic suppurations may end in recovery, 
but with sequelae akin to those seen after the same conditions of non- 
traumatic origin. 
Treatment.—Asepsis and immobilization of the chest, with treatment GUNSHOT WOUNDS. 
345 
appropriate for any traumatic pleurisy or pneumonia, is all that is requi- 
site for non-penetrating wounds—i. e. those involving only the parietes 
—contusions or flesh-wounds. In penetrating and perforating Avounds 
shock must be combated, and the ball should only be sought for if felt 
lodged in the chest-wall. Sterilization of the wound, must be effected, 
and after any bleeding has been arrested by ligature, forcipressure, or 
possibly tamponade, the thorax must be put at rest by strapping or a 
plaster-of-Paris jacket. Aspiration may be done for extensive hsemo- 
thorax producing pressure, but this, as Avell as empyema, is better 
treated by excision of a portion of a rib to secure free drainage and 
the remo\ral of any foreign bodies, as a bullet, fragments of bone, cloth- 
ing, etc. Concomitant fractures present the same indications as Avhen 
occurring elsewhere. Pulmonary, intestinal, or omental hern he through 
the loAver intercostal spaces must be restrained by pressure. 
Heart.—Contusions, penetrations of the pericardium, penetrations and 
the slighter perforations of the heart-muscle alone come under treatment. 
Contusions result from nearly spent balls Avhich retain enough momentum to 
tear the pericardium and then bruise the heart. Only a “ tangential blow ” can 
wound the pericardium alone. Lodgement Avithout penetration, and penetration 
of one or more cavities Avith lodgement of a missile, will only folloAV pistol- or 
small-shot injuries. Concomitant lung-Avounds are common. 
Prognosis.—Wounds of the base are usually promptly fatal, even 
when caused by small balls, but when resulting from the modern rifle- 
balls are invariably so from shock, or shock and hemorrhage combined. 
When the base escapes, temporary recovery, lasting for from days to 
years, sometimes occurs, bleeding being arrested by clot and contraction 
of muscular fibres until more permanent repair is effected. More com- 
monly death ensues within a short time from the accumulation of blood 
in the pericardium arresting the heart’s action, rather than from actual 
loss of blood, although this may be profuse. After so-called recovery 
permanent damage of the organ remains. 
Diagnosis.—Any lesion of the heart produces the most profound 
shock—even fatal—with irregular action and modification of the heart- 
sounds—i. e. bruits. Increase in area of the dulness on percussion 
denotes bleeding into the pericardium. Pneumo-pericardium, will cause 
a reversal of this symptom—diminution of dulness. 
Treatment.—Relief of shock, arrest of hemorrhage, asepsis, re- 
moval of the pressure of accumulations of blood and exudate in the peri- 
cardium by incision or aspiration comprise all the expedients usually 
available. Suture will hardly be feasible, however possible for an incised 
wound. 
Abdomen; Solid and Hollow Viscera.—The parietes, especially 
in civil life, may be wounded Avithout penetration of the cavity, 
although this is exceptional. Contusions, usually produced by contact 
Avith spent cannon-balls or bloAvs from fragments of shell, often mean 
serious laceration of the ATiscera or rupture of the muscular parietes, 
possibly ending in gangrene of the abdominal Avail. 
Prognosis.—In the absence of visceral lesions recovery should take 
place. 
Treatment.—Contusions require aseptic dressings for any abra- 
sions and early evacuation of pus and sloughs if these form. Flesh- 346 
INJURY AND REPAIR. 
wounds of the parietes require only that which is appropriate for sim- 
ilar wounds situated elsewhere. Laparotomy is requisite when visceral 
laceration exists. 
Penetrating and Perforating Wounds.—Although 3 to 5 per cent, of 
wounds pursuing an antero-posterior direction are free from visceral 
lesions, it is safer to consider that such complications exist, especially 
with wounds traversing the abdomen from side to side. The probable 
order of frequency of visceral injury is—small intestines; large intes- 
tines ; liver; stomach; kidney; spleen; pancreas. Usually multiple 
lesions exist, involving omentum, mesentery, lung—when the ball 
enters through or emerges from the thorax—or the large vessels, in 
addition to strictly visceral lesions. 
Prognosis.—This depends in each case upon the extent and nature 
of the lesions; hence no specific direction as to prognosis can be given. 
The death-rate varies from 24 to 87 per cent., and results primarily 
from shock and hemorrhage, later from septic peritonitis. 
Although the dangers of hemorrhage and sepsis can in the future be measur- 
ably diminished, yet the mortality will always remain high. Wounds of the 
stomach and large intestine are less lethal than those of the small bowel, and 
perforation of any hollow viscus is less dangerous when the organ is empty at the 
time of injury. 
Diagnosis.—Protrusion of bowel, omentum, spleen, or the escape 
of bile or faeces render diagnosis easy, but such indications are rare 
even with the old-fashioned bullet of large calibre. In default of these 
signs exploration by incision of the ball-track or laparotomy can alone 
render penetration, much more visceral lesion, certain. The relation 
of the wounds of entrance and exit in complete perforations usually 
decides the question of visceral penetration. Vomiting or the passage 
of blood per anum or urethram, the physical signs indicating rapid 
accumulation of fluid—i. e. blood—in the belly, loss of liver-dulness 
from free air in the abdominal cavity, are, when all are present, positive 
signs of visceral lesions. Bloody vomit, stools, or urine might indicate 
mere contusion, but free peritoneal air can only mean bowel-wound, and 
rapid accumulation of intra-abdominal fluid, bleeding from omentum, 
mesentery, great vessels, or from a solid viscus. The hydrogen-gas test 
before laparotomy, when successful, will demonstrate intestinal wound, 
but its failure does not preclude the possibility of such an accident. 
Careful exploratory incision, opening up the wound-track, or in the 
median line when the wound is a transverse one, may be necessary, and 
is a safer diagnostic procedure than exploring with the probe or finger. 
The direction pursued by the ball, the point of entrance, shock, bloody 
urine, with the possible external escape of urine if the wound be situated 
in the back, will usually indicate a kidney-wound. 
Serious intra-abdominal lesions, according to Redard, always produce a depres- 
sion of temperature for from four to many hours, and when such subnormal tem- 
perature is detected it is strong presumptive evidence of penetration with visceral 
wounding. Peritonitis, usually developed after the first eighteen hours, may show 
only slight rise of, or even depression of, temperature, but the pulse is usually 
notably frequent. In many cases, however, the ordinary complexus of symptoms 
indicative of peritonitis are present. 
Treatment.—This must be either purely medical, by opium, small 
amounts of fluid food, and maintenance of local and general quiet, or GUNSHOT WOUNDS. 
347 
operative. The mortality with the expectant treatment, as given by 
numerous observers, varies from 59.4 to 65 per cent,, the figures given 
by Reel us being so extraordinarily favorable as to throw suspicion upon 
their accuracy. The mortality after operation varies from 66 per cent, 
to 78 per cent., but it must be remembered that the operated cases are 
usually those worst injured. 
Early operation, arresting bleeding and fecal extravasation or remov- 
ing this and draining, gives the best result, success almost never attending 
section after development of generalized peritonitis. 
In military practice the difficulties of making a proper laparotomy may prove 
insuperable, but when possible must be attempted. In civil practice where pen- 
etration is certain section should be done, lest some foreign body, as a piece of 
cloth, be lodged, although no visceral wounds exist. Such action is all the more 
imperative if faeces, bile, or urine escape externally. Severe and rapidly increas- 
ing collapse usually means internal hemorrhage, which if not arrested by art will 
prove fatal. As balls traversing the abdomen from side to side on a level with and 
below the umbilicus almost invariably damage the small intestines, such wounds 
indicate exploratory section. Although wounds resulting from 22-calibre balls 
involving the empty stomach, the liver, kidney, or colon are sometimes recoverable 
from, laparotomy done by a skilled hand is safer than conservatism. When the 
present army bullet strikes within the “ zone of explosive action,” laparotomy will 
always be demanded when circumstances permit. Hemorrhage or urinary extrav- 
asation alone demands operation for kidnev-wounds inflicted from behind when the 
peritoneum is intact. Kidney-bleeding may be treated by ligature or suture, as 
practised by Tiffany, with or without previous resection of the damaged portion of 
the organ, leaving nephrectomy as a last resort. 
Technique.—If doubt exists as to penetration, determine this point 
by careful enlargement of the ball-track. This may settle the point 
where the abdomen should be opened, but a median incision is that 
which gives the best access to the organs most commonly injured. After 
having opened the abdomen, any bleeding should first be arrested by 
ligature, compressing the aorta as a temporary measure while the bleed- 
ing vessels are being exposed, or sterilized gauze packing may be em- 
ployed for the same purpose. The bleeding usually comes from the 
mesenteric vessels or from one of the solid viscera, although the intra- 
pelvic vessels, an intercostal or the internal mammary artery, may be 
its source. The small and large intestines must next be systematically 
examined, inch by inch, covering the protruded parts with towels or 
pads wrung out of hot sterilized salt solution, returning each loop as 
soon as examined. Every opening must be closed transversely, as 
detected, by fine silk Lembert sutures. Contused spots—as shown by 
Park—will slough, and must therefore be treated as if wounds. When 
closure of several closely contiguous wounds would constrict the lumen 
of the bowel too much, resection with end-to-end or lateral anastomosis 
must be done. Rents in the omentum shook! be closed, bleeding vessels 
ligated, and damaged omentum removed after tying oft’ in sections. 
Wounds of the stomach, large intestine, urinary bladder, and solid viscera 
or gall-bladder must next be sought for, the three first being treated by 
suture, the last by suture or plugging with gauze. 
Inflation with hydrogen gas or air may aid in detecting intestinal wounds, but 
is not infallible, faeces sometimes plugging the openings. Suture works best for 
liver- or kidney-wounds, plugging with gauze and drainage for those of the spleen 
and pancreas. Splenectomy and nephrectomy are only demanded for extensive 
lacerations. Repeated flushing of the abdomen with hot sterilized salt solution 348 
INJURY AND REPAIR. 
during and after the manipulations is advisable. Drainage must depend upon the 
amount of peritoneal fouling with faeces, urine, etc., the freedom from hemorrhage, 
and the probability of subsequent extravasations of urine from a wounded kidney 
or of bile from a damaged liver. 
The after-treatment consists in combating shock, careful alimentation, 
and, later, the draining off by the intestines of septic products by saline 
purgatives, differing in no material way from that adopted after other 
laparotomies involving intestinal lesions. Fecal fistula following wounds 
of the colon is a rare accident, and if spontaneous healing does not occur 
—a very common result—operative interference is indicated. Rectal 
wounds which are not part of other intra-abdominal lesions are chiefly 
of moment from the probability of widespread suppuration and slough- 
ing from infection. If the wound be below the peritoneal investment, 
it should be treated by disinfection of the wound and bowel, quiet of the 
latter induced by opium, and incisions for drainage if burrowing of pus 
occurs. Rectal wounds opening into the peritoneal cavity demand lapa- 
rotomy and suture, or possibly tamponade with drainage, if the wound 
for any reason cannot be sutured. 
Genito-urinary Apparatus.—Bladder-wounds are often complicated 
with lesions of the pelvis, pelvic vessels, and rectum. An empty blad- 
der is seldom wounded. Partial penetration by guttering sometimes 
occurs, which usually soon becomes complete by ulceration. When the 
portion uncovered by peritoneum is wounded, the consequences are 
much less serious than when the peritoneum is involved. 
Prognosis.—This depends upon the associated lesions, especially 
opening of the peritoneal cavity. 
Symptoms.—Those pecular to bladder-wounds are irritability of the 
organ and possibly the rectum, hsematuria, and the escape of urine by 
the external wounds—a rare occurrence except after wounding with 
balls of the largest calibre. Hcematuria may also result from wounds 
of the urethra, ureter, or from simple contusion of the bladder. Mic- 
turition may or may not be possible, the latter symptom sometimes 
resulting from accumulation of blood-clot. Peritonitis rapidly super- 
venes if the peritoneal cavity is opened, and this may even arise by 
extension when the urine escapes into the perivesical cellular tissues, 
although this latter accident commonly only leads to abscess-formation. 
Treatment.—Abdominal section, suture of the bladder, and a care- 
ful peritoneal toilet are indicated, with drainage if deemed requisite. 
If reasonable doubt exists as to whether the peritoneum has or has not been 
opened, a suprapubic incision may be made, the prevesical space opened and drained 
after any vesical wound has been repaired. Advantage must be taken of the 
laparotomy or suprapubic wound to remove any ball, piece of bone, or clothing 
lodged in the bladder or elsewhere. Late cystotomy may be required to remove an 
undetected ball or pieces of bone which have primarily lodged in the bladder or 
found their way in by ulceration. Quiet, disinfection, and drainage of the wound- 
track, and prompt incisions to give egress to urine or pus, are requisite. Super- 
ficial wounds of the external genitals differ neither in danger nor treatment from 
similar ones produced by other traumatisms. Lodgement and even encapsulation 
of a ball have occurred. Masked laceration is the rule if the corpora cavernosa or 
glans penis are perforatedthe urethra is usually also opened. 
Prognosis.—Cicatricial deformities, urethral stricture, and fistulte 
are not uncommon. 
Treatment.—Bleeding must be arrested by ligature, suture, or com- GUNSHOT WOUNDS. 
349 
pression effected by firm bandaging of the organ after the introduction 
into the urethra of a metallic catheter. Antiseptic dressings are useful 
adjuncts. Any urethral wound must, when possible, be sutured, and t 
the urine partially diverted by a retained catheter or completely by a 
perineal opening. When the whole organ has been shot away the * 
corpus spongiosum must be dissected free and a perineal meatus estab- 
lished. Injuries of the testes, provided infection can be obviated, will 
usually do well, although atrophy or neuralgia are common sequelae. If 
completely disorganized, castration should be done. Wounds of the 
female genitals are exceedingly rare, and often involve the peritoneal 
cavity. Wounds of the pregnant uterus usually produce death by abor- 
tion, shock, hemorrhage, or infectious peritonitis. Fistulce giving exit 
to menstrual fluid have sometimes followed recovery after ball-wounds. CHAPTER XXIY 
PROCESSES OF REPAIR 
Charles B. Nancrede, M. J> 
Repair is effected by the same processes in the hard and the soft, the 
vascular and the avascular tissues, the differences being temporary, non- 
essential, and chiefly dependent upon physical conditions. Thus, the 
lime salts render the bone so dense that until they are removed only a 
limited accumulation of leucocytes and, later, proliferated tissue-cells, 
can take place at the site of injury; yet from the outset the soft 
parts of the bone undergo the same changes, in kind, as does the least 
compact connective tissue. 
Two forms of repair are usually described, but in reality there is but 
one, the second variety being at the outset only a modification of the 
first, caused by disturbing influences: when these cease to be operative 
the processes of repair tend to proceed as at their inception, any varia- 
tions from the typical methods being accidental, not essential, parts of 
the process. In the normal method reparative processes commence from 
the moment the physical disturbance of the part ceases and the bleeding 
is checked. Here the minimum of reparative material is requisite, 
and the wound is said to heal by the first intention, by simple adhesion, 
or by aseptic inflammation (obsolete expression), because it is only possi- 
ble in the absence of infection. Where infection occurs the reparative 
processes are interferred with and thwarted, reverting eventually to those 
seen in the absence of suppuration, but vast quantities of reparative 
materials are wasted, unnecessary tissue-destruction results, and the sub- 
sequent changes in the excessively developed germinal tissue often cause 
serious interference with function. Healing is here said to have taken 
place by granulation or by the second intention, but the end-processes are 
the same in both forms. 
The following are the minute phenomena observed in the healing of an incised 
wound by primary union, or by the first intention. Haemostasis is effected by 
thrombi occluding the vessels usually up to the first collateral branch. The blood, 
mingled with numerous leucocytes escaping from the divided lymphatics, provides 
elements for the formation of a coagulum (largely fibrinous), which extends for a 
short distance into the interstices of the tissues on either side, mechanically unit- 
ing the wound. Later the union becomes a vital one by the formation of fibre- 
cells and blood-vessels bridging the gap and developing into scar-tissue. The 
borders of the wound soon become crowded with wandering cells, which rapidly 
invade the fibrinous clot and any blood-coagulum filling up the recesses of the 
wound. By the close of the third day a mass of leucocytes, separated by a scanty 
intercellular substance and scattered remains of the clot, has replaced the coagu- 
lum. About the sixth day large epithelioid cells, resulting from proliferation of 
350 PROCESSES OF REPAIR. 
351 
the fixed connective-tissue cells and endothelial cells of the small vessels, appear. 
These are the formative cells, the fibroblasts, those capable of conversion into con- 
nective tissue. Most of the leucocytes serve as food for the new tissue-cells oi 
wander back into the circulation by way of the lymphatics. Reinke believes that 
the lymphocytes which appear after proliferation of the fixed connective-tissue 
Fig. 132. 
Phagocytosis of a piece of dead liver implanted in abdominal cavity of rabbit for twenty-four 
hours (Tillmanns). 
cells has commenced are of different nature from those first appearing, and are 
capable of development into tissue, while Ribbert teaches that they aid in tissue- 
formation by providing the lymph-spaces with endothelium. Thq fibroblasts, at 
first round, enlarge and assume spindle or club shapes, or develop one or more 
processes, even becoming branched: giant cells also form, which, with some of the 
Fig. 133. 
Wound of kidney, fourth day; leucocytic invasion of blood-clot: a, blood ; b, connective-tissue 
cells; c, leucocytes (Tillmanns). 
fibroblasts, degenerate, become granular, and are absorbed. Anastomoses form 
between the cellular processes, and the cells themselves so increase in numbers 
that in some places they lie in contact. The fibrous portion of the forming scar- 
tissue has a twofold origin, developing partly from a homogeneous intercellular 
substance produced by the cells and partly from the protoplasm of the cells. The 
fibrillation commences on one or both sides of the cells or at one end, or, again, in 352 
INJURY AND REPAIR. 
one of the processes, the fibrils fusing with those of adjoining cells; the nuclei 
wuth some of the protoplasm form the fixed connective-tissue cells. 
Fig. 134. 
Cicatrizing wound of liver, tenth day: a, young cicatricial tissue ; b, altered liver-tissue (Tillmanns) 
Examination of a young cicatrix shows numerous elongated cells, which, 
becoming still further converted into fibres, 
diminish in size until little but fibres can be 
detected. 
Rendering these changes possible is the 
nutriment supplied from the newly-formed 
vessels; moreover, some of the fibroblasts are 
derived from the cells of the intima of the 
new vessels. At the outset the cells receive 
nourishment from the plasma coming from 
relatively distant vessels in the surrounding 
tissues by way of the plasma-channels. The 
first steps in new vessel-formation consist in 
an accumulation of granular protoplasm1 
on the exterior of a pre-existing capillary 
loop which gradually forms a solid, nucleated 
filament. This may be simple or branched, 
and fuses with another vessel, with another 
hud from a neighboring capillary loop ; or, 
again, the filament may arch back and become 
Fig. 135. 
Healed wound of liver, twenty-eighth day; 
blood-pigment in cicatrix still unabsorbed 
(Tillmanns). 
Fig. 136. 
Cicatrized defect in lung-tissue: a, cicatrix; b, infiltration with wandering cells (Tillmanns) 
1 By division of the endothelial cells at one spot. PROCESSES OF REPAIR. 
353 
connected with the vessel from which it sprang. The young connective-tissue cells 
(fibroblasts) near the vascular outgrowths arrange themselves alongside them or as 
Fig. 137. 
Formation of new capillaries by budding in liver, seventeen days after injury (Tillmanns). 
bundles form solid continuations; again, they are said by some to form channels 
which later communicate with the lumen of some capillary : occasionally a proto- 
Fig. 138. 
Formation of new vessels by budding: a, b, c, first stages; d, /, g, simple and branching buds 
e, tubulation of a bud (TiJlmanns). 
plasmic filament will join a process of one of the branched formative cells. These 
solid protoplasmic processes liquefy in their centres, a lumen forming continuous INJURY AND REPAIR. 
354 
with that of the parent vessel. Sometimes the protoplasmic outgrowth is from the 
outset hollow, admitting blood, but even then it terminates by a filamentous pro- 
longation, and develops further after one of the methods already described. At 
first the new capillaries have homogeneous 
walls. Later they display nuclei, and finally 
present the ordinary endothelial structure, 
their walls becoming strengthened by apposi- 
tion of some of the neighboring tissue-cells. 
Most of the new vessels become obliterated by 
the condensation (contraction) of the newly- 
formed tissue, which accounts for the change 
of color in the scar from red to white. An 
aseptic wound with loss of substance may 
heal by “ organization of blood-clot.” This 
is merely an extension of the process by 
which the interstices of any aseptic wound 
are obliterated when filled with blood-clot. 
The coagulum serves as a scaffolding, being 
first invaded by leucocytes and then by 
germinal cells. These latter subsist upon the 
leucocytes, the cell-mass becomes vascularized, 
and the usual conversion into scar-tissue takes 
place. The gradual removal of blood-clot 
by the pressure of granulations springing from 
the surrounding tissues, which is sometimes 
spoken of as organization of a clot, is a 
different process, the clot here being a me- 
chanical obstacle requiring removal, rather 
than an aid to healing. 
The so-called filling up of a wound by 
granulations is a misnomer. The organiza- 
tion of the deeper layers of the granulations 
into contracting scar-tissue draws down the 
wound-margins and lessens the superficial 
area. Microscopically, granulations consist 
superficially of numerous multi- and mono- 
nucleated leucocytes, with many delicate 
blood-vessels running more or less vertically 
to the surface. Deeper epithelioid cells 
abound, and still deeper spindle-cells ar- 
ranged in bundles can be seen, in old wounds 
having become distinctly fibrous tissue, with 
the blood-vessels forming a horizontal net- 
work. The classical capillary loops capped 
with cells, which are said to account for the 
granular form of the granulations, do not exist, parallel vessels, ascending more 
or less vertically, as has just been said, being alone detected. 
The foregoing statements include all the essential facts concerning 
the aseptic formation of granulations by which healing is effected in 
every tissue, although in certain highly specialized ones, as spinal nerves, 
regeneration of nerve-tubules takes place. Indeed, the end-processes 
are the same even when infection has occurred. Epithelial repair, 
covering the surface-defect, results from proliferation of the epithelium 
at the margins of the wound. Healing by granulations or by the second 
intention may pursue an aseptic or an infective course. The former 
occurs in wounds with loss of substance resulting from the original 
injury or from subsequent separation of dead tissue. Separation of 
devitalized tissue takes place without suppuration, the discharges are 
serous or lymph, cloudy from excess of leucocytes and young tissue-cells 
(not pus), and healing occurs with the minimum waste of material, dis-r 
Fig. 139. 
Organization in blood-clot: a, fresh blood- 
clot ; b, leucocyte; c, new capillary; d, 
cross-section of a capillary: e, young 
connective-tissue cells (Smith). PLATE XI. 
Granulation Tissue ; a, Subcutaneous Fat; b, Proliferation from Surrounding Skin ; c, Granulation Layer ; 
a', Fat Cells ; a", Blood Vessel. (Klebs.) PROCESSES OF REPAIR. 
355 
charge, and formation of contractile scar-tissne : the minute processes 
are the same which will be mentioned as those terminating the healing 
of a suppurating wound. When infection of a wound occurs any 
mechanical bond of union is broken down; the scaffolding afforded by 
the uniting coagulum, by which the formative cells bridge the gap, is 
destroyed ; many of the newly-formed cells perish, peptonizing ferments 
dissolving the intercellular cement and separating the cells from their 
source of nutriment, while other toxic bacterial products directly attack 
the vitality of the cells. The infiltrated surfaces of the wound are also 
destroyed to a varying extent by the same agencies, and a proliferation 
of cells far in excess of the needs for repair takes place, many of these 
being lost in the discharges, many not receiving enough pabulum to 
develop properly; but far too many survive to form dense cicatricial 
tissue. Where sloughing occurs the fragments of dead tissue provoke a 
lively proliferation of the cells of the neighboring living tissues, so that 
finally the dead and living parts are only held together by a mass of 
cells. These are soon disassociated by death of some and solution of 
the intercellular cement by bacterial products, when the sloughs sep- 
arate, leaving usually far more granulation-tissue and consequent con- 
tracting scar than is produced by mere prolongation of suppuration 
without sloughing. The end-processes of this suppurative granulating 
process are the same as those already studied under aseptic union by 
the first intention. The same conversion of cells into fibres, the same 
method of vascularization, an identical but greater condensation (con- 
traction) of the deeper layers of the healing granulating surface, reducing 
its superficial area, occur. ( Vide Plate XI.) 
Epidermization is effected by proliferation of the epithelium of the 
wound-margins, the remains of the Malpighian layer of the skin or the 
sebaceous and sweat-glands when the skin has escaped total destruction. 
In healing by either variety of second intention only a comparatively 
limited formation of new epithelium is requisite, because, as just seen, 
the defect to be covered is very materially lessened by contraction of 
the granulation-tissue. The last small area of granulations—and this 
is true of the end of any method of healing—may become covered by a 
dried crust of exudate, beneath which the epithelial cells form: when 
healing is completed the crust drops off. This is healing by scabbing 
or under a scab, and is a desirable method to attempt under appro- 
priate circumstances. Two aseptic granulating surfaces, if maintained 
in contact, will often fuse together, healing then being said to occur 
by the third intention or secondary adhesion. Upon this fact depends 
the success of many cases of secondary suturing. The vitality of 
skin-grafts (not epidermic) of a severed nose or a finger-tip is main- 
tained, according to Thiersch and Tillmanns, by direct communications 
formed between the vessels of the granulations and those of the graft 
or severed part through the medium of the intercellular plasma-chan- 
nels. Later, all the phenomena described as pertaining to union by first 
intention (primary adhesion) occur. The transplanted part is passive 
until after the third day, when it commences to become vascularized. 
Despite the two or more (lays’ interruption of direct blood-supply, only 
the epidermal layer, a portion of the rete‘ Malpighii, and most of the 
vessels perish, the latter by atrophy and hyaline degeneration. In from 356 
INJURY AND REPAIR. 
three to four days the epithelial cells of the sebaceous and glandular 
follicles proliferate and penetrate the mass of newly-formed cells, and 
in two weeks, according to Garre, the conversion of granulations into 
connective tissue is completed. 
A few words as to repair in non-vascular tissues, as cornea and car- 
tilage. In the former its anastomosing intercellular plasma-channels 
readily admit wandering cells coming from the vessels of the related 
vascular structures (sclera and conjunctiva), and later proliferation of 
the fixed cells and vascularization occur. The same remarks hold good 
for cartilage, except that the scar is alleged to remain fibrous for a long 
time if aseptic healing has occurred, while “ if a severe inflammatory 
reaction takes place the cicatrix will rapidly become hyaline, like normal 
hyaline cartilage.” 
Regeneration of Tissues.—In only a few tissues does repair pro- 
ceed beyond the formation of scar-tissue. Where regeneration is pos- 
sible its perfection will be in proportion to the apposition effected and 
the asepsis secured. Surface epithelium and all connective-tissue struc- 
tures, as fascia, bone, or tendons, can be completely regenerated. 
Epidermis.—This, including the epithelium of the intestinal tract, 
is completely re-formed, the new cells being descendants of pre-existing 
epithelial cells found at the margin of the wound, or, after partial 
destruction of the skin, originating by division of the epithelium of 
various cutaneous glandular structures whose extremities lie in the 
deeper portions of the skin or actually in the cellular tissue beneath. 
Skin.—Regeneration of the fibrous portion is complete, although the 
arrangement of the bundles is more irregular, and it is long before elas- 
tic tissue is developed in the scar, but the hair, sebaceous and sweat-fol- 
licles, with the true rete Malpighii, are not re-formed. Lymphatics are 
also absent, and an old scar is so much less vascular than normal skin, 
from obliteration of most of its vessels, that it is liable to break down 
from slight causes. 
Fasciae, Tendinous Sheaths, and Tendons.—Repair in these tissues 
amounts practically to regeneration. After division of a tendon the 
proximal end retracts, and the method of repair varies somewhat 
according to the presence or absence of blood-clot. In the rabbit, when 
but little blood is effused emigration of leucocytes occurs, followed in 
from two to three days by rapid proliferation of the cells of the sheath. 
Many of the cells of the tendon-stumps rapidly degenerate, but about 
the fourth or fifth day some take part in the formation of the granula- 
tion-tissue. The exudate extends some distance above and below the 
extremities of the softened, succulent, and newly-vascularized tendon. 
According to Warren, when the sheath is filled with blood the clot is removed 
by ingrowths of vascular granulation-tissue springing from the sheath without 
primary infiltration with leucocytes; other observers deny this. The grayish cel- 
lular mass becomes pinker from vascularization (fifth day, Paget; tenth to four- 
teenth day, Warren), the new vessels in the granulations communicating with those 
of the tendon-ends. By the fifth day a spindle-shaped bond of union fills the gap. 
In the absence of any blood-clot the sheath collapses and adheres to the tendon- 
stumps, regeneration taking place by proliferation of the cells of the tendon- 
sheath and of the cut tendon. The new tissue gradually approximates that of 
normal tendon until microscopically no difference can be observed. The sheath 
is slightly adherent at the point of section. PROCESSES OF REPAIR. 
357 
Muscles.—Muscular defects are only repaired by scar-tissue forming 
from the connective tissue and endothelial elements. Near the cicatrix 
or after slight injuries and contusions regeneration is observed to a limited 
extent—according to one view, commencing by enlargement and prolif- 
eration of the muscular nuclei, resulting in the formation of large mono- 
and poly nucleated cells, occupying the place of the destroyed fibres. 
These develop into spindle-cells lying side by side, which soon become 
longitudinally fibrillated and show commencing transverse striation dur- 
ing the third week. According to another view, granulation-tissue first 
forms among and around the necrosed muscle-fragments. The ends of 
the damaged muscle-cells break up into spindle-shaped fragments which 
undergo fatty degeneration preliminary to absorption. The nuclei of 
the living muscle-cells proliferate, forming bundles of muscular cells 
near the injured area which totally disappear by the third week. The 
disappearing fibre is replaced by a bundle of longitudinally striated fibres 
and spindle-cells formed by splitting up of the muscle-fibres and prolif- 
eration of the nuclei. Growth of muscle-fibres into the granulation- 
tissue and disappearing mass of muscular debris commences about the 
sixth day by small, multinucleated protoplasmic fibres springing from 
the stumps of non-degenerated fibres or from those longitudinally split. 
These outgrowths may be bifurcate, with club-shaped or fusiform extrem- 
ities which contain many nuclei. Longitudinal striation occurs early, 
followed at the close of the second week by transverse striation. The 
new muscular filaments interlace, lateral budding being not uncommon. 
The fibres gradually increase in bulk and become striated transversely, 
Fig. 140. 
Obliteration of artery of dog four days after ligature: m, media; t, thrombus; l, ligature (Warren) 
but many fail to develop and soon disappear by fatty degeneration, those 
which remain interlacing with others from the opposite side of the gap 
until the connective-tissue scar in very slight wounds may disappear. 358 
INJURY AND REPAIR. 
Much of the interlacing disposition of the fibres is gradually replaced 
by a normal arrangement, but some irregularity always remains. 
Blood-vessels.—Vascular repair depends upon the formation and 
so-called organization of thrombi—i. e. the formation of vascular cica- 
trices. Injury to or destruction of the endothelium and partial or com- 
plete arrest of the blood-current are requisite. 
The exact role played by blood-plaques and white cells need not here occupy 
us, except that a vascular thrombus differs materially from a mere mass of clotted 
blood, being often entirely white.1 Once started, unless only a portion of the cir- 
cumference of the vessel is injured, the thrombus usually extends in time to the 
next collateral branch above and below. A mere rent or small wound may have a 
limited thrombus form, filling the gap, which may organize, leaving only a thicken- 
ing: this is quite common in veins, but may also occur in arteries of any calibre. 
Once formed, the thrombus may organize, may calcify, or may soften. 
The minute processes are as follows : The vascular wall first and the 
thrombus next become infiltrated with leucocytes, which seem to pene- 
trate the latter by many routes, thus breaking it up into isolated masses. 
The endothelium proliferates where injured, and the thrombus gradually 
becomes replaced by formative cells thence derived, which penetrate 
along the tracks prepared by the previous invasion of leucocytes. A"as- 
cularization and subsequent development of the germinal tissue is effected, 
all traces of the thrombus being removed. The organization will be 
slower when the thrombus does not entirely occlude the vessel, because 
the formative cells can only enter through those portions in contact with 
the vessel-wall. One or more of the new vessels may persist or enlarge, 
restoring in a measure the continuity of the vascular lumen, but usually 
the occluded segment of vessel shrinks into a fibrous cord.2 
A small wound of an artery may be repaired by blood-clot occluding the open- 
ing, hemorrhage being prevented by tense surrounding tissues. Here the thrombus 
extends through the gap in the wall and in the interior of the vessel around the 
wound, but does not entirely occlude the lumen. Granulation-tissue grows into 
and replaces the portion of thrombus occupying the vascular wound—a connective- 
tissue scar forming. Intravascular pressure causes gradual yielding of this scar, 
an aneurism forming, or perhaps the cicatrix suddenly ruptures, giving rise to an 
arterial hsematoma. Repair after ligature of a vessel is essentially the same—viz. 
formation of protective thrombus, infiltration of vessel-wall and thrombus with 
leucocytes, proliferation of intimal and connective-tissue cells, substitution of the 
clot by these formative cells, vascularization of this germinal tissue, and conver- 
sion of the segment of vessel into a fibrous cord. Warren insists that at the site 
of ligature the vessel becomes converted into granulation-tissue, the vessel-ends 
separate, expand, and the granulations freely penetrate the thrombus, carrying in 
new vessels. Between the irregular masses of granulations spaces are left which 
after absorption of the clot form blood-spaces, opening on one side into the lumen 
of the vessel, on the other communicating with the capillaries of the granulation- 
tissue. As the clot and excess of exudate are absorbed a perfect cicatrix is formed, 
lined by intima, containing unstriped muscle, and externally composed of connec- 
tive tissue. The persistence of a small central vessel communicating with the lumen 
above and the “ capillaries surrounding the arterial stump ” is also described as 
common. While Warren’s observations stand alone with regard to the formation 
of a muscular scar, they are worthy of further investigation as explaining—if con- 
firmed—why aneurismal dilatation so rarely results from the scar of a ligation in 
continuity. 
1 This does not, of course, preclude accretions of genuine clot, either ante- or post- 
mortem. 
2 Rokitansky’s sinus-degeneration and other rare secondary changes must be studied 
elsewhere. PROCESSES OF REPAIR. 
359 
Nerves.—Under favorable circumstances repair is here complete.1 
The alleged immediate union of nerves with restoration of their con- 
ducting power, with no degeneration of the peripheral end occurring, 
appears to have been established clinically, but experiments upon ani- 
mals negative this view, while anastomoses between nerves, supplemental 
or vicarious sensibility, and differences in the distribution of a given 
nerve probably explain the so-called primary union.2 Degeneration of 
the whole of the distal with a portion of the proximal end is the rule, 
repair taking place chiefly by growth downward of embryonic fibres, 
originating from pre-existing fibrils: these penetrate the granulation- 
tissue by which the physical union of the trunk is effected. According 
to Howell and Huber’s experiments upon the dog, in four days after 
section the myeline sheath becomes segmented and the axis-cylinder is 
fragmented in the peripheral portion of the nerve. By the seventh day 
active nuclear proliferation has begun in the neurilemma, with migration 
of the new cells, several often occupying one internodal space. During 
the next week the segmented myeline and fragmented axis-cylinder 
disappears by absorption, complete removal being effected in fourteen 
days. Next the nuclei acquire an investment of protoplasm, which 
increases until a single solid protoplasmic fibre with imbedded nuclei 
occupies the old sheath. “ When union is made with the central end 
this is the rule, but if this does not take place, one or more fibres may 
arise within an old sheath by longitudinal cleavage.” These amyelinic 
embryonic fibres later acquire a myeline sheath, the old sheath probably 
becoming part of the endoneural connective tissue. Return of function 
in the dog commences about the twenty-first day and is complete in 
eighty days. 
From these experiments it also appears that nerve-impulses can be con- 
veyed in the embryonic-fibre stage when they are united with normal fibres of the 
central end. Note carefully that the best results followed immediate suture 
(Howell and Huber), even an hour’s delay producing a recognizable difference. It 
is probable, both from experiment and clinical observation, that when immediate 
suture is done, although complete degeneration of the peripheral end apparently 
occurs, yet regeneration is more rapid. Aseptic healing is more apt to be followed 
by a perfect result, the formation of much granulation-tissue as a sequence of 
suppuration presenting unfavorable conditions for penetration by the newlv-formed 
nerve-fibres. The greater the extent of the distal portion, the longer will be the 
time requisite for cure. The same is true as to the time and perfection of result 
if a segment of nerve-trunk is destroyed. Where suture is not done regeneration 
is arrested at the “ embryonic ” stage, and a bulbous enlargement is apt to form 
composed chiefly of fibrous tissue: this is most likely to involve the proximal end. 
The preceding statements, although differing somewhat from previous teachings, 
probably correctly represent the present state of our knowledge upon this important 
subject, modern methods of research having invalidated some of the earlier 
observations. 
Bone.—The union may be immediate or by second intention—i. e. by 
granulation, the bond being usually genuine osseous tissue. Examining 
a fracture of a long bone, considerable blood will be found effused from 
the ruptured medullary and Haversian vessels as well as from those of 
1 The peripheral end of one nerve (sensori-motor) lias been united with the central 
end of another, with restoration of function. 
2 When these rare cases are opposed by the vast bulk of clinical and experimental 
results, demonstrating the apparent impossibility of this method of union, alleged cases 
of “ immediate union ” are to be viewed with grave doubt as to the accuracy of the 
observations. 360 
INJURY AND REPAIR. 
the periosteum and contiguous soft parts which have been lacerated. 
Even in the rare event of the periosteum not having been torn, it is 
more or less stripped off the broken extremities. The injured tissues, 
infiltrated with blood, are soon invaded by leucocytes and exuded blood- 
plasma, and, fibrinous coagulation occurring, the extremities of the 
broken bone lie imbedded in a dense, ill-defined mass of firm cellular 
exudate involving periosteum, connective tissue, and possibly environing 
muscle. The blood entirely disappears by absorption in from fourteen 
to twenty-one days, when the firmer cellular exudate (callus) is seen to 
be a dense tissue, most abundant in and beneath the periosteum and 
extending between the ends of the fragments : in some parts the callus 
is cartilaginous. In from seven to fourteen days longer the soft callus 
ossifies, forming a spindle-shaped ferrule of porous bone (provided the 
fragments have not been much displaced). Meanwhile similar changes 
have also been taking place in the medullary tissues—viz. the blood-clot 
has been with the neighboring soft parts of the medulla infiltrated with 
leucocytes, the blood is next absorbed, the fat disappears as the connec- 
tive and endothelial cells proliferate, and granulation-tissue forms from 
both bone-fragments, which soon fuses and develops into porous bone 
blocking the medullary canal. Much later the connective and vascular 
tissues occupying the Haversian canals in the compact bony tissue con- 
tiguous to the fracture proliferate, the lime salts gradually disappear, 
and the granulation-tissue thus formed is converted into bone, definitely 
uniting the fragments. When union has been finally completed the 
excess of external and internal callus is absorbed, the medullary canal 
is restored, and in time the site of the fracture may be hard to detect if 
the reduction has been perfect. When overlapping occurs, the open 
ends of the medullary canal become closed off by bone, and its lumen 
is usually only imperfectly restored by gradual conversion of the over- 
lapping and fused portions of cortical bone into cancellous bone. 
The following are the minute changes observed during the healing 
of bone. There is first infiltration by leucocytes of the effused blood, 
lacerated periosteum, muscles, etc. The cells of the soft parts of the 
bone, especially those of the deeper (osteogenetic) layer of the periosteum 
some little distance from the fracture, begin to proliferate, numerous 
angular and stellate cells (osteoblasts) appearing, which originate from 
the deep periosteal cells. Sooner or later similar changes take place in 
all the osseous soft parts—i. e. the periosteum, bone-cells, medullary 
tissue, and contents of the Haversian canals, which are all continuous 
structures. 
Where the earthy salts and matrix of dense bone oppose a temporary physical 
obstruction to cell-proliferation, which can only be gradually removed, the soft- 
part changes occur more slowly. The new cells (osteoblasts), probably formed by 
division of the fixed connective tissue and endothelial cells of the bony soft parts 
as wrell as from the deeper periosteal cells, lie separated by a finely striated inter- 
cellular substance, each surrounded by a halo somewhat* like that seen around 
cartilage-cells, the more highly differentiated portions forming interlacing trabec- 
ulje: this is “ osteoid tissue.” Direct ossification may now take place, the cells 
growing smaller and some becoming branched, occupying spaces in the calcareous 
matrix—i. e. they are now bone-corpuscles. The lime salts commence to be 
deposited at numerous points in from ten to fourteen days, trabeculae of true bone 
developing, while blood-vessels of new formation spring from those occupying PROCESSES OF REPAIR. 
361 
neighboring Haversian canals to ramify between the bone-plates: the new vessels 
run at right angles to those of the old bone. 
Ossification usually starts in the angles formed between the separated 
periosteum and bone, and extending thence, the two buttresses meet and 
fuse at the middle of the spindle-shaped mass of provisional callus. Bone 
callus, as the tissue is now termed, is formed of a network of trabeculae, 
the interstices of which are occupied by masses of young cells which 
have not yet ossified : the peripheral layer of these masses, however, are 
steadily being converted, layer by layer, into bone. Most of the hyaline 
cartilage sometimes found in callus disappears before the advancing 
ingrowths containing osteoblasts, but some is directly converted into 
bone by deposition of lime salts in the matrix, a portion of the cells 
remaining as bone-cells. 
Similar changes occur in the medullary canal, the osteoid tissue com- 
mencing at the periphery of the canal and spreading thence concentri- 
cally until its occlusion is effected. Hyaline cartilage is rarely seen in 
this internal callus. Finally, the Haversian canals of the compact tissue 
of the ends of the fragments become choked with a round-celled infil- 
trate ; the lime salts are dissolved and removed with the ground sub- 
stance, large cancellous-like spaces thus resulting filled with young 
osteogenetic cells. The germinal tissue thus formed on the ends of the 
fragments with the contiguous portions of the cellular exudate compos- 
ing the internal and external callus fuse, and union of the cortical bone 
takes place by ossification of this definitive callus} 
Healing of bone by the second intention—i. e. by granulation—takes 
place in open fractures where either loss of bone or death of bone 
occurs. In the first place, the periosteum having usually been destroyed 
over the osseous defect, the cells of all the soft tissues of the neighbor- 
ing bone proliferate, forming the granulation-tissue, which, as the super- 
ficial parts close over and cicatrize, becomes converted into bone by one 
or more of the methods described. When necrosis occurs, at the border- 
line between the dead and living parts lively proliferation of the cells 
of the periosteum, medulla, and Haversian canals produces a mass of 
germinal tissue, some of the cells (osteoclasts) causing absorption of the 
bone-substance until the continuity of the dead and living bone is 
interrupted by a layer of cells. In suppurating wounds the bacterial 
peptonizing ferments effect the solution of the intercellular cement, thus 
detaching the dead fragment, but in aseptic wounds a similar result 
follows from a more gradual loss of vitality, disintegration, and solution 
of cells and cement. When the dead bone is removed the granulations 
go on to cicatrization—i. e. ossification. 
1 As the callus passes through a stage resembling the formation of fibrous tissue, and 
as the cartilage is often fibro-cartilage, it would seem that so-called fibrous union is a mere 
arrest of union at a certain stage of the process. If the disturbing causes can be removed 
in time, Nature may—as we know she often does—take up the process where it was left 
off and complete bony union. This explains the benefits accruing from rubbing of frag- 
ments together, subcutaneous drilling, and blistering over the fracture in cases of delayed 
union. CHAPTER XXV. 
TREATMENT OF WOUNDS: ANTISEPSIS AND ASEPSIS. 
Charles B. Xancrede, M. D, 
In this last decade of the nineteenth century it would seem needless 
to do more than state the fact that modern surgery only became a possi- 
bility since Listerism—i. e. the principles of wound-treatment first 
enunciated by Lister—has become the rule in practice. 
Although the injection of a number of irritant germ-free substances 
may initiate the formation of a puruloid fluid, this fact really has no 
bearing upon wound-treatment, since we are never confronted with such 
conditions clinically, and the resultant fluid is innocuous when injected 
into another animal. Again, the injection of culture-media or pus, in 
which the germs have been destroyed, merely produces the condition 
resulting from the action of living germs—viz. the presence of toxines 
and ptomaines, which are the active agents in the production of pus. 
In practice, then, all pus and interference with normal wound-pro- 
cesses result from the presence of pathogenic organisms, for all germs 
are not harmful. To effect their exclusion or destruction it is requisite 
to understand the sources whence derived and the conditions favoring 
their development. They are present in the air, in water, in dust, and 
in the soil, and of course in pathogenic wound-discharges. 
Surgically, those in the air will, if currents are prevented, gravitate and leave 
it completely or relatively free;1 hence the necessity of avoiding draughts when 
operating or dressing wounds, long skirts worn by nurses, and sweeping, dusting, 
or moving hangings and furniture shortly previous to operations or dressings. 
Air in motion is never actually germ-free,2 except above the snow-line on moun- 
tains, in the midst of extensive forests where much atmospheric moisture is 
present, and in mid-ocean, but under ordinary circumstances the number is too 
small to consider in a properly-kept operating-room, ward, or dwelling-house if 
draughts are avoided. Water, including rain-water, always contains germs, except 
sea-water some distance from inhabited coasts. 
The soil and ordinary house-dust is a fruitful source. It is hardly necessary 
to say that the dust of hospital wards or private houses where suppurating cases 
have been treated teem with organisms; hence the advantages of such methods of 
construction and material as will least favor the lodgement of dust, which entangles 
and precipitates the germs. All exposed objects, then, may afford lodgement for 
germs, as instruments and dressings. Finally, the surgeon's, attendant's, and patient's 
integument, or, in the case of the latter, certain mucous cavities or canals,3 are the 
chief source of pyogenic organisms. The foregoing embraces the really essential 
facts to be remembered in practice. Foul odors from sewers and privies contain 
1 The author has more than once exposed a Petri dish containing a culture-medium 
for one hour and a half in his operating-room, and been unable to detect a single colony 
after weeks in the incubator. 
2 Germs found in the air of ordinary dwellings are usually non-pathogenic moulds and 
fungi. 
3 The expired air is free. 
362 TREATMENT OF WOUNDS, ETC. 
363 
few if any organisms, being damp, but the dried material from these sources may 
be carried by currents of air and will prove most harmful. 
Some germs cannot live or develop when oxygen is present, others require the 
presence of air, but all varieties must have a proper temperature, moisture, and 
pabulum. Theoretically, pathogenic organisms should be best destroyed by the 
withdrawal of one of these essentials, but moisture is the only requisite that we can 
nearly absolutely control, although the amount of pabulum can be markedly 
minimized. 
While it is true that if a wound is germ-free nature’s reparative 
processes will pursue an uninterrupted course, it is also true that germs 
may be present and yet no harm ensue. The healthy blood and tissues 
destroy or remove germs, so that unless they are present in large num- 
bers or the vitality of the tissues be lowered, no disturbance results and 
the germs promptly disappear. The more vascular tissues seem to possess 
the highest degree of immunity, as seen in wounds of the face. The 
absence or scarcity of pabulum produces similar results, as shown by 
Grawitz’s experiments, where the introduction of sterilized fluid indu- 
cing a serous exudation determined a peritonitis after inoculation with 
pyogenic organisms, pabulum being present, because the peritoneum 
could not remove rapidly enough that which the germs fed upon and 
multiplied in. In the absence of the serous exudate relatively large 
quantities of pyogenic organisms could be introduced with impunity. 
Again, slight traumatisms of the peritoneum by lowering the vitality of 
the tissues at such points enabled the germs to gain a foothold, multiply, 
and initiate a spreading peritonitis. 
These facts teach a twofold lesson : (1) that fluids that serve as germ- 
food should not be allowed to accumulate in wounds, and (2) that all 
unnecessary damage to the tissues must be avoided, because it diminishes 
their germ-inhibitory and destructive power. 
To enable germs to produce their effects they must be either present 
in overwhelming numbers, or, more commonly, the resistance of the 
tissues being lowered, a moderate number multiply into a host. This 
explains the fact that an injury inflicted upon a person in health may 
produce little effect, but let the resisting powers of the tissues be lowered 
by previous disease at the point of injury, or let the vitality of all the 
body-cells be lowered by a serious disease, as glycosuria,1 and extensive 
suppuration will often result from a trivial hurt. The general belief 
that atmospheric influences—cold, heat, moisture, etc.—can of them- 
selves interfere with the healing of wounds is untenable, as is the alleged 
influence of individual predisposition to suppuration, or that cancer, 
tubercle, or syphilis causes failure in primary union. While it may be 
true that congestions, or local or general depression of vitality induced 
by such conditions, may render effective the implantation of a few germs 
which under other circumstances would be disposed of by the tissues, if 
germs are absolutely excluded, primarily or secondarily, wounds will pur- 
sue a similar course whether the weather be hot or cold, dry or damp— 
whether the patient be syphilitic or tubercular or absolutely free from 
any taint. Of course it is not contended that the healing processes will 
occupy the same time in all individuals, but that no interruption to these 
processes will occur if germs be excluded. (Vide also Chapter III.) 
1 Grape-sugar apparently favors the development of pyogenic organisms. See Medico- 
chirury. Soc. Trans., vols. lxxv. and lxxvi. 364 
INJURY AND REPAIR. 
ASEPTIC SURGERY. 
Two courses are open to the surgeon when operating or in the treat- 
ment of accidental wounds. He may remove, inhibit the growth of, or 
destroy all germs upon his own hands, those of his assistants, his instru- 
ments, sponges, the part to be operated upon, and in the dressings, 
nothing but that which is aseptic—e. germ-free—coming into contact 
with wounded surfaces. With proper precautions this germ-free condi- 
tion persists, healing occurring with the minimum of disturbance. To 
this method the term aseptic is applied, the ideal outcome of Lister’s 
work. 
Owing to the impossibility of certainly excluding all germs or germs 
in harmful numbers, as in certain operations within the mouth, rectum, 
or in accidental wounds, measures must be adopted calculated to inhibit 
the growth of, or destroy when possible, all micro-organisms which 
have gained access to the wound, and to further prevent their subse- 
quent multiplication in the dressings, whence secondary infection of the 
wound might result. Wound-treatment conducted according to these 
principles is termed antiseptic and is the original plan advocated by 
Lister. As many of the measures employed in this latter method are 
requisite preliminaries rendering possible aseptic operating, they must 
be considered. 
Too much stress has been laid by some upon laboratory experiments and those 
upon the lower animals. It is indeed true that, lacking the knowledge thus 
gained, our present successes would be impossible or rest upon an insecure basis, 
yet these essential differences must never be lost sight of—viz. that in dealing with 
cultures of pathogenic micro-organisms thermic or chemical agents are afforded 
the freest possible access to the germs, whereas clinically much of their potency is 
lost by precipitation, dilution, or the mechanical impossibility of proper contact. 
The susceptibility to infection with pathogenic germs varies much among the dif- 
ferent species of lower animals and in them and man, so that, while laboratory 
experiments suggest and warrant clinical experiments on man, they are not con- 
clusive and sometimes prove disappointing. 
Disinfection, or Sterilization (Germ-destruction), and Disinfecting 
or Sterilizing Agents (Germ-destroying or Inhibiting Agents).—Koch 
and his followers have demonstrated beyond cavil that heat, and heat 
alone, is universally germicidal, but while this is a fact, certain inherent 
difficulties confront us in practice. Much difference in results follows 
the method of employing heat. Thus contact with boiling water for 
one to live seconds will destroy the adult forms of any pathogenic micro- 
organisms, and the spores even of anthrax in two minutes. Steam may 
be used superheated—i. e. under pressure—or simple “ live,” actively 
generated, and freclv-escaping steam. In this latter form it will destroy 
anthrax-spores in from ten to fifteen minutes. It must be remembered 
that spores are vastly more resistant than adult micro-organisms, and 
that all varieties of pathogenic micro-organisms succumb with ease as 
compared to the anthrax bacillus. A too common mistake is made in 
forgetting that while a limited period only is required for the action of 
any efficient degree of heat, it must be that degree of heat applied directly 
to each spore or adult germ. Hence even boiling water requires longer 
time to be germicidal, than in laboratory experiments, when employed 
for bulky, tightly-folded, or wrapped dressings, or when, as is often TREATMENT OE WOUNDS, ETC. 
365 
true, germs are included in masses of coagulated pus, blood, or mechan- 
ical filth. This fact is of still more importance when steam is employed. 
All dressing materials and instruments must be, as far as possible, 
mechanically cleansed and then so arranged that the steam readily gains 
access to all parts, especially the interior of dressings. 
It is folly to put tightly-folded, cold towels into a steam sterilizer for the mini- 
mum time employed in the laboratory to destroy pyogenic organisms, and then 
expect aseptic results. Hot air is the least efficient method of employing heat, 
because of the higher temperature and longer period of exposure requisite and its 
feeble power of penetration. Anthrax-spores, none of which survive after two 
minutes’ contact with boiling water or fifteen minutes’ exposure to “ live ” steam, 
require three hours’ dry heat at 140° C. to produce the same effect, and much 
longer exposure when occupying the interior of dressings, folded clothing, etc. 
Confusion of the essential differences between the germ-inhibiting 
action of chemical substances and between their action in the presence 
of living tissues and the wound-fluids is answerable for much of the 
past and some of the present theoretical and practical disbelief in asepsis 
and antisepsis. Nearly every agent we employ in the strength in which 
it actually reaches the germ is not germicidal, but does usually prevent 
the growth of micro-organisms to any harmful extent. Let the most 
thorough mechanical cleansing and chemical disinfection of the skin be 
employed, such as will presently be described, yet in most instances the 
chemical precipitation of the alleged germicide, say mercuric chloride, 
will demonstrate by culture-experiments that germs in harmful num- 
bers are present, although incapable under ordinary circumstances of 
producing evil. It is not denied that when concentrated some of the 
chemicals ordinarily employed will destroy either at once or in a short 
time adult germs or even the resistent anthrax-spores, but in the 
strength possible safely to employ in a wound they inhibit only ; hence 
the great importance of their mechanical removal and exclusion and 
conservation of tissue-resistance, because under certain circumstances 
chemical inhibition may fail. 
Space will not be occupied with the daily lengthening list of substances which, 
in the laboratory, have proved to be germ-inhibitors or germicides, but only such 
will be mentioned as have proved most reliable clinically, can be resorted to in any 
emergency, or are peculiarly applicable to meet exceptional indications 
Marked Inhibition. 
Complete Inhibition. 
Mercuric chloride . . . . 
1 : 1.600,000 
1 : 300,000 
Oil of mustard 
i : 333,000 
1 : 33,000 
Thvmol 
. . . • • 1 :86.000 
Oil of turpentine . . . , 
1 : 75,000 
Iodine 
1 : 5,000 
1 : 1000 
Salicylic acid 
1: 3,300 
1:1500 
Eucalyptol 
1 : 2,500 
1 :1251 
Borax 
1: 2,000 
1 : 700 
Potas. permang 
1:1400 
Boracic acid 
1:1250 
1:800 
Carbolic acid 
1:1250 
1 : 850 
Quinine 
1 : 830 
1 :625 
Alcohol 
. . . . 1:100 
1 : 12.5 
Discrimination must be exercised in applying these facts demonstrated by 
Koch as true of anthrax-spores. No albumen or chemical substances interfered 
1 The reader is referred for details to Gerster’s work on Aseptic and Antiseptic Surgery, 
and to the same surgeon’s article in Dennis’s System of Surgery. The author would here 
acknowledge his indebtedness to Dr. Gerster for much valuable information. 366 
INJURY AND REPAIR. 
with the action of the agents. They were in absolute and prolonged contact with 
the organisms in a way impossible to imitate clinically. The equality, or rather 
slight superiority, of boracic over carbolic acid alone shows how rigidly experi- 
ment must be checked by clinical observation. Oily materials preventing contact 
with organisms or albumen forming inert albumenates are the chief foes of chemi- 
cal germicides. In practice a proper choice of agents or a combination with other 
substances will often obviate these objections. Only such agents or procedures are 
commendable which are efficacious within a limited period, and which in them- 
selves do not damage the tissues—i. e. reduce the tissue-resistance. 
The last means of sterilization to be considered, although of the 
most importance so far as the surgeon’s and assistant’s hands and the 
field of operation are concerned, is the mechanical removal of extraneous 
dirt, accumulated epithelium and germs, and the superficial epidermic lay- 
ers in which at least one pyogenic micro-organism has its normal hab- 
itat.1 By the same means much of the oily matter abounding in the 
skin is removed, but when extra precautions are requisite certain sub- 
stances especially adapted for the removal of fatty materials should also 
be employed. 
Mechanical Sterilization. 
The preparation of the surgeon’s, assistant’s, and nurse’s hands will 
first be described. Sterilized water as hot as can be borne should be 
employed. This must, of course, be never cooled by the addition of 
any but cold sterilized water. In hospital practice this water is always 
to be removed front the vessel in which it is sterilized by heat at the time 
when about to be used. In private practice, after thorough boiling, the 
water, previously filtered when necessary, may be placed in sterilized 
vessels protected from atmospheric dust—i. e. that containing germs— 
by a sterilized towel. Special care must be exercised that the cup or 
dipper used to transfer the water from the vessel—oftentimes a wash- 
boiler or large tin dish—is always replaced in the boiling water to main- 
tain its asepsis. The nail-brush, best made of vegetable fibre, must be 
always carefully rinsed after use and be sterilized by heat for each ope- 
ration.2 The heat employed may be live steam for fifteen to twenty 
minutes or boiling in water for five minutes. Although it is alleged 
that all soaps made by heat are sterile—indeed, that potash soap is an 
active germ-inhibitor in the proportion of 1 :5000—yet it is the part of 
prudence to combine with the soft soap 5 per cent, hydronapthol or 
thymol to ensure that the soap itself is free from germs. After thor- 
oughly rubbing in the hands and arms and under the nails abundance 
of soap, the nail-brush and hot water must be vigorously used, especi- 
ally beneath and around the nails, for from two to five minutes. Next 
carefully clean the nails and around them with a nail-cleaner. Removal 
of all grease can now be effected by ether or by immersion in alcohol, 
or best by alcohol containing 5 per cent, of dilute acetic acid, which 
should be rinsed off thoroughly with sterilized water, removing the last 
traces of soap. Finally, the hands should be immersed—not merely 
dipped—in a 1 : 2000 mercuric solution, for not less than three—prefera- 
bly five—minutes. Instead of corrosive-sublimate solution, ordinary 
mustard flour mixed in the hands into a thin paste with sterilized water, 
Staphylococcus epidermidis albus (Welch). 
2 And be placed in a carbolic acid solution until needed, as any soap left on the brush 
would interfere with the action of a bichloride solution. TREATMENT OF WOUNDS, ETC. 
367 
used with gentle friction for two or three minutes and then removed 
with sterilized water, will prove a most successful germicide (Park). 
The efficacy of the mercuric bath may be increased by scrubbing the 
hands and arms with the sterilized brush, previously freed from every trace 
of soap. This solution is to supplement the mechanical cleansing, which, 
it is again urged, must be that relied upon, and to inhibit the growth of 
any germs not removed and those normally resident in the epidermis. 
Were the fatal blunder not so common, it would be superfluous to men- 
tion that after the final cleansing described the hands must not be wiped 
on an ordinary towel, and should touch nothing but the disinfected 
instruments, towels, or field of operation. Should circumstances arise 
necessitating the use of a towel, a recently sterilized one or one wrung 
out of an antiseptic solution must be employed. Accidental contact 
with unsterilized objects, as clothing, the hair,1 or beard of an assistant, 
demands, if slight, washing in a germicidal solution and rinsing this 
off with sterilized water. Fouling of the finger with buccal or nasal 
mucus, faeces, or pus necessitates a repetition of one or all of the 
original procedures: mustard flour is especially to be commended, 
promptly sterilizing and removing the odor of faeces better than any- 
thing the author is acquainted with. 
Sterilization of the Field of Operation.—The same principles are 
applicable and almost identically the same measures are to be employed. 
When the patient’s condition permits, a general warm bath should be 
taken, after which recently laundried clothing should be donned. Care- 
ful shaving should precede all operations. Next should follow prolonged 
but gentle scrubbing with nail-brush, hot water, and soft soap, especial 
attention being paid to such parts as the axilla, pubes, and umbilicus. 
All grease left must be removed by free bathing and rubbing with alco- 
hol and acetic acid. Finally, a careful scrubbing with 1 : 2000 mercuric- 
chloride solution—or mustard flour used as already indicated—should be 
done, and the parts covered with a dressing wet with the same solution 
or one of per cent, carbolic acid, the latter being especially applicable 
where much oily matter is to be met with, as the scalp or axilla. This 
dressing should only be removed after anaesthesia has been induced, when 
the parts should be again cleansed with a germicidal solution, which then 
can be removed by free ablutions with sterilized water. 
Certain additional precautions should be taken for brain-operations or those 
about the feet, hands, or involving opening of non-suppurating joints. In the 
former the sterilization just described might fail, because oily material normal to 
the scalp might prevent the germicidal solution proving effective; and in the latter, 
because of the accumulation of thickened epidermis harboring the germs, securing 
them against either mechanical removal or chemical destruction. The simplest 
adjuvant after shaving, alcohol, etc. is to apply, for a few hours, a thin layer of 
soft soap on absorbent cotton as a poultice, which must preferably be removed by 
free irrigation with weak carbolized or sterilized water, after which the permanent 
antiseptic dressing can be applied until the time for operation. Certain modifica- 
tions become requisite when dealing with such cavities as the mouth, vagina, rec- 
tum, or where operative interference may possibly open into them. All of these, 
with the possible exception of the bladder, teem with organisms, and in none of 
them can strong chemical germicides be employed. Careful attention to the con- 
dition of the teeth, removal of all salivary calculus, extraction or filling of carious 
1 During operations about the head and face the hair must be covered with an aseptic 
or antiseptic towel carefully secured in place. 368 
INJURY AND REPAIR. 
teeth, mouth-washes and sprays containing thymol, boric, or salicylic acids—one 
of the best being Listerine—with such treatment of any nasopharyngeal catarrh 
as circumstances will admit of, is the most desirable preparation for operations for 
cleft-palate, temporary or permanent resection of the jaws, ablation of the tongue, 
nasopharyngeal tumors, etc. The after-use of iodoform packing is also efficacious. 
Vagina—Mechanical cleansing is here our mainstay. Abundance of 
soft soap on a vaginal mop made of sterilized cotton or gauze or a long 
soft jeweller’s brush 1 should be employed to scrub the vagina, free irri- 
gation with sterilized water being employed while doing this. 
Follow this by douching with a 2.5 per cent, solution of carbolic acid or a 
1: 2000, or eVen 1 : 1000, mercuric solution, provided all the chemical be removed 
by free flushing with sterilized water and care to be taken to empty the vagina 
by firm pressure on the posterior commissure: permanganate of potassium or 
Thiersch’s solution may be substituted. When vaginal hysterectomy is contem- 
plated, these procedures had best be adopted some hours before operation and 
repeated upon the operating table. Dilatation of the cervical canal, curettage 
with the irrigating curette, disinfection by iodine, zinc-chloride solution, or the 
cautery, should also precede in most instances such operations. Curetting followed 
by milder but efficient disinfection must be employed before trachelorrhaphy. 
Intestines and Rectum,.—Thorough purgation and liquid diet must be 
employed, the former being sometimes properly secured in tight rectal 
strictures by a previous inguinal colotomy. Free and repeated lavage 
of the colon with sterilized water in the “ knee-elbow ” position is indi- 
cated shortly before operation. 
After anesthesia, when dealing with the rectum, a good-sized sponge secured 
by a strong thread should be passed well up the rectum, the field of operation be 
freely swabbed and flushed with Thiersch’s solution. It may even be cautiously 
curetted and touched by the thermo-cautery in certain cases of ulcerating neo- 
plasms. Possibly the internal exhibition of salol or thymol might aid in securing 
asepsis. Subsequent packing with iodoform gauze will aid in maintaining the 
asepsis. Temporary proximal and distal ligation or clamping of the intestines, 
walling off the healthy peritoneum by iodoform-gauze packing, stripping away by 
the fingers the intestinal contents before applying the clamps, mopping rapidly up 
all remaining fluid after incising the gut with pledgets of aseptic gauze, usually 
secure asepsis during intestinal operations. When the loop or loops of gut involved 
in the procedure can be placed entirely outside the belly, as is often the case, com- 
plete isolation from the general peritoneal cavity can be effectually secured by 
gauze packing and removal of the bowel-contents by flushing with sterilized salt 
solution. When healthy peritoneum is incised during operations for appendicitis 
or pus-tubes—i. e. when the opening is outside the adhesions2—careful packing 
with iodoform gauze should precede opening the pus-focus, all infected material 
should be removed as completely as possible, and, the soiled gauze having been 
cautiously removed, a clean packing should be introduced to remain until adhe- 
sions have shut off the general serous cavity. 
The object in view when preparing the field of operation tints far has 
been the prevention of contamination of the deeper parts by germs 
derived from without or resident upon or in the integument or mucous 
membrane. While not, strictly considered, preparation of the field of 
operation, the special measures adapted to prevent infection by pus or 
secretions of the peritoneum, cerebral membranes, pleura, pericardium, 
and healthy bladder can best be considered in a general way here, refer- 
ring the reader to the proper sections of this work for details. 
1 Gerster. 
2 The Trendelenburg posture must carefully be avoided when dealing with pus-foci, 
lest the remaining healthy portions of the peritoneal cavity become flooded with infec- 
tious material. TREATMENT OF WOUNDS, ETC. 
369 
Cerebral Membranes.—No precautions other than those already men- 
tioned are demanded except when operating for a known or suspected 
abscess. Then the site of the purulent collection must be surrounded 
with (aseptic) iodoform gauze before the abscess is opened to avoid a 
generalized lepto-meningitis, after which every particle of pus should be 
removed by careful irrigation with sterilized salt solution. If the pus 
be especially virulent, such slight risk as attends the employment of a 
weak bichloride solution may be safely encountered. Thiersch’s solu- 
tion may be employed with impunity if desired instead of the sterilized 
water. 
Stomach.—When fecal vomiting exists from any cause or preceding 
gastrostomy, gastrectomy, gastro-enterostomy, gastrotomy, etc., gastric 
lavage should be done with Thiersch’s solution or the normal salt solu- 
tion, the latter being usually abundantly sufficient. Peritoneal infection 
must further be guarded against by suture of the stomach to the parietal 
peritoneum (gastrostomy) before incising the viscus, or after bringing 
the organ as far as possible into the parietal wound by careful walling 
off by packing with sterilized or iodoform gauze. 
In gastrectomy and gastro-enterostomy clamps or temporary ligatures must be 
applied to the stomach (when possible in gastrectomy) and to a segment of intes- 
tine, carefully stripping this of all faeces, drawing the loop outside the abdomen 
when possible, packing gauze about it, and then, after opening, thoroughly but 
rapidly removing what little contents remain by pads of dry (sterilized) gauze, or, 
when outside the abdomen, by flushing with sterilized salt solution. 
Liver, Gall-bladder, and Ducts.—Similar procedures are indicated 
when dealing with these structures. 
Accidental Operative Wounds of the Pleura, Pericardium, and Peri- 
toneum.—If the conditions are favorable, immediate suture is preferable, 
but if subsequent manipulations might open again the wound, tempo- 
rary gauze packing must be done. This may be removed and the wound 
sutured at the close of the operation, or a clean packing1 allowed to 
remain to induce limiting adhesions, aid in disinfection, and serve as a 
drain if the serous membrane has certainly or probably been infected 
during the operation. 
Bladder.—Although the introduction of a few pathogenic germs into 
a healthy organ may prove harmless, owing to their prompt removal 
with the urine, they may produce the most disastrous results. An 
already diseased viscus containing a stone or tumor is what the surgeon 
usually has to deal with, and here the introduction of streptococci or 
staphylococci—the usual causes of cystitis—is certain to give rise to 
trouble. As operations involving the bladder demand in nearly every 
instance the introduction of instruments per urethram, an antecedent 
aseptic condition of this canal must be secured. Normally, the urethra 
is alleged to harbor many germs which if carried into the bladder can 
originate a cystitis. Most careful lavage of the urethra must be per- 
formed, when possible, by a retro-acting deep urethral catheter, using 
sterilized salt, boro-salicylic, or bichloride solution according to the con- 
dition present. 
If urethritis be present, any introduction of instruments is to be deprecated, 
and when unavoidable a most careful employment of the measures is indicated. 
1 The so-called Mikulicz drain is the best way to employ packing in such cases. 370 
INJURY AND REPAIR. 
Urethral first, and then vesical, lavage must precede all operations upon the 
bladder except where impassable structure exists. As soon as any such impedi- 
ment is overcome most thorough washing out of the bladder and urethra should 
follow or be used during the operation—first with an antiseptic solution, then 
abundance of sterilized salt solution. The internal use of salol, quinine, or boracic 
acid for a few days previous to operation often markedly changes the character of 
unhealthy urine, and is imperative when the upper urinary passages or kidneys are 
involved in the infective process. Salol must not be exhibited for a lengthened 
period, owing to its noxious action upon the kidneys. 
Antiseptic Surgery. 
This aims to remove, destroy, or neutralize the noxious effects of germs 
which have gained lodgement in the tissues. Heat, when applicable in 
the form of the cautery, is most efficacious, directly destroying the germs 
and the tissues in which they reside, converting these into an aseptic 
eschar, which must separate by processes which commonly leave a layer 
of healthy granulations usually competent to bar the further ingress of 
germs. Chancroids, lupus, tubercular and such spreading processes as 
hospital gangrene, are amenable to this treatment. Except when em- 
ployed as potential cauteries, chemical substances cannot be used in suf- 
ficient concentration to destroy all germ-life in an infective process. 
Hospital gangrene and some few analogous conditions have, it is true, 
been successfully combated with pure bromine, carbolic, and chromic and 
fuming nitric acid, and strong solutions of chloride of zinc, but these 
must destroy, as the hot iron does, all the infected tissues, otherwise after 
a period of quiescence the disease will break out anew. Many of these 
and other substances employed, as corrosive-sublimate paste, are poisonous 
if applied to large areas. Most usually, disinfection by lotions is limited 
to the superficial portions of the infected area. Removal of all in fected 
tissues by excision—when limited by curetting or dissection with knife 
or scissors—is most efficacious, as in some carbuncles or in anthrax. 
When complete mechanical removal is impossible partial excision may 
be supplemented by the actual cautery, as is often done in anthrax. 
Incisions by relieving tension, giving exit to discharges and sloughs, me- 
chanically remove many germs and toxines, besides rendering possible 
the access of germ-inhibitory substances. Irrigation with a powerful 
stream is an important mechanical adjuvant to incision, but distention 
of the cavity must never be permitted, two tubes being employed or a 
counter-incision made. Rough handling must also be avoided, as calcu- 
lated to rupture granulations or the tissues and thus open up new ave- 
nues for infection. An exception to this rule is often presented by certain 
ischio-rectal abscesses, where the cavity should be made a simple one by 
breaking down the irregular partitions. 
Peroxide of hydrogen is useful to disinfect irregular cavities when not 
too large. Tubes are preferable to packing in all cases where it is not 
certain that all infection has been removed, because the solid portions of, 
pus cannot be removed by capillary action; but packing to secure the 
prolonged contact of iodoform with sloughs or infected tissues, because 
of its germ-inhibitory and toxine-destroying property and to prevent 
re-infection, is often useful and may be combined with, tube-drainage. 
When the discharge becomes serous and small in amount, drainage can be 
dispensed, with, but gradual shortening of the tubes and lessening of the TREATMENT OF WOUNDS, ETC. 
371 
quantity of packing at each dressing must precede this until the cavity 
becomes nearly effaced. 
At each dressing any sloughs remaining must be removed, but frequent irriga- 
tion is only necessary for anfractuous cavities, where efficient drainage is anatomi- 
cally impossible. Sometimes continuous irrigation or the continuous bath is indi- 
cated, as in extensive cellulitis of an extremity, when only non-toxic chemicals, 
as boric or salicylic acids or aluminum acetate, should be employed, lest systemic 
poison occur. The powerful aid of position to favor drainage and relieve conges- 
tion must be invoked. When packing a wound each recess should have its own 
piece of gauze, one end being left protruding, and careful count be kept of the 
number of pieces. When re-dressing replace each piece with a clean one as the 
soiled one is withdrawn, although this rule often cannot be followed. Moist anti- 
septic dressings are indicated until only serum is secreted, because drying of dis- 
charges upon the dressings would interfere with' drainage; moreover, the wound- 
discharges, being septic, would tend to infect the wound if the germs were per- 
mitted to multiply unchecked. When the wound becomes aseptic a dry aseptic 
dressing may be applied. 
Drainage.—Many aseptic operations require no drainage. Increas- 
ing experience and improved technique lead each surgeon gradually to 
discard it. In some form it becomes necessary—(1) when much bloody 
serum will be poured out; (2) where cavities must be left; (3) where per- 
fect asepsis or its maintenance is doubtful; (4) where infection has oc- 
curred. 
Drainage may be direct—i. e. where discharges are removed by tubes 
etc.; or, indirect—i. e. by leaving a part or the whole of a wound open; 
packing or employing secondary suture ; by buried sutures, compresses, 
bandages, etc., so disposed as to leave no cavities in which fluids can 
collect. 
Direct drainage is tubular or capillary. Well-annealed glass tubes 
with lateral openings are best when of the proper length, because non- 
collapsible and readily sterilized by boiling. Rubber tubes are more 
commonly employed because capable of being used of any length. 
The tubing selected should be sufficiently rigid to prevent kinking. Boiling 
for five minutes in soda solution or placing them in the steam sterilizer for twenty 
minutes will sterilize them. They should be cut in lengths and stored in a 5 per 
cent, carbolic solution. Tubes should reach well into the cavity, but not impinge 
upon its base, and with this end in view must be cut flush with the skin, being 
secured in situ by a sterilized safety-pin thrust through the tube or by a special 
stitch through one margin of the wound, including the tube. No tube should rest 
upon or against a nerve or blood-vessel. 
Capillary drainage is only adapted to the removal of blood or serum, 
and must never be used for pus. A strip of gauze protruding from an 
angle of a wound is sometimes employed. Sterilized horsehair or fine 
catgut is the usual material. Certain precautions must be observed. 
Secure the middle of a bundle of from twenty to forty strands of hair or gut 
to the deepest portion of the wound by a stitch of catgut. If buried sutures are 
employed, bring four strands between each two stitches. Between each pair of 
skin-sutures the same disposition is to be made. The threads must be carefully 
smoothed out, so as to be parallel and in contact, their ends cut off squarely, and a 
piece of protective laid over all. This must extend some distance beyond the 
ends of every drain, otherwise they become agglutinated by desiccation and cease 
to drain. Neglect of these precautions invariably leads to failure. Catgut is ab- 
sorbed, but horsehair must be withdrawn at the end of forty-eight to seventy-two 
hours, either entirely or a few hairs at each dressing. 372 
INJURY AND REPAIR. 
Sterilization of Instruments, Ligatures, Sponges, and 
Dressings. 
Instruments.—All instruments should be entirely metallic, with 
smooth plane or simply curved surfaces. If complex, they must be 
readily separable into their component parts to permit mechanical 
cleansing. Wooden or ivory handles are damaged by heat, and from 
the inequalities of their surfaces are hard to cleanse mechanically ; still, 
they can be sterilized by the exercise of care. Aluminum being attacked 
by alkaline fluids is therefore undesirable. Too much stress has been 
laid upon the receptacles in which instruments are stored. It is de- 
manded that they be constructed of enamelled iron and glass tightly 
closing to exclude dust. Even the pocket-case must be metallic or made 
of canvas, so that it can be frequently sterilized.1 While desirable, 
these are unnecessary refinements, deluding to those not thoroughly 
versed in aseptic principles, because the asepsis is only relative and ig- 
nored by the expert, because 
he never trusts to such inad- 
equate precautions, but speci- 
ally sterilizes his instruments for 
each operation? 
The importance of mechanical 
cleansing by soap, hot water, and 
friction is demonstrated by recent 
experiments where smooth, metal- 
lic, or even gum instruments have 
been made germ-free by brisk rub- 
bing first with a wet (sterilized) 
cloth, then for a few minutes with 
a dry sterilized towel. All instru- 
ments after use should be mechani- 
cally cleansed and kept polished. 
Chemical disinfection of in- 
struments has long been aban- 
doned in favor of heat, except 
to meet special indications, be- 
cause of its unreliability and 
the injurious effects exerted 
upon instruments, destroying 
the cutting edge and polish and 
interfering with the smooth- 
ness of working if com- 
plicated. Dry heat, being 
tedious in its application, 
injurious to temper unless 
skilfully employed, and re- 
quiring cumbersome apparatus, is rarely employed. Many surgeons 
prefer in hospital work “live” steam, the water from which it is (Fig. 
1 Unquestionably, if instruments are sterilized for operation at the surgeon’s office, an 
aseptic case is requisite, but few adopt this plan. 
1 The author has more than once taken a polished steel instrument off a velvet-cov- 
ered shelf in a general hospital, and has been unable to detect germs by culture- 
methods. 
Fig. 141. 
Briggs’s sterilizer. TREATMENT OF WOUNDS, ETC. 
373 
141) generated being charged with 1 per cent, of washing soda. This 
prevents rusting and adds to the germicidal powers. From five to ten 
minutes’ exposure will kill any pyogenic organisms, since twelve minutes 
will destroy anthrax-spores. More than ten minutes may be advan- 
tageously employed to ensure the best results. 
In private practice boiling water containing 1 per cent, of soda is more rapid 
and convenient than steam, any vessel large enough to contain the instruments 
serving to boil them in. Pure cultures of the pyogenic organisms will succumb in 
the boiling soda solution in from two to three seconds, and anthrax-spores in two 
minutes. 
In hospital work Schimmelbusch’s apparatus is probably the best, each set of 
instruments being placed in a separate wire tray, which is immersed in the boil- 
ing water for five minutes, taken out, drained, and the instruments placed in 
cooled sterilized salt solution or laid upon and covered with sterilized towels until 
needed. Any instrument accidentally infected during an operation can be steril- 
ized by dipping in the boiling solution for a few seconds. 
Fig. 142. 
Schimmelbusch’s instrument-boiler. 
While the sterilization of metallic bougies and catheters by heat or 
boiling presents no difficulties, it is far otherwise with the elastic 
(English), the soft (French), and the pure rubber (Nelaton) instruments. 
If oily substances be used as lubricants for these soft instruments, they 
should be soaked for a short time in warm (not hot) solution of washing 
soda previous to sterilization. If glycerin is employed, simple sterilized 
water will suffice. 
The NSlaton catheter, according to Gerster, may be sterilized by immersion 
for fifteen minutes in the soda solution at a temperature “just below the boiling- 
point.” How this is to be maintained or ascertained in practice is not described, 
and if done often will assuredly render them dangerously brittle. The asepticity 
thus gained must be maintained by storing them (suspended) in a tall jar filled 374 
INJURY AND REPAIR. 
with 5 per cent, carbolic-acid solution or 1 : 2000 bichloride. They must be rinsed 
in sterilized water before using, and carefully cleansed before replacing in the jar. 
If glycerin is not employed as the lubricant, all grease is to be removed by a soda 
solution. The other varieties of catheters can be sterilized by a short immersion 
in strong solutions (20 per cent.) carbolic acid or 1 : 500 mercuric chloride, after- 
ward removing every trace of these chemicals by sterilized water. Storing in anti- 
septic solutions seriously damages these instruments, and should be avoided. 
Mechanical cleansing after use must be carefully done.1 Farka’s instrument for 
passing steam through these catheters is efficient, but is often not accessible. Lu- 
bricants, as vaseline, oil, or glycerin, must be first sterilized by heat. The instru- 
ments should never be dipped into the receptacle, but a sufficiency be dropped into 
the hand and transferred to the instrument, making all the manipulation with 
sterilized hands. Montgomery has suggested sterilizing catheters by steam, placing 
them in strong glass tubes, longer than the catheters, the ends of the tube being 
plugged with cotton. In these tubes the catheters are kept, one in each, until 
wanted for use. After using and cleansing they are again sterilized in the same 
way. 
Sterilization of Accessory Apparatus and Instruments.—By these 
are meant inhalers, mouth-gags, tongue-forceps, throat-mops or sponges, 
hypodermic syringes, and hypodermic solutions. As the so-called Esmarch 
inhaler or its modification for chloroform, Allis’s for ether, or the 
extemporized towel cone, have nearly superseded all others in this 
country, their disinfection will be now considered. Where the flannel 
or cottonet is sewn upon the metallic frame the whole apparatus must 
be boiled or steamed and dried, a fresh one being required for each 
patient. If the Scliimmelbusch type is used, the metallic portions must 
be boiled for a few minutes and a fresh piece of recently laundried 
flannel employed for each patient. The same remarks apply to the 
Allis inhaler, so that in hospital practice several of these must be on 
hand ready sterilized. A fresh extemporaneous cone made of sterilized 
towels (recently laundried) must be used for each patient. Mouth-gag, 
forceps, and throat-sponges must also be sterilized, and for similar 
reasons—viz. the danger of conveying syphilis from patient to patient or 
the introduction into the oral passages of pathogenic germs. Fatal 
results from sepsis, tetanus, and malignant oedema having followed hypo- 
dermic injections, and tedious convalescences from the effects of dirty 
needles have so often occurred that asepsis is essential. No solution 
should ever be employed which has not been subjected to boiling—best 
just previous to use. The hypodermic pellet or drug, the needle, and 
the water can all easily be boiled for a few minutes in a spoon over a 
gas-jet, lamp, or even a wax or ordinary match. The syringe itself 
should be occasionally filled with warm water, placed in the same, and 
carefully boiled. This is recommended because, while repeated rinsing 
out with boiling water has been proved to be efficient, and ought to be 
employed before using, yet additional precautions should be adopted 
where such instruments are in constant use. Aspirating apparatus 
when the direct method is used must be disinfected in a similar manner; 
but the indirect method—i. e. where a reservoir is used—is to be pre- 
ferred, as the syringe never becomes contaminated. Brisk friction of 
the skin for a minute with alcohol, followed by a germicidal solution, 
must precede the introduction of the needle. 
As vulcanite syringes can only be cleansed by repeated filling with and empty- 
ing of hot water, wherever possible gravity should be employed instead of such 
1 See p. 25 or Scliimmelbusch, Anleitung Zur asept. Wundbehandlung, p. 192. TREATMENT OF WOUNDS, ETC. 
375 
instruments, using fountain syringes or irrigators. The receptacles, tubes, and 
points of these can all be readily disinfected. In hospital practice a glass point 
for each patient is desirable, to be cleansed after and disinfected before using. 
These precautions should extend to the enema-syringes or irrigators, to the vag- 
inal douche-points and reservoirs, because disastrous results have followed the 
neglect of these apparently superfluous precautions. Rubber bags and tubing 
should be immersed in strong germicidal solutions, afterward removing all traces 
of these with sterilized water. 
Sterilization of Dressings. 
Materials.—Cheese-cloth, butter-cloth, cotton, jute, moss, pine- 
sawdust, peat, ashes, asbestos-wool, sand, and innumerable absorbent 
substances have been employed, but cheese-cloth, butter-cloth, cotton, 
sawdust, and moss are those which are most available. As we have 
seen, moisture is essential to germ-life, therefore an ideal dressing must 
(1) desiccate the wound—i. e. promptly abstract the wound-secretions, 
absorb them, and permit rapid evaporation of the fluid portions; (2) 
they must be aseptic, and (3) capable of maintaining this by preventing 
multiplication of germs. The first requisite is secured by removing all 
oily material from the cheese-cloth, cotton, or textile fabric employed 
by boiling for fifteen to thirty minutes in a solution containing 5 per 
cent, of washing soda, rinsing out in cold water, and drying. Butter- 
cloth does not require this treatment. Sawdust, oakum, and all kinds 
of gauze or moss must be sterilized by dry or moist heat or by immer- 
sion in a germicidal fluid if moist dressings are to be employed. If this 
is not convenient, they can be sterilized and remain in boxes, such as 
recommended by Schimmelbusch, or in sterilized fruit-jars.1 
Maintenance of the aseptic state of the dressings of an aseptic ope- 
ration is secured by their arrangement in such a manner as will favor the 
drying of wound-secretions as soon as possible after their absorption. 
Exposure for thirty minutes to steam in any steam sterilizer, such as? 
that of Schimmelbusch or Arnold, which fulfils the indications of pre- 
vious warming of the dressings and generation of steam under some 
pressure will secure dry, efficiently sterilized dressings. 
Schimmelbusch’s and Willy Meyer’s apparatus provides for sterilization of 
instruments by boiling in the soda solution, and of the dressings, operating gowns, 
etc. by the escaping steam. The former’s boxes are 
metallic, with numerous lateral openings closed by 
revolving the circular collars. The dressings, operat- 
ing gowns,and towels are placed in one loosely folded ; 
it is closed and put in the sterilizer with the fenes- 
tra opened. After half an hour it can be removed 
and the collar rotated so as to close the opening,, 
when the contents will remain aseptic. In the 
absence of such boxes the dressings, etc. must be 
carefully placed in sterilized towels, the coverings 
only being removed at the time of using. While 
portable sterilizers of all these patterns are con- 
venient, boiling of dressings, aprons, and towels for 
fifteen minutes in the soda solution suffices for pri- 
vate practice. If dry dressings are imperative, 
enveloping them in a sterilized towel, thorough 
wringing, and drying in a hot oven will do admira- 
bly. 
Fig. 143. 
Schimmelbusch’s dressing-box. 
1 No reliance should be placed in the commercial antiseptic gauzes or ligature 
materials. 376 
INJURY AND REPAIR. 
Chemical sterilization is best effected by corrosive sublimate—when 
not contraindicated—employed in the strength of 1 : 2000. The gauze 
(if possible previously sterilized by heat), cut and folded, should be 
steeped in the solution, not be merely dipped in, and when applied 
wrung as dry as possible. 
Sponges.—These may be marine, but those made of knitting wool, 
absorbent cotton, or wood-wool loosely gathered up and secured within 
a double layer of absorbent gauze, or pads of sterilized gauze so folded 
as to prevent ravellings being left in the wound, are preferable for most 
purposes, because both cheap and sterilizable by heat. 
Sterilization of Marine Sponges.—Beat with stick or in large mortar to free from 
sand; place for twenty-four hours in potassium-permanganate solution 1 : 500 ; 
transfer to 1 per cent, sodium-subsulphate solution containing 8 per cent, by vol- 
ume of hydrochloric acid (C. P.) for fifteen minutes; remove all traces of this by 
repeated rinsing in sterilized water and store in 5 per cent, watery solution of car- 
bolic acid; when used they must be freed of the carbolic acid by rinsing in steril- 
ized water.1 
Sterilization by heat can be done thus: free from sand ; wash and then mace- 
rate in water seven to fourteen days; wash in warm water and place in a muslin 
bag; immerse for thirty minutes in 1 per cent, soda solution removed from the fire 
when actively boiling;2 rinse in cold sterilized water while yet in the bag; store 
in sublimate or carbolic-acid solution.3 
All forms of gauze sponges and pads should be boiled for fifteen minutes in the 
1 per cent, soda solution or subjected to the action of steam for thirty minutes. 
Sterilization of Ligature and Suture Materials. 
Heat is again superior to chemicals, and can be employed in a num- 
ber of ways: usually both methods are combined. For metallic wire, 
horsehair, silkworm gut, silk or flax thread, after 
loosely rolling on glass spools or rods, boil for 
thirty minutes in a soda solution and store in a 
5 per cent, carbolic-acid or a 1 : 3000 corrosive- 
sublimate solution or in previously boiled abso- 
lute alcohol. 
The theoretical objection to the employment of any 
chemical substance in sterilizing ligature materials be- 
cause damaging the tissues, thus lowering their resist- 
ance and favoring infection, can usually be ignored in 
practice, the amount of the drug in each ligature being 
infinitesimal; still, if this objection is considered a valid 
one, boiling immediately before use in the soda solution 
or storage in previously boiled alcohol will meet all ob- 
jections. 
Catgut or Other Animal Ligatures.—Roll 
loosely on glass rods or spools; place in large 
jar of absolute alcohol with screw cap or in pre- 
serve-jar, with cover, in either case only mod- 
erately tightly closed to prevent unnecessary 
waste of alcohol; place in water-bath and sub- 
ject to the boiling temperature for two hours; 
screw cover down firmly and keep stored. 
1 Frisch, from Gerster, p. 699, Dennis’s Syst. Surgery, vol. i. 
2 The temperature will not fall below 80° C. until all germs have been destroyed, 
anthrax bacilli requiring only between 80° and 90° C. for from ten to twelve minutes! 
3 Sehimmelbusch. 
Fig. 144. 
Aseptic portable ligature-box. TREATMENT OF WO UNDS, ETC. 
377 
Brunner's Method.—Subject the gut, immersed in xylene in a closed vessel, to 
steam (100° C.) for three hours; wash in alcohol and store in alcoholic solution of 
bichloride 1 : 2000. 
Schimmelbusch’s and, Bergmann’s Method.—Place receptacle and glass spools in a 
steam sterilizer for forty-five minutes or boil in soda solution ; then roll the catgut 
on spools and soak in ether for twenty-four hours to remove grease; pour off ether 
and substitute a solution of corrosive sublimate parts 10, absolute alcohol parts 
800, distilled water 200 parts; replace this in twenty-four hours, because it will 
become turbid; allow the gut to remain for seventy-two hours ; store in the same 
solution, or, if stiff gut is desired, in absolute alcohol (boiled); if moderately stiff, 
add 20 per cent, of glycerin to the alcohol (both boiled). 
Chromieized Catgut.—This does not disappear so rapidly in the tis- 
sues. Macewen places the commercial gut for two months in glycerin 
20 parts, aqueous solution of chromic acid (20 per cent.) 1 part; it is 
then washed and stored in a 20 per cent, solution of carbolic acid in 
glycerin. 
Numerous other methods have been employed,1 but those given are reliable and 
possible for any surgeon to carry out. The illustrations will serve without words 
to describe the more convenient but not essential receptacles, portable and station- 
ary, for the storage of ligature material. It is advisable to subject the receptacles 
and their contents to the action of steam. 
Fig. 145. 
Glass jar for wet catgut or silk. 
Aseptic Solutions; Chemical Germicides; Antiseptic Ointments. 
—Sterilized Salt Solution.—This is a 6 per mille solution of sodium 
chloride prepared by boiling for fifteen minutes. 
Corrosive Sublimate.—As most waters contain lime, which decomposes 
this drug, acetic, tartaric, citric, or some mineral acid, as hydrochloric, 
or table salt must be added. The vegetable acids and table salt may be 
added in the same quantities as the mercurial salt, the hydrochloric so 
as to render the solution faintly acid to litmus. Moreover, these acids 
prevent the formation of an inert albuminate when used in the wound. 
1 H. Kelly subjects the gut, suspended in a bottle, to 80° C. for two hours to get rid 
of moisture. It is then boiled for one hour in curnol placed in a sand-bath (160° to 
170° C.). It is then placed in chemically pure benzine (which is sterile), where it may 
remain stored, or it is transferred to sterilized absolute alcohol. The author has used 
this method with entire satisfaction. 378 
INJURY AND REPAIR. 
The strength of mercuric solutions are for irrigation 1 : 150,000 to 
1 : 5000; 1 : 2000 to 1 : 1000 for infected wounds, disinfecting hands, 
and the field of operation ; for bone-cavities, possibly as strong as 1 : 500. 
Where strong solutions are employed, or even weak ones, it is good practice to 
secure the removal of all traces of mercury from the wound by flushing with steril- 
ized water. Patients must be closely watched, lest salivation or gastro-intestinal 
irritation result, shown by abdominal pain and frequent mucous or bloody stools. 
Locally, dermatitis and vesication may result. Carbolic acid is employed in 1, 2, and 
5 per cent, solutions, the weaker for irrigation and instruments, the stronger for 
septic wounds. It is readily absorbed, requiring watching, especially in children. 
An olive-green tint of the urine is usually an early symptom of poisoning, which soon 
may be followed by cerebral and circulatory symptoms, as headache, vertigo, coma, 
eclampsia, vomiting, feeble heart-action, suppression of urine and entorrhagia, in 
the worst cases terminating fatally. Locally it is irritant, often causing eczema, 
while the long application of strong solutions has often determined dry gangrene 
of the fingers or toes. 
Salicylic acid, best used as Thiersch’s solution (acid, sal. parts 2, acid, 
boric parts 12, aquae 1000), is a weak, non-poisonous germicide. It may 
also be used in ointment form. Acetate of aluminum in 1 per cent, 
solution is effective, safe, and specially adapted for irritable skins. 
Potassium permanganate, 1 : 500 to 1 :2000, weak but safe, is useftd 
in the mouth, urethra, and bladder. Peroxide of hydrogen, a powerful 
germicide, is specially useful for foul, sloughing wounds. The fifteen- 
volume solution may be used pure or diluted once, twice, or thrice, 
Salivation has been attributed to its free use. 
Chloride of zinc, 5 to 20 grains to the ounce, is most efficient. 
Iodoform is invaluable, acting by virtue of the iodine set free in the 
presence of infected living tissues, neutralizing the ptomaines, etc. and 
inhibiting germ-growth. It is poisonous, especially to the old and 
anaemic, and often produces dermatitis. As iodoform gauze it is the chief 
reliance in the oral, rectal, vaginal, and vesical cavities when secondary 
suture is to be employed, as a protective dam in various conditions, and 
as packing to arrest oozing after certain abdominal operations. Slight 
poisoning is shown by headache, mental depression, anorexia, or nausea 
and vomiting; more severe cases exhibit insomnia, have a rapid pulse, 
high temperature, delirium, sometimes maniacal, coma, and convulsions : 
iodine can be detected in the urine. These symptoms may develop early 
or late, may disappear upon the removal of the dressing, or may per- 
sist—most often follow the use of large amounts, but the reverse has 
been observed. 
Bismuth subnitrate is non-irritant, desiccant, but poisonous when used 
in large quantities: it may be employed as powder, emulsion, or ointment. 
Zinc oxide is a weak, non-poisonous, desiccating substance, and may 
be employed in the same way as bismuth. 
Acetanilid is far more powerful than the preceding two, is safe and 
efficient; the powder is simply dusted over wounds.1 
Treatment of Wounds.2 
A wound is a solution of continuity suddenly effected by anything 
which cuts or tears. When the skin remains intact the injury is a sub- 
1 Pages might be filled with accounts of other chemical compounds which have 
been recommended, but the most reliable and commonly accessible have been described. 
2 Vide also Chapter XXII. TREATMENT OF WO ENDS, ETC. 
379 
cutaneous wound, and little if any constitutional symptoms result, the 
lesion being repaired by those reparative processes erroneously called 
simple adhesive inflammation or aseptic inflammation. Wounds are 
termed incised when caused by a sharp-edged object; contused, when 
produced by a more diffused force dividing the tissues, leaving the 
wound-surfaces bruised; lacerated, when irregularly torn; punctured, 
when the depth much exceeds the superficial area. 
Incised Wounds.—The pain is apt to be less than in the other 
varieties, because the tissues are cleanly divided, the vulnerating object 
not dragging upon or injuring contiguous sensitive parts. Bleeding 
tends to be freer than in lacerated or contused wounds, varying with the 
vascularity or structure of the tissues. Thus, facial wounds bleed freely, 
even if no considerable vessel be divided ; scalp-wounds, not only because 
of the free blood-supply, but because the vessels cannot readily contract 
and retract in the dense tissues. Retraction of the edges of incised 
wounds always occurs, varying with the subjacent structures and the line 
pursued. Proper planning of incisions therefore may lessen the number 
of sutures requisite. Skin and fascial wounds passing across the course 
of underlying muscular fibres gape widely. If made parallel to their 
course, they will remain in contact or require but few sutures. Skin 
and muscle retract most freely when the former is divided across the 
line of cleavage,1 the latter at right angles to its fibres: inflammatory 
tension of subjacent parts increases gaping. 
Union of Incised Wounds.—Under proper treatment (see p. 354) 
the normal reparative processes described in Chapter XXIV. effect 
repair. Locally, where the epithelium is thin, the wound-edges may 
present a faint blush for forty-eight to seventy-two hours : they are per- 
haps slightly swollen, warmer than normal, and tender; but all these 
symptoms are often absent. Although union appears to be firm at the 
end of seventy-two hours, it is mechanical, not vital—i. e. it is a mere 
gluing together by cellular exudate and fibrin. A few days suffice to 
complete true healing, a narrow reddened line indicating the former cut, 
which gradually fades until only a faint white scar remains. 
If true inflammation—i. e. germ-infection—occurs, the faintly reddened wound- 
edges soon become decidedly reddened, swollen, and tense; throbbing pain is com- 
plained of, union fails, and pus appears. A chill or rigor may occur, but some 
headache, fever, anorexia with coated tongue, and constipation are noticed in vary- 
ing degrees, with diminution in and high color of the urine. Symptoms of nerv- 
ous disturbance, varying from mere restlessness to delirium, will make their 
appearance: septic traumatic fever has commenced. With effective drainage and 
antisepsis both local and general symptoms tend to diminish and disappear, hut 
healing now can only occur by granulation, the old “ healing by the second inten- 
tion.” When two surfaces covered by healthy aseptic granulations can be main- 
tained in contact, fusion often occurs, and healing by “ secondary adhesion ” or by 
“ third intention ” takes place: upon this fact depends the success of secondary 
suturing. 
Treatment.—Sterilization of hands, instruments, and the surround- 
ing parts must precede examination of any variety of accidentally in- 
flicted wound. Bleeding may temporarily be checked by a tourniquet, 
pressure on the main vessel, or aseptic compression in the wound. Arrest 
the hemorrhage permanently by torsion or ligature. After some opera- 
tions, even when all visible bleeding points have been tied, free oozing 
1 See Langer’s observations. 380 
INJURY AND REPAIR. 
persists, notably in some cases of intracranial excision of the semilunar 
ganglion or brain-tumors. Again, in all wounds of cerebral sinuses or 
other large veins ligatures may be difficult of application. In either 
instance, especially the former, tamponade with iodoform gauze should 
be employed. If the oozing has been mainly from small veins, forty- 
eight hours commonly suffices, when secondary suturing may be done, 
the wound healing as if primary closure had been made. If a large 
vein has to be occluded, at least a week should elapse before removal 
of the packing. 
Remove foreign bodies with forceps and dean the surfaces with a gen- 
tle stream of aseptic salt solution, sterilized water, or antiseptic lotion, 
carefully avoiding distention of the wound-cavity. If the dry method 
of operating be employed, gentle pressure with sterilized gauze pads or 
absorbent cotton serves for cleansing. With an irregular, deep wound, 
especially in poorly vascularized tissues, one of two courses must be pur- 
sued : (1) buried sutures must be so disposed as to efface all spaces in 
which blood or serum can collect, or (2) free exit must be afforded, pri- 
marily for blood, later for exuded serum : although the coagulable por- 
tion of wound-discharges contains enough nucleins to be germicidal, 
serum does not. Drainage is only requisite for an aseptic wound for 
twenty-four to forty-eight hours to prevent the accumulation of serum 
which will break down the mechanical bond of union effected by the 
coagulated exudate, and thus delay union. If infection has taken place 
or the success of disinfection be doubted, drainage is certainly indicated 
until the dangers of sepsis are passed. Rest of the parts by position, 
splints, compresses, and gentle bandaging will secure prompt union of 
the dee]) as well as superficial parts, thus doing away with much of the 
necessity otherwise arising for drainage. 
Incised wounds are best closed by sutures, which may be interrupted 
or continuous. Union of cut muscle with muscle, fascia with fascia, and 
skin with skin by buried sutures is the ideal plan, the skin stitches being 
passed through the dense corium, avoiding the epithelium with its pos- 
sible germs and stitch-abscesses and the certain scarring of the needle- 
punctures. 
When strain is probable on the coaptating sutures, relaxation sutures may be 
employed, but are seldom requisite. Absorbable sutures are preferable, especially 
when buried, because not giving rise to future trouble, as the non-absorbable some- 
times do, nor requiring removal when passed through the skin. Any pliable sub- 
stance, such as silk, silkworm gut, catgut, kangaroo tendon, or silver wire,1 can, 
however, be safely employed for a perfectly septic wound. 
Coaptation sutures must only be tight enough to bring the surfaces 
gently in contact, less constriction impair the vitality of the tissues and 
favor suppuration. Strain can sometimes be advantageously removed 
from the coaptation sutures by relaxation sutures, but they ought seldom 
to be requisite. 
Needles should never be larger than requisite to carry the thread, 
and may be straight, curved, or partially curved, depending upon 
whether the wound is on a free surface, a concave, or a convex one. 
1 See Bolton’s experiments as to the germ-inhibitory or germicidal action of certain 
metals, especially silver. Subepithelial sutures of silver wire are the most satisfactory 
of any of those mentioned, but require removal at the end of ten days to a fortnight. TREATMENT OF WOUNDS, ETC. 
381 
Round sewing-needles are best for suturing the bowel, bladder, or peritoneum. 
Strips of gauze fixed first on one side of the wound by collodion and then on the 
other after it has been approximated, are sometimes excellent substitutes or suc- 
cedanea to sutures. This expedient can be advantageously adopted after removal 
of sutures to support the line of union. Adhesive plaster must never be used to 
directly approximate a wound, but may be employed to take strain off' stitches or to 
support a recent scar if sufficient aseptic gauze be interposed. Aseptic compresses 
and bandages, exercising pressure through superimposed elastic materials, such as 
sterilized cotton, oakum, etc., serve as adjuvants to suturing by promoting drain- 
age, securing quiet of the deeper parts, and thus relieving strain upon the stitches. 
In small uncomplicated operation-wounds, where no drainage is requisite, catgut 
sutures may be used and the whole line sealed by a strip of gauze saturated in iodo- 
form or even plain collodion, or sterilized silver-foil may be employed. Aseptic or 
antiseptic gauze in amount proportioned to the expected oozing must next be laid 
in place. When germicides are employed some form of protective should cover 
the wound. Outside of all, abundance of sterilized absorbent cotton should be 
used, being secured in place by a firmly applied bandage, carefully avoiding all 
constriction. If a limb is involved, proper splints should secure quiet; if the thorax 
be concerned, the arm of the corresponding side should be secured; if the neck, a 
stiffened collar or dressing is advisable. 
Indication for Change of Dressing.—Dressings should never be 
changed except for good cause. If penetrated by discharge at some spot 
or spots, and prompt drying at the margins of the stained area tends to 
occur, a pad of aseptic gauze had better be secured over the stained 
spot rather than undress the wound; but if the dressings are thoroughly 
soaked, the superficial portions must be changed, leaving those immedi- 
ately related to the wound unchanged if possible. When drainage-tubes 
require removal dressings must be changed, usually about the fourth 
day. If filled with firm clot, the wound is aseptic and the tube should 
not be replaced; when doubt exists as to the asepticity, drainage had 
better be continued until this question is settled. A sustained tempera- 
ture unexplainable by complications external to the wound demands 
inspection, since drainage may be defective or infection have occurred. 
Constitutional Effects of Wounds.—It is a common mistake to 
expect no constitutional symptoms after wounds or operations, and when 
they arise to ascribe them invariably to infection. After the nausea, 
vomiting, pain, and often subnormal temperature of the first few hours 
some rise of temperature occurs in about two-thirds of thoroughly 
aseptic cases, but the patient has a clean, moist tongue, the pulse is not 
usually much accelerated, the appetite is unimpaired, and the intellect 
clear. 
This aseptic fever results from the absorption of fibrin-ferment and nucleins and 
is seen in subcutaneous fractures. ( Vide Chapter VII.) It begins as soon as reac- 
tion from shock is established, gradually but promptly subsides, and the general 
condition is frequently not noticeably altered. The local pain diminishes in pro- 
portion to the time which has elapsed since operation, and there is no tenderness 
of the neighboring lymphatics. True wound-fever from infection commences 
later, on the second or third day, is often preceded by chill or rigor, and the local 
pain increases and the pulse and nervous symptoms clearly indicate a systemic 
intoxication. 
Symptoms of Lacerated and Contused Wounds.—As some 
degree of contusion is usually combined with laceration, these two 
classes of wounds will be considered together. Pain is greater than in 
incised wounds, but hemorrhage is not so marked. Where contusion 
preponderates, much blood is extravasated in the tissues, interfering 382 
INJURY AND REPAIR. 
with the circulation; hence sloughing is usually proportionate to the 
contusion, as is also the risk of secondary hemorrhage when the dead 
parts separate. Sloughing and profuse suppuration will occur in a certain 
proportion of cases despite all efforts at antisepsis. Septic cellulitis and 
gangrene and any form of sepsis may occur, the former often resulting 
in extensive sloughing and producing serious scarring. 
Treatment of Lacerated and Contused Wounds.—It is diffi- 
cult to render these wounds thoroughly aseptic, but no reasonable effort 
should be spared. Temporary sterilized or antiseptic dressings must be 
used until efficient antisepsis can be secured. The preliminary precau- 
tions mentioned under Incised Wounds must be adopted. Free irriga- 
tion with an efficient chemical germicide should be employed, exposing 
and disinfecting under anaesthesia if necessary every recess. Many 
cases will do better with light iodoform-gauze packing. When seen 
later, after infection is well advanced, incisions to liberate pus, sloughs, 
and the contained poisons, and to relieve tension, free irrigation and 
drainage by tube or packing, or by both, become requisite. If the form 
and location of the wound ensures free escape of wound-fluids, no drain- 
age is requisite, but if drainage is needed, tubes must be employed until 
the discharge becomes aseptic and small in amount. 
Slight trimming of the margins of a face-wound is permissible to secure pri- 
mary union and a smaller scar, but even here unaided nature is often equal to the 
task, any serious deformity being remediable later by operation. The same advice 
applies to hopelessly damaged structures in slightly vascular parts, but for the 
scalp, oral cavity, or face the surgeon should usually rely on antisepsis. Sutures 
are only applicable to the face, where good results often follow their use.1 Rest 
secured by voluminous aseptic dressings, splints, and position, with (possibly) the 
external application of dry cold, is often useful. Where much contusion exists 
cold should be employed tentatively, watching lest the sloughing should be 
increased. When spreading cellulitis and free suppuration occur, proper incis- 
ions, followed by continuous antiseptic irrigation or the continuous hath 2—warm or 
cold according to the vitality of the tissues—is usually better than a closed 
dressing. 
Punctured Wounds.—These much exceed in depth their width, and 
result from pointed objects, as knives, swords, nails, stakes, etc. 
Especial dangers attend these wounds, such as dangerous hemorrhage 
(primary or secondary) from the deep vessels, damages to important 
nerves, penetration of cavities, and deep, widespread septic inflammation. 
If a smooth, uninfected instrument—as a trocar—inflicts the wound, no trouble 
results, but when a rough object, as a board-nail or stake, is the vulnerating 
object, almost necessarily harboring germs, the results differ, as fragments of tis- 
sue, pieces of clothing, the softened inner sole of a shoe, may be, and they often 
are, torn off and deposited in the depths of the tissues, the tissue-fragments usu- 
ally themselves being infected, as the fragments of the foreign bodies always are. 
While the change of relation of the wounds in the various planes of tissues inter- 
feres with the escape of exudates, and this favors spread of an infective inflam- 
mation, in itself it does not initiate such a process. This mechanical fact does not 
alone explain the gravity of punctured wounds, while the combination with infec- 
tion does. 
Symptoms.—These must vary so with the tissues and parts involved 
—nerves, vessels, or cavities—that no general description can be given. 
1 Subepithelial, when possible, to avoid scarring. 
2 If poisonous substances be employed, any symptoms indicating their absorption must 
be carefully watched for. TREATMENT OF WOUNDS, ETC. 
383 
Treatment.—Hemorrhage must be arrested if serious after 
enlargement of the wound. Any divided nerve must be sutured. 
Where infection has occurred thorough disinfection, including removal 
of any foreign body, must be effected by incisions, irrigations, etc. 
under anaesthesia. Drainage-tubes reaching to the bottom of the 
wound, possibly a counter-opening, and absolute rest by splint and 
position, are demanded. If septic inflammation follows, sufficient incis- 
ions, counter-openings, and the treatment suggested for contused wounds 
must be employed. If the brain-case, spinal column, thorax, or abdo- 
men be penetrated, effective disinfection and drainage are indicated, 
demanding an exploratory operation in most instances, certainly if infec- 
tion is known or strongly suspected to have occurred. 
Constitutional Treatment.—This is rarely of importance, certainly immaterial 
if infection does not occur. Simple, easily-digested liquid or soft food is advisable 
for the first two or three days, after which, if the bowels act naturally and fever is 
absent, ordinary full diet may be given when the patient desires it. Forced ali- 
mentation may be requisite to relieve the effects of severe hemorrhage or the pre- 
vious drain of pus. Stimulants, as alcohol, ammonia, strychnia, digitalis, quinine, 
etc., will often prove useful. Proper emptying of the bladder must be ensured. 
The renal and alvine secretions must be normally maintained or even stimulated, 
especially where sepsis is present, to get rid of toxic substances and germs. Sleep 
in proper amount must be secured, especially for the young and the old, even by 
drugs when necessary. PART Y. 
SURGICAL AFFECTIONS OF THE TISSUES 
AND TISSUE-SYSTEMS. 
CHAPTER XXVI. 
CYSTS AND TUMORS. 
Roswell Park, M. D. 
General Considerations. 
A tumor is a new formation, not of inflammatory origin (i. e. not clue 
to the presence of as yet recognized and determined parasitic agents), cha- 
racterized by more or less histological conformity to the tissue in which it 
has originated, and having no physiological function. 
The above is perhaps as good a working definition of the term 
tumor as can be given in a few words. Nevertheless, it needs explana- 
tion in more than one direction. By the above definition it is purposely 
intended to separate the new growths now to be considered from a dis- 
tinctive class of neoplasms which are positively of inflammatory (i. e. 
of infectious) origin, to which the generic term of infectious granulomata 
has been given, and which have been dealt with as amply as space will 
allow in Part II. 
In that portion of this work a variety of common surgical disorders, such as 
tuberculosis, syphilis, glanders, leprosy, etc., were considered, while others more or 
less rarely met with were alluded to whose distinctive anatomical lesion consists 
of new growths of this kind. These are tumors which certainly possess no physi- 
ological function, but are of parasitic origin; and between them and those here- 
after to be considered it is intended to make the most accurate possible distinction. 
As between tumors and tissue new formations which are diffused—as in the over- 
growth of a given part, hyperplasia being due to persistent hypersemia or to com- 
pensatory changes—there is this distinction to be made, that in these instances 
there is more or less assumption of physiological function, or more or less of use- 
ful purpose achieved, by the new tissue-elements, whose business is to atone for 
previous defect, to repair, or to strengthen. Such new growths are rarely, if ever, 
strictly circumscribed, while the majority of tumors are. 
Again, as between certain outgrowths or exuberances of development and 
tumors in the same locations and of the same tissue it is not always easy to make 
a distinction. An exuberant deposit of calcareous material or callus can scarcely 
be considered to constitute a true tumor so long as it serves the purpose of strength- 
ening a part. On the other hand, if it assume irregular and inconsequent shape 
385 386 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
and position, and appear to subserve no useful purpose, it may then be considered 
a tumor. A simple enlargement of a bony process which has its place in the nor- 
mal anatomy, either of man or of his predecessors, is seldom to be regarded as a 
true tumor, because its purpose was useful—if not in man at least in his ancestors. 
This is true, for instance, of the supracondyloid process, which sometimes assumes 
large proportions, but is to be regarded rather as an exostosis than as a true bone- 
tumor, the distinction being that in the latter case there has never been the sem- 
blance of usefulness. 
Lastly, while in the definition above given it has been stated that tumors are 
not due to parasitic activity, it is to be distinctly understood that this refers to 
organisms at present accurately recognized or known to be concerned in the pro- 
duction of disease in the human race. It will be necessary shortly to take up the 
parasitic theory of the production of certain tumors, and, lest the reader might 
find apparent contradiction, this disclaimer is inserted at this point. There is 
good reason to suspect the parasitic nature of at least growths of a certain class, 
but the biological position of these supposititious parasites is not yet established, 
nor is their role as causative agents positively demonstrated. 
In the past exceedingly vague notions have prevailed concerning the 
nature and origin of tumors, and, while the clinical observations of writ- 
ers of past generations will never lose their value, the ideas which have 
prevailed concerning their pathology constitute interesting reading in an 
historical sense, but are now of relatively small value. Accurate notions 
scarcely prevailed until Virchow, for instance, demonstrated that tumor- 
cells in no wise differ from cell-types which are met with either in em- 
bryonic or in adult tissues. Tumors, like all other parts of the body, 
are built up of cells, and the points concerning which we now most want 
light are with regard to the influences which determine cell over-produc- 
tion in these characteristic forms. Concerning the variety of views that 
have prevailed at different times (their number being large), this is 
scarcely the place in which to offer even an epitome. I shall therefore 
take up but a few of the numerous explanations which have been offered 
to account for tumor-growth, and must emphasize distinctly, and at the 
outset, that, according to our present light, there is no one explanation 
sufficient to cover all cases, but that in all probability it is now one 
cause and now another which may determine this peculiar form of cell- 
activity. 
The spontaneous origin of tumors was a view adhered to in time 
past by men of erudition, but is essentially a cloak for ignorance, since 
to confess that a tumor grows spontaneously is simply to acknowledge 
that we know nothing about it. This theory, then, may be completely 
discarded. 
Dyscrasia has been advanced bv men of surgical eminence as 
accounting for tumor-growth. It would appear that this also is a delu- 
sion, and that the condition, in which patients with tumors that cause 
loss of strength, etc. are found, is the result rather than the cause of 
their presence. There is no known dyscrasia which by itself is known 
to give rise to neoplasms. 
Diet is regarded by some as an explanation for many of these in- 
stances. While it is undoubtedly true that peculiarities of diet have 
much to do with nutrition, there would be much more to substantiate 
this view could it be proven that particular diet led always to this result. 
While there is no doubt but that restricted regimen of one kind or 
another may bring about diathetic conditions, there is as yet reported no 
sufficiently extended experience which will permit us to give anything CYSTS AND TUMORS. 
387 
more than a tentative adherence to the view that diet has much to do 
with the production of tumor, particularly of cancer. It has been 
claimed, nevertheless, that while of phosphides or compounds of phos- 
phorus in excess are of beneficial influence in the diet of tubercular patients, 
they predispose to cancer-formation. This claim has been ingeniously 
defended, especially by certain English writers, and may prove to have 
more in it of value than is yet really substantiated. Among the laity 
prevail most foolish and puerile superstitions, to which not the slightest 
importance should be attributed. 
Heredity seems to be a factor of some importance, since it is impos- 
sible to deny that now and then we meet with striking instances in which 
several members of one family are sufferers from tumors, particularly of 
malignant type. We sometimes trace a history to this effect through 
three or four generations; and, while it may be something in the environ- 
ment rather than something which is transmitted from parent to off- 
spring, there is, nevertheless, good reason to think that heredity is a 
factor of importance in this direction. Should this hypothesis in the 
future be positively proven, there is yet no knowledge in our present 
possession which may explain the kind of tendency which is thus trans- 
mitted. 
Perverted nerve-influence is an explanation which probably has in 
it more than we can at present distinctly define. The influence of the 
nervous system over cell-growth and changes, and consequently upon 
tissues, is by no means yet well defined, and is a subject upon which 
investigation is most urgently needed. The effect of the nerves upon 
nutritional changes is readily conceded by all, but the laws which regu- 
late it are not yet understood. One of the best explanations which is 
to-day afforded for the undoubted increase of cancer is the influence of 
the nervous system, disturbed as it seems to be by causes connected with 
so-called civilization—in other words, with the high-pressure life which 
modern society entails, and the artificial conditions, accompanied by the 
mental worry, which seem inseparable from our modern ways of acting 
and of doing business. These few words in all probability mean much 
more than one can clearly express, but are perhaps sufficiently explicit 
to indicate at least that much may be expected from a more accurate 
study of the nervous system. 
Irritation and Trauma.—The effort is often made to explain the 
presence of tumors upon the hypothesis or the known fact of some 
previous injury, trifling or serious. It undoubtedly is often the case 
that tumors appear in sites where there have been previous traumatisms, 
but this sequence of events by no means proves a definite relation of 
cause and effect. On the other hand, there are certain forms of irrita- 
tion which are so often followed by tumor-formations that one is never 
surprised upon meeting with them. Probably no woman escapes with- 
out one or more bumps or bruises upon the breast, yet they do not pro- 
duce tumors of the breast in anything more than a very trifling propor- 
tion of cases. Per contra, upon the lower lip of inveterate clay-pipe 
smokers and the scrotum of chimney-sweepers there develop certain 
forms of malignant ulcer (epithelioma), which so often and so signifi- 
cantly follow upon the irritation thus produced that it is impossible to 
avoid conviction that the one is the cause of the other. Should events 388 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
prove the parasitic nature of any of these growths, they may also prove 
that the irritation causes surface lesions through which infection easily 
occurs. At all events, at present it may be accepted as a fact that 
tumors, benign and malignant, not infrequently follow irritation and 
trauma, but by no means with certainty. 
Inflammation.—This must refer to inflammation in the sense in 
which it has been used by older writers, implying a very variable con- 
dition, sometimes including, sometimes excluding infection, and being a 
term covering a somewhat confused mixture of irritation, hypersemia, 
infection, etc. In so far as it concerns inflammation as alluded to in the 
present work, it should not be here included, since inflammation (7. e. 
infection) produces neoplasms of .a class considered in Part II. and dis- 
tinctly ruled out from present consideration (/. e. the infectious granu- 
lomata). 
If, then, while inflammation in this former sense is more than hyper- 
semia, it may be regarded as predisposing to cell-activity, but not neces- 
sarily to tumor-formation as distinguished from hypertrophy of a given 
part or tissue. If it refer to irritation, this has been already acknow- 
ledged as one factor in the etiology of tumors, but as a very uncertain 
one. The cancer of the gall-bladder or liver which occasionally results 
from the irritation of a gall-stone, or the cancer of the breast that fol- 
lows eczema of the nipple, may be regarded in this light as additional 
illustrations if one prefers to interpret them in this way. If, finally, by 
inflammation be meant the infectious granulomata, they have already 
been considered. As the term “ inflammation ” can scarcely mean any- 
thing except hyperaemia, irritation, or infection, we seem to have pretty 
completely ruled it out from consideration as by itself an active cause 
leading to tumor-formation. 
The Embryonal Hypothesis of Cohnheim.—This in its ingenuity 
and in its applicability is a most fascinating explanation, which is 
undoubtedly sufficient for at least a certain number of instances. 
According to Cohnheim, only one causal factor for tumors exists—/. e. 
anomalous embryonic arrangement. He regards them as entirely of 
embryonal origin, no matter how late in life they may develop and 
appear. Briefly summarizing his views, they are to the effect that in 
the early stages of embryonal development there are produced more 
cells than are necessary for the construction of a certain part, so that a 
certain number of them remain superfluous. While this number may 
remain very small, they possess, on account of their embryonal nature, 
a most potent proliferating power. This superfluous cell-material may 
be distributed uniformly, in which case it will develop whole system- 
arrangements, like supernumerary fingers, etc., or it may remain by 
itself in one place, and will then develop a tumor. In this latter case 
the tumor may appear promptly or not until late in life, according to 
the time at which the cell-collection receives the necessary stimulus, or 
because of its suppression bv resistance of surrounding structures. It 
may be an irritation or an injury, such as above alluded to, which shall 
give it this stimulus ; as, for example, it is reasonable to think that cer- 
tain naevi and other congenital conditions which develop later into can- 
cers do so in accordance with this view. Surgeons generally find little 
fault with Cohnheim’s hypothesis, except that as yet they decline to see PLATE X!I. 
ILLUSTRATIONS OF THE ALLEGED PARASITES OF CANCER. 
1. A free Parasite subdividing into Leucocytiform and Granular bodies 
2. Two free Parasites—the upper dividing into round Daughter-cells; the 
lower dividing into Leucocytiform Cells, simulating Phagocytosis. (After 
Jackson Clarke; Zeiss 1-12; Biondi’s stain.) 
8-7. Sporozoa of Sarcoma (?). Developmental Stages; the cell represented 
in 8 had a diameter of one mikron. 
8, 9. Nuclei of Sarcoma Cells appearing through the Sporozoa (i. e., 
translucency of the latter). 
lO, 11. Sporozoa free in the Connective Tissue; a, Youngest or smallest. 
12. Nuclear division in Sporozoon. 
18, 14. Endogenous division of the Sporozoon. (After Vedeler.) 
18. Free Parasite in the Cell of an Alveolar Sarcoma; n, Nuclei; a, Chro- 
matin bodies; b, Spore; c, Parasite (Acinetaria). 
18. Free Parasite; a, Erythrophile portions; 6, Chromatin Zone; c, Cyto- 
plasm of the Parasite. 
17. Free Parasite undergoing Mitotic division. (After Jackson Clarke; 
Biondi-Ehrlich stain.) CYSTS AND TUMORS. 
389 
in it an explanation for all cases. Nevertheless, for dermoid and tera- 
tomatous tumors and for all heteroblastic tumors it seems to afford the 
only tenable explanation, Thus, chondroma of the parotid and of the 
testicle are most easily explained in this way, and that cartilaginous 
islands occur in the shafts of adult bones is well known. 
The parasitic theory of tumor-formation is one which lias been 
vaguely hinted at for a considerable length of time, and which has only 
very lately taken anything like distinctive form. It implies that tumors 
(and most writers limit it to the malignant tumors) are due to the 
irritation produced by parasitic agents of some kind, which, introduced 
from without, act as do the bacteria in the now well-known infectious 
granulomata. This also is in certain respects a satisfactory theory, and 
has more or less in clinical experience to justify it, while, at the same 
time, at present there is but little upon which men can agree in the mi- 
croscopical appearances of these growths to corroborate it (Plate XII.). 
At present students are concentrating their investigations mainly upon the 
class of unicellular animal organisms belonging in a general way to the coccidia. 
It is definitely established that coccidia, which are a class of the sporozoa, are the 
cause of certain well-known disease-mani- 
festations in the lower animals, as, for ex- 
ample, in the livers of rabbits. Minute 
organisms, resembling these, differently 
classified and regarded by different in- 
vestigators, have been found in and about 
the distinctive cells of numerous cancers 
and sarcomas, and have given rise to the 
greatest difference of opinion, some hold- 
ing that they were there accidentally, 
some that they were the actual disease- 
agents, and others that the bodies thus 
regarded by some as parasitic animal 
forms were in effect mere evidences of 
karyokinetic cell-division or of breaking 
up, in some sense, of cell-contents or tissue- 
debris ; in other words, that they were not 
parasites at all, but results rather than 
causes of disease. At present writing the 
controversy is still actively waged, and 
one may not yet surely say which party 
in the discussion is correct. From the 
pathological side the principal objections to this view are that these little bodies 
have not yet been positively identified by enough observers to justify their accept- 
ance by all, and that so far their endeavor to cultivate and inoculate them has 
failed. * It should be emphasized that it is not claimed that any of these organisms 
are bacteria, but it is generally supposed that they belong, rather to the animal 
than to the vegetable world. From the clinical side there is much to justify the 
parasitic theory. That cancer prevails in certain families and localities, and even 
in certain houses (the so-called cancer-houses), is now well established; that it is 
capable of being spread from one part of the body to another by mere contact is 
established, as from the lower to the upper lip, from one labium to the other, etc.; 
and that it acts in almost every way as do well-known parasitic lesions is fre- 
quently seen. Thus, its contagiousness and inoculability have received enough clini- 
cal demonstration to be suggestive, if not widely acceptable as definitive; and, in 
spite of all statements to the contrary, there are enough inoculation-experiments 
from man to the lower animals or from these to each other to place it now beyond 
possibility of denial that cancer can be transmitted from man to the animals. It 
is, then, not yet possible to state with any distinctness that the parasitic theory of 
tumor-formation is as yet tenable. One must, at least, however, say that, it has 
much to commend it, and that it certainly deserves the earnest, consideration of 
individuals and the collective investigation of the entire profession. 
Fig. 146. 
Psorosperms in rabbit’s liver (Spencer, £"obj.). 390 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
As may be expected, when one takes into consideration the crude 
notions and the vague, contradictory statements that have obtained in 
the past concerning the nature of tumors, their nomenclature has been 
sadly confused; and if some new terms are introduced to-day, it is 
wise, perhaps, rather than to hold to some of those which have done 
duty in the past for varied and varying conditions. Various systems 
have been followed of naming them according to their supposed nature 
or their evident tendency, or according to some purely arbitrary classifi- 
cation ; thus we have the distinction into homologous and heterologous or 
heteroblastic, according as they are similar to or variant from that tissue 
in which they seem to originate, or they have been spoken of as benign 
and malignant according to the disposition which they evince; and 
these terms are to-day in sufficiently frequent use to demand acceptance. 
In fact, the distinction as between benign and malignant is both con- 
venient and in some respects accurate, implying little with regard to 
histological structure, but everything with regard to their effect upon 
the individual. 
N OMENCL ATURE. 
Still, contradictions will arise even in using these simple terms, as, for instance, 
a fibroma, which ordinarily is an innocent type of tumor, but which when grow- 
ing from within the skull may so press upon the brain as to produce death, or 
which might press upon some important organ or passage-way and again prove 
fatal. Thus a tumor usually innocent may be malignant by accident of location. 
On the other hand, those tumors ordinarily spoken of as malignant—known to the 
laity as cancers—evince always their destructive tendency, no matter where 
located or at what age appearing. 
So far as method of classification goes, the anatomical (i. c. the histo- 
logical) has proven so far the most satisfactory, and is that which is now 
everywhere adopted. It is the basis for the classification followed in 
the ensuing pages. But even here it is impossible to maintain abrupt 
or always accurate distinctions, because tumors are frequently of mixed 
type, and require us, if we desire to express their composition by their 
names, to sometimes combine words in an awkward fashion. By com- 
mon consent that tissue which predominates furnishes the concluding 
portion of the compound term, while by prefixing other terms we 
endeavor to imply the composite character of the neoplasm. 
Thus we have osteo-chondroma, fibro-myoma, myo-fibroma, etc., and it is neces- 
sary often to reduplicate terms in order to be accurate in description. While this 
complicates phraseology, it nevertheless furnishes to the intelligent reader a 
reliable clue as to the general character of such a growth; and if one reads, for 
instance, of a myxo-chondro-sarcoma, he promptly infers therefrom that he has to 
deal with a tumor essentially a sarcoma, in which both myxomatous degeneration 
and cartilaginous formation have taken place. In the same way, the prefix cysto 
is frequently used to imply a combination of originally solid tumor which had 
undergone cystic changes in whole or in part. 
The old term cele is even to-day frequently used as a suffix, implying neo- 
plastic changes in an organ, or at least the formation there of a tumor. Thus we 
have bronchocele, hydrocele, cystocele, etc. Again, certain terms are now used in a 
different sense from that originally intended. Thus, the term sarcoma now has a 
definite significance, whereas originally it had little meaning and was applied 
inadequately and indiscriminately. Old terms also, Y\ke fungus hcematodes, are now 
used rather in a descriptive sense, because for any such tumor on accurate 
examination we can find a proper term taken from descriptive pathology. Con- 
sequently, it happens that the student of to-day must read the works of the older CYSTS AND TUMORS. 
391 
writers, especially concerning neoplasms, with a certain amount of intelligence, as 
well as of apology for the inaccuracy and misnomers of the past. 
Treatment. 
The results of treatment of tumors leave much still to be desired, 
particularly when dealing with those of malignant nature. So far as 
purely internal treatment is concerned, we have not yet discovered 
drugs which with any certainty influence cell-growth to the extent of 
making them reliable or effective. In the past, and even the present, 
numerous remedies have been advocated as having more or less of 
power in this direction. Of them all it is probable that arsenic in some 
form is more efficacious than any other. This is certainly true in the 
case of the disease elsewhere spoken of as malignant lymphoma, or Hodg- 
kin’s disease, which partakes much of the character of some of the other 
neoplasms. But to say that arsenic alone or any other known remedy 
can be relied upon at all times is probably going too far. 
The treatment of all operable tumors, then, is essentially surgical 
(i. e. operative), although it must be confessed that to a large extent 
results are based upon the essential character of individual tumors. 
But at least this much can be positively stated, that to be successful in 
the removal of any tumor its complete extirpation is demanded. Even 
the most benign tumors will return if only partially removed. This is 
true even of innocent cysts, which will often be re-formed if a portion 
of the cyst-wall be allowed to remain. Complete extirpation is ordi- 
narily a simple measure when tumors are encapsulated, as many of the 
innocent tumors often are. On the other hand, the performance of 
some of these operations is made difficult and hazardous by the location 
of the tumor, as in many large uterine fibroids, tumors of the thyroid, 
etc. But when dealing with malignant tumors the only secret of suc- 
cess is to extirpate them in the most merciless possible manner, sacri- 
ficing everything which may appear to be involved, unless, like a large 
blood-vessel or important organ, it be essential to the life of the part or 
of the individual. These general statements are made when speaking 
of tumors in a general way. More particular directions will be given 
when dealing with particular forms or in the chapter on Special and 
Regional Surgery. ( Vide also the Treatment of Malignant Tumors by 
Inoculation, Appendix to this chapter.) 
Classification. 
Following custom in large degree, yet being guided by generally 
undeniable facts concerning histological structure, tumors will be classi- 
fied and considered as follows : 
1. Cysts. 
2. Dermoids. 
3. Teratomata. 
4. Tumors of immature mesoblastic tissue-type. 
5. Tumors of simple mesoblastic tissue-type. 
6. Tumors of more complex mesoblastic tissue-type. 
7. Tumors of epithelial type or of epiblastic origin. 
8. Tumors of glandular tissue-type. 
9. Tumors of endothelial type. 392 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
A cyst may be defined as a tumor containing one or more cavities 
filled with fluid or semifluid contents. This specifies nothing with regard 
to the location nor the character of the cyst-wall nor the nature of the 
fluid contents. Following Sutton, I divide cysts into four groups : 
1. Retention-cysts. 
2. Tubulo-cysts. 
3. Hydroceles or Distention-cysts. 
4. Gland-cysts. 
Retention-cysts.—These imply a previously existing cavity whose 
outlet is obstructed and whose contents consequently accumulate, often 
to such a degree that the original character of both containing wall and 
contained fluid is entirely altered. When this occurs in glands or gland- 
ducts there is usually complete atrophy of gland-tissue, providing suf- 
ficient time have elapsed. Such cysts are, then, due either to permanent 
or temporary arrest of flow. In hydronephrosis, for example, there is 
obstruction of the renal outlet and dilatation of its pelvis, with partial 
or complete atrophy of the kidney-structure, until a cyst of enormous 
size maybe present. When a similar condition obtains in the uterus,as 
by obstruction of the cervix, perhaps due to injury done during labor, 
we have a condition known as hydrometra, seen occasionally in women, 
often in the lower animals, and particularly in those having a bicornate 
uterus, causing a condition often mistaken for an enormously dilated 
Fallopian tube. Similarly, when the common bile-duct is obstructed, 
which may be due to impacted gall-stones, to inflammatory lesions, 
tumors, etc., we may have such backing up of bile in the gall-bladder as 
to produce the condition known as hydrocholecyst. 
1. CYSTS. 
Under any of these circumstances pyogenic bacteria may produce infection 
which will be more or less promptly followed by suppuration; and then, instead 
of hydronephrosis, hydrometra, hydrosalpinx, etc., we get pyonephrosis, pyornetra, and 
pyosalpinx. 
Tubulo-cysts.—These are cystic dilatations of certain functionless 
ducts and obsolete canals which no longer serve a useful purpose. They 
comprise— 
1. Cysts of the Vitello-intestinal Duct.—Cysts originating from this 
functionless duct occupy the umbilical region, sometimes projecting exter- 
nally, sometimes internally. They are usually lined with mucous mem- 
brane furnished with villi and columnar epithelium. Such a cyst may 
possibly be confounded with an umbilical hernia. These cysts occasion- 
ally open at the umbilicus and discharge irritating material, sometimes 
fecal matter. Cystic dilatation of the portion of the duct originally 
connected with the ileum is also occasionally met with. 
2. Allantoic Cysts.—These are connected with the urachus, which 
should ordinarily be found as a fibrous cord, but which occasionally per- 
sists in a pervious condition, in whole or in part. At birth it is often 
traversed by a very narrow canal lined with epithelium continuous with 
that of the bladder. The urachus lies outside the peritoneum, and may 
be dilated at any point between its two extremities. When the entire 
urachus is pervious urine is discharged from the navel. 
3. Cysts connected with Remains of the Wolffian Body.—The Wolffian CYSTS AND TUMORS, 
393 
body, or the mesonephros, is intimately related with the development of 
the kidney, the ovary, and the testis. In the two latter locations glan- 
dular elements may be met with, persisting in adult life. 
In the male the tubules persist as excretory ducts from the testis, but in the female 
they persist in a vestigial condition as the parovarium and Gartner's ducts. The 
ovary proper consists of the oophoron and the paroophoron, the former being the egg- 
bearing portion, the latter receiving the tubules from the adjoining structure 
known as the parovarium. The paroophoron gives rise to cysts which burrow 
deeply between the layers of the broad ligament, make their way alongside the 
uterus, and raise the peritoneum. It is a peculiarity of these cysts that their inner 
walls often become papillomatous, and may even develop such a crop of warty out- 
growths that these make their way through the cvst-wall and protrude into the 
abdominal cavity, where they sometimes become detached and are dropped as loose 
bodies into the peritoneal sac. The condition is also often accompanied by warty 
growths upon the peritoneal surfaces. These need give rise to no alarm, because 
they usually disappear spontaneously with removal of the tumor. Paroophoritic cysts 
are to be distinguished from parovarian cysts, which develop from the parovarium, 
this latter consisting of a number of tubules situated between the layers of the meso- 
salpinx, composed of an outer series of tubules known asKobelt's, an inner set, about a 
dozen in number, known as the vertical tubules, with a straight tube running at 
right angles to these through the broad ligament to the vagina, known as Gart- 
ner's duct, which is homologous with the vas deferens of the male. Cystic dilata- 
tion of Kobelt’s tubes is often met with, these cysts being very small and having no 
clinical importance. Cysts arising from the vertical tubules are usually transpar- 
ent until they attain considerable size, when their walls thicken. Their contained 
fluid is not harmful, and after rupture of such cysts internally the fluid is absorbed, 
and thus disposed of. Such cysts may rupture and refill several times. As between 
the paroophorons and parovarian cysts, the latter are usually easily enucleated, carry 
the ovary upon one side, and have the Fallopian tube stretched over them without 
communication. 
The internal sections of Gartner's duct are more often involved in animals than 
in women, but excellent illustrations of cystic dilatation of its various portions 
have been met with, usually in the walls of the vagina. 
Corresponding to the above-mentioned conditions met with in the female we 
find in the male, as the result of changes in the Wolffian body, two quite common 
conditions—encysted hydrocele of the testicle and general cystic degeneration of the same. 
Like the ovary, the testicle is a complex organ with remnants of the mesonephros 
persisting among its ducts, while only a few of the Wolffian tubules remain. True 
encysted hydroceles arise sometimes in the efferent tubes of the testis, and some- 
times in Kobelt's tubes (the same structures which in the female give rise to 
parovarian cysts), the two conditions, therefore, being analogous and homologous. 
These cysts, though closely associated with the testis, lie outside its tunica vagi- 
nalis. Their contained fluid is usually clear or of a milky whiteness, due to fat- 
globules. Sometimes it contains spermatozoa. Another variety is cystic dilata- 
tion of one or more of Kobelt's tubules, which is often described as involving the 
hydatid of Morgagni. 
General cystic disease of the testis, known also as adenomatous degeneration, was 
formerly spoken of as hydatid disease of the same organ. The multiple cysts 
appear to originate in the remnant of the mesonephros still persisting known as the 
paradidymis. The cavities are lined with epithelium, wad. papillomatous intracystic 
formation is not uncommon. These tumors in time past have been unfortunately 
spoken of by a number of improper names, such as “ cystic sarcoma,” etc. 
Hydroceles.—In time past this name also has been made to cover a 
multitude of conditions. At present, by common consent, when no 
other locality is spoken of, hydrocele of the tunica vaginalis is under- 
stood. (The term really implies a collection of watery fluid in a 'pre- 
viously existing serous cavity.) This is the most common form. 
Possibility of its formation depends upon the prolongation of the peritoneal 
cavity, which takes places in advance of or along with the descending testicle, and 
which in almost all the lower animals remains connected with the general cavity 394 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
throughout life. In men only is it expected to close, even before birth. When 
the portion which extends along the spermatic cord is not completely obliterated 
we have encysted hydrocele of the cord, or funicular hydrocele, which is not common. 
The common form of hydrocele is constituted by serous effusion into the tunica 
vaginalis, and occurs usually without recognizable exciting cause. It will be 
treated of more fully in its appropriate place in Volume II. 
The corresponding process of peritoneum in the female is known as the canal 
of Nuc/c; and, when persistent, this also becomes distended with fluid and forms 
a cyst known as hydrocele of the canal of Nuck, occupying the inguinal canal. 
In many of the lower animals the ovaries are contained within a serous sac 
derived from the peritoneum which is connected with the opening of the Fallopian 
tubes, so that when the ova escape from the ovary they enter these tubes and pass 
to the uterus without entering the general peritoneal cavity. This ovarian sac is 
subject to serous distention, and constitutes a condition named by Sutton as 
ovarian hydrocele. An homologous condition obtains sometimes in the human 
female by pathological adhesion, and such cysts sometimes attain large size. They 
project from, and are intimately connected with, the posterior layer of the broad 
ligament. 
Hydroceles of the neck, so called, are cystic collections of con- 
genital origin found in the cervical region, due to dilatation of ducts or 
Fig. 147. 
Congenital hydrocele of neck. 
clefts which should have disappeared at or before birth. The form of 
cyst to which the name of “ hydrocele of the neck ” is usually limited 
is recognizable at or soon after birth, and constitutes a fluctuating 
tumor, often extending beneath the clavicle into the axilla or down upon 
the thorax. They may occupy the entire lateral region of the neck, and 
may be unilateral or bilateral—may be single or multilocular, and may 
even intercommunicate (Fig. 147). 
They originate always beneath the deep fascia. Some of these cysts are 
undoubtedly due to dilatation of lympli-spaces. This is particularly true of the CYSTS AND TUMORS. 
395 
multilocular forms. There is noted in many of them a tendency toward spontane- 
ous recovery, but many of them require operative measures for their eradication. 
Occasionally their walls are extremely vascular, even to the degree meriting the 
term ncevoid. 
Some of these cysts are considered by Sutton to be essentially examples of the 
laryngeal saccules which are met with as diverticula from the laryngeal mucous 
membrane, which undermine the deep cervical fascise of certain monkeys. These 
air-chambers, which are normal in the monkey, communicate with the larynx 
through the thyro-hyoid membrane, and occasionally run down beneath the upper 
border of the thorax. Many of the cysts having this resemblance are closely 
related to the hyoid bone and to the larynx, and there is very much to substantiate 
the view thus alluded to. 
Glandular Cysts.—Ranula is an altogether too comprehensive term 
which has long been used in surgery, alluding to certain cysts met with 
for the most part in the floor of the mouth, and not indicating minutely 
their character nor their exact location. At present this term should 
either be restricted in signification or, perhaps, better still, be elimi- 
nated. If used, it should be confined to retention-cysts due to obstruc- 
tion of the submaxillary or sublingual ducts. Such obstruction is often 
caused by salivary calculi impacted in the duct-orifices. In other 
instances it is due to cohesion of the margins of the outlet. A similar 
condition in the parotid duct is known, but is very much less common. 
Aside from this, certain other cysts originate from minute beginnings 
in and about the floor of the mouth, being due to dilatation of the 
mucous glands, particularly one near the tip of the tongue, sometimes 
known as Nnhn’s gland. Dermoid cysts in this locality are not uncom- 
mon. In time past every cyst of the floor of the mouth was described 
as ranula. 
Pancreatic cysts correspond in large degree to salivary cysts, the 
pancreatic duct becoming dilated by retention when its orifice is 
obscured; and, indeed, the condition has been spoken of as pancreatic 
ranula. Sometimes the canal is dilated in distinct portions, so that the 
condition resembles a string of cysts; at other times it is the terminal 
portion which is most enlarged. Such cysts attain large size and con- 
tain for the most part mucoid material. Examples have even been 
reported showing that they have attained a capacity of two gallons. 
In the mesentery there sometimes develop cysts which are known as 
chyle-cysts, whose sacs appear to be formed of separate mesenteric layers, 
their cavity being occupied by fluid identical with chyle. Such tumors 
also sometimes attain great size. 
In the eyelids one occasionally meets with cystic dilatations of the 
lachrymal ducts. These are known as dacryopic cysts or dacryops. 
Fistulse result when they are opened through the skin, and if meddled 
with at all they should be radically extirpated. 
In his elaborate work on tumors Sutton has made a distinct classifi- 
cation of pseudo-cysts, which lack some of the characteristics of genuine 
cysts, yet, nevertheless, are entitled to consideration in this place. 
Among these are included intestinal diverticula and vesical diverticula, in 
either of which instances hernial protrusions of the mucous membrane 
through the outer coating of the bowel or of the bladder occur, thus 
Pseudo-cysts. 396 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
forming pouches. These are common in the bowel, rare in the bladder; 
especially in the former locality they are often multiple. This condi- 
tion is often spoken of as sacculation, and sacculation of the bladder 
may even be confounded with true urachus-cyst. They are of little 
consequence so long as foreign materials, such as feces, urinary calculi, 
etc., do not lodge in them. 
Pharyngeal diverticula give rise to rare but most interesting tumors. 
It is well known that the branchial clefts, which in early foetal life con- 
nect with the pharynx, are sometimes not completely closed, and that a 
portion of one may persist abnormally, giving rise to a condition known 
as the pouch of Rathke. There may also occur sacculation of the 
pharyngeal wall where it joins the oesophagus, or hernial protrusions, 
especially in Rosenmuller’s fossa. 
Cystic dilatation of Rathke’s pouch occurs near the upper part of the pharynx, 
and may attain the size of a marble. Hernial pouches are seldom mistaken for 
cysts, and are of importance mainly because of the fact that food or other foreign 
material gathers and lodges in them. Most of the other cystic abnormalities of 
the pharynx pertain to dermoids, and will be considered shortly. In a general 
way, these pharyngeal tumors have been grouped as pharyngoceles. 
Similarly, in the oesophagus and trachea hernial protrusions occur, and lesions 
closely resembling retention-cysts may be met with. 
Synovial cysts (i. e. those containing synovial fluid) may arfee (1) by 
protrusion of synovial sheaths ; (2) by distention of bursae in the vicinity 
of joints ; or (3) bv hernial protrusions of joint membranes. They are 
often met with in connection with the larger joints, more particularly 
perhaps about the knee. In this way tumors as large as goose-eggs 
may be formed, while their location may be so shifted that they present 
themselves in perplexing ways. To that form produced by hernial pro- 
trusion of the lining of a tendon-sheath has been given the name gan- 
glion. 
The simple ganglion is most often seen on the back of the wrist, and, while it 
is often only connected with the tendon-sheath, it undoubtedly frequently con- 
nects with the synovial membrane of the carpal joints. The compound ganglion, 
so called, is a much more serious and extensive affair, being one which has pro- 
longations in two or more directions, and usually containing peculiar bodies, 
known commonly as melon-seed bodies, which appear to be fibrinous concretions 
worn round and smooth by attrition. These are present sometimes in enormous 
numbers. ( Vide Tuberculosis of Synovial Structures, Chapter IX.) 
Bur see are normal in many well-known situations in the body, but 
may undergo cystic dilatation and become annoying tumors. In many 
other places, under the influence of friction or mechanical irritation, 
there develop bursae which are known as adventitious. These are some- 
times subtendinous, and may communicate alike with joint- and tendon- 
sheaths. These are true cysts of new formation not developed from a 
pre-existing cavity. 
They are largely the effect of peculiar occupation, as in housemaids and carpet- 
layers there frequently is formed a prepatellar bursa, while miners get them upon 
the elbow, porters upon the shoulder, plasterers upon the forearm, etc. In the 
same way, by the pressure of ill-fitting boots, an adventitious bursa is developed 
over the expanded head of the first metacarpal bone, thus forming a condition 
known as bunion. CYSTS AND TUMORS. 
397 
Neural Cysts. 
This term has been applied by Sutton to pseudo-cystic dilatation of 
certain cavities found in the brain and central nervous system. Hydro- 
cephalus is in one sense a pseudo-cyst of this variety. Quite corre- 
sponding to it in foetal life is hydramnios. Hydrocele or cystic dilata- 
tion of the fourth ventricle is well known. Cranial meningoceles, which 
are hernial protrusions of brain-membranes, are also pseudo-cysts, to be 
included in this category, They will be considered at due length in the 
opening chapter of the Second Volume. Cephalhcematoma might possi- 
bly be also included in the same way. Spina bifida, a condition to be 
more minutely described in Volume II., is, nevertheless, practically, a 
cyst of congenital origin involving the spinal meninges. One form of 
spina bifida is constituted by cystic dilatation of the central canal of 
the spinal cord, and produces the condition accurately spoken of as 
syringo-myelocele. (Vide Chapters I. and II. Vol. II.) 
Sutton has rendered a very great service by showing that the brain and spinal 
cord are really evolved from a segment of the primary intestine, and- that the 
intestinal canal and the neural canal communicate in foetal life at their lower termina- 
tions ; while it has been shown by several that in the earlier forms of mamma- 
lian life they were also connected by their anterior terminations. It is in this way 
that certain complex and rarely met-with tumors of the sacral and coccygeal 
region are to be explained. So also is the collection of lymphoid tissue in the 
vault of the pharynx, known as Luschka’s tonsil, and in the coccygeal region, 
known as Luschka's gland, it being a curious and most instructive fact that 
lymphoid tissue of this character always is met with in the neighborhood of obso- 
lete canals. 
Hydatid Cysts. 
Hydatid cysts constitute a distinct class of pseudo-cysts due to the 
presence of parasites. In this particular instance it is the ordinary 
tape-worm (Taenia echinococcus), whose adult form inhabits the intes- 
tines of dogs, and whose eggs are conveyed either with food or drink 
into the alimentary passages of man, where they are hatched, while the 
embryo, migrating into some distant organ or tissue vid some blood- 
vessel, gradually becomes transformed into a cyst whose wall has a 
peculiar structure and which is usually surrounded by a fibrous capsule. 
The cyst-wall consists of an elastic outer coat, with a lining layer consisting 
of granular matter, muscle-tissue, etc., while from it there develop, as the cyst 
grows, small vesicles, the brood-capsules of writers on this subject, containing num- 
bers of scolices, which are minute animal heads furnished with sucking disks and 
a distinct parasitic organization. Hydatid cysts attain sometimes enormous dimen- 
sions, and contain within them repetitions of themselves, known as daughter-cysts. 
Occasionally such a cyst fails to reproduce vesicles or brood-capsules, and then is 
spoken of as sterile. Multilocular hydatid cysts also are found. The characteristic 
hooklets which form a part of the parasitic organism are distinctive and pathog- 
nomonic whenever met with. They can be shown by a low power of the micro- 
scope. Hydatid disease is very uncommon in this country, but extremely preva- 
lent in certain localities, particularly so in Iceland and Australia. 
Another term used in connection with many tumors or cystic forma- 
tions must be defined here. Hsematocele is an expression meaning a 
tumor composed originally of effused blood which has undergone chemi- 
cal and other changes, which consist of lamination and thickening of its 
Cystic Degenerations. 398 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
exterior portion and fluidification of the interior, until in course of time 
such an internal blood-clot may be converted into a distinct and plainly 
walled cyst. This condition is met with especially often in two loca- 
tions—namely, in the pelvis and between the cranium and the brain, or in 
the brain, where distinct and beautiful illustrations are not infrequently 
met with. As time goes on the haemoglobin entirely disappears, and the 
contents of these cysts are translucent or even watery in appearance. 
Haematoceles may form where there has been internal hemorrhage in 
certain locations which has failed to absorb, and where no pyogenic 
infection has occurred. 
Pseudo-cystic changes occur in many other tumors and in other parts 
of the body as the result of mucoid and colloid liquefactions—conditions 
which are amply described in works on general pathology. Suffice it to 
say here that in the midst even of apparently dense and entirely defined 
tumor-masses changes of this kind occur, and lead to formation of cavi- 
ties containing fluid of variable consistence, causing the tumor when 
divided to present much the appearance of the geodes or quartz rocks 
containing cavities lined with quartz crystals. The occurrence of such 
cystic changes is indicated in naming such a tumor by prefixing the 
term cysto-, as cysto-sarcoma, cysto-fibroma, etc. 
2. DERMOIDS. 
Dermoids are cysts or tumors containing tissues and appendages which 
are developed from the epiblast, and which occur in situations where skin 
and mucous membrane are not normally found. The simplest form of 
dermoid is a cyst whose interior is lined with modified skin, containing 
sebaceous glands and hair-follicles, from which often numerous long 
hairs are produced. Even sweat-glands may be present. Its cavity is 
occupied by mixed material, pultaceous in character, made up of sebum, 
cholesterine, and growing hairs which are often rolled into balls. The 
sebum is the product of the glands contained in the cyst-wall. 
A more complex form of so-called dermoid cyst is met with, in 
which we find unstriped muscle-fibre, teeth, mammary glands, etc. 
These, strictly speaking, belong rather to the class of teratomata, since 
they contain more or less tissue not of epiblastic origin. 
A dermoid tumor is one lacking cystic characteristics, made up of 
tissue largely developed from the epiblast, with more or less tissue of 
mesoblastic origin. Such a tumor may contain much connective tissue, 
fat, foetal hyaline cartilage, and even nerve-tissue, while from its exte- 
rior long hair may grow, and teeth may project from its surface or be 
imbedded within its substance. Such tumors are most often found in 
the pharynx and about the rectum. 
The whole explanation of dermoids and teratomata must be gleaned 
from embryology, and rests upoii the combined arrangement of the dif- 
ferent blastodermic layers of the developing ovum and upon the facts 
already alluded to in explaining Cohnheim’s hypothesis of the origin of 
tumors. Strictly speaking, a dermoid should contain only that which 
may be developed from the epiblastic layer. It is well known that teeth 
and hair, as well as sebaceous material, are epiblastic products. Conse- 
quently, such material may be found within a dermoid and call for no 
further explanation than an epiblastic inclusion, according to Cohnheim’s CYSTS AND TUMORS. 
399 
views. But, so soon as such a tumor contains bone, muscle, nerve-tissue, 
etc. (i. e. tissues of mesoblastic origin) we should, strictly speaking, drop 
the term dermoid and consider it a teratoma. Such is the accurate dis- 
tinction between these two terms. 
The most prominent characteristics of dermoid cysts are—First, skin, which 
may be thick or thin, lined with papillae, containing more or less pigment, its 
deeper layers possessing a quantity of fat. Second, hair, which next to skin is the 
most constant structure found in dermoids; this maybe present in very trifling 
amount or in long coils or balls. It is of interest that in dermoids found in ani- 
mals covered with wool we find the same character of hairy structure, while in 
birds dermoids contain feathers rather than hairs. Third, sebaceous glands and 
their peculiar secretion are almost invariably found. These may be of large size, 
and sebaceous retention-cysts may be seen in the walls of dermoids. Sometimes 
horny matter or tissue is found in these, indicating the same relation between horn 
and sebaceous structures as we see upon the external skin in other instances. So, 
too, material resembling the texture of finger-nails is occasionally found project- 
ing into the cavity. 
The fluid or semifluid contents of these cysts consist usually of sebaceous mate- 
rial, cholesterine, epithelial debris, etc. Sometimes it is thick, sometimes thin— 
sometimes consists almost entirely of mucus. 
It is not uncommon to find structures in ovarian dermoids closely 
analogous to, or actually resembling, mammary glands. These may be 
mere nipple-like processes of skin, or completely developed mammae, 
well formed, but without ducts or gland-tissue, may occupy such a cyst. 
These really are pseudo-mammae, because they have no ducts. Never- 
theless, glandular tissue is not always absent. This resemblance pro- 
ceeds even further, in that in some of these ovarian mammae changes 
occur analogous to those which take place in normal breasts. 
The epiblast seems to have the power of developing mammary glands or super- 
numerary mammae in most locations—in fact, upon any part of the body-surface. 
About the thorax they are common ; upon the abdomen they are rarely met Avith ; 
and they have been found even upon the labia. 
Sweat-glands are infrequent in dermoids. Teeth are quite common. These may 
vary in number from two or three up to several hundred—may be imbedded in 
definite sockets or simply sprout from the cyst-wall. Occasionally bone-material 
lodging such teeth and crudely resembling a jaw will be found. 
Dermoids containing mucous membrane are found, especially in con- 
nection with the ovary and with the post-anal gut (i. e. the original pas- 
sage communicating between the spinal and alimentary canals). 
It is curious that under these circumstances mucous membrane is sometimes 
furnished with hair, as it normally is in the stomach or other cavities of some of 
the lower animals. Mucous glands and retention-cysts of these glands are also 
found in ovarian dermoid*. This will be much more readily understood if the 
mutability of skin and mucous membrane be not forgotten. The transition from 
one to the other is not difficult, and we find all intermediate stages between the 
two extremes—if not in man, at least in the animals. This will account also for 
the fact that skin-covered dermoid tumors are found in certain parts of the ali- 
mentary canal, and particularly in the pharynx. These tumors grow also from 
the mucous membrane of the bowel, of the rectum, or even of the small intestine. 
Sutton has made a happy division of dermoids into three classes: 
1. Sequestration. 
2. Ovarian. 
3. Tubulo-dermoids. 
1. Sequestration dermoids occur chiefly in situations where during 
embryonic life coalescence takes place between two surfaces possessing 400 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
an epiblastic covering, although sometimes this coalescence practically 
occurs late in life and by implantation. 
Dermoids of the trunks occur particularly where opposite halves of the body- 
wall coalesce—that is, in the mid-line of the trunk and head. Dermoid cysts are 
found rarely in connection with spina bifida, and certain tumors spoken of as spina 
bifida undoubtedly are, in effect, dermoids. Anteriorly, dermoids occur frequently 
in the scrotum, possibly occasionally in the testicles. At the umbilicus they are 
rarely met with—usually as pedunculated tumors projecting externally. In the 
mid-line of the thorax and neck they are most common opposite the manubrium, 
dropping down behind it to invade the anterior mediastinum. Near the hyoid 
bone they occur relatively frequently ; about the head they are met with most com- 
monly at the angles of the orbits—more so at the outer than the inner angle. Der- 
moid cysts are known to oculists as growing upon the iris or springing from the 
conjunctiva. About the ear they are not infrequent; in the roof of the mouth, 
especially when this be incomplete, we frequently find cysts of epiblastic origin. 
Sequestration dermoid cysts are also undoubtedly found in connection with the 
dura mater, in the scalp, most commonly at the anterior fontanelle, at the root of 
the nose, and at the external occipital protuberance, where they may be con- 
founded with sebaceous cysts or with meningoceles. In order that a dermoid of 
the dura may communicate with the skin there must of course be osseous defect. 
Sequestration dermoids upon the limbs have been mostly reported as sebaceous 
cysts. They are rare, and usually associated with antecedent injury, by which 
epiblastic structures are driven in and implanted in such a way that as they 
develop they give rise to these peculiar tumors. These are what Sutton speaks 
of as implantation dermoids. They have been met with upon the fingers and else- 
where. 
Tubulo-dermoids.—These are largely connected with obsolete canals 
and ducts. It is a great service which Sutton has rendered us in prov- 
ing, apparently beyond the possibility of doubt, that the central canal 
of the nervous system is really of intestinal origin, and maybe regarded 
as a disused segment of the primary alimentary canal. He has shown 
also how it behaves occasionally as do other functionless ducts, and that 
cysts and dermoids in connection with it are to be thus, and thus only, 
explained. He and others have also shown the anterior as well as the 
posterior communication of these canals, and the pituitary body is to be 
regarded in this light as the same formation of lymphoid tissue around 
an obsolete canal which we see in Luschka’s tonsil close by, and in 
Luschka’s gland at the other extreme of the canal. 
The primary alimentary canal, then, was a continuous tube lined with a con- 
tinuous layer of columnar epithelium. That portion connected with the yolk-sac 
develops into the intestine, the balance into the central nervous canal. Portions 
of this canal are in post-natal life absolutely obsolete; others persist in a very 
rudimentary condition. Dermoid cysts and dermoid tumors develop in connection 
with each of these. In some of these there is a large central cavity; others are 
almost absolutely solid. Thus we meet Avith dermoids in the coccygeal region 
which have been variously regarded as sarcomata, adenomata, etc., which are 
really of origin as stated above, and which should be considered simply as der- 
moid tumors. Most of these project outwardly; some of them arise and develop 
within the pelvis. Dermoid cysts and tumors are also met with in connection with 
the rectum—sometimes between the rectum and the bladder, sometimes between 
the rectum and the spine. Dermoid tumors are also found in connection with the 
pituitary body. These sometimes develop within the cranium, or, again, protrude 
perhaps into the orbit, perhaps into the pharynx. 
Thyroid dermoids are tumors of very great interest. They develop sometimes 
about the cranio-pharyngeal canal, which may be detected as a small canal in the 
macerated sphenoid bone of a foetus, and which before birth is filled with fibrous 
tissue. It connects with a recess in the middle line and at the base of the skull, 
presenting in the pharynx, which is often spoken of as the bursa pharyngea. It is 
around this recess that the lymphoid tissue known as “the pharyngeal tonsil” CYSTS AND TUMORS. 
401 
develops. It may thus be expected that the roof of the pharynx should be the 
occasional site of dermoids. It is from the pharynx or the floor of the mouth that 
in vertebrata the thyroid body arises. In higher forms it becomes dissociated from 
the pharynx and shifts its position. The thyroid body is developed around the 
thyroid duct, which first appears as the thyro-hyoid duct, which later becomes 
divided, that portion in relation with the tongue becoming the thyro-lingual duct, 
the remaining portion persisting as the thyroid duct. These are present about once 
in every ten subjects, according to Sutton, the canal when persistent being lined 
with epithelium. When the extremities of these ducts become occluded, we may 
Fig. 148. 
Fig. 149. 
Solid tumor escaping from pelvis (original). 
have retention-cysts. In the same way dermoids of the tongue are formed, similar 
to those occurring on the scalp. These are frequently mistaken for sebaceous cysts. 
They may be unilateral, central, or even bilateral. The lingual duct is also of 
interest, because it would appear that certain cases of epithelioma of the tongue 
arise along this duct, and perforating malignant ulcer of the tongue is thus pro- 
duced. Dermoid tumors of the lingual or thyroid ducts resemble in structure the 
thyroid body. The thyroid duct may also be detected in many adults running 
from the isthmus of the thyroid body to the posterior aspect of the hyoid bone, 
and surrounded by muscle-tissue. Sometimes the space usually occupied by this 
duct is represented by a series of detached bodies known as accessory thyroids. 
These are not infrequently the seat of cysts, sometimes of considerable size. (The 
accessory thyroids often enlarge when the main thyroid has been extirpated for 
disease.) Thus cysts in close relation to the hyoid bone are common. Some of 
them grow slowly; others, rapidly and contain much fluid. Many of them are 
unilateral, and are often mistaken for enlargements of one lobe of the thyroid. 
Cysts growing from accessory thyroids are often filled with papillomatous masses, 
and are occasionally the seat of malignant degeneration. 
In the omphalo-mesenteric duct or its remains, especially in relation with the 
umbilicus, we often meet with small cysts or tumors in infants and young children. 
Congenital dermoid cyst of pelvis (Ahlfeld). 402 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
When the duct is persistent it presents normal intestinal structure, and, like the 
appendix, possesses much adenoid or lymphoid tissue. 
Another and very important form of tubulo-dermoids develops in connection 
with the branchial clefts of the neck. Congenital fistulae of the neck have been 
long known, but only comparatively recently understood. Of the branchial clefts, 
it is well known that the first alone should persist, as the Eustachian tube, etc. 
Occasionally, however, they fail to become completely obliterated, and then we 
have congenital tumors or cysts, which may, however, not develop to appreciable 
size until somewhat late in life; or we may have fistulous passages opening either 
into the pharynx or externally, forming canals varying in length from half an inch 
to two inches, secreting a little fluid because lined with epithelium. When these 
become inflamed an abscess results. When they open externally the opening is 
often marked by a little tag of skin containing a fragment of yellow cartilage. 
These are often spoken of as cervical auricles. They open usually along the line 
of the sterno-mastoid muscle. The internal openings of these fistulae frequently 
form diverticula from the pharynx or oesophagus. Thus it will be seen that der- 
moid cysts about the neck are, for the most part, relics of openings or ducts which 
are normal in embryonic life, but which should have been obliterated at or long 
before birth. Congenital fistulae, however, may be met with in the middle line of 
the neck which are not to be confounded with branchial fistulae, but rather with 
the ducts previously described. 
Ovarian Dermoids.—These may be unilocular or multilocular cysts, 
usually the latter. They are lined with epithelium, and contain for the 
most part mucoid fluid, the inner coat 
being practically identical with mucous 
membrane. Occasionally, however, 
we meet with skin furnished with 
hair, sebaceous glands, teeth, and even 
nipples. The multilocular cysts are 
practically an aggregation of those 
just described. They are surrounded 
by dense oapsules, often attain great di- 
mensions, and are made up of primary 
cysts resembling large cavities in a 
honeycombed-like mass, which itself 
is occupied by secondary cysts, and 
belong rather to the class of mucous 
retention-cysts ; and these are occupied 
by still smaller ones which are histo- 
logically indistinguishable from dis- 
tended ovarian follicles. In these 
large tumors we find in some cases 
hair, in others teeth, in yet others sebaceous glands, etc., the dermoid 
constituents being scattered throughout. 
Fig. 150. 
Ovarian dermoid, showing ball of hair 
(original). 
3. TERATOMATA. 
So far, I have endeavored to limit the term dermoid to tumors which 
are essentially of epiblastie formation, which, nevertheless, may be pres- 
ent in deep situations, their location here to be explained on the inclusion 
theory of Cohnheim. There is next to be dealt with a still more com- 
plicated type of tumor, composed of tissues of both epiblastie and meso- 
blastic origin, perhaps even hypoblastie, whose structure is too complicated 
to be taken up at length in this place. Their consideration belongs 
rather to that department of pathology known as Teratology, which is CYSTS AND TUMORS. 
403 
supposed to deal especially with monsters. Strictly speaking, a teratoma 
refers to an irregular tumor or mass containing tissues and fragments 
of viscera of a suppressed foetus which is attached to an otherwise nor- 
mal individual. Nevertheless, the term is often applied to growths 
which are the result of luxuriant mesoblastic development in which 
yet neither form nor member of a suppressed foetus is present. 
As between exaggerated mesoblastic growth in this direction, which supposes 
the presence of a single ovum or the presence of supernumerary members, even 
to the extent of conjoined twins, which presupposes two distinct embryos, one of 
which goes on to complete development, while only certain parts of its companion 
develop, we cannot stop here to go into minutiae. The presence of supernumerary 
members is largely connected with what is called dichotomy, alluding thereby to 
cleavage either at the anterior or posterior end of the developing embryo. When 
the whole embryonic axis divides twins may be produced, but should cleavage be par- 
tial we may have a monster with two heads if it be anterior, or if it be posterior 
with three or more limbs. Children born with these deformities are usually spoken 
of as monsters, and the study of such cases belongs entirely to teratology. But in 
certain tumors small portions of a suppressed foetus may develop, as, for instance, 
from the posterior portion of the sacrum, or within the abdomen or thorax, or 
upon the neck or face, which on dissection may contain a few vertebrae or pro- 
cesses resembling fingers, associated perhaps with a structure resembling intestine 
or liver. This is what should be spoken of as a true teratoma. Such tumors 
possess for the pathologist the greatest value, In surgery, however, they are rare, 
and there are scarcely two cases alike. The question of operation will often come 
up, as it does with supernumerary limbs, and each case must be studied and decided 
purely upon its own merits. Sometimes they are amenable to extirpation. 
Teratomatous tumors are sometimes found hanging in the pharynx, 
attached by a small pedicle. In this location they are likely to be con- 
founded with dermoids unless carefully examined after removal. Many 
instances of this type of tumor are met with in animals. Here no false 
sentiment will prevent complete examination and preservation of the 
specimen. (For further information, however, the reader must be re- 
ferred to the large works on Teratology or to works like those of Sutton 
on Tumors.) 
4. TUMORS OF IMMATURE MESOBLASTIC-TISSUE TYPE. 
Sarcoma. 
To these the now well-defined and perfectly understood name of 
Sarcoma is given. In times past this name, which simply implies a 
fleshy tumor, has been made to cover many different conditions, and the 
reader of literature of forty years or more ago may be much misled by the 
use of this term in many significations. To-day sarcoma means a tumor 
composed of immature mesoblastic or embryonic tissue in which cells predomi- 
nate over intercellular material. Sarcomata are sometimes encapsulated : 
they merge into and infiltrate the surrounding tissue and disseminate 
widely, and for the most part have these propensities and characteristics 
to such a degree as to constitute malignancy. For the laity sarcomata 
and carcinomata are together included in the comprehensive term of 
cancer ; for us they may constitute but one form of cancer. Sarcomata 
are classified, according to the shape of their cells and their disposition, 
into— 
A. Round-celled, 
B. Spindle-celled, 404 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
C. Myeloid, 
D. Alveolar, and 
E. Melanosarcoma. 
A variety of the round-celled sarcomata is also distinguished as 
lymphosarcoma. 
A. Round-celled Sarcoma.— 
This is simple in construction, and 
consists of round cells containing 
very little intercellular substance. 
The nuclei of the tumor-cells stain 
easily, the cells themselves varying 
very much in size in different cases. 
Blood-vessels lead up to the tumor, 
but in the interior appear rather as 
channels. These tumors have no 
lymphatics: they grow rapidly, in- 
filtrate easily, recur quickly, and 
give rise to numerous metastatic or 
secondary deposits. They may affect 
any part of the human body. The 
size of the cells is supposed to be 
in some measure an index of their 
malignancy—the smaller the cell the 
more malignant the tumor. They appear at all periods of life. They 
are perhaps the most commonly met with of malignant tumors in animals. 
Fig. 151. 
Small round-cell sarcoma of thigh (X VT; 
Spencer). 
Fig. 152. 
Recurring sarcoma of parotid (original). CYSTS AND TUMORS. 
405 
Lympho-sarcoma.—This is composed of cells similar to the pre- 
vious form, but enclosed in a delicate meshwork resembling that of 
lymph-nodes, hence the term lympho-sarcoma. Lympho-sarcomata are 
not to be confounded with enlargements nor with the specific granu- 
lomata involving these lymphatic structures. 
B. Spindle-celled Sarcoma.—In this form the cells have a spindle 
shape and run in all directions, so 
that sections will show them in 
various shapes and sizes. In some 
cases the cells are very small and 
slender, in others very large. Here, 
again, the size of the cell is a meas- 
ure of the malignancy of the tumor. 
The largest type of these spindle-cells 
is frequently striated transversely like 
voluntary muscle-fibre, and tumors com- 
posed of this form have been considered 
as tumors of striped muscle-tissue, and 
have usually been called rhabdomyoma. 
Strictly speaking, there is no tumor of 
striped muscle-fibre, and the rhabdomy- 
omata of writers generally must be con- 
sidered as spindle-celled sarcoma or may 
be dignified by the name myosarcoma. In 
these growths also one occasionally meets 
with immature cartilage, sometimes even 
to such an extent that they are regarded as cartilaginous rather than sarcomatous, 
this cartilage frequently calcifying, sometimes even ossifying. The sarcomatous (i. e. 
the malignant) character of these tumors is clinically demonstrated, if not micro- 
scopically betokened, by the frequency with which they recur after removal. In 
certain spindle-celled sarcomata, however, the cells sometimes undergo conversion 
into fibrous tissue, and may then be spoken of as fibro-sarcoma or fibrifying sarcoma. 
Fig. 153. 
Spindle-cell sarcoma of thyroid (X 34"; 
Spencer). 
Fig. 154. 
Sarcoma of femur following fracture—i. e. developing in callus (original). 
C. Myeloid or Giant-celled Sarcoma.—In this form the tissue 
resembles histologically the red marrow of young and growing bone, 406 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
containing large numbers of multinuclear cells imbedded in a matrix of 
spindle- or round cells. These tumors, for the most part, occur in the 
long bones, and when freshly cut look much like a piece of liver. 
Giant or multinuclear cells should be present in relatively considerable num- 
bers to entitle a tumor to classification in this group. When round, spindle-, or 
giant cells mingle in nearly equal proportion, the tumor should be spoken of as a 
mixed-cell sarcoma. 
D. Alveolar Sarcoma.—This is a rare form, in which the cells, con- 
trary to the general rule of sarcomata, assume an alveolar arrangement 
strongly imitating that of epithelial cells in carcinoma. Almost invari- 
ably, however, on minute examination it will be possible to distinguish 
a delicate reticulum between individual cells, which is never met with 
in cancer. By some the alveolar sarcomata are grouped as belonging to 
endotheliomata (q. v.). On this point we need further light. Their 
common situation is in the skin, especially in connection with congenital 
defects, such as hairy and pigmented moles. 
E. Melano-sarcoma, sometimes known as Melanoma.—This refers to 
the deposition of pigment, rather than to type or shape of cell, the dis- 
tinguishing feature of these growths being the presence both in the cells 
and in the intercellular substance of a variable quantity of blackish 
pigment. Of all the forms, the melanotic growths are generally con- 
Fig. 155. 
Fig. 156. 
Melanotic sarcoma of back (contributed by 
Dr. Holloway). 
Melanotic sarcoma of liver (secondary) 
(X M"; Spencer). 
sidered the most malignant. They invariably recur after removal, they 
lead to secondary deposits at long distances, and they present the most 
intractable and incurable form of cancer. Deposition of pigment in 
carcinomata is most rare, if ever met with, and the growths heretofore 
spoken of as melanotic cancer should be relegated entirely to the class 
just under consideration. ( Vide Plate XIII.) 
General Characteristics of Sarcomata.—The vascular supply of 
sarcomata varies within wide limits. In nearly all instances it is of 
capillary character, the blood circulating rather through vessels with 
well-marked walls. While large vessels may be found about and in the 
periphery of these tumors, distinct vascular structure is usually absent PLATE XIII. 
Melano-Sarcoma of Skin ; a, Stroma with Pigment Cells; b, Endothelial Cell Nests 
with Migrated Pigment Cells. (Klebs.) CYSTS AND TUMORS. 
407 
from the more internal vessels; all of which will explain the frequency 
of hemorrhage, its persistency after operation, and the ease with which 
large extravasations occur. True hsematocele may thus take place 
within sarcomatous tumors with the usual later cystic alterations, and thus 
in one way we have the condition frequently spoken of as cysto-sarcoma. 
In attacking these growths the most 
vascular and bloody area may be met with 
just about their margins, the blood-vessels 
expanding as they arrive at the tumor, 
and bleeding sometimes furiously. Under 
most circumstances, however, this hem- 
orrhage can be controlled by packing or 
hy operating at a little greater distance 
from the circumference of the growth. 
Metastasis in sarcoma is common, 
dissemination occurring mainly along 
the veins, since these growths often 
penetrate into the venous channels 
and permit of easy detachment of 
fragments, which are then carried 
along as emboli. These emboli pass 
naturally to the right side of the 
heart, and thence to the lungs, where 
it is most common to find secondary 
growths, except in areas emptying into the portal veins, in which case 
the liver will be the most common site. Sarcomata are destitute of 
lymphatics, and dissemination does not occur through these channels. 
Infiltration is also a common phenomenon with these growths. This 
is perhaps most often seen in muscular tissue, particularly with growths 
proceeding from the periosteum and projecting into it. 
Sarcomata, like other tumors, tend to grow along the lines of least 
resistance. Hence processes of these tumors will insinuate themselves 
into fissures and interspaces, and penetrate perhaps even into the cavi- 
ties, from which it is hazardous or impossible to remove them. Thus, 
sarcomata springing from the head of a rib have been known to extend 
through an intervertebral foramen and give rise to an intraspinal tumor, 
causing fatal pressure. 
Secondary changes are commonly met with in sarcomata, the most 
frequent being hemorrhage. Myxomatous degeneration is also frequent, 
and gives rise to cystic conditions. Calcification is common, particu- 
larly in the more slowly-growing tumors which arise from bone. Upon 
the other hand, necrosis (i. e. ulceration) is common in growths which 
project upon the surface or into any of the open cavities of the body. 
Ulceration here is simply an expression of growth at a rate relatively 
faster than the possibilities of nutrition permit, and gangrene is to be 
regarded as a failure to supply sufficient blood. It may also mean infec- 
tion, of which it is, indeed, a usual expression. 
Tumors of this character, which luxuriate upon reaching the surface, 
and which bleed easily upon the slightest touch, were known in time past 
as fungus hcematodes. The name may be preserved for the sake of con- 
venience, but should be held to mean in almost every instance a rapidly- 
growing, round-celled sarcoma. 
Fig. 157. 
A ngeio sarcoma: blood-vessel with coagu- 
lated blood (X W; Spencer). 408 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
In bone these tumors may arise centrally (i.e. in the marrow-cavity) or may 
spring from the periosteum. The former variety rarely affects the adjacent lymph- 
nodes. Myeloid tumors are practically always central. Tumors located thus 
centrally always expand the bone, sometimes to enormous dimensions. Periosteal 
sarcomata are never myeloid, always round- or spindle-celled, and are more liable 
to calcification, or even to ossification, than central tumors. Sarcomata arise in 
the follicles of the teeth, but only in children, and are particularly apt to involve 
the bone about the first permanent molar (Sutton). The jaws are very apt to 
become involved in growths springing from adjacent parts, particularly from the 
nasopharynx and the nasal fossae. From the vault of the pharynx spindle-celled 
growths are often seen growing, projecting down into the parts beneath, plugging 
one or both nasal fossae and impeding both respiration and deglutition. These 
basal growths also penetrate upward and invade the cranial cavity. 
In the eye sarcomata are common and produce hideous pictures of malignant 
disease, which were formerly spoken of as medullary or encephaloid tumors or as 
fungus liaematodes. Sarcoma of the eye almost invariably recurs after removal, 
Fig. 158. 
Fig. 159. 
Sarcoma of antrum and jaw (original). Cystic osteo-sarcoma of pelvis (contributed by Dr. 
(Fatal in two months from com- Holloway), 
mencement.) 
and the prognosis in all such cases is bad. In the salivary glands sarcomata are 
common, particularly in the parotid. In these growths secondary changes are 
quite common, and a mixture of cartilaginous development and cystic degenera- 
tion is frequently seen. 
The testicle is quite prone to sarcomatous infection. Lympho-sarcoma is 
occasionally seen here. The spindle-celled variety attacks only one of these organs 
at a time, and in many instances these growths contain so much cartilage as to 
have been considered in time past as enchondromata. Sarcoma of the ovary is 
not less common, both organs being sometimes simultaneously affected. The dis- 
ease is most common in early life—is seldom seen after fifteen years of age. 
The mammary gland is not infrequently the seat of sarcoma, which originates 
in the connective tissue of the breast, entangles the secreting structure, and, when 
seen in microscopical sections in which the ducts are cut across, is frequently mis- 
taken for adenoma, because of the duct-spaces which are lined with epithelium. 
Nearly all of these tumors recur quickly after removal, and especially in nursing 
women they grow with great rapidity. 
Lympho-sarcoma is most common in the posterior mediastinum, and constitutes 
a rapidly-growing tumor which quickly encroaches upon the important thoracic 
organs and viscera. Interference with venous circulation because of less resistant 
walls is almost always evident. The important nerve-trunks of the part are often 
involved, and illustrations of pressure upon the pneumogastric are usually not 
wanting. In the abdomen lympho-sarcoma arises usually in the connective tissue CYSTS AND TUMORS. 
409 
posterior to the peritoneum, again involving vessels and nerves in the same way 
as before. In the ring of lymphoid tissue which surrounds the upper end of the 
oesophagus, of which the tonsils are the most conspicuous features, lympho-sarcoma 
is also quite common. In other words, in and about the tongue and the larynx 
we meet with many growths of this character. 
The deposition of pigment, and in particular its expression of malig- 
nancy, are the most interesting features of these growths. Deposit of 
pigment is normal in certain locations, and in certain races is extensive. 
The amount of pigment in the uveal tract usually compares closely with 
that in the skin. Excessive development of pigment is much more rare 
than excessive lack of it—that is, albinism is much more common than 
melanism. Pathological pigmentation is found usually in connection 
with tumors, either in the skin or within the eyeball. Melanotic sar- 
comata contain variable amounts of pigment, the particles of pigment 
being found not only in the proper cells of the tumor, but even in the 
Avails of its blood-\’essels. It is singular that the secondary groAvths 
frequently contain more of this material than the primary, which may 
almost entirely lack it. In the skin Ave most commonly meet with 
melano-sarcoma as arising either from pigmented moles or from the matrix 
of a nail. In the former case the cells are collected in alveoli, and the 
general type of the tumor is of the alAreolar sarcoma. Pigmented moles 
do not necessarily undergo this change, but are always sources of danger. 
31elanosis occurring in connection with the tips of the fingers or toes 
should always be ATieAved Avith the greatest apprehension, and should 
lead to prompt amputation of the member. In the eye melano-sarcoma 
occurs usually in the uAreal tract. So far as I know, these intraocular 
tumors invariably recur after surgical attack. It has been shoAvn that 
melano-carcinoma rarely occurs in the ciliary body of the eye, but, as 
stated aboATe, almost all melanotic tumors belong to the sarcomata. 
Sarcoma is common in the loAver animals, particularly so in horses— 
most common in those of gray color. It is met with also in coaa’s and 
various other domestic and undomesticated animals. 
Glioma. 
Glioma, by some regarded as a variety of sarcoma, is by others (e. g. 
Sutton) considered as a distinct variety of tumor. Inasmuch as the 
nervous system is really of epiblastic origin, it is questionable whether 
gliomata may, after all, belong in Group VII., Tumors of Epithelial or 
Hypoblastic Origin. For purposes of simplification, at least, it may be 
well included here as a type of sarcoma. It consists of delicate con- 
nective tissue, identical with that which is known in the histology of the 
nervous system as neuroglia. It bears the same relation to the central 
nervous system that plexiform neuroma bears to peripheral nerves. It 
occurs only in the former—that is, in the brain, in the spinal cord, and 
perhaps in the optic nerve. Structurally, it consists of cells with delicate 
ramifying processes held in place by fibrous tissue. Gliomata are 
usually quite vascular, the vessels being even sometimes sacculated. 
For the most part these tumors are solitary—i. e. do not give rise to 
secondary deposits. When near the surface of the cortex such a tumor 
may appear like an enormous convolution (Virchow). In the basal 
portions of the brain these tumors may attain considerable size. 410 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
Gliomata in the spinal cord are rare, occurring twenty times as often 
in the brain as in the cord. In the latter location they are usually 
indistinctly outlined and cause a general enlargement of the cord. They 
may occur anywhere along its length, but are most common in the 
cervical portion. They are most common also between the fifteenth 
and thirtieth years of life, but may be met with in old age. The 
symptoms of these growths consist usually of pressure-effects, and it is 
ordinarily impossible to diagnose them before either operation or autopsy. 
If attacked at all, they need to be most radically extirpated, else these, 
like sarcomata in general, are most prone to return. 
5. TUMORS OF SIMPLE MESOBLASTIC-TISSUE TYPE. 
Lipomata, or tumors composed of fat, are the most commonly met 
with of all neoplasms. Their normal type is the ordinary adipose tissue 
of the body, while, anatomically, they may be divided into the encap- 
sulated and the diffuse, the former of which are surrounded by more or 
less of an investment of fibrous tissue by which a certain form and 
integrity are preserved. The diffuse lipomata are those which are pos- 
sessed of no capsule, where the pathological collection of fat merges 
into that normally present—in other words, they are not circumscribed. 
Lipoma. 
Fig. 160. 
Diffuse lipoma of neck (Madelung). 
Subcutaneous lipomata are perhaps the most common of all, and are usually 
irregularly lobulated and encapsulated, adherent rather to the skin than to the 411 
CYSTS AND TUMORS. 
deeper tissues. Usually but one is found in a given individual, though instances 
of multiple lipomata are not rare. They develop sometimes to enormous size, 
cases being on record where the tumor has even weighed one hundred pounds. 
They may be met with at any point on the surface of the body. The lobules often 
burrow between the muscles, and those found in the palm of the hand penetrate 
even beneath the palmar fasciae. They are sometimes markedly pedunculated, and 
hang often by a small stem. The diffuse subcutaneous lipoma is most common 
about the neck ; next most common in the groin and axilla. 
Subserous lipomata are for the most part retroperitoneal, and very large tumors 
of this character, mistaken for ovarian tumors, have been successfully removed by 
operation. In the hernial canals and spaces they also are met with. They develop, 
moreover, beneath the peritoneum covering the intestines, and in this location they 
give rise occasionally to intussusception. Here they have the general form and 
significance of appendices epiploicce in their pathological development. 
Subsynovial lipomata occur about various joints and tendon-sheaths ; especially 
within the knee they assume a distinctive type which has been called lipoma 
arborescens, where they take on a dendritic appearance and arrangement. Submucous 
lipomata are rare. Intermuscular fatty tumors are occasionally met with, an inter- 
esting variety being that which develops between the masseter and buccinator 
muscles. Intramusmlar forms are also rarely met with, as well as a variety known 
as parosteal, which arise in connection with the periosteum. Fatty tumors also 
occur within the spinal dura, as well as outside of it within the spinal canal, and 
more or less lipomatous alterations are common in connection with spina bifida. 
Lipomata are ordinarily easy of recognition, save when deeply located. 
The subcutaneous forms are intimately related with the overlying skin, 
and have a dough-like consistence which is usually pathognomonic. Those 
tumors, suspected to be fatty, which are met with in the middle line of 
the back or cranium are always to be viewed with suspicion, since they 
are often connected with congenital meningeal protrusions. 
An encapsulated lipoma, when thoroughly removed, will not return. 
It is when one deals with the diffuse variety that he often finds inter- 
ference unsatisfactory or regrets that he has attempted it, the difficulty 
being in knowing where to stop. 
Mixed forms of fibrous and fatty neoplasm are not infrequently met 
with, which may be spoken of as lipoma fibromatosum or fibroma lipoma- 
tosum according as one or the other tissue predominates. These growths 
are innocent in their character, but call for thorough extirpation. They 
frequently give rise to considerable discomfort or pain—so much so that 
they have been spoken of as lipoma dolorosa. 
Fibroma. 
Fibromata are tumors composed of fibrous tissue, which, when of 
pure type, are found to be not so common as was formerly supposed, the 
majority of tumors hitherto roughly grouped as fibromata containing 
either muscle-tissue or sarcomatous elements, which takes them out of 
the category of pure fibroma. A typical fibroma is ordinarily dense, 
and is composed of wavy bundles of fibrous tissue whose cells are long 
and slender and closely packed together, the mass being permeated by 
distinct blood-vessels. 
Fibroma occurs most commonly in the ovary, the uterus, the intestine, 
the gum (epulis), in nerve-sheaths, and in the skin in the form of so-called 
painful subcutaneous tubercles and molluscum jihrosum. There is also a 
fibrous tumor of the skin, known as keloid, sustaining to fibroma the 
same relation that obtains between exostosis and osteoma. 412 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
The painful subcutaneous tubercle of many writers is a sample of pure fibroma 
in the shape of a small, flattened pea-like tumor which never attains great size. 
It is situated loosely in the subcutaneous structure and may form a visible prom- 
inence. Insignificant as it would thus appear, it becomes the seat of exasperating 
pain, particularly when touched or handled: this may radiate to considerable dis- 
tances. The etiology of these little growths is absolutely unknown. 
In the ovary, the uterus, the intestine, and the larynx pure fibrous tumors are 
pathological curiosities rather than common lesions. 
Epulis means, in effect, any tumor growing upon the gum. The term was 
formerly applied in an indistinct and too comprehensive way, although it is still 
retained in literature. But pure fibromata do spring from the fibro-osseous struc- 
ture of the gum and alveolar process. They are covered with the gingival mucous 
membrane and seem to spring from the periodontal membrane. They seldom 
attain large size; then only through neglect. By the pressure of such tumors 
teeth may be separated and no little distortion of the mouth produced. 
Molluscum jibrosum has also been described as dermatolysis and pachydermatocele. 
It consists essentially in hypertrophy of the fibrous elements of the body-covering, 
which may affect a small area like the scalp or a large area of integument which is 
made to hang in folds. It may also assume the form of scattered nodules, varying 
in size. It may be associated with true fibroma of nerve-sheaths or with true 
neuroma. It is seldom observed in this country, and is for the most part confined 
to the African races. 
Keloid is a fibrous neoplasm arising, for the most part, in cicatricial 
tissue, which is essentially fibroid in structure. It is a neoplasm which 
often follows the general outline of the scar in which it grows, consists 
in elevation of the surface, ordinarily quite smooth, sometimes of a 
delicate pink from the dilated vessels which it contains. Keloid is the 
b&te noir of surgeons, since it frequently complicates and disfigures scars 
which have been at first perfectly satisfactory, and since it indicates a 
condition which it is discouraging to deal with, because when it is 
removed there is usually recurrence of growth within a few months 
after cicatrization. It occurs often in stitch-hole scars and upon the 
site of extensive burns, may be met with after puncture of the ears for 
ear-rings, and has also been observed in scars left by smallpox, acne, 
etc. It is more prevalent in the col- 
ored than in the white race. In negroes 
multiple keloid tumors are often seen, 
occasionally even in large numbers. 
Their explanation is unknown, and it 
may be that some trifling injury has 
preceded each individual tumor. Vide 
Plate XIV. 
Fig. 161. 
Chondroma. 
The true chondroma is a tumor 
composed of hyaline cartilage. It 
occurs most often and typically in 
the long bones, usually in relation 
with epiphyseal cartilages, and, con- 
sequently, is most often noted during 
the earlier years of life. While it 
is usually a solitary tumor, multiple 
chondromata are often seen, especially upon the hands. These tumors 
are often encapsulated, and form deep hollows in which they rest. 
Enchondroma from inner aspect of pelvis 
(contributed by Dr. Holloway). PLATE XIV. 
Keloid of External Ear; «, Dense Tissue of Skin; b, Fibrous Connective Tissue; 
c, Epidermis. (Klebs.) CYSTS AND TUMORS. 
413 
Unless pressing upon nerve-trunks they are painless and slow of 
growth. They are exceedingly dense and hard, and ordinarily immov- 
able. Mucoid softening (i. e. cystic degeneration) is common, and the 
softened areas may give rise to fluctuation. There may be coincident 
calcification or ossification in any of these growths. It is noted as a 
curious circumstance, by Sutton, that their tissue resembles histologi- 
Fig. 162. 
Multiple enchondromata (contributed by Dr. Holloway). 
cally the bluish, translucent epiphyseal cartilage which is seen in pro- 
gressive rickets. 
To the small local hypertrophies of cartilage which are seen especially about 
joints, about the laryngeal cartilages and the triangular cartilage of the nose, are 
given the term ecchondroses. They are most common in the knee in connection with 
rheumatoid arthritis, and occur as prominences along the margins of the joint- 
cartilage. They may project to such an extent as to be detached by accident, after 
which they become movable and floating bodies in the joints. Many of the float- 
ing cartilages or bodies found in joints are, in other words, detached ecchondroses, 414 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
which may be smoothed off by attrition, and which may be found singly or multi- 
ple, even several hundred existing in one joint. 
Chondromatous changes as occurring in sarcomatous tumors have already been 
alluded to. It seems to be easy for connective tissue to form hyaline cartilage, 
and mixed tumors may thus be met with in connection either with sarcoma, 
fibroma, or other forms. 
The treatment of chondroma is solely operative. Unless the 
integrity of a member or a limb be compromised, such a tumor can usu- 
ally be shelled out from its location, but requires that the matrix be 
completely extirpated; all of which may call for the use of powerful 
bone-instruments. At other times amputation is the only measure 
which may relieve from deformity, pain, and disability. The ecchon- 
droses occurring within joints call usually for incision and evacuation 
with the most rigid aseptic precautions, without drainage, as the case 
may be; when practised according to modern technique this is almost 
invariably successful. In former times many lives were lost because of 
septic infection, which is now avoidable. 
Osteoma. 
Under the head of Nomenclature I have already endeavored to dis- 
tinguish as between exostosis, or irregular bone-outgrowth, and oste- 
oma, as a distinct tumor which is composed of bone-tissue, with the 
subvariety odontoma, or tumors of dental origin and structure. Oste- 
oma is regarded by some as ossifying chondroma, since it is nearly 
Fig. 163. 
Double osteoma of skull (Mus6e Dupuytren). 
always found near epiphyseal lines, and is always covered by hyaline 
cartilage when thus found. Nevertheless, it is not invariably such. 
We speak of compact or ivory osteoma and of a cancellous form. The 
former is identical with the compact tissue of the shafts of long bones, 
and may occur anywhere, but is most common about the cranium, at the 
frontal sinus, the external meatus, and the mastoid process. Osteomata 
growing into the frontal sinus of oxen, for instance, form large lobulated 
bony masses, sometimes weighing several pounds and as dense as ivory. 
Some of these tumors growing into the cranial cavity have been 
absurdly regarded as ossified brains. Osteomata in connection with the 
external auditory meatus partially or completely obscure this channel 
and cause deafness. They constitute ivory-like growths, which defy 
sometimes the finest steel instruments with which the surgeon can sup- 
ply himself. CYSTS AND TUMORS. 
415 
Cancellous osteomata grow in the cranium as well as in the long 
bones, and, like the compact forms, only occasion pain by pressure upon 
nerve-trunks. 
Exostoses are classed by Sutton as— 
(1) Those formed by ossification of 
tendons and their attachments. One 
should exclude from this group such 
natural or evolutionary processes as 
the superior condyloid process, the third 
trochanter of the femur, etc. Over or 
around such exostoses bursse will form 
to mitigate as much as possible the etfect 
of friction. 
(2) Subungual exostoses, occurring 
usually beneath the nail of the big toe. 
(3) Exostoses due to calcification of in- 
flammatory exudations, including the rare 
condition known as myositis ossificans. 
When a true osteoma is once 
thoroughly removed there is no tend- 
ency to recurrence. Thorough removal, 
however, calls sometimes for serious 
and often mutilating operations, which 
may become dangerous when the growth 
involves the curve of a rib or a large 
portion of the skull. At other times amputation is rendered necessary. 
Special forms call for special treatment suitable to the case in hand. 
Fig. 164. 
Osteoma of frontal sinus (Neisser). 
Odontoma.1 
The odontomata are tumors composed of one or more of the dental 
tissues, arising either from tooth-changes or teeth in process of develop- 
ment. They may be divided, according to Sutton, as follows: 
(a) Epithelial Odontomata.—These are provided with a capsule, and 
present usually as a series of cysts separated by thin septa, containing 
mucoid fluid, while the growing portions have a reddish tint not unlike 
sarcoma. They are most frequent about the twentieth year of life, but 
may occur at any age. They probably arise from persistent remains of 
the epithelium of the original enamel-organs. 
(b ) Follicular Odontomata.—These are often spoken of as “ dentiger- 
ous cysts,” a term used altogether too loosely. They arise in connection 
with permanent teeth, and especially with the molars, sometimes attain- 
ing great size and producing conspicuous deformity. The tumor con- 
sists of a wall representing the expanded tooth-follicle, and a cavity 
containing viscid fluid, with some part of an imperfectly developed 
tooth, occasionally loose, occasionally more or less displaced in location. 
The cyst-wall always contains calcareous material. These tumors 
rarely suppurate. They occur also in animals. 
1 These tumors are really of epithelial origin, since the teeth are epithelial products. 
They therefore really belong in Group VII., but are retained here because of their clini- 
cal resemblance to the osteomata, and lest previous classifications suffer too violent a 
shock. 416 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
(c) Fibrous Odontomata.—These consist of condensed connective 
tissue in a developing tooth, and presenting as a tumor with a firm outer 
wall and a loose inner texture, blending at the root of the tooth with 
the dental papilla and indistinguishable from it. The developing tooth 
thus becomes enclosed within the capside before it protrudes from the 
gum. These tumors are most common in ruminants, being often mul- 
tiple. 
(d) Cementoma.—This refers to a tumor of fibrous character whose 
capsule has ossified or calcified, the developing tooth thus becoming 
imbedded in a mass of dental cementum. These tumors occur most 
frequently in horses. 
(e) Compound Follicular Odontomata.—These are tumors containing 
a number of masses of cementum resembling small teeth, or even 
amounting to well-formed but ill-shaped teeth composed of all three 
dental elements. In such a tumor teeth may be found by the score. 
They are met with in the human subject as well as in animals. 
(/) Radicular Odontomata.—These are tumors which arise after the 
crown of the tooth has been completed and while its roots are yet in 
process of formation. The crown, being unalterable enamel, does not 
enter into the composition of these growths, which then consists of 
dentine and cementum in varying proportions. These tumors are rare 
in man, but frequent in other animals, and often multiple. 
(g) Composite Odontomata.—These are hard tumors, bearing little or 
no resemblance in shape to normal teeth, occurring in the jaws, consist- 
ing of a conglomeration of enamel, dentine, and cementum, presenting 
abnormal growth of all the elements of the tooth-germ. So far, this has 
only been found in man. 
So little is said about the odontomata in general surgical literature 
that I have devoted some space to the subject here, since these tumors, 
as they grow, are often regarded as due to necrosed bone or to unerupted 
teeth, while fibrous odontomata have often been regarded as myeloid 
sarcomata. No tumor of the jaw, especially in young people, should 
lead to excision of the jaw until it has been fairly demonstrated that the 
tumor is not one of the above forms, and that it really is something call- 
ing for so severe an operation. When one has to deal with a true odon- 
toma its complete removal is all that is called for, and no further sacrifice 
of tissue is necessitated. 
The myxomata are composed of mucous tissue, whose best-known 
normal representative is the Whartonian jelly of the umbilical cord. 
True myxoma should be distinguished from myxomatous degeneration, 
which occurs frequently in cartilage, fibrous tissue, and sarcoma, and 
which brings about a similar condition of affairs, though of essentially 
different origin. Myxomata appear under the following forms : 
(a) Polypi, growing most often in the nose. The pure form of nasal 
myxoma proceeds from the mucous membrane of the nasal passages or 
sometimes from the accessory sinuses. The polypi hang usually as gelat- 
inous tumors of grayish-yellow tint, being present sometimes singly, 
sometimes in clusters or in large numbers. Their principal effect is to 
produce nasal obstruction, with, perhaps, subsequent serious disorder, 
Myxoma. CYSTS AND TUMORS. 
417 
due to decomposition or to extension into the pharynx or other cavities. 
Similar growths also occur from the mucous membrane of the tympanum, 
and constitute the common variety of aural polypi. 
(b) Cutaneous myxoma is not common. It presents usually as a ses- 
sile tumor, although about the perineum and labia the tumors may 
become pedunculated. It is often difficult to distinguish between a 
myxoma of the skin and a sarcoma of the same which has undergone 
myxomatous degeneration, and which then should be strictly called sar- 
coma myxomatodes. The latter tend to recur after removal; hence the 
importance of exact diagnosis, if possible, in which the history of the 
case will largely aid. 
(c) Neuromyxoma is a similar condition involving the nerve-trunks, 
and is dealt with rather under the heading “ Neuroma.” 
Myxomata require complete removal, and in the nose especially cau- 
terization or destruction of the surface from which they spring. When 
this is thoroughly done they do not recur; otherwise, they are quite 
likely to require subsequent operation. 
Myoma. 
The true myoma is a tumor composed of unstriped or involuntary 
muscle-fibre. Until very recently it has been customary to divide the 
myomata into the leiomyomata in contradistinction to the rhabdomy- 
omata, the latter being supposed to be tumors of voluntary muscle-fibre. 
The latter, however, are now known to be spindle-celled sarcomata (q. v.), 
in which a certain striation of spindle-cells is often observed, and have 
been already spoken of in their proper place. Myomata, then, are met 
with only where involuntary muscle-fibre is found—namely, in the uterus 
and adnexa, the vagina, the oesophagus, alimentary canal, the prostate, 
the bladder, and the skin. They form encapsulated tumors composed of 
fusiform muscle-cells with a rod-like nucleus, the size of the cells vary- 
ing greatly in different specimens. The bundles of muscle-fibres are 
much contorted, and it is often difficult in a single section to decide to 
just what class of cells they really belong. 
These tumors are by all means most common in and about the uterus, and are 
spoken of as intramural when developing in the true uterine tissue, and submucous 
and subserous when situated closely beneath one or the other of the adjoining mem- 
branes. They differ greatly in their rate of growth, are, as a rule, quite firm in 
composition, and are moderately vascular, sometimes containing areas of softening 
and becoming even cystic. In rare instances they become enormously vascular, 
and have then been spoken of as cavernous myomata. Aside from mucoid or col- 
loid changes, such as referred to, they occasionally undergo fatty metamorphosis 
or calcareous infiltration. The latter is possible even to such an extent as to lead 
to the condition formerly spoken of as uterine calculi. 
Uterine myoma is quite liable to septic infection, which frequently follows 
exploration of the uterus or the changes incident to pregnancy or parturition. It 
then becomes a case for immediate and most radical surgical attack. Uterine 
myomata do not occur before puberty, rarely before the age of thirty-five, and are 
most common between the thirty-fifth and forty-fifth years of life. More definite 
information concerning the enormous size which they attain or the special cha- 
racteristics which they display must be sought in the special treatises on Gyne- 
cology. They produce disaster not alone by their size, but by hemorrhage, by 
pressure on adjoining viscera (rectum, kidneys, etc.), and occasionally by torsion 
of a long pedicle. The operations, including myomectomy and hysterectomy, 
which are necessary so often for their complete removal, will be treated of at 418 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
greater length in Volume II., while for full information the reader must necessa- 
rily be referred to the special treatises. 
Myomata are found in the oesophagus anywhere along its course, in the walls 
of the stomach, where they are frequently confounded with malignant tumors, and 
in the prostate and wall of the bladder. Also in connection with the skin they are 
occasionally met with. Wherever met with, so soon as they give rise to incon- 
venience or to dangerous symptoms they are to be dealt with surgically, since no 
other treatment has been proven to be of lasting benefit. 
6. TUMORS OF COMPLEX MESOBLASTIC TYPE. 
Angeioma. 
Angeiomata are tumors composed, in whole or for the most part, 
of blood-vessels, and naturally group themselves under three headings, 
in accordance with the structure of the vascular 
system : 
(а) Capillary angeioma or naevus, the most com- 
mon form of all, and frequently seen in the skin and 
subcutaneous tissue. When the condition is spread 
over a relatively large area it gives rise to a discol- 
oration known to the laity as port-wine mark. This 
is spoken of by pathologists as a telangiectasis, 
referring to vessels which are present in abnormal 
number and of abnormal size. The condition is 
often congenital or begins soon after birth. Accord- 
ing to the color of the affected area it may be deter- 
mined quickly whether the vessels belong mainly to 
the venous or to the arterial system. These tumors 
may be found in all parts of the body, upon the sur- 
face, and less often are seen upon the submucous sur- 
faces of the tongue, the inside of the mouth, the con- 
junctiva, and the vulva. The tendency is toward 
gradual increase in size ; rarely spontaneous contrac- 
tion and obliteration occur. 
(б) Cavernous Tumors.—These are similar in 
structure to the corpus cavernosum, and are often 
spoken of as erectile tumors. They are most com- 
mon in connection with the skin, and are simply 
exaggerated forms of the variety first described, the 
vessels becoming not merely dilated, but cavernous 
in arrangement. They occur occasionally in the 
tongue, in the voluntary muscles, and in the liver, 
and are noted very rarely in the mammae, in the 
larynx, and subperitoneally. (Vide Plate XV.) 
Fig. 165. 
A similar condition, but much more exaggerated, is met 
with in the so-called cavernous tumors which involve various 
organs, especially the thyroid and the liver. In these instances 
a part or the whole of the organ may be involved, and pre- 
sents great increase in size and evidences of excessive vas- 
cularity, which one cannot fail to distinguish sometimes 
even at a distance. In cavernous growths of the thyroid, 
for instance, one may meet with vessels, veins especially, the size of his thumb, 
while with the ear not touching the body of the patient a distinct venous mur- 
mur may be appreciated. 
Angeioma; medullary- 
tumor in shaft of hu- 
merus, leading to spon- 
taneous fracture (Lan- 
ceraux). PLATE XV. 
Cavernous Angeicma of Inver ; a, Vascular Portion ; b, e, d, Growing Neoplasm ; 
c, Hepatic Tissue. (Klebs.) CYSTS AND TUMORS. 
419 
(c) Arterial or plexiform angeiomata, which when of any particu- 
lar size are ordinarily spoken of as cirsoid aneurism or aneurism by 
anastomosis. This form consists of arteries abnormal both in number, 
length, and diameter, tortuous in arrangement, occurring perhaps most 
often in the scalp, rarely in the perineum or genitalia, and exceedingly 
rarely in other parts of the body. They will be spoken of at greater 
length under the heading Aneurism in Chapter XXXII. These 
tumors are exceedingly liable to rupture from external injury, and call 
usually for ligation of the main arterial trunks, with perhaps extir- 
pation of the tumor-mass. 
Recognition of angeiomata is never difficult unless they are deeply concealed. 
The effect of intermitting pressure, the emptying and refilling, and the distinction 
between arterial and' venous growths by the result of alternating pressure and 
relaxation, either above or below the growth, coupled with the discoloration of the 
skin, and, in the larger growths, the very audible murmur,—all these signs should 
leave one ordinarily in little or no doubt as to the character of the growth in hand. 
When such growths are small they may be dealt with by electrolysis, 
the needles from both poles being introduced, or only from the negative, 
the positive being applied upon some neighboring portion of the body— 
perhaps with the understanding that the treatment may have to be 
repeated once or oftener in order to bring about final obliteration of the 
tumor. The effect of the electric current is to determine the coagula- 
tion of the blood in the tissues acted upon, and this, in turn, is followed 
by organization of thrombus, conversion of vascular into cicatricial 
tissue, shrinkage, and possible eventual disappearance of the mass. It 
is good treatment with many forms of these growths to make a radical 
excision under an anaesthetic, dissecting out the mass as one would any 
other tumor, securing bleeding vessels, and reuniting the parts by 
sutures, with the expectation of securing primary union. This is the 
quickest and in many cases the least disfiguring method. Old methods 
of ligation or surrounding vessels or the subcutaneous ligature are now 
practically discarded. Still worse, and to be most severely condemned, 
are the injection methods as formerly practised, especially the use of 
iron salts in solution. Death has promptly followed resort to this 
expedient, and it is now never justifiable. With the two expedients of 
electrolysis and excision the surgeon has at hand nearly all the measures 
which he will ever need to practise for the medical treatment of angei- 
omata. In exceptional cases other methods may be resorted to which it 
is not necessary to discuss here. 
Lymphangeioma. 
Lymphangeiomata are tumors composed of lymph-vessels and 
bearing an exact resemblance to the tumors just above considered. 
They may likewise be divided into three varieties: 
(a) The lymphatic nsevus, composed for the most part or entirely 
of lymphatics nearly normal in size, but abnormal in number, occasion- 
ally colored red by the presence of blood-vessels. When pricked, pure 
lymph or blood-stained lymph will flow. They are for the most part 
quite small, and are noticed during the earlier years of childhood. They 
may occur anywhere upon the surface of the body or in the mouth, most 
frequently in connection with the tongue, where they appear most often 420 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
Fig. 166. 
as large papillae involving a portion 
or all of the dorsum. When all the 
lymphatic structures of the tongue 
are thus abnormally enlarged and 
involved, the condition is known as 
macroglossia, and consists of' more or 
less enlargement of the organ, some- 
times to a degree not permitting its 
retention in the mouth, but leading 
to its constant protrusion. 
(6) Cavernous lymphangeioma 
corresponds to cavernous angeioma, 
and is a condition in which the lymph- 
vessels become positively cavernous 
and sacculated. 
(c) Lymph-cysts are the still 
more aggravated form which lym- 
phatic dilatation may attain, and are 
usually encapsulated, complicated 
with more or less tense tissue, and 
produce a condition of the parts, espe- 
Lymphangeioma of lip; macrocheilia 
(Neisser). 
Fig. 167. 
Fig. 168. 
Congenital lymphangeioma (original). 
Lymphangeioma of lower extremity (original). CYSTS AND TUMORS. 
421 
daily about the scrotum and labia, to which the term elephantiasis is often 
applied. 
The old question of congenital occlusion or dilatation of lymph-channels is one which 
has been made the subject of large separate monographs (especially by Bussey), 
and, while deserving of the greatest consideration, cannot be more than touched 
upon in this place. Suffice it to say that numerous tumors, essentially of lymph- 
vascular origin, are found upon the lips, in the neck, and elsewhere, which grow 
slowly, are more or less elastic and spongy upon pressure, are frequently covered 
by skin from which hair grows most luxuriantly, and in which pigment or papil- 
lomatous structures are dispersed, and by which diagnosis may be aided. These 
tumors are often spoken of as cavernous tumors, are of slow growth, and occasionally 
undergo spontaneous involution, but usually eventually call for surgical relief. 
They are often confused with branchiogenic and other congenital cysts of the 
neck. 
The treatment for the smaller lymphatic tumors is simple, but 
here electricity is less to be relied upon and excision is more urgently 
called for. Electrolysis will cause coagulation of blood, but not of 
lymph—at least not to nearly the same extent; consequently its useful- 
ness is restricted to blood-vascular tumors. Excision, then, is almost 
the sole, at least the best, remedy. When this is impracticable much 
can be done by galvano- or ignipuncture, the cicatricial contraction 
following multiple punctures leading often to reduction in size of the 
affected part. The enlargement of the tongue spoken of above as 
macroglossia may be treated by ignipuncture or by electrolysis, if neces- 
sary under an anaesthetic, the effect of the electric current here being 
not to produce coagulation, but apparently absorption of fibrous tissue 
and changes which come slowly rather than by obliterative processes. 
7. TUMORS OF EPITHELIAL TYPE OR OF EPIBLASTIC 
ORIGIN. 
In this general group of tumors epithelium or epiblastic tissue is the 
essential and distinctive feature. According to differences in shape and 
disposition of epithelial cells, or according to the embryological origin 
of certain complex tissues (nerve), these tumors may be arranged as 
follows : 
1. Neuroma. 
2. Papilloma. 
3. Epithelioma. 
4. Adenoma. 
5. Carcinoma. 
But of these the first, though often considered by itself, essentially 
belongs here, while the fourth and fifth may be advantageously considered 
by themselves as Tumors of Glandular-tissue Type. 
Neueoma. 
The entire nervous system is produced by infolding of the epithelial 
or epiblastic layer of the embryo. Hence the consideration of neur- 
omata in this place. 
True neuromata spring from the structures of nerve-trunks, which 
trunks may also be the site of other tumors, mainly fibromata and sar- 
comata, with which neuromata may easily be confounded. The most 
common nerve-tumor is the neuro-fibroma, which grows from the struc- 422 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
ture of a nerve-sheath, its long axis usually coinciding with that of the 
nerve-trunk. Tumors of this class vary greatly in size, are often mul- 
tiple, and in other instances affect nearly all the nerves in the body. 
Fig. 169. 
Neuroma: a, large nucleated cells; b, nerve-fibres cut transversely (Lanceraux) 
They are extremely liable to myxomatous degeneration, which will account 
for many of the instances reported as myxo-neuroma, etc. They attack 
cranial and spinal nerves alike, and no nerve or nerve-root in the body 
Fig. 170. 
Multiple neuromata (Lanceraux) 
is necessarily exempt. The sensory nerves appear more liable to attack 
than the purely motor. The nerve least often attacked is the optic. CYSTS AND TUMORS. 
423 
They are not rare upon the roots of the spinal nerves, in which location 
one may attain to such size as to press upon the cord and induce 
paraplegia. Multiple neuromata are often associated with molluscum 
fibrosum (q. v.). There is one instance on record in which one thousand 
six hundred of these tumors were found after careful dissection of the 
neuro-skeleton, and another in which at least two thousand were found, 
sixty of them involving the pneumogastric trunks and their branches. 
Plexiform neuroma is relatively rare. This means a type of nerve- 
tumor in which all the branches, for example, of a given nerve which 
are distributed to a particular area become enlarged and elongated, the 
overlying skin being stretched and thin. Such a tumor seems like a 
loose bag containing a number of vermiform bodies, resembling the 
sensation given when palpating a varicocele. On section each of the 
affected nerves reveals a quantity of myxomatous tissue replacing the 
nerve-sheath. They are in large measure congenital. 
Malignant neuroma (so called) will usually be found to be a true sar- 
coma of nerve-structures, usually of the spindle-celled variety. Trau- 
matic neuroma is most often seen in amputation-stumps, where the ter- 
minations of the divided nerves become bulbous, attaining the size of 
cherry-stones, the tumors being composed of a mixture of connective 
tissues and nerve-fibre, from which in time the true nerve-structure 
usually recedes or vanishes. They seem to form more often when sup- 
puration has been profuse or healing long delayed, and most often when 
sufficient care has not been exercised to prevent entangling of the nerve- 
ends in the scar of the wound. They give rise to a great deal of pain, 
and often necessitate re-amputation. The bulbous enlargement seems 
always the result of prolonged irritation in a nerve, and has been noted 
around various foreign bodies. 
True neuroma is innocent in tendency, though often extremely pain- 
ful. It is the sarcoma of nerve-tissue which produces signs of malig- 
nancy. A true neuroma which causes unendurable pain should be 
removed when accessible. It is sometimes possible to separate the 
tumor-mass from the balance of the nerve-trunk, and thus to remove it 
without excision of the nerve. At other times it is impossible to avoid 
division and ensuing paralysis. Whenever possible divided nerve-ends 
should be brought together by catgut suture, by which means it may be 
possible to avoid permanent loss of function. Nerve-grafting is also 
resorted to for filling such defects. Removal of painful neuromata due 
to injuries to the head has more than once been the means of curing 
traumatic epilepsy. 
Papilloma. 
The type of papilloma is the common wart, consisting of a central 
stem of fibrous tissue and blood-vessels covered by epithelial projections 
and proliferations. Papillomata are mainly sessile and villous, as well 
as occasionally met with in other forms. 
(a) Warts.1—These are sessile papillomata, most common on the skin, 
often seen on mucous surfaces, and occurring sometimes singly, often in 
crops. They are exceedingly common about the perineum, where skin 
1 The warts are by many pathologists considered as mere evidences of hypertrophy 
from persistent irritation. They are here retained among the tumors lest too much vio- 
lence be done to formerly-received notions. 424 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
and mucous membrane meet, and are regarded as, for the most part, due 
to the irritation of specific discharges. The papillomata occurring about 
the genitalia are ordinarily spoken of as condylomata. The growths in 
these instances are frequently so luxuriant and proliferative that they 
assume fungoid shape, and are often spoken of as mulberry growths. 
Warts grow slowly or rapidly according to circumstances not easily 
appreciated. Warty growths may attain relatively enormous size and 
become very vascular. Late in life they are frequently the starting- 
points of epithelial in-growths, and then become true epitheliomata— 
i. e. cancer. Warty growths sometimes line the buccal cavity and com- 
plicate cases of macroglossia. They are also met with in the larynx, and 
when situated near the glottis may cause dyspnoea or even fatal obstruc- 
tion to respiration. 
(6) Villous Papillomata.—These are met with most commonly in 
the bladder, occasionally in the pelvis of the kidney. They are strictly 
identical with chorionic villi. They occur for the most part singly. It 
Fig. 171. 
Papilloma of bladder. 
often happens that long fine tufts are detached and carried away with 
the escaping urine : their presence when recognized should be pathogno- 
monic. Another form of villous growth arises from the choroid plexuses 
of the lateral ventricles in the brain. These may grow and attain a size 
sufficient to produce disturbance. 
(c) Intracystic Villous Growths.—These are seen, for example, in 
mammary cysts. These, of course, are lined with epithelium, which 
acts here as it does in other localities, and proliferates under unknown CYSTS AND TUMORS. 
425 
circumstances more or less rapidly. In dealing with paroophoritic cysts 
the presence of these growths has also been alluded to. 
(d) Psammomata.—These are peculiar epithelioid tumors composed 
of a globular arrangement of epithelial cells in layers, enveloped by con- 
nective tissue and usually calcified. They are met with exclusively in 
the pict mater of the brain and cord. In the former case the epithelium 
comes from the neighboring choroid plexus. Calcareous degeneration is 
a marked characteristic, and these little tumors often feel like stone. In 
this respect the arrangement is identical with that in the pineal body. 
Psammomata never grow to large size: they are for the most part no 
larger than peas or small cherries. They are somewhat common in 
horses, developing from the surrounding plexus, as in man. Here they 
may attain the size of a walnut and still produce no recognizable dis- 
turbance. Psammomata of the spinal pia are much more serious, since 
here they will probably produce disastrous pressure-effects. 
(e) Cutaneous Horns.—These are also epithelial outgrowths, and are 
met with in four varieties (Sutton) : 
(1) Sebaceous horns, quite common, arising by protrusion of contents of a seba- 
ceous cyst through a rupture in its wall or through its duct, with consequent desic- 
cation by exposure to the air, while fresh material is consequently added at the 
basis so long as sebaceous secretion continues. These growths quickly soften when 
soaked in weak liquor potassse. 
(2) Warty horns, structurally identical with the above, but growing from warts 
instead of from sebaceous cysts. Both these forms are found most commonly about 
the head. Cutaneous horns are also met with in ovarian dermoids. They are com- 
mon in the lower animals and may attain large size. 
Fig. 172. 
Nail horns (original). 
(3) Horns growing from cicatrices, especially of bones, are rare, but a cornified 
condition of the cicatrix itself, with formation of scales resembling those from 
horns, is not uncommon. 
(4) Nail-horns are simply overgrown nails, occurring for the most part on the 
digits and toes of bed-ridden patients who never walk. 426 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
Treatment.—All these forms of epithelial outgrowth call for radical 
removal, after which, if effected, there is no recurrence. Radical re- 
moval, however, implies complete extirpation of the membrane or tissue 
from which the growth occurs, since if even a little be left there is 
tendency to recedive. 
Epithelioma is common, especially where there is transition from one 
kind of epithelium to another, and, of all other localities, particularly 
where skin and mucous membrane 
meet—e. g. the lips, the vulva, and 
the anus. Epithelioma differs from 
papilloma in that the former is no 
longer limited by basement-mem- 
brane, but passes beyond it into the 
underlying connective tissue and pre- 
sents down—rather than up—growth. 
Characteristic of epithelioma are the 
so-called cell-nests or pearly bodies, 
where there seems to be tendency to 
a globular arrangement of cells with 
such condensation or alteration that 
they lose their ability to take stains, 
and appear as a more or less lustrous 
mass, showing off by contrast among 
the standard surrounding tissue. On 
this account they are often spoken 
of as pearly bodies. Recognition of these is tantamount to diagnosis of 
epithelioma. 
Epithelioma. 
Fig. 173. 
Epithelioma of face (X /4"; Spencer). 
This form of neoplasm is essentially the same, no matter what its clinical 
varieties. These comprise a wart-like 
growth or nodule, which quickly becomes 
an ulcer with elevated edges, ulceration 
being due to necrosis of cells farthest from 
the periphery; or, again, the disease may 
start as an ulcerated fissure, ulceration and 
infiltration keeping pace, in which case 
we have a sharply-defined ulcer with un- 
dermined edges. A third variety, often 
seen upon the lips, comprises a projecting 
mass, often with more or less horny sur- 
face. In all of these, however, the charac- 
teristic cell-nests with their onion-like 
arrangements of cells will be found. 
Epitheliomata, especially when 
exposed to the air or to surface-irrita- 
tion, quickly ulcerate and tend to 
involve all the surrounding tissues, 
while occasionally the distinctive cells 
proliferate so rapidly as to give the 
ulcer more or less of a bursal or a cauliflower-like arrangement. From 
such a surface there is a constant discharge of foul-smelling detritus 
or even of sloughs. Even bone cannot resist progressive invasion and 
Fig. 174. 
Epithelioma of face, with “pearly” body 
X"; Spencer). 427 
CYSTS AND TUMORS. 
slowly disintegrates before the advancing mass. Cartilage is most resist- 
ant, and usually preserves its integrity to the last. In other words, the 
tendency of epithelioma is toward constant encroachment and infiltra- 
tion, and toward a fatal termination from hemorrhage by ulceration, 
from septic infection, exhaustion, or other accidents. The wart-like 
forms run the slowest course of all, but even here the malignant ten- 
dency is most evident. 
Lymph-node Infection.—A striking characteristic of epitheliomata is 
the usually prompt invasion of the adjoining lympli-nodes, which attain 
a size astonishingly disproportionate and bearing no necessary relation 
to the size of the primary growth. This constitutes one of the most 
serious complications of the condition. This lymphatic invasion par- 
takes of the distinctive malignant character of the disease, and from 
every focus of this character infiltration and destruction proceed. 
Infected nodes show also early a tendency to central degeneration and 
to spurious cyst-formation. When the overlying skin becomes involved 
we have extensive sloughing and the conversion into large malignant 
ulcers. Dissemination to a distance (/. e. metastasis) is rare in epithe- 
lioma—much more so than in carcinoma. 
About the mouth epithelioma is not common before the thirty-fifth year of 
life, though I have seen it on the lip of a twenty-year-old woman. It is vastly 
more common in men than in women, and more frequent on the lower than the 
upper lip. In the tongue it seldom occurs before the fortieth year of life. It 
Fig. 175. 
Fig. 176. 
Epithelioma of forehead and eyelid (Neisser). 
Epithelioma of lip (Neisser). 
seems to be more common both in the lip and tongue in men with bad teeth and 
in confirmed smokers, thus giving rise to the view often held that it is purely a 
matter of irritation. It may, however, with equal truth be laid to contact infec- 
tion should one regard it as of parasitic origin. In one-fifth of the cases of epi- 
thelioma of the tongue there are preceding lesions, usually described as leucoplakia 428 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
or ichthyosis of the tongue—conditions characterized by epithelial reduplication 
and the formation of dense plaques or scales. These lesions are for the most part 
regarded as pre-cancerous conditions. 
The disease often starts near the stump of a carious tooth, in which case infil- 
tration and erosion begin promptly and progress rapidly. Epithelioma of the 
tongue has been known to follow down along the obliterated track of the thyro- 
lingual duct, and in this way to bring about a perforating ulcer. 
Epithelioma of the oesophagus is a common cause of stricture of this passage- 
way. It leads always to ulceration, and usually eventually to perforation into the 
trachea or some other cavity or passage (i.e. a blood-vessel). In the larynx the 
disease is well known, and gives rise to intense, and finally fatal, symptoms, but 
has been dealt with successfully by radical operations for extirpation of the entire 
organ. 
Occurring upon the scrotum, epithelioma has been in time past spoken of as 
chimney-sweeper's cancer or soot-warts, and has been usually ascribed to the irrita- 
tion of foreign material. Ulceration and infection of the inguinal nodes proceed 
usually rapidly and disastrously. There is much reason also to believe that tar 
and paraffin may produce similar irritation, and paraffin cancer has been described 
by various writers. It occurs also usually upon the scrotum. 
The skin-lesions which precede the formation of paraffin cancer resemble very 
closely those seen in chimney-sweeper’s cancer. The skin becomes dry, thickened, 
parchment-like, while the openings of the sebaceous glands become obstructed by 
the tar or other material, producing acne-like lesions. Warty outgrowths then 
occur, and these become the seat of malignant ulceration. 
In chimney-sweeper’s cancer the scrotum is usually first affected in a chronic 
dermatitis, to which warty outgrowths succeed, these enlarging and growing down- 
ward as ulceration takes place. 
About the external genitalia epithelioma is not uncommon, particularly in 
and about the prepuce. Such a degree of phimosis as leads to retention of smegma 
is certainly a predisposing cause, not only in man, but in the lower animals. 
Epithelioma of the vulva has been described under the name esthiomlne, and 
requires to be recognized and dealt with promptly if one would attempt a radical 
cure. In the vagina and about the cervix uteri it is common, a large proportion 
of cases of cancer of the uterus being essentially epitheliomata of the cervix. 
In and about scars epithelioma is quite common ; also upon granulating ulcers. 
One danger to which a chronic ulcer is always exposed is that of epitheliomatous 
transformation, and in time past disaster has been the penalty of lack of early 
recognition. These growths also attack lupus-scars, or even any tissues actively 
involved in the lupoid process. This is particularly true between the fortieth and 
sixtieth years of life. Vide p. 97. 
Among the viscera, the gall-bladder is probably more often involved in distinct 
epitheliomatous changes than any other. It presents as a pretty uniform thick- 
ening, and causes augmentation in size, so that a distinct tumor projects from 
beneath the liver. In this location dissemination is rare. 
Epithelioma is to be regarded as having an essential and too often a 
rapidly malignant tendency, and should be attacked from the very out- 
set with determination and without mercy. Its successful treatment 
demands early and wide removal of diseased parts and complete extir- 
pation of all involved lymph-nodes—both of these to be carried out 
without regard to anything but complete removal. The involved tissue 
being excised, the question of plastic closure of defect or operative 
atonement for loss of tissue may call for the best of judgment and the 
highest degree of operative skill, in order that the best cosmetic results 
may be obtained. It is only the very small and incipient growths 
which ought to be ever attacked bv such destructive agencies as cancer- 
pastes or the electrolytic current. While these occasionally give satis- 
factory results, their use is for the most part unscientific, and therefore 
barbarous. 
Rodent Ulcers.—Under the name of rodent ulcers, herpes exedens, CYSTS AND TUMORS. 
429 
lupus exedens, noli-me-tangere, etc. writers, for the most part English, 
have described a variety of epithelioma commonly met with upon the 
face to which in time past a separate classification has usually been 
assigned. Until recently it lias been generally regarded as a local 
ulceration, distinct from cancer. In most of the older text-books it is 
referred to as lupus exedens. It is preceded usually by a nodular con- 
dition ol the skin, quite vascular, breaking down into a regular ulcera- 
Fig. 177. 
Fig. 178. 
Rodent ulcer (original) 
tion, but little, if at all, elevated, the base of the ulcer deeply excavated, 
with a striking disproportion between ulceration and new growth. In 
this particular variety infiltration seems to be continuously in advance 
of the rodent process, the former being excessive, the latter but slight. 
This variety of epithelioma rarely, if ever, produces lymphatic involve- 
ment ; the discharge is slight, the pain complained of inconsiderable. 
Occasionally it entirely alters its aspect, and in whole or in part presents 
features of the conventional epitheliomatous type. 
Rodent idcer allies itself rather with the type of tubular epithelioma 
springing from the outer sheath of the hair-follicle, sending out cylin- 
drical processes which freely blend with one another. 
Rodent ulcer is to be regarded as an equally malignant type of 
ulceration with other cancerous ulcers, and demands the same thorough 
and radical measures for its relief as do any other forms of epithelioma. 
It is perhaps the most favorable one to deal with, because of the usual 
freedom from involvement of deep lymphatics. No distinctive meas- 
ures are necessary for its relief—only those which are thorough and 
merciless. 
These include adenoma and carcinoma. 
8. TUMORS OF GLANDULAR-TISSUE TYPE. 
Adenoma. 
Adenoma is a tumor whose type is the normal secreting gland, from 
which it differs in being an abnormal outgrowth or product, but par- 430 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
ticularly in that it has no power of producing the secretion peculiar to the 
gland-tissue or type from which it grows. The adenomata occur for the 
most part as circumscribed tumors in the mammee, parotid, thyroid, liver, 
and in the mucous membranes of the bowel and the uterus. They may 
be single or multiple; in the intestine they are usually multiple. In 
certain locations (e. g. the mamma) they attain occasionally enormous 
dimensions, and in the ovary tumors of this character may be met with 
weighing forty or fifty pounds. The true adenoma shows no tendency 
to infection of neighboring lymphatics, and gives rise to no secondary 
deposits, and when it causes death it is usually because of size or pres- 
sure upon important organs. It displays a marked tendency to cystic 
alteration, while the relative proportion of epithelium and connective 
tissue or stroma varies within wide 
limits. In certain cases, where the 
former is small in amount, the great 
preponderance of the latter has caused 
the use of the term adeno-sarcoma, 
which is really a misleading name. 
The distinction between adenoma 
and true carcinoma is in some respects 
but slight ; and this fact will account 
for the conversion which many in- 
nocent gland-tumors seem to undergo 
from adenoma into carcinoma. So 
soon as the epithelial cells lose their 
regularity of disposition and collect 
in groups or make their way outside 
of the acini into the tissues, then the 
change from the benign to the malig- 
nant tumor has begun and the entire clinical aspect of the case has altered. 
This change may be the result of external irritation, of such tissue-changes 
as pregnancy and lactation, or of the undefined influence which advan- 
cing years seem to produce. 
Fig. 179. 
Adenoma (rectal polyp) (Spencer, J" obj.). 
Adenoma occurs in the breast as cystic adenoma or fibro-adenoma. The former 
attains often large size, are encapsulated, the acini are much dilated, and from the 
walls of the epithelium-lined cavities frequently project papillomatous processes, 
forming what are called intracystic growths. Cystic adenomata grow slowly, pro- 
duce atrophy of mammary tissue by pressure, occur after puberty until the meno- 
pause, and rarely give rise to pain until they become large. As they grow they 
distort the breast until it may become very pendulous. 
Fibro-adenoma occurs also in the breast as a small tumor, encapsulated, usually 
superficially placed, movable in its site, often multiple ; most common between the 
twentieth and thirtieth years of life ; often painful, especially during menstrua- 
tion ; tender upon pressure. Both forms may occur in young men. A form of 
fibro-adenoma in which fibrous tissue is greatly in excess, which never attains 
great size, is common in the breasts of unmarried women. They give rise to much 
pain and distress, but are clinically not malignant. 
Adenoma occurs frequently in sebaceous glands, as— 
(a) Sebaceous cyst, ordinarily known as “ wen.” These tumors 
commonly begin as retention-cysts, the duct of the sebaceous gland 
becoming occluded. But in many cases there is no occlusion of the 
duct, and the secretion may be easily expressed on pressure. They occur 
wherever sebaceous glands abound, but especially often upon the scalp. CYSTS AND TUMORS. 
431 
They are usually multiple, vary greatly in size, are easily movable over 
the bone, and are intimately related to the skin, while the duct-orifice 
is frequently recognized by a black spot, on removing which sebum can 
be expressed. These cyst-adenomata are encapsulated, and can be 
easily shelled out of their matrices, save when inflamed; in which case 
they are often astonishingly adherent. Their contents consist of pul- 
taceous debris resembling old epithelial scales, fat, cholesterin, etc. The 
contents of these cysts are very prone to decompose, and they become 
as offensive as anything with which the surgeon has to deal. Putrefac- 
tion may be independent of inflammation or coincident with it. When 
irritated these gland-cysts become inflamed and may suppurate, suppu- 
ration being tantamount to cure by spontaneous processes. They may 
also ulcerate, without suppurating, and form foul-smelling ulcers, or give 
rise to cutaneous horns, as already mentioned. 
(6) Sebaceous Adenomata.—These spring from the sebaceous 
glands, which are lobulated like those about the nose and ear. Ade- 
nomata from this source are extremely liable to ulceration, may under- 
go calcification, and are often mistaken for epithelioma because of the 
fungous ulcerations to which they give rise. 
(c) Sutton has also described an adeno-carcinoma of the peculiar 
sebaceous glands named after Tyson. These are found particularly at 
the base of the prepuce, this form of tumor being exceedingly rare. 
Fig. 180. 
Fig. 181. 
Adeno-carcinoma; X 65 (Spencer, £" obj.). 
Adenocarcinoma of breast; X 170 (Spencer, 
i" obj.). 
Adenomata springing from the mucous glands, which are usually 
quickly transformed into cysts, are also known, as well as other gland- 
tumors springing from the glands of Bartholin, Cowper, etc. They are, 
however, so infrequent as to not deserve further mention here. 
Adenoma of the thyroid body is described in Clinical Surgery usu- 
ally as cystic goitre or bronchocele. It constitutes for the most part 
an encapsulated tumor containing structures similar to that of the nor- 
mal tissue, forming tumors of various sizes, usually single, sometimes 
double, and occasionally occurring in the isthmus of the thyroid. These 
tumors contain central cavities with colloid fluid often heavily loaded 
with cholesterin. As they grow older and larger all traces of original 432 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
thyroid tissue disappear, and we then have to deal with a cyst with a 
toughened, often calcified, wall. Thyroid adenomata usually are easily 
enucleated, even when they attain large size. When small they usually 
cause little trouble or pain; when large they may give rise to alarming 
dyspnoea, and may thus jeopardize life. 
The pituitary body, which is analogous to the thyroid in structure, 
is occasionally occupied by an adenomatous tumor closely corresponding 
to that just considered. 
In the prostate adenoma is not rare, since its structure is composed 
of mixed involuntary muscle and glandular 
tissue. Many instances of the senile enlarged 
prostate are due to adenomatous alterations. 
The so-called third lobe of the prostate, as 
found enlarged in old men, is usually an 
adenoma of the portion posterior to the veru 
montanum, which has grown into the prostatic 
urethra or toward the bladder, because this is 
the direction of least resistance. 
In the parotid and other salivary glands 
true adenoma is occasionally observed. Almost 
always it is distinctly encapsulated, but may 
have undergone marked cystic changes. 
Adenoma is common in the liver, either as 
a single or multiple lesion. Its pseudo-ducts 
often contain inspissated material of bile-green 
tint. 
In the kidney adenoma presents for the 
most part as a congenital adeno-cystic lesion, 
which is by no means rare. Both kidneys are 
usually eventually involved and the outlook 
is most unfavorable. By this lesion the kid- 
neys are converted into cystic masses, and 
most resemblance to original structure is lost. 
They may, when thus affected, attain great 
size. 
Fig. 182. 
Congenital adenoma (cystic) of 
kidney (original). 
The clinical aspects of some of these cases necessitate early operation. In one 
instance I removed an enormous cystic tumor of this kind from a little child of 
twenty-three months by abdominal section. The child was the youngest which up 
to that time had ever survived nephrectomy, and lived for several years, until, 
eventually, the other kidney acted in the same manner and caused his death. 
Vide Fig. 182. 
In the ovary we meet with adenoma, in which, however, there will 
be seen but little imitation of true ovarian tissue. In the testicle there 
is known to be a form of adenoma originating in the paradidymis, in no 
way connected with the secreting structure of the testis, but leading 
often to cystic alterations. 
In the mucous membrane of the stomach and bowels adenoma presents 
usually as an ovoid tumor, attaining possibly such size as to give rise to 
mechanical obstruction either by pressure or by traction. Adenoma of 
the pyloric region is a repetition in structure of the pyloric glands. In 
the rectum it presents, for the most part, as a polypoid outgrowth, most CYSTS AND TUMORS. 
433 
often met with in young children. Such tumors are generally small, 
and when solitary they often hang by a distinct stalk. 
Similar polypoid tiimors present in the cervical canal of the uterus, 
where also are found sessile and racemose tumors; all of which are 
structural repetitions of the glands met with in the cervix uteri. Ade- 
noma of the uterine cavity is most rare; it is also rare in the Fallopian 
tube, but occasionally presents as a dendritic outgrowth from the mucous 
membrane distending the tube. 
Carcinoma. 
Carcinoma is a tumor always springing from, pre-existing gland- 
tissue, which it more or less closely resembles in type, save that the 
structural mimicry is incomplete, the epithelial cells now collecting in 
irregular clusters, or filling the acini and obstructing the ducts, or 
bursting beyond the basement-membrane and invading the surrounding 
tissues. They frequently so fill the ducts as to appear in columnar 
arrangement when seen under the microscope, and this has given rise to 
the use of a term so vague as to have no place in pathology—i. e. cylin- 
droma. Carcinomata may arise from any of the secreting glands, but 
much more commonly from some than from others. They have no cap- 
sules ; they infiltrate the surrounding tissues, usually involve the lym- 
phatics early, are prone to spread to the superficial tissues and to ulcerate, 
and to undergo various degenerative changes. Nearly all cancerous 
tumors abound in lymphatics, which will explain the rapidity with which 
the lymph-glands become infected, as well as the tendency to dissemi- 
nation which is characteristic of these growths. Dissemination leads to 
so-called secondary or metastatic growths, which may make their appear- 
ance in any organ or tissue, even in the bones, where they give rise to 
changes of texture that make spontaneous fracture easy. It is charac- 
teristic of carcinoma that the metastatic tumors which it may produce 
will reproduce almost perfectly the type of the primary tumor whence 
the embolic fragments which have produced them spring. The amount 
of dissemination varies exceedingly : it may even become so marked and 
so widespread as to produce a condition analogous to that met with in 
miliary tuberculosis, and consequently spoken of as miliary carcinosis. 
A similar condition, much more rare, is met with in dissemination of 
sarcoma, and is known as miliary sarcomatosis. A constantly-spreading 
cancerous infiltration of the superficial tissues, which is noted most often 
after mammary cancer, is described under the form of cancer en cui- 
rasse, or jacket or corset cancer. Sad instances will be seen in which 
this infiltration of the surrounding structures has extended nearly or 
even completely around the thorax. It gives rise to a brawny indura- 
tion which is most unyielding, and which is studded here and there by 
nodules that tend to ulcerate, to fungate, and to bleed easily. It is per- 
haps the most hopeless form of cancerous disease. 
The older writers have constituted two or three clinically distinct forms of 
carcinoma, based mainly upon the relative hardness or softness of the tumor and 
the invaded tissues. The term scirrhus is, e. g., thus applied to a tumor in which 
connective tissue preponderates and epithelial cells are relatively deficient. On 
the other hand, the term encephaloid has been applied to a tumor in which the 
connective tissue seems barely sufficient to hold the mass together, while the 434 
AFFECTIONS OF THE TISSUES ANI) TISSUE-SYSTEMS. 
epithelial cells are in vast preponderance. These are all tumors of the round epi- 
thelial-celled type, and these distinctions are of clinical interest, yet have no great 
pathological import, save that in a general way the greater the proportion of epi- 
thelial elements the sooner will life be terminated by destructive processes. In 
other words, the more the tumor may partake of the encephaloid type the worse the 
prognosis or the shorter the probable duration of life. Again, these tumors pursue 
Fig. 183. 
Fig. 184. 
Soft (encephaloid) carcinoma (X W \ Spencer). 
Scirrhous carcinoma of breast (X WSpencer). 
a widely varying clinical course. In those, particularly of the scirrhus type, where 
the connective tissue largely preponderates, there is often an eventual reduction in 
the size of the part involved, and such reduction of vascularity and of nutritive 
activity that the rate of growth is thereby very perceptibly checked. The so-called 
atrophying cancers of the breast are the best examples of this type of cancerous 
disease. Here the volume of the gland is 
diminished rather than augmented, and 
the disease may last for a number of years, 
even so many as twenty. It is question- 
able whether in the presence of this type 
of disease it is well to operate. It would 
scarcely seem so, at least, in old and more 
or less enfeebled women, for it has usually 
been found that these live longer and in 
greater comfort if treated symptomatically. 
The so-called colloid forms of cancer 
are simply the expression of pathological 
changes occurring in growths of more dis- 
tinct type. Thus, colloid softening may 
occur in any tumor in which cancer-cells 
predominate, and the so-called colloid 
cancers of the peritoneum, the ovary, etc. 
are either examples of such alterations 
or are possibly endotheliomata arising in 
these locations. The term villous cancer, 
with other terms like it, should be ex- 
punged from all scientific literature, unless 
these terms be used in a purely adjective and clinical sense, for they imply noth- 
ing accurate as to the histological structure, and are too often misleading and 
inaccurate. 
Fig. 185. 
Carcinoma of rectum undergoing colloid de- 
generation (X W; Spencer). 
Carcinoma is most common in the following regions : 
In the breast it appears particularly in two forms (Sutton): 
(a) Acinous Cancer, and 
(b) Duct Cancer. CYSTS AND TUMORS. 
435 
(a) Acinous carcinoma is most often of the scirrhous type. It may 
arise at any portion of the breast, and if anywhere near the nipples it 
will early cause retraction of that 
prominence, which is always pathog- 
nomonic when noticed. When else- 
where situated it leads early to puck- 
ering and adhesion of the overly- 
ing skin. These tumors infiltrate 
widely, especially along the connec- 
tive-tissue stroma and the fibrous 
tissue which intersperses the fat of 
the breast. They are always firm, 
sometimes exceedingly dense, in con- 
sistence. A particular form of scir- 
rhus, known as atrophying scirrhus, 
consists largely of strands of fibrous 
tissus injected here and there with 
epithelial cells. It is the most slowly 
growing of all the forms of cancer, 
and by its contraction tends to reduce 
rather than augment the size of the mamma. 
Yol. II. 
Fig. 186. 
“Pig-skin” appearance of cancerous breast 
(original). 
Vide also Chapter XI V 
Acinous cancer is rare before the age of thirty, most common between forty 
and fifty. It occurs in women in all walks and conditions of life, married and 
single, and is rarely noted in the male breast. The most dangerous form of all is 
that which appears during lactation. Ordinarily its progress is comparatively slow. 
As it augments in volume it infiltrates all the surrounding tissues, becomes adhe- 
rent to the pectoral fascia, infiltrates the muscle-fibres, and finally attaches itself 
to the periosteum of the ribs. The infiltrated tissues tend to shrink rather than 
to increase in volume. Lymphatic infection occurs early in this form and is a 
pathognomonic sign. It is most common in the axillary lymphatic nodes, but 
may often be detected in the neck above the clavicle. When the skin is com- 
pletely involved there is a tendency toward ulceration and fungoid condition. 
This is always preceded by the purplish appearance of the tense skin. 
Pain is a very uncertain and variable feature. It is important to emphasize 
this fact, since in time past many of these conditions have been lightly regarded 
because of freedom from pain. Pain is by no means a constant phenomenon in 
any form of cancer, and the sooner old notions regarding it are discarded the 
better. On the other hand, pain is sometimes intense, either localized or radiat- 
ing and referred to distant points. Pain is particularly noticed in cases which 
assume the form of cancer en cuirasse. Secondary deposits in viscera are fre- 
quently met with, particularly in tbe abdominal organs and the lungs; but any 
organ may be the seat of secondary infection, and this is found occasionally in the 
bone-marrow, not alone of the sternum or ribs, but of distant bones. This is 
spoken of as marrow infection. As the result of cancerous affection of serous mem- 
branes we frequently get effusions of fluid, as in the pleura, peritoneum, and peri- 
cardium : and this fluid is often blood-stained. 
In consequence of pressure upon the venous trunks in the axilla there is often 
a swelling of the arm upon the affected side, dropsical in character, known as 
lymphatic oedema. It is one of the most distressing features of some of these cases: 
the arm grows heavy, the patient loses control of it, and the skin may become so 
distended by effusion as to cause the limb to resemble a cast rather than a living 
member. This is due not alone to pressure upon the veins, but to involvement of 
the lymphatics, and upon careful examination positive dilatation of the lymphatic 
vessels may be noted. Pain is a usual accompaniment of this form of oedema. 
(6) Duct Carcinoma.—This appears especially about the time of the 
menopause, when glandular structure has disappeared and only ducts 436 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
remain. It is common, without reference to cancer in these instances, 
to find cystic dilatation of numerous ducts which vary in size from a 
mustard-seed to a cherry. These are spoken of by Sutton and others as 
involution-cysts. They are filled with mucoid material and have a bluish 
Fig. 187. 
Recurring carcinoma of male breast (original). 
tint. They are most common upon the under surface of the gland. 
Such cystic breasts are common, and when appearing in diffused form 
maybe easily mistaken for cancer. Pain is rarely complained of. This 
condition is certainly a pre-cancerous stage, since the dilated ducts are 
often the starting-points of cancer, and occasionally of papillomatous or 
villous outgrowths from their walls. 
Duct cancer implies the form which arises in these dilated ducts, most 
commonly in the terminal branches, appearing ordinarily as a single 
tumor, but sometimes as a mass of separate nodules. Intracystic and 
intracanalicular growths of this character will often be found. When 
assuming the truly cancerous phases they may be spoken of as duct can- 
cers ; otherwise, as duct papillomata. In time past these have, for the 
most part, been spoken of as intracanalicular fibromata. Duct cancers 
are less tense than the preceding variety, and when situated near the 
surface often discolor the skin quite dark. It is from these cases that 
we often see a more or less abundant discharge of fluid resembling bloody 
milk. These tumors grow relatively slowly, lymphatic involvement is 
late, and in general they present the least malignant forms of breast 
cancer. 
Carcinoma of sebaceous glands is by all means most common in those 
specialized glands named after Tyson, met with about the prepuce. They 
give rise to the common forms of cancer in this locality. CYSTS AND TUMORS. 
437 
Carcinoma in the prostate is not common, and is usually confined to 
old men. Infiltration proceeds around the base of the bladder at the 
same time and binds the pelvic viscera together. The pelvic lymphatics 
become early infected and dissemination is frequent. 
In the salivary glands carcinoma is not common ; it is most so in the 
parotid region, occurring at middle life, growing rapidly, infiltrating 
surrounding parts, and tending early to ulceration. 
Carcinoma of the liver varies not a little in its arrangement and 
appearance. Sometimes it appears in the form of nodules; at other 
times, as a more diffuse malignant infiltration by cells relatively abun- 
dant in number, so that the clinical aspects of the case conform rather 
to the encephaloid or medullary type. 
Carcinoma of the kidney was formerly ordinarily described as en- 
cephaloid, meaning thereby simply a malignant tumor of soft structure. 
It is probable that a large proportion of these tumors were sarcomata. 
Nevertheless, true carcinoma of the kidney is possible, though rare. 
Concerning carcinoma of the ovary, we must also remain in some 
doubt until the subject has been more thoroughly studied. That malignant 
tumors appear here is unquestioned; and that many of them infect the 
peritoneum and disseminate widely is also true : that some of them are 
of distinctly epithelial type may not be doubted, and yet there can be 
no accurate description to-day of true cancer of this organ. 
On the other hand, in the testicle such tumors are common—more 
common, in fact, than sarcomata. It is quite likely that many of them 
arise from the paradidymis. Even here, while recognizing their clinical 
frequency, we need more light. 
Carcinoma of the stomach is a common disease. It involves the 
tubular glands, especially in the pyloric region, and conforms to them 
in type. After involving, first, the mucosa, it spreads to the entire coats 
of the stomach and infiltrates adjacent structures, while the mesenteric 
lymphatics are usually early and notably involved. Were it possible to 
recognize this involvement early in the course of the disease diagnosis 
of pyloric cancer and operative interference would be much more com- 
mon and hopeful. Secondary involvement is most common in the ad- 
joining viscera, but may be seen at a distance. Miliary carcinosis has 
been noted after pyloric cancer. This form is most common between the 
fortieth and sixtieth years of life, the duration of the disease not being 
long. 
In the intestine, and particularly in the rectum, carcinoma proceeds 
also from the mucous glands, and tends constantly to extend at its 
periphery and involve the entire lumen of the bovrel. It seems to be 
inseparable from a tendency to contraction of the gut and consequent 
annular stricture. Ulceration, favored by surface-irritation and infec- 
tion, occurs almost always early. Above the rectum it is most common 
in the neighborhood of the sigmoid flexure. Cripps has observed that 
when cancer of the rectum spreads downward and involves the anus, it 
loses its typical glandular character and assumes the type of epithelioma 
or squamous-celled cancer. In all of these cases the pelvic and mesen- 
teric lymphatics are early infiltrated and secondary and metastatic affec- 
tions are common. 
Carcinoma may appear in any portion of the uterus, but is more com- 438 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
mon in the lower than in the upper half. It assumes the type of the 
cervical glands, spreads rapidly, infiltrates widely, idcerates early, and 
disseminates frequently. By exten- 
sion of ulceration the formation of 
urinary and of fecal fistuhe is com- 
mon. Pyosalpinx and hydrosalpinx 
are also favored, because of infection 
from putrefying malignant tissue, 
while the spread of the disease is, 
in fact, more common when it in- 
volves the cervix than when it in- 
volves the uterine fundus. 
Fig. 188. 
1). ENDOTHELIOMA. 
This is spoken of by Snow as the 
cancer of endothelial cells. It has gone 
under various synonyms in past time, 
and, while undoubtedly a pathologi- 
cal possibility, is either rare in occur- 
rence or difficult of recognition. 
Endothelioma is, as its name should imply, a tumor distinctly of 
Endothelioma of liver (Spencer, J" obj.). 
Fig. 189. 
Endothelioma (of skull) (Volkmann): a, cell groups; b, cylindrical arrangement of cells; 
c, blood-vessel. 
endothelial tissue. The possibility of such neoplasms lias been for a 
long time recognized, yet, in spite of arduous study of these growths, we CYSTS AND TUMORS. 
439 
are not yet in position to speak as accurately concerning them as we 
could desire. They are, first of all, rare, and usually by the time they 
come to operation and subsequent examination have undergone changes 
which to some extent at least obscure their original characteristics. 
Considered from the developmental standpoint, they are to be considered 
as atypical proliferations of fiat endothelial cells, springing either from 
connective-tissue interspaces or from the inner wall of blood- and 
lymph-vessels, on serous membranes, or else from the so-called perithe- 
lium of the capillaries. In one respect they may be regarded as con- 
nective-tissue tumors. Nevertheless, they are to be pathologically, if 
not clinically, sharply distinguished from tumors proceeding from the 
other connective-tissue elements. Endotheliomata are, in fact, to be 
abruptly separated from carcinomata and epitheliomata, although tran- 
sitional forms may be observed. They are so nearly allied to certain of 
the sarcomata as to be often included or more often confused with 
them. 
For the most part, these tumors proceed from the endothelial lining 
of lymph-spaces, less often from the other areas mentioned above. They 
Fig. 190. 
Endothelioma (of soft palate) (Volkmann): a, dilated lymph space; b, endothelial cells with 
beginning cystic formation; c, completely formed cyst. 
undergo many degenerations and metamorphoses. Thus, cartilaginous, 
myxomatous, and hyaline changes may be noted in them, as well as 
formation of lymph-dilatations, alveolar arrangements, or even semblance 
of cylindrical or tubular construction. Some of the tumors heretofore 440 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
vaguely termed cylindroma in all probability belong in this class. At 
other times they have been confused under such names as angeio-sarco- 
mata or plexiform or alveolar sarcomata, or they appear as villous out- 
growths ; and it is largely owing to this confusion that we are now cer- 
tain that these tumors are of more frequent occurrence than was 
formerly recognized. Even psammoma is by some regarded as calcifying 
endothelioma. For example, most of the tumors of the salivary glands 
and of the soft palate belong to this class. It has been shown, e. g., 
that 28 out of a consecutive series of 29 parotid tumors were really 
endotheliomata. It also appears that they may develop within the bones 
—for example, in the skull, in the neck of the femur, etc.—as well as in 
the cervical and dorsal lymphatics.1 The endotheliomata also include 
the cholesteatomata or pearly growths met with in the cerebral pia mater. 
Clinically, these tumors have no certain characteristics by which they 
can be separated from the sarcomata. It requires practically minute 
and microscopic examination to clearly place them where they belong. 
It will be enough, then, to say of them that they possess the ordinary 
clinical features of malignancy, including liability to recedive when not 
thoroughly eradicated, and that they call for exactly the same treatment 
as any other neoplasms presenting similarly malignant features. 
GENERAL DIAGNOSTIC FEATURES OF MALIGNANT 
GROWTHS. 
The following tables are here inserted, trusting that they may aid 
the young practitioner in distinguishing in a general way between 
benign and malignant tumors, and even in making a diagnosis between 
sarcoma and carcinoma. I have also inserted a table differentiating the 
clinical appearances of epithelioma and of lupus. In these tables com- 
prehensiveness has not been aimed at, rather simplicity, while it is not 
denied that cases are met with in which diagnosis may be exceedinglv 
difficult, and in which the common signs herein mentioned maybe found 
either absent or misleading : 
Table I.—Differentiation between Benign and Malignant Growths. 
Benign 
and 
Malignant. 
Common at all ages. 
Usually slow in growth. 
No evidences of infiltration or dissemina- 
tion. 
Are often encapsulated, nearly always cir- 
cumscribed. 
Rarely adherent unless inflamed. 
Rarely ulcerate. 
Overlying tissue not retracted. 
No lymphatic involvement when not in- 
flamed. 
No leucocytosis. 
Elimination of urea unaffected. 
Rare in early life. 
Usually rapid in growth. 
Infiltration in all cases, dissemination in 
many. 
Never encapsulated, seldom circumscribed. 
Always adherent. 
Often ulcerate—nearly always when surface 
is involved. 
Overlying tissue nearly always retracted. 
Lymphatic involvement an almost constant 
feature. 
Leucocvtosis often marked. 
Deficient elimination of urea (?). 
1 By all means the most able paper which has appeared upon the subject is that by 
Yolkmann in the Deut. Zeit.f. Chir., 1895, vol. xl. p. 1. CYSTS AND TUMORS. 
441 
Table II.—Diagnosis between 
Sarcoma 
and 
Carcinoma. 
Occurs at any age. 
Disseminates by the blood-vessels (veins). 
Arises from mesoblastic structures. 
Distant metastases are more common. 
Contains blood-channels rather than com- 
plete blood-vessels. 
Less prone to ulceration. 
Involvement of adjacent lymphatics not 
common. 
Secondary changes and degenerations are 
more common. 
(Sugar present in the blood?). 
Rare before thirtieth year of life. 
Disseminations by the lymphatics. 
Arises from glandular (epithelial) tissues. 
Less so. 
Contains vessels of normal type. 
More so. 
Almost invariably adjacent lymphatics are 
involved. 
Degenerations not common ; other second- 
ary changes rare. 
(Peptone present in the blood ?). 
Differential diagnosis between epithelioma and nlcerating gumma 
will be found in Chapter X. 
Table III.—Diagnosis between 
Preceded usually by continued irritation 
or warty growths. 
Diathesis plays no known part. 
Rarely multiple. 
Area of thickening ahead of ulceration. 
Ulceration advancing from a central focus. 
Border usually raised and everted, regular 
in outline. 
Often assumes fungoid type. 
Base may be deeply excavated. 
Usually painful. 
Bleeds easily. 
Never tends to cicatrize. 
Most rare in the young. 
Discharge is very offensive. 
Lymphatic involvement nearly always. 
Epithelioma 
and 
Irritation plays no figure. Preceded usu- 
ally by nodules. 
Diathesis evident. Coincident evidence of 
tubercular disease elsewhere. 
Often multiple. 
Extension of ulceration not preceded by 
thickening. 
Various foci, which may coalesce. 
Border abrupt, eaten, irregular, thickened, 
firm, often inverted, irregular in out- 
line. 
Never fungoid. 
Base nearly level with surface. 
Seldom painful. 
Seldom bleeds. 
As marginal ulceration proceeds there is 
often cicatrization at centre. 
Common in the young. 
Discharge rarely offensive. 
Rarely. 
Tuberculosis (Lupus). 
General Remarks on the Treatment of Cancer, 
Aside from the remarks already made in the earlier portion of this 
chapter on the general topic of Treatment of Tumors, it is best to em- 
phasize here that the treatment of cancer is too often hopeless because 
instituted too late. It must be part of the teaching of modern surgery 
to indicate to the laity in every possible way and through every legiti- 
mate channel that it is the greatest mistake which they can possibly 
make to conceal the existence of tumors or to put off operative or other 
treatment. Little as there is to be said of cancer that can be inter- 
preted as favorable, it must yet be acknowledged that in at least the 
majority of instances carcinoma originates in localities which are more 
or less accessible and as a local lesion, which, if radically attacked early, 
before the disease has spread beyond possibility of extirpation, would 
give vastly more favorable results. I hold, in other words, that in cases 
of cancer in accessible parts of the body, when operation can be made 442 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
early enough and when tissues are sacrificed in a perfectly merciless man- 
ner, there is a large possibility of cure. This involves sometimes opera- 
tions which are too frightful for the average patient to contemplate. 
Nevertheless, the fact remains that even the pylorus may be successfully 
extirpated if only the operation be done at a time when disease is limited 
in extent and patients are not debilitated by its ravages. That carcinoma 
so frequently returns after operative attack, and that the outlook for 
these cases is so often hopeless and discouraging, are largely due to the 
fact that the general practitioner, under whose observation most of these 
cases first come, is slow to recognize the malady, timid to advise radical 
methods, and too frequently finds patients to whom the fatal policy of 
delay is more attractive than early and prompt interference. It is not, 
then, so much to the discredit of surgery that cancer appears in its 
present hopeless light as it is to the discredit of those who fail to recog- 
nize it early enough and to appreciate the urgent necessity for surgical 
procedures. 
Enough, it would seem, has already been said to insist upon more 
than the expediency—the absolute necessity—of wide extirpation ; and 
the surgeon should feel in attacking all cancerous growths that the tis- 
sue which is not plainly healthy is of suspicious character and should be 
removed. The mistake rarely is made of doing too much, while with 
unfortunate and fatal frequency its counterpart is made—i. e. the mis- 
take of doing too little. 
APPENDIX. 
Recent Advances in Non-operative Treatment. 
Inoculation Methods.—Within the past two years a great deal of interest 
has been excited by endeavors to apply certain well-known facts to advantage in 
the treatment of malignant disease. These facts have been elicited by both labo- 
ratory research and clinical experience. They are, briefly, to the effect that it has 
been known for many generations that in rare instances cancerous tumors have 
been known to cease growing, or in some cases to spontaneously disappear, after 
an attack of erysipelas involving the part. After Fehleisen had identified 
and studied the specific organism of erysipelas (streptococcus) experiments were 
made with the consent of patients suffering from this disease, deliberately inocu- 
lating them with this surgical infection. While in some instances the endeavor 
resulted disastrously, in others it was followed by so much of success as to justify 
further trial in a very limited class of cases. It was made manifest later that the 
effects of inoculation depended rather upon the toxic products of the erysipelas 
cocci than on their active presence, and thus came about the endeavor to treat this 
disease by the filtered products of their cultivation from which all living organisms 
had been carefully excluded. With these efforts in this country the name of Coley 
is particularly associated. The method has been even further modified to the 
destruction of the organisms in cultures by heat, the degree of heat necessary for 
their death not being sufficient to interfere with the activity of their toxic products. 
It is necessary, first of all, to make these cultures with organisms possessing a 
very high degree of virulence, those from the ordinary, so-called idiopathic, cases 
of erysipelas not being virulent enough to produce the desired effect. 
Working with these products, by injecting them beneath the skin in the neigh- 
borhood of the tumor some remarkable results have been achieved, and in a few 
instances complete dissipation of the tumor has been obtained. So far as these 443 
CYSTS AND TUMORS. 
results are concerned, however, it must be said, that, first of all, the method is one 
which should be reserved mainly for the inoperable cases, and of sarcoma rather 
than of carcinoma ; and, second, that there is about it no certainty of result and no 
absolute exemption from risk. By the use of the sterile disease-products there is 
no fear of conveying erysipelas, but it must be borne in mind that all these mate- 
rials are pyrogenic and depressing, and that the amount required to affect the 
tumor-cells may be more than the general organism can safely withstand. The 
method is one deserving of elaborate trial, but one from which as yet no positive 
results can be predicted in any given case. 
There is, in fact, reason to think that there are many substances whose intro- 
duction into the system may for a short time produce amelioration of symptoms 
or some effect upon the malignant growth. Unfortunately, these most desirable 
results seem, too generally, short-lived. Another recent effort in this direction is 
the 
Serum-therapy of Cancer.—This is still newer than the inoculation-treat- 
ment, and is based on the same general principles which obtain in the treatment 
of certain of the infectious diseases by antitoxines formed from the serum of 
immunized animals. In brief, the method consists of frequent inoculation of an 
animal (e. g. a goat or a horse) with the juice of cancerous tumors or with an infusion 
made from them. Such injections produce temporary disturbance for a time, after 
which they seem to have little, if any, effect. When this time is reached a meas- 
ure of blood is withdrawn from the animal, the serum separated by the usual 
methods, preserved with thymol in sterilized flasks, and is then used for injection 
into the tissues of human patients. This method is so completely in its infancy 
that at the date of writing one can only say that it is deserving of much further 
investigation. For myself, I may add that I have seen one or two remarkable 
results from its use. 
Treatment by Aniline Preparations.—Several years ago an impure ani- 
line preparation was placed upon the market under the fanciful name of pyoktanin 
which was alleged to have remarkable antiseptic powers. In this respect it was 
shown to be very deficient. It was then loudly recommended as an agent of 
remarkable efficiency in combating the growth of cancer-cells. In this respect it has 
had now a quite extended use, and there may be said of it that to a certain (small) 
extent the statements have been justified. When used for this purpose solutions 
should be made never stronger than 1 per cent., even so weak as 1:400. These 
are hypodermically injected into and around the tissues, and, while the general 
effect is usual by relief from pain, it will often happen that the injections themselves 
are irritating and temporarily painful. For this purpose it is customary to combine 
cocaine, and sometimes morphine, to such an extent that the injections can be 
made without giving rise to discomfort of more than a few moments. The effect 
of the subcutaneous use of pyoktanin is in many instances happy, especially in the 
smaller and superficial growths. It may be resorted to in other cases where the 
tumors are inoperable; and, while no absolute reliance can be felt that the progress 
of the growth will be affected or its painfulness diminished, such is, nevertheless, 
the effect in many instances, and the remedy is often worth a trial. 
Upon the surface of malignant tumors, upon rodent ulcers, epithelial ulcers, 
etc. stronger solutions may be pencilled, and often with excellent effect. The color 
is, however, so extremely penetrating that dressings need to be carefully managed 
or the clothing and the adjoining parts will be stained to a quite unpleasant degree. 
Aniline blue is also given internally by some, in combination with the above 
treatment, or alone. CHAPTER XXVII. 
SURGICAL DISEASES OF THE SKIN. 
By W. A. Hardaway, M. D. 
Milium.—A milium is a small, whitish body commonly found on the 
face ; it may occur upon other parts of the body, notably the penis and 
scrotum of males and the labia minora of females. Milia are usually 
about the size of grains of sand, but may attain the dimensions of peas. 
If the very thin layer of skin covering a milium be incised, the mass 
can be turned out: it is generally soft and easily crushed, though in 
long-standing cases a calcareous change may occur. One or many milia 
may be present, and in certain regions, as the eyelids and cheeks, there 
may be groups of the little tumors. Milia cause no trouble beyond a 
slight disfigurement. 
The affection is quite common in children and young adults. After pemphigus 
milia have frequently been observed appearing where the blebs had existed. About 
the edges of scars also they often occur. 
It has been generally supposed that a milium was due to retention of the secre- 
tion in a sebaceous gland. Recently Robinson has expressed the opinion that 
some milia are due to miscarried embryonic epithelium from the hair-follicle or 
the rete. 
A simple manner of curing milia is to incise the tumor, squeeze out 
the contents, and touch the little cavity with nitrate of silver. Another 
satisfactory method is to pierce each growth with a fine needle attached 
to the negative pole of five or six cells of a galvanic battery. In chil- 
dren frequent washings with soap and water are usually all that is 
required. 
Acne and Comedo.—Acne is an inflammation of the sebaceous 
glands and of the minute hair-follicles. To acne many sub-titles have 
been given, most of the names used being founded on clinical differences. 
Acne is essentially a disease of the young, often coming on at 
puberty. It usually disappears at the age of thirty or before. The 
sites on which the malady most commonly manifests itself are the sides 
of the brow, the cheeks, the shoulders, the back, and the chest. The 
lesions which make up the eruption of acne are comedones, papules, and 
pustules. The comedo is a sebaceous plug filling the orifice of a seba- 
ceous gland ; when expressed the comedo resembles a small white worm, 
but when in situ it has the appearance of a black point, from the dirt 
which has adhered to the end of the greasy mass. It is about the 
comedo that the inflammation commonly begins, leading to the forma- 
tion of the acne-papule, though papules may form independently of 
comedones. The papule is at first red, conical, and firm, but in a short 
time suppuration sets in, and a pustule situated on a red base results. In 
444 SURGICAL DISEASES OF TIIE SKIN. 
445 
a few days this dries into a crust which falls, leaving a slight purplish 
stain and eventually a small pit. 
All of the papules do not run this course: some undergo involution before the 
stage of suppuration is reached; in other cases the inflammation extends beyond 
the sebaceous gland and hair-follicle; a hard purple nodule forms as large as a pea 
or even larger, in which after some time softening occurs, with the formation of a 
small cutaneous abscess. To this type of acne the name acne indurata is given. 
The amount of scarring following acne depends on the number and size of the 
precedent lesions; sometimes it causes marked disfigurement. Acne is usually 
unattended by subjective symptoms. Quite frequently the condition called rosacea 
is an attendant of acne: the skin of the nose, chin, or cheeks assumes a more or 
less permanent flushed condition. After a time in the affected area dilated vessels 
can be seen. After this condition has persisted a long time hypertrophy of the 
skin and subcutaneous tissue develops. The nose is especially liable to this com- 
plication, and when markedly affected presents the appearance of a large, reddish, 
lobulated tumor. 
Since acne is universally associated with the second decade of life, it 
would seem that age must be regarded as in some way an etiological 
factor. Many have thought that menstrual disorders play an important 
part in the causation of acne, and it is often noticed that in those suffer- 
ing from acne new crops of lesions appear about the menstrual epoch. 
A thick oily skin, especially if associated with a sluggish circulation, 
acts as a predisposing cause. But the most important etiological factors 
are no doubt certain reflex circulatory disturbances of the skin caused by 
lesions of the stomach and intestines, such as neuroses and catarrhs. 
The fact that a form of acne may be caused by the ingestion of drugs, 
such as iodide and bromide of potassium, is well known. 
As has been said, the first pathological step in acne is the plugging 
of a sebaceous gland with its own secretion. This either directly or 
indirectly determines inflammation. Attempts have been made to asso- 
ciate some specific organism with this inflammation, but so far unsuc- 
cessfully. 
The diagnosis of acne cannot, as a rule, be difficult if the cardinal 
symptoms of the affection are borne in mind. It is possible that cer- 
tain of the syphilides may resemble acne, but the location of the lesions, 
the history and concomitant symptoms of syphilis, will generally suffice 
to differentiate them. 
Whether it be treated or not, acne will usually terminate sooner or later, 
but there is no doubt that by proper treatment the course of the malady 
can be stayed and much of the unsightly scarring prevented. In the 
way of internal treatment it may be said that there are no drugs which 
exert a specific influence on the affection, and yet in nearly every case 
one must use some internal medication. If anaemia exists, tonics, especi- 
ally ferruginous preparations, will do good; if the patient is strumous, 
fresh air, sunshine, and cod-liver oil are indicated. In the vast majority 
of acne patients a careful investigation will prove the presence of some 
gastric or intestinal affection. This should be treated by regulation of 
the diet and habits and by such remedies as seem appropriate. When 
every fault in the general health of the patient is as far as possible cor- 
rected, we proceed to the local treatment of the acne. It is impossible 
to catalogue all the methods which have been used, and only the plan of 
treatment which has been most successful in the hands of the author 
will be mentioned. 446 
AFFECTIONS OF THE TISSUES ANT) TISSUE-SYSTEMS. 
A thorough washing of the face with hot water night and morning 
is of prime importance. White castile soap, or if something more 
stimulating seems desirable Bagoe’s prepared olive soap, may be used. 
All comedones should be pressed out: this is best done after the use of 
hot water. A comedo-presser is necessary, and the one recom- 
mended by Piffard is the best for the purpose. It is only a modifica- 
tion of the watch-key with the sharp cutting edge replaced by a bevelled 
surface. When pustules have formed they are promptly opened with 
the acne-lancet. In acne indurata and in all cases where large, hard 
papules are present it hastens their disappearance to incise them even 
before pus has collected. 
Of all drugs to be used locally, sulphur or some one of its prepara- 
tions is best. Precipitated sulphur or equal parts of sulphur and boric 
acid can be used in powder form, being dusted on the affected region 
each night. An excellent stimulating lotion is the lotio alba, the formula 
for which is—Zinci oxidi, sij ; zinci sulphatis, 3ij ; potassii sulphured, 
3ij ; glycerini, sij ; Aquam ad 3iv.—M. Sig. Apply at night. This 
lotion is mopped on at night after thoroughly shaking the bottle. The 
next morning it is washed off with hot water. After this lotion has 
been used for a time it will generally be found necessary to use a 
stronger preparation. Vleminckx’s solution is a valuable remedy. It 
is made thus: Calcis, 3ss; sulphuris sublimat., sj ; aqme, 3x.—M. Boil 
to six ounces and filter. ATeminckx’s solution is at first diluted with 
five parts of water. After this strength has been used for several nights 
less water is added, till finally the pure liquid is used. It is mopped on 
the affected regions and allowed to remain over night, when it is to be 
washed off with soap and hot water. 
In addition to the measures indicated it is well to order the following 
lotion : Acidi borici, 3iij ; alcoholis, .$v.—M. Sig. Shake and apply. 
This should be mopped on the face several times a day. By the evap- 
oration of the alcohol a thin layer of the boric acid is deposited over 
the surface, thus keeping up a constant antiseptic effect. 
Sebaceous Cyst.—Sebaceous cyst, also known as steatoma and 
atheroma, is a cyst which is filled with sebaceous matter. (Vide also 
Chapter XXVI., Adenomata.) The cysts may occur singly or there 
may be a number present. They are seen upon any part of the 
body, but occur with great frequency on the face or scalp. As usually 
observed, a steatoma presents as a tumor from a cherry to an egg in 
size, partly buried in the skin. In rare cases the tumor is peduncu- 
lated. The skin over the growth is usually normal in appearance, but 
it may be very thin and atrophic, or, on the other hand, thickened and 
somewhat reddened with dilated capillaries. The consistency may be 
hard or soft and doughy: this will depend in a great measure on the 
thickness of the cyst-wall. 
In some steatomata a small depression can be found through which on pressure 
the thick, butter-like contents can be forced. These cysts are likely from time to 
time to empty a portion of their contents through the opening. In other cases 
the tension in the cyst becomes so great that it ruptures and afterward fills again. 
After sebaceous cysts of the scalp have existed for a long time the hair over them 
falls out. 
It sometimes happens that sebaceous cysts become inflamed and suppurate, SURGICAL DISEASES OF THE SKIN. 
447 
and occasionally this results in a cure by destruction of the cyst-wall. Sometimes 
an ulcer with infiltrated base is left, resembling an epithelioma. 
Sebaceous cysts cause no pain, and are usually annoying for cosmetic reasons 
only. An epithelioma may result from a sebaceous cyst. Occasionally a steatoma 
has caused absorption of a portion of the skull and perforation. 
There is some difference of opinion among authors as to the true pathology of 
steatomata. Virchow classes them as retention-cysts; Winiwarter regarded them 
as adenomata which had undergone cystic degeneration ; while Tbrok thinks they 
should be considered as dermoid cysts. The cyst-wall consists of a more or less 
thick capsule of connective tissue lined with epithelium. The contents vary from 
a white, cheese-like substance to a milky-looking fluid. 
It is usually easy to diagnosticate a sebaceous cyst, especially when 
there is an orifice through which some of the contents may be pressed. 
The history of the tumor will serve to distinguish it from a cold 
abscess, and the same factor will differentiate an inflamed steatoma from 
an acute abscess. Sebaceous cysts may at times be practically indis- 
tinguishable from other growths, such as lipomata or fibromata. The 
likeness which the fungating base of an ulcerated sebaceous cyst may 
present to an epithelioma lias already been mentioned. A microscopical 
examination would generally decide the nature of the growth. 
In the treatment of sebaceous cyst the one thing to be aimed at is 
complete destruction of the cyst-wall, for if even a small part of this 
remains recurrence is very likely to take place. The most generallv 
applicable way of accomplishing this is to dissect out the entire cyst with 
the knife. The skin should first be anaesthetized by cocaine injections 
or by the ethyl-chloride spray. In dissecting out the sac the success of 
the operation is ensured by taking pains not to rupture the cyst before 
it is completely removed. The operation must of course be done anti- 
septically. 
The use of caustics has been advocated by many. The author much prefers 
the method already mentioned. In using caustics a sharp stick of nitrate of sil- 
ver can be bored into the cyst, and after the eschar thus formed is separated the 
sac can be pulled away with forceps. A method which is said to be of special 
advantage when the cyst has become adherent to the skin and is difficult to dissect 
is to make a free incision into the cyst, and, after cleaning out the contents, to 
paint the walls thoroughly with tincture of iodine: in the violent suppuration 
which follows the wall is destroyed. 
A great many other caustics have been advised, but what has been said serves 
to illustrate their use. 
Furuncle.—A furuncle is an acute inflammation of a hair-follicle or 
gland of the skin which usually terminates by necrosis of the central 
part of the affected region with suppuration. 
A single boil only may be present upon the body, but very commonly 
several boils in rapid succession or simultaneously affect a region. In 
some cases one crop after another without limit attacks a person, and this 
condition is designated as furunculosis. A boil commences as a small, 
red, painful, very tender papule, protruding from which a lanugo hair 
may generally be detected. Often at the apex of the nodule a small 
vesicle of cloudy serum may be seen. The papule rapidly enlarges into 
a conical swelling from a pea to a pigeon’s egg in size. The surrounding 
area becomes red and infiltrated, while the skin over the boil assumes a 
dusky hue. At the end of three or four days the skin at the apex of 
the boil softens, gives way, and a small amount of pus exudes. At the 
opening a piece of white pultaceous necrotic tissue is now visible, which 448 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
is thrown off in a day or two, leaving a granulating cavity. With the 
opening of the boil the intense throbbing pain is relieved, and with the 
separation of the core it ceases. After healing a small bluish-red scar 
remains, which gradually fades to a dead white, or a slight amount of 
pigmentation may remain for years. A boil may not run through all 
these stages, but may stop short of suppuration and disappear without 
opening. 
With large boils or where many are present a certain amount of febrile dis- 
turbance is noted; the patient loses appetite, and sleep is interfered with on 
account of the pain. The lymphatic ganglia in the neighborhood are often en- 
larged and tender, and may suppurate. 
A form of boil originating in the sweat-coil, and first described by Yerneuil, 
differs from the ordinary furuncle. It affects especially the axillae and the genital 
region. The process commences in the subcutaneous tissue as a small firm nodule. 
This enlarges till a raised, red, pea-sized mass is formed, which is soft and little 
painful. If left alone, these little abscesses burst, giving issue to a drop or two of 
pus, and a crust forms, under which healing occurs. 
Etiology and Pathology.—Since boils depend on the infection 
of the follicles by the germs of suppuration, we can readily understand 
that their formation is favored by circumstances which would decrease 
the physiological resistance of the parts, as well as by those circum- 
stances which increase the exposure of the patient to the germs. Thus 
a local injury is often followed by a boil. Certain depressed states of 
the general constitution act in a similar manner; for instance, we know 
how common boils are with diabetes. Eczema and other itching diseases 
often predispose to furuncles, as the follicles become inoculated from the 
nails during scratching. Those whose occupation brings them into inti- 
mate association with opportunities for infection, as butchers, tanners, 
cooks, surgeons, etc., are especially liable to boils. Infrequent bathing 
and dirty habits may act in a similar way. Lastly, prolonged contact 
with a person having boils, such as sleeping in the same bed, may 
inoculate them upon the sound person. 
The organism usually found in furuncles is the staphylococcus pyogenes aureus. 
The central necrotic mass constituting the core of the boil is due to the rapid action 
of the poison liberated by the invading micro-organisms. 
Diagnosis.—The only affection with which furuncle is likely to be 
confounded is Carbuncle, which see for differential diagnosis. 
Prognosis.—As far as life is concerned, the prognosis is good, but it 
is wise to be cautious in promising speedy relief to a patient who is 
afflicted with a succession of boils, as the surgeon often finds that this 
affection taxes his therapeutic resources to the utmost. 
Treatment.—Though many internal remedies have been recom- 
mended in the treatment of boils, it may be said that beyond putting 
the general health in the best condition possible, and correcting any 
constitutional vice which may be present, there is nothing which we can 
accomplish by dosing the patient with drugs. In the earliest stage there 
is a chance of aborting a boil if only a means of destroying the germ in 
the hair-follicle can be used. For this purpose two methods commend 
themselves: The first was introduced by Tuholske, and consists of 
passing a needle attached to the negative pole of a galvanic battery 
down into the follicle and destroying it and its contents by electrolysis. SURGICAL DISEASES OF THE SKIN. 
449 
The other means has been advocated by Lowenberg,1 and consists in 
destroying the affected follicle by thrusting into it the fine point of the 
actual cautery at a white heat. 
If the boil has advanced beyond the stage when it can be aborted, it 
may still be beneficially influenced by certain topical applications, all of 
which belong to that class termed “ revulsants.” Painting repeatedly 
with iodine or touching with the lunar-caustic stick will often yield good 
results. The constant application of the mercurial-carbolic-acid plaster 
mull of Unna has many advocates, and in the hands of the writer has 
given good results. A soap plaster containing 5-10 per cent, of salicylic 
acid has recently been highly spoken of by Neuberger,2 and a similar 
preparation was previously recommended by Klatz. 
in the treatment of boils none of the ordinary poultices should ever 
be used, since they favor the development of other boils in the neighbor- 
hood of the first. If a poultice is deemed necessary, cotton wool wrung 
out of a 2 J per cent, carbolic-acid solution and covered by rubber tissue 
and a bandage is the best application. This gives much relief, and often 
seems to limit the suppuration. In those cases where crops of boils 
succeed each other Van Hoorn3 advises this plan of treatment: The 
entire skin is washed with a warm bath and soft soap. The boils and 
the surrounding skin are washed with 1 :1000 bichloride solution. The 
boils are covered with mercurial-carbolic-acid plaster mull and the patient 
puts on clean linen. Twice a day fresh plasters are applied, and if the 
boils have opened, the pus is gently squeezed out and the region disin- 
fected with the mercuric solution. 
As soon as fluctuation can be made out, or as soon as pus is thought 
to have collected in a boil, a free opening should be made with antiseptic 
precautions and antiseptic dressings applied. After the separation of 
the core, if an ulcer is left which is indolent, iodoform dusted in often 
serves to hasten cicatrization. 
In the condition known as furunculosis it may occasionally happen 
that the patient becomes so reduced as to demand a change of climate, 
a course of tonics, and such other measures as are applicable after any 
debilitating disease. 
Carbuncle.—A carbuncle is a severe localized inflammation of the 
skin and subcutaneous tissue which results in necrosis, usually at several 
distinct points. It is sometimes difficult in the inception of a carbuncle 
to distinguish it from a boil, but usually the greater gravity of the 
malady is announced from the beginning. Not infrequently the disease 
is ushered in by a chill, and there is nearly always considerable fever 
and constitutional disturbance. The site of the carbuncle is red, swollen, 
oedematous, and quickly gets of a peculiar brawny hardness. There is 
pain of a burning or throbbing character. The redness grows more 
dusky, the swelling extends, and several pustules appear upon the sur- 
face. In eight days to two weeks the process has attained its maximum, 
and the carbuncle is two to three inches in diameter. Softening now 
commences, but instead of pointing at one place, as occurs with an 
abscess, the skin gives way at several points, emitting small quantities 
of sanious pus and exposing a white mass of necrotic tissue. These 
1 Journ. Cut. and Genilo-urinary Dis., Oct., 1894. 
2 Derm. Zeitschrift, 1894, i. 387. 3 llonatshefte f. Prakt. Derm., Ed. xix. No. 1. 450 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
masses gradually come away through the openings, and leave deep, 
ragged ulcers. As soon as the openings have formed pain grows less 
and the constitutional symptoms grow better. 
Certain variations from this course are to be noted. The process may be much 
protracted by repeating itself for some time at the periphery, and the carbuncle 
may thus attain considerable proportions, the author having at one time treated 
one in an old man which occupied almost the entire region outlined by the tra- 
pezius muscle. In such cases the patient often stands in great danger of death 
from septicaemia. Sometimes, instead of the skin giving way at several points, it 
becomes gangrenous en masse and is cast off, leaving a deep, spongy-looking exca- 
vation, or it may undergo dry gangrene, becoming mummified. Accidents of a 
serious nature which may arise during the course of a carbuncle are septic phlebitis 
of the sinuses of the brain and septic embolism of other organs. 
The most common site for carbuncles is the back of the neck, but 
they may occur upon the face and other parts of the body, attacking 
most often the extensor surfaces. It is said that patients never recover 
after carbuncle upon the upper lip, but the author’s experience is quite 
to the contrary of' this statement. 
Etiology and Pathology.—What has been said of the etiology 
of furuncle applies almost equally well to carbuncle. It is usually 
regarded as a collection of boils. It is most common in adult life and 
forms a frequent complication of diabetes. The same micro-organism 
is found in carbuncle as has been mentioned in furuncle, and why in the 
one case a boil should result from its inoculation and in another a car- 
buncle has not been explained, except on the supposition that for some 
anatomical reason it happens in carbuncle that the direction of least 
resistance is not toward the surface. 
Diagnosis.—Carbuncle differs from furuncle in its greater size, 
brawniness, and multiform openings. Phlegmon of the face is not so 
circumscribed, not so hard, not so dark red, and opens at but one point. 
Anthrax begins as a sharply-defined red area upon which a vesicle 
rapidly forms in which anthrax bacilli can be found. 
Prognosis.—A carbuncle is always a dangerous affection, and especi- 
ally so in the aged or those debilitated from any cause. A carbuncle 
on the head or face is more dangerous than on other parts of the body. 
Treatment.—In all cases of carbuncle attention should be directed 
to keeping up the strength of the patient. To this end morphia must 
usually be given to secure rest, the hygienic surroundings must be made 
the best possible, a nutritious and easily digestible diet arranged, and 
alcoholic stimulants and tonics must frequently be administered. In 
very mild cases those local means which have been recommended in 
furuncle may be used, but in the majority of cases more radical measures 
will be called for. The method that is perhaps most generally useful 
is a crucial incision through the entire thickness and width of the 
infiltration, followed by the removal with the sharp spoon and scissors 
of all necrotic masses as far as possible. A moist, antiseptic dressing 
should then be applied and changed daily. A method which is much 
used on the Continent consists of the parenchymatous injection of a 5 
per cent, carbolic-acid solution. A number of injections are made, and 
the operation is repeated if necessary, the aim being to saturate the 
carbuncle as thoroughly as possible short of producing carbolic-acid 
intoxication in the patient. SURGICAL DISEASES OF THE SKIN. 
451 
The most radical of all methods thus far proposed is that of Riedel, by which 
the entire affected tissue is removed by the knife just as though it were a malignant 
tumor. The method is highly spoken of, but its use will probably be confined to 
those cases in which urgent symptoms are presented, as, for example, profound 
sepsis. 
Callosities.—Callosities of the skin of various parts of the body are 
of frequent occurrence. They are most common upon the palms of 
those who handle tools or the soles of those who are much upon their 
feet. Callosities are thickenings of the corneous layer of the skin, and 
represent an effort on the part of nature to protect tender parts from 
injurious pressure, though occasionally callosities are congenital. 
As a rule, callosities do not require treatment, as they afford pro- 
tection ; furthermore, if removed and the occupation which excited 
them be still pursued, they will return. When it is deemed necessary 
to interfere, the part upon which the callosity occurs should be soaked 
in hot water containing borax; the upper layer of the callosity can 
then be scraped off. Salicylic acid, either in the form of Unna’s 
plaster mulls or in a paste, such as the following, should be kept con- 
stantly applied: Talci, 3vj; zinc oxidi, 3v; acidi salicylici, 3ss-yj ; 
vaselini, §j.—M. Sig. Apply. 
Clavus (Corn).—A corn may be either hard or soft. A hard corn is 
really a callosity with the addition of a peg of horny scales which pro- 
jects from its under surface and causes pain by pressure upon the sen- 
sitive tissue beneath. A soft corn differs only in that it occurs in 
situations where it is kept sodden by moisture. Corns nearly always 
occur on the feet, and are the result of ill-fitting shoes. Their usual 
situations are the joints of the toes, especially the outer side of the little 
toe. It sometimes happens that a corn becomes inflamed, and this may 
lead to the formation of an abscess or ulcer, or even to caries of the bone. 
In the treatment of corns the first thing is to remove injurious 
pressure and to see that a properly-fitting shoe is worn. Hard corns 
may be treated just as if they were ordinary callosities. It is well, in 
addition, to place a felt corn-plaster over the corn in such a way as to 
prevent pressure. In the case of soft corns the feet should be washed 
twice a day, using plenty of soap. As much of the thickened epi- 
thelium as possible should be removed with a knife, and then the fol- 
lowing pigment painted on three times a day : Acidi salicylici, gr. xv; 
ext. cannabis Indie., gr. viij; alcoholis, Tflxv; setheris, Tflxl; col- 
lodii flex., Tfllxxv.—M. At the end of a week the corn can be pulled 
away with the layers of collodion. 
Cornu Cutaneum.—Horns growing from the skin are comparatively 
rare, yet on account of the striking appearance which they present they 
have attracted much scientific as well as popular attention. Generally, 
only one cutaneous horn is present, but sometimes horns are multiple. In 
size they vary from a barely noticeable projection to a protuberance sev- 
eral inches long. They resemble the horns of the lower animals, but 
are rougher, often twisted and bent or striated. They grow slowly, and 
may fall spontaneously and be reproduced. They cause no pain unless 
injured, when the base may become inflamed and suppurate. They 
occur chiefly upon the scalp and forehead, but may also affect the 
extremities, the sulcus behind the glans penis, and the trunk. 452 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
It is stated that not uncommonly cutaneous horns degenerate into epithe- 
liomata. Quite frequently horns start from sebaceous cysts or warts or scars. ( Vide 
Chapter XXVI., Group VII.) They are most frequent after forty years of age. 
Horns are essentially warts in which the horny cells are much exaggerated. They 
are always seated upon large papillae. 
In the treatment of horns the first thing is to soften the horn by 
applying water dressings, having added borax to the water. Then the 
horn is torn off or cut off at the level of the skin. The base should 
be curetted, and then cauterized with nitrate of silver or chloride of 
zinc. 
Verruca.— Warts have been variously named according to certain 
characteristics which they present, and for clinical purposes it is well to 
retain these titles. 
Verruca Vulgaris.—This is the form of wart so commonly seen upon 
the hands of young persons. Generally, a considerable number are 
found upon the body. They are sessile growths, from a pinhead to a 
pea in size, either with a smooth surface or beset with numerous little 
elevated points. Usually of a yellowish color, they may from accumu- 
lation of dirt become blackish. These warts are most frequently found 
on the hands, but may be seen upon any part of the body. 
The Seborrhoeic Wart.—This form occurs quite frequently upon the 
faces, backs, and arms of elderly persons. They are usually pigmented 
of a brown or black color, and present upon their surface a certain 
amount of scaling. They often itch intolerably. 
Verruca Digitata.—In this form the development of the individual 
papillae is great, giving rise to several long, finger-like processes seated 
upon a common base. These warts are found especially on the scalp, 
and one or several may be present. When only a single papilla is 
specially enlarged, the name verruca jiliformis is given to the wart: 
it is found frequently on the eyelids. 
Verruca Acuminata.—This form of wart, to which the term venereal 
is also applied, occurs with much frequency about the genital organs and 
the perineal region of both sexes, but may be found in almost any 
other situation. The growths are pointed or sessile, and are often com- 
pared to various vegetable growths, as a cauliflower, a mulberry, etc. 
On parts of the body where they remain dry they are the color of the 
surrounding skin, but in the region which they most often affect they 
are constantly moist and become covered with a whitish, mucus-like 
coating and exhale a very disagreeable odor. If the coating is wiped 
off, bright-red, easily-bleeding tufts are exposed. These warts some- 
times develop with great luxuriance, forming masses as large as the 
fist. 
Until recently we have been entirely ignorant as to the etiology of warts, but 
now the opinion that they are due to a parasite is becoming more and more gen- 
eral. A number of instances of contagion can be cited in support of this belief. 
Verruca acuminata occurs especially where regions are kept moist by a chronic 
discharge; for instance, gonorrhoea, or during pregnancy, when an unusual activity 
of mucous secretion occurs in the female genitals. Anatomically, all warts con- 
sist of a central vascular connective-tissue covered by more or less epithelium. 
Until recently the treatment of warts has been purely local. Col- 
rat made the observation that magnesium sulphate, given for some time 
in doses of ten to thirty grains three times a day for adults, was capable SURGICAL DISEASES OF THE SKIN. 
453 
of curing warts. Other observers have borne witness to this, and the 
method is certainly worth a trial. A great many methods for the local 
treatment of warts have been advised. Some one of the caustic agents 
may be used. One of the best methods is by applying salicylic acid in 
the form of a plaster or in collodion, as recommended for corns, or, 
where the warts are very close together, by applying a saturated solu- 
tion of salicylic acid in alcohol several times a day. It is often neces- 
sary to resort to stronger remedies, among which may be mentioned 
chromic acid, acid nitrate of mercury, and trichloracetic acid. The fili- 
form warts may be snipped off with scissors and the base cauterized. 
An excellent manner of removing warts is by means of the electrolytic 
needle. The needle attached to the negative pole of five to ten cells of 
a galvanic battery is passed several times through the wart just above 
the level of the skin. It is better not to attempt to complete the ope- 
ration at one sitting, but to operate at intervals of a week or two, as in 
this way scarring is best avoided. In the treatment of acuminate warts 
the chief point is to keep the parts dry and clean. Frequent washings 
are necessary, followed by dusting with a powder, such as this : Acidi 
borici, 3j ; hydrarg. clilor. mit., gr. x ; acidi salicylici, gr. x ; zinci 
stearatis, 3ij.—M. Where two surfaces which lie in apposition, as the 
glans penis and preputial sac, are affected, a piece of absorbent cotton 
should be interposed. When the growths are very luxuriant, they may 
first be trimmed away with the scissors and then the bases touched with 
pure carbolic acid or some other caustic. When these warts arise dur- 
ing pregnancy it is not necessary to treat them, as they nearly always 
disappear after delivery. 
Nsevus Pigmentosus.—A pigmented nsevus is a congenital deposit 
of pigment in the skin which may or may not be accompanied by other 
changes in the integument. 31oles have been variously named according 
to their clinical appearance. Ncevus spilus is the name given when noth- 
ing more than an abnormal pigmentation is observed. Such moles vary 
in size from a pinhead to a dime or even larger, and in color from fawn 
to black. Though most common on the back, they may be found on 
any part of the skin. If the surface of the mole is thrown into folds 
and ridges, it is called ncevus verrucosus. Arery commonly a number of 
hairs, fine or coarse, spring from the nsevus, and the name ncevus pilosus 
is given. If soft, papillary growths cover the surface, the mole is 
termed ncevus papillomatosus. Some large moles contain a good deal of 
fat, and may resemble dermatolytic growths, thus receiving the name 
ncevus lipomatodes. Lesions occur in all respects similar to raised pig- 
mented nsevi, except lacking the color, and are spoken of as white 
moles. 
Moles vary much in size and number in different individuals. They are especi- 
ally often found on the face, neck, and back. Sometimes a pigmented nsevus 
covers a large region of the body; again, a number of pigmented nsevi may be 
found in the course of some nerve. Sometimes a sarcoma or a carcinoma springs 
from a pigmented nsevus, and this renders the affection of more surgical import- 
ance than it would otherwise be. 
If the surgeon is asked to remove a mole for cosmetic purposes, it is 
well for him to be quite sure before undertaking the operation that the 
resulting scar will be less disfiguring than the mole. If a mole with 454 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
hairs is to be dealt with, the hairs should first be removed, and then, 
after sufficient time has elapsed for the full effect of the operation to 
become evident, what remains of the mole can be dealt with. The elec- 
trolytic needle gives the best results. In its use it is best to proceed 
carefully, doing a little at a time, as in this wav scarring will best be 
avoided. Generally it will not be possible to remove all the pigment, 
but usually its amount can be much lessened and the mole can be 
brought to the level of the surrounding skin. If removed by the knife, 
as a rule too much scarring results. The caustics are unsafe. If a 
mole is where it is constantly irritated, as by the clothing, especially in 
advanced life, or if a mole shows a tendency to grow rapidly or to ul- 
cerate, it is wise to remove it without delay. 
Nsevus Vascularis and Telangiectasis.—By a vascular ncevus we 
mean a growth which is characterized by an increase in number and 
size of the blood-vessels of a part of the skin. If the blood-vessels 
have become dilated after the individual has reached adult life, they are 
usually spoken of as telangiectases. ( Vide Chapter XXVI., Group VI.) 
A vascular nsevus may be present at birth or it may first manifest itself after 
weeks or months. Only one may exist or numbers may occur upon the same per- 
son. The nsevus may occupy a space no larger than a pinhead, or, on the other 
hand, large areas may be involved. In color nsevi vary from a light red to a dark 
purple: if pressure is made a part of the color disappears, hut rapidly returns as 
soon as the pressure is removed. Some nsevi are quite flat and level with the 
skin, but others are raised and the surface rugose, warty, or presenting little 
tumors darker than the rest of the growth. In the elevated growths it can fre- 
quently be seen that the tumor grows more turgid on straining or crying, and in a 
few of these growths pulsations synchronous with a heart’s impulse can be felt; in 
these tumors a bruit may be heard. 
Nsevi have received special names founded upon certain clinical 
peculiarities. The birth-mark may consist of a central red dot with 
radiating red lines springing from it; this has been called norms araneus. 
When the nsevus occurs as a large red or bluish discoloration, it is 
called a port-wine mark. A nsevus may be so much raised above the 
surface as to form a veritable tumor, which is usually of a purplish 
color, and, though easily emptied of blood by pressure, rapidly fills 
again. On account of their reticular structure the term angioma caver- 
nosum has been applied to such growths. Sometimes the angioma lies 
entirely in the subcutaneous tissue, the skin over it not showing any 
change Vascular nsevi occur also upon the mucous membranes, and do 
not differ in any essential particular from those which affect the skin. 
Though nsevi occur upon any part of the body, they are most frequently 
seen upon the head, face, and extremities. They are of importance 
chiefly on account of the disfigurement which they cause. 
The course of nsevi is always uncertain. In some cases they dis- 
appear as life advances, but, on the contrary, those which have seemed 
of little importance may suddenly and unaccountably grow. Various 
complications may arise with a nsevus; the skin covering the growth 
may ulcerate and alarming hemorrhage follow, or a traumatism may 
precipitate the same evil. It occasionally happens that a nsevus and the 
surrounding tissue become gangrenous. There are, as a rule, no sub- 
jective symptoms with nsevus vascularis. 
Telangiectases develop as secondary phenomena, although it may be SURGICAL DISEASES OF THE SKIN. 
455 
at times difficult to ascertain the cause. The usual sites for telangiec- 
tases are the face, the neck, and the upper part of the trunk. One of 
the most common clinical forms exactly resembles the nsevus araneus. 
In other cases small red or bluish vessels are seen coursing over the 
skin. These are frequently seen in elderly persons upon the cheeks and 
in those suffering from rosacea. In other instances the telangiectasis 
occurs as a smooth red or purplish elevation, the surface of which may 
in the course of time become tuberculated, so as to resemble a raspberry. 
Tn some rare instances almost the entire surface has been occupied by 
telangiectases. Telangiectases are not infrequently seen upon mucous 
membranes, as about the nares, in the conjunctiva, and in the pharynx. 
Sometimes a telangiectasis spontaneously disappears, but more commonly 
it increases in size and others develop in its neighborhood. 
Etiology.—Since maternal impressions can no longer be accepted 
as a cause for vascular nsevi, we are in the dark as to their etiology. 
Telangiectasis can result from any cause which produces long-continued con- 
gestion of the skin, such as interstitial changes in the kidneys or liver, emphysema, 
and other chronic lung troubles. Local obstructions to the cutaneous circulation 
also cause them; consequently we find them at the periphery of scars, over new 
growths, and with inflammatory troubles, such as acne rosacea. They form an 
essential feature of Kaposi’s disease. 
Pathology.—The pathological anatomy of even the simplest vas- 
cular nsevus is frequently complicated, for not only is there an increase 
in the number of yessels of the part affected, but their walls often pre- 
sent marked changes. The pulsating nsevi are made up of a mass of 
arteries and veins confusedly twined together. In the cavernous nsevus 
there are intercommunicating chambers formed by trabeculae of connec- 
tive tissue lined with endothelium. 
Diagnosis.—There is no difficulty in making the diagnosis of nsevus 
vascularis or of telangiectasis if the peculiarities mentioned. above are 
kept in mind. 
Prognosis.—The prognosis in both nsevus vascularis and telangiec- 
tasis must be guarded. It often happens that a flat nsevus, insignificant 
at first, extends or develops into a pulsating angioma. Telangiectases 
are apt to keep on forming unless the predisposing cause can be removed. 
Treatment.—In some of the more formidable vascular nsevi serious 
surgical operations, such as ligature of the large vessels or even ampu- 
tation of the affected part, may be necessary, but here only those cases 
suitable for treatment by the ordinary means of the dermatologist will 
be considered. The methods of treatment which have been found most 
generally useful are—destruction by chemical a gents, extirpation by the 
knife, and coagulation and inflammatory obliteration by electricity. 
1. Destruction by Chemical Agents.—In the case of superficial nsevi 
the application of some caustic agent may suffice for a cure. Ethylate 
of sodium has been recommended, because it leaves only a superficial 
scar. Its use is tedious, as it must be repeated several times, and it is a 
preparation difficult to obtain. Nitric acid, acid nitrate of mercury, and 
chloride of zinc are other caustics which, properly used, give good 
results. In using them the application should be carefully made, lest 
more destruction of tissue and scarring result than is necessary for the 
cure of the nsevus. The sloughs which form should be allowed to 456 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
separate of themselves. The injection of irritating chemicals into ele- 
vated nsevi has often been practised, but this is not a safe method and 
should not be used where other means will answer. 
2. Extirpation by the Knife.—If the naevus is small and so situated 
that tissue can be spared, probably no other method is more satisfactory 
than excision, as there is thus left only a linear scar. In removing a 
naevus by the knife the incision should be made well outside the affected 
area, as otherwise the hemorrhage may be great and the growth may 
recur. 
3. Coagulation and Inflammatory Obliteration by Electricity.—For the 
cure of vascular naevi electricity may be used in two ways—as elec- 
trolysis or as the galvanic cautery. Electrolysis is perhaps the most 
generally useful method at the disposal of the dermatologist for treating 
vascular naevi. In the case of small naevi it is ideal: if the naevi are 
large, its usefulness is limited by the fact that, since the area of vessels 
affected by each thrust of the needle is small, the sittings are long and 
must be repeated. The operation is performed in this way : A slender 
needle is attached by a suitable holder to the negative pole of a galvanic 
battery, while to the positive pole is connected an ordinary sponge elec- 
trode. The needle is passed into the nsevus and the positive electrode 
applied to some convenient part of the body. The tissue immediately 
surrounding the needle soon commences to assume a whitish color, which 
gradually extends, and this, together with the amount of destruction 
occurring about the needle, will be the index of the length of time the 
current is to be allowed to pass. The depth to which the needle is to be 
passed, the number of insertions of the needle, and the strength of the 
current used must all be determined by the size and nature of the growth. 
Usually the current supplied by twenty cells of an ordinary battery is 
amply sufficient. 
In treating telangiectasis the steps are similar to those described above. The 
needle is inserted into each vessel, and as the current passes the small red line 
changes to a white line, when the current is stopped. 
The galvanic cautery is used chiefly in the large elevated nsevi. A fine cautery- 
point heated to a dull red is thrust into the tumor at various points and in various 
directions. The effect can be judged only after healing from the inflammation 
that follows is completed. It is usually necessary to repeat the operation. In 
using either one of these methods strict antiseptic precautions should be observed. 
Two other methods of treatment deserve mention—vaccination and the method 
of Marshall Hall. A small flat nsevus may often be cured by introducing into it 
vaccine virus, just as in performing ordinary vaccination. By the “ Marshall Hall ” 
method a cataract needle is introduced at one edge of the nsevus and is thrust 
through to the opposite side: it is almost withdrawn, and then pushed through at 
a little distance from the first puncture, and so on till the whole growth has been 
traversed by closely-set radiating punctures. By the cicatrix which follows the 
vessels are frequently shut off’. 
Lymphangioma.—By lymphangioma is meant a growth made up of 
lymphatic vessels. The form which most often affects the skin is lym- 
phangioma circumscriptum, and even this is a rare disease. It usually 
makes its appearance in the early years of childhood, and may attack 
almost any region of the body. When fully developed the appearance 
presented is striking. One or more patches, varying in size from a silver 
dollar to an area larger than the palm, will be seen raised above the level 
of the skin. At the first glance the patches seem to be made up of small 457 
SURGICAL DISEASES OF THE SKIN. 
closely-packed warts. The surface is uneven and rough in aspect, and 
varies in color from a dirty gray to black. On more careful examin- 
ation the seeming warts are found to be really vesicles from a pinhead 
to a pea in size, and so closely pressed together that their form is very 
angular and irregular. The vesicles are very deep-seated, their roofs 
being formed of the whole thickness of the epidermis. Borne of the 
lesions are semi-transparent, but the epidermis of others is so thick that 
the lesions are opaque : it is the predominance of such lesions that gives 
to the patch its warty look. 
Small dilated blood-vessels can often be seen coursing over the vesicles. By a 
careful examination the impression is conveyed that the lesions are not vesicles in 
the ordinary sense, but rather that they are cavities deep in the skin filled with 
fiuid. The lesions are firm, tough, and nor easily ruptured. Around the edges of 
the main plaques are generally lesions that have thinner coverings, and therefore 
appear more as simple vesicles than those described. In color they may be pink, 
red, or yellowish. If one of the lesions be pricked, a variable amount of clear 
fluid containing lymphatic corpuscles escapes. This may amount to only a few 
drops or the discharge may last several hours. In some cases the part upon which 
the lymphangioma is situated is increased in bulk. Lymphangioma persists indef- 
initely, tending to increase slowly in size by the formation of new vesicles and 
plaques. 
Some mention should be made of the acquired dilatations of lymph- 
channels to which the name lymphangiectasis has been applied. In its 
most frequent form it constitutes elephantiasis. ( Vide Chapter I.) Aside 
from elephantiasis, lymphangiectases are rare. They are always the 
result of antecedent causes which it is often difficult to discover. It is 
probable that both an acute and a chroma form exist, but nearly all cases 
described belong to the latter class. As an example of the acute form 
may be mentioned Trelat’s case,1 in which eight days after an injury to 
the penis there occurred, besides an ordinary lymphangitis of the fore- 
skin, prominent vesicles which discharged lymph. 
Chronic lymphangiectases develop slowly, their progress sometimes 
being marked by paroxysmal erysipelas-like attacks, such as are fre- 
quently seen in elephantiasis. The lower extremities are usually 
attacked. The skin lesions consist of nodosities often arranged in rows 
corresponding to the course of lymph-vessels. The skin is glazed, cedem- 
atous, and of violaceous hue. The nodules, at first hard, break down 
and discharge lymph, with the consequent formation of lymph-fistulse. 
Various secondary lesions accompany this condition, such as oedema, 
dermatitis, pachyderma, phlegmon, and lesions of the periosteum. 
We know nothing of the etiology of lymphangioma circumscriptum. 
The etiology of lymphangiectasis may be plain or obscure. In some 
cases it results from the pressure of tumors on large lymph-trunks. 
Other forms of obstruction to the circulation, such as result from a 
chronic heart or kidney lesion, may cause the disease. Long-continued 
simple irritation, such as might result from an in-growing nail or an ulcer, 
has been thought to act as a predisposing cause. Lastly, various para- 
sites, such as the filaria, the tubercle bacillus, and the specific causes of 
glanders and syphilis, can localize themselves in the lymphatic vessels and 
cause the lymphangiectasis. 
If the description given above of lymphangioma circumscriptum is 
1 Besnier and Doyon, Mai. de la Peau, p. 384. 458 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
borne in mind, there should be no difficulty in making a diagnosis. 
Lymphangiectases may simulate ulcers, indolent abscesses, or varicose 
veins, but the discharge of lymph, flowing spontaneously or purposely 
withdrawn, would decide the diagnosis. 
The prognosis in all cases of lymphangioma must be regarded, as 
there is a tendency slowly to extend and to recur after removal. In 
lymphangiectasis the prognosis depends largely upon the cause of the 
dilatation of the vessels : if this is susceptible of removal, the lymphatic 
lesions may be cured. It is of importance to remember that the most 
scrupulous aseptic precautions should be taken in all operations upon the 
lymphatics, as septic infection has very often followed such operations. 
In the treatment of lymphangioma the only procedure is destruc- 
tion of the growth. Where scarring docs not matter, the cautery is the 
best method, as by it the vessels are sealed for some distance beyond the 
portion actually destroyed. When a limited area is involved and scar- 
ring is to be avoided, excision with the knife is advisable. Chemical 
caustics have not given good results. Whatever method is employed, 
the removal must be thorough or the growth will re-form. In lym- 
phangiectases elastic support should be used as for varicose veins, and 
compression applied to prevent lymphorrhagia. If only a few super- 
ficial vessels are involved, they may be dissected out. In chronic cases 
with ulcers and fistulae deep cauterization with such active agents as 
chloride of zinc or Canquoin’s paste has resulted in cure. In cases 
where the lymphangiectasis is the result of tuberculosis of the lymph- 
vessels all sinuses as far as possible should be laid open, the diseased 
tissue should be removed, and the wound thoroughly cauterized with 
zinc chloride. In severe cases, with large growth of the bones and tis- 
sues and exhausting lymphorrhagia, amputation may be demanded. 
Keloid and Hypertrophied Scar (vide Chapter XXVII. Group 
V.).—It is often of the utmost difficulty to make a clinical diagnosis 
between true keloid and the much commoner hypertrophied scar. The 
two affections are therefore classed together, and in many essential 
points they are identical. Alibert regarded the true keloid as a growth 
springing from the uninjured skin, but it is doubtful if an absence of a 
history of injury could be taken as implying the non-traumatic origin 
of keloid, since in many cases growths indistinguishable from keloid 
have followed injuries so trifling as to have been readily forgotten had 
not some accidental circumstance fixed the occurrence in the memory. 
True keloid may present itself as a single tumor or many may be seen 
upon the body. In a negro recently seen by the author there were 
hundreds of tumors scattered all over the body. 
The tumor varies much in size and in shape, though, as a rule, the 
outline is more or less oval, the border of the growth jutting out over the 
integument, which has suggested the likeness of the disease to the paw of 
an animal placed upon the skin. The color is a glazed, white or reddish, 
and often small dilated vessels may be seen coursing over the tumor. 
In the negro the color is frequently of a darker hue than the surround- 
ing skin. Keloid usually causes no subjective disturbance, but, on the 
other hand, pricking or burning is sometimes experienced, or even an 
intolerable neuralgic pain. Keloid may cease to grow after a time or it 
slowly but steadily enlarges, or, very rarely, it undergoes partial or PLATE XVI 
KELOID. SURGICAL DISEASES OF THE SKIN. 
459 
complete involution. Keloid may occur upon any part of the cutaneous 
surface, but it is very commonly found over the sternum (Plate XVI.). 
The hypertrophied scar differs from keloid clinically in that it does 
not spread beyond the limits of the ordinal injury, and in fact often 
contracts into narrower bounds. 
The true and intimate etiology of keloid remains unknown. Cer- 
tain races, notably negroes, are especially prone to it. The disease very 
commonly occurs where lesions of the skin have been produced, as by 
piercing the ears, or following acne, small-pox, or syphilitic eruptions. 
Anatomically, true keloid consists of a dense connective-tissue new 
growth seated deep in the corium, most of the fibres being arranged 
parallel to the surface of the epidermis, and the papillae over the growth 
being preserved. In hypertrophied scar the connective-tissue bundles 
are less dense, more irregular in their arrangement, while the papillae 
are destroyed by the injury from which the scar resulted. Warren be- 
lieves that the growth has its starting-point in the walls of the vessels. 
In young subjects there is always some prospect that spontaneous 
involution may occur. As a rule, no operation demanding the use of the 
knife is permissible in true keloid, as there is a strong probability that 
the growth will recur. In hypertrophied scar, if deformity is caused 
or severe pain is present, removal may be necessary, but particular care 
should be taken that immediate union in the wound is obtained. The 
incision must be wide enough to embrace not only the scar, but also a 
portion of the surrounding tissue. Where there is not sufficient tissue to 
permit of this, skin-grafting by Thiersch’s method should be employed 
at the time of the operation to cover in the defect. In this way recur- 
rence will best be avoided. 
All the methods of treatment which have had any success in keloid 
depend on occlusion of the vessels of the growth. Verneuil has strongly 
advocated pressure by the elastic bandage, taking care that no friction 
is produced which would tend to stimulate the growth. Vidal has em- 
ployed with success deep multiple incisions, finely mincing the growth, 
the operation being several times repeated. The author has obtained 
some favorable results from electrolytic puncture; Brocq also urges 
this method. A weak current and many sittings are the requisites to 
success. This method is indicated only in small growths, and is most 
apt to succeed in hypertrophied scar. 
Elephantiasis.—Elephantiasis is a malady due to the blocking of 
the lymph-channels, the most notable clinical feature of which is a 
hypertrophy of the skin and subcutaneous tissue. The disease occurs 
as an endemic in certain tropical countries, but in this country only 
sporadic cases are seen. The endemic form usually commences by 
attacks which much resemble erysipelas. There are fever and swelling 
and redness of a part, usually a lower limb. The lymph-vessels often 
become turgid, and on puncture emit a chyle-like fluid. In a short time 
the fever subsides and the swelling of the leg partially disappears, leav- 
ing the limb slightly larger than before the attack. It is by the repeti- 
tion of such attacks that the endemic form of elephantiasis progresses. 
In the sporadic form nothing which corresponds to the elephantoid 
fever is observed, except in the cases occasionally seen where repeated 
attacks of erysipelas have blocked the lymph-channels. 460 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
If the disease is fully developed, it forms a striking picture. The leg is the 
member most often involved. The part is two or three times its normal size. The 
natural folds are increased in depth till they form fissures in the skin. In these 
crevasses is a slimy, offensive fluid formed by decomposing excretions and epithe- 
lium. The skin is frequently discolored, of a brownish or black hue. The sur- 
face may be smooth, or, on the other hand, covered with dilated lymph-vessels 
and presenting plaques of warty-looking hypertrophied papillse. Ulcerations often 
occur, and not uncommonly open a lymph-vessel; so that lymph freely escapes. 
The surface is also subject to periodical eczematous inflammations. 
Next to the lower limbs, the genitals are most frequently attacked. 
In some eases the scrotum has attained such enormous proportions as to 
reach almost to the ground. Very rarely the arm, hand, or face has 
been found involved. 
As a rule, there is no pain attending elephantiasis. The general 
health is unaffected, save by the restriction of movement and occasion- 
ally by the amount of the lymphorrhagia. 
Etiology and Pathology.—Elephantiasis affects both sexes and 
all ages, but is most common in men. It may be congenital. It is 
most frequent among dark races. The affection is due to the blocking 
of the lymph-channels. In the endemic form the obstruction is due to 
the jilaria sanguinis hominis. 
Erysipelas, syphilis, phlegmasia alba dolens, tumors pressing on large lvmph- 
trunks, may all result in lymph-obstruction and elephantiasis. The greater por- 
tion of the enlargement is found to be due to 
a growth of fibrous tissue in the subcutaneous 
layers. The corium is increased in thickness 
and the epidermis often proliferates. Lym- 
phatics, blood-vessels, and nerves may be en- 
larged, as may the bones also. 
Diagnosis.—There is no other affec- 
tion which is liable to be mistaken for 
elephantiasis. 
Prognosis.—As far as health is con- 
cerned, the prognosis is good. The affec- 
tion, if of long duration, will probably not 
be much benefited save where it is so 
situated that removal is possible. In the 
countries where the disease is endemic 
removal to another climate often im- 
proves the condition. 
Treatment.—As far as general treat- 
ment is concerned, the indications must 
be drawn from the cause of the disease 
as well as its stage at the time of treat- 
ment. Thus, where a syphilitic origin 
can be suspected antisyphilitic treatment 
offers hope. If an endemic case is seen 
while in a febrile attack, a fever diet and 
attention to the general functions of the 
body are requisite. If a patient has been 
reduced by ulceration with lymphorrhagia, 
a nutritious diet and reconstituent remedies should be employed. In 
cases where it is possible, as about the genitals, removal is proper and 
Fig. 191. 
Elephantiasis. SURGICAL DISEASES OF THE SKIN. 
461 
nearly always successful. Ligation of the main vessels supplying the 
part affected was once practised, but is not now advocated. Where the 
lower limb is involved the use of a properly-applied rubber bandage 
gives most relief. Galvanism has been used with success in some 
eases. 
Myoma.—Myomata are new growths composed of fibrous tissue and 
muscle-fibre. They occur as a number of nodules more or less grouped, 
and also as single tumors. The variety in which the tumors are multi- 
ple is extremely rare. The tumors develop slowly, in the course of 
years attaining the size of peas or beans. When multiple they are 
usually grouped and appear only in one region of the body or in several 
limited regions. The lesions are of the color of the normal skin or 
pink or red, and are firm to the touch. Most of the cases have been 
spontaneously painful as well as tender on pressure. 
The single tumors are more common; they occur chiefly on the 
mammae of women and about the genitals of both sexes. The tumors 
are usually small, but may be as large as an apple. They will often 
contract on exposure to cold. 
Myomata are supposed to originate from some of the muscles con- 
nected with the skin, as the erectores pilorum. 
The diagnosis of myomata may be very difficult, and only a micro- 
scopical examination is to be relied upon. 
The only treatment is ablation of the growth, and this may be 
impossible in the multiple form. 
Lipoma.—A lipoma is composed of fat-tissue. The growth is 
usually situated in the subcutaneous tissue, and may be single or multi- 
ple. Lipomata vary in size from a plum up to tumors weighing many 
pounds. A lipoma is very rarely congenital except in connection with 
lymphatic anomalies, but usually develops in adult life. 
Although lipomata may occur upon any portion of the body, the commonest 
sites are the back and the buttocks. The skin over a lipoma is usually unchanged, 
but may be pigmented and covered with telangiectases. To the touch the tumor 
is soft and elastic, and it usually gives the impression of being lobulated. When 
the skin is made tense over the tumor, a peculiar dimpling is generally noticed, 
due to the adhesions of the fibrous septa of the tumor, which draw down the skin 
at certain points. 
Lipomata are usually unattended by subjective symptoms, but wdiere nerves 
are pressed upon neuralgic pain may be caused. The lesions are slow-growing, 
and frequently, having attained a moderate size, remain stationary. Anatomically, 
lipomata consist of masses of ordinary fat-tissue separated by fibrous septa con- 
taining blood-vessels. Lipomata of the skin are perfectly benign, and interfere 
with health only when their size becomes so great as to inconvenience their 
bearers. 
The only treatment of lipomata which merits attention is excision, 
and this should be undertaken only when the size or situation renders 
it necessary. 
Fibroma.—Fibroma of the skin manifests itself by the presence of 
variously sized tumors made up of fibrous tissue. Clinically, at least 
two varieties of fibromata can be recognized. In the first a small, firm, 
round tumor is present covered by normal skin. As a rule, these little 
growths are single, and are most commonly found on the face, trunk, or 
extremities. 462 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
In the second form, known as molluscum fibrosum, the growths are 
multiple, hundreds being sometimes present upon the body. The tumors 
vary in size from a pea to masses weighing many pounds. The growths 
do not feel firm to the touch, but lax, and can be rolled between the 
fingers. The skin in the smaller tumors is normal in color, but upon 
the larger ones telangiectases are often seen, as well as more or less 
hyperpigmentation. 
The smaller nodules are usually hemispherical, projecting from the skin, but 
as they increase in size they tend to become pedunculated. Upon some of the 
tumors one can see very large comedones. Among the other lesions will generally 
be found little empty sacs of skin from which the contents have been absorbed. 
Sometimes great folds of skin are formed, which hang down like a cape. This 
may occur without the ordinary tumor-formation. This condition is termed der- 
matolysis. This form of fibroma affects most commonly the trunk, then the back 
of the head, the face, and the limbs. 
In the case of single tumors excision may be practised where there 
is sufficient reason, such, for instance, as pain from pressure on a nerve. 
With the multiple tumors it may become necessary to remove the larger 
growths or the pendulous masses of skin. In such cases the hemorrhage 
is often alarming on account of the large vessels, and the surgeon must 
be prepared to meet this emergency. 
Neuroma.—Under the name neuroma authors have from time to 
time described tumors of the skin or subcutaneous tissue which were 
accompanied by more or less pain, often neuralgic in character. On 
microscopical examination such tumors have usually been found to be 
made up of fibrous tissue with some nerve-fibres. 
It is a mooted question whether there is an actual increase of nerve-tissue in 
these growths: many believe that the tumor has only accidentally, as it were, 
involved the nerve. The author has reported a case which would certainly in a 
clinical way have been called a case of neuroma cutis, but a microscopical examina- 
tion revealed that the little tumors were made up of small muscle-fibres, and no 
nerve-elements could be demonstrated.1 
The only treatment for all these cutaneous and subcutaneous 
nodules, whatever their nature, is excision. When there are large 
numbers of tumors present, it often suffices to remove those which are 
most painful. 
Epithelioma.—Three forms of epithelioma are usually described, 
and, though this division is purely artificial, it is retained for conveni- 
ence of description : 
(1) The superficial or discoid form of epithelioma often commences as 
a small pearly or waxy-looking papule, upon the apex of which usually 
a few thin scales collect. On removing the scales after the lesion has 
existed for a time there are exposed red granulations. The papules 
may remain for years without any further change, but more commonly 
they become very gradually infiltrated at the base, while the top assumes 
more and more the character of an indolent ulcer. The amount of 
tissue destroyed by the ulcer is variable. Sometimes, after a course of 
years, the epithelioma has only eaten away a small area, involving no 
more than the tops of the papillae of the skin, while in other cases 
great disfigurement and death may result from the amount of tissue 
lost. 
1 Am. Journ. Med. Sciences, April, 1886. SURGICAL DISEASES OF THE SKIN. 
463 
In this variety of epithelioma it is rare to find the lymphatic ganglia involved, 
except in the very latest stages of the disease. It is also a very rare occurrence to 
find other organs affected by metastasis. 
(2) Papillary epithelioma is the name given to a form of epithelioma 
in which from the first there is a marked tendency to the formation of 
hypertrophied papillae. This type of epithelioma is most prone to affect 
the border where mucous membrane and skin join, the mucous mem- 
branes, the extremities, and the scrotum. Not uncommonly the affec- 
tion starts where a wart or other benign papilloma has existed for a 
long time. 
Gradually the base of the simple growth becomes indurated, while the papillary 
formation becomes more marked till the papillary epithelioma is developed. When 
fully formed the tumor consists of a hard, infiltrated base which is covered with 
large florid granulations. The tumor often has the shape of a cauliflower or cock’s 
comb. For a long time the growth of the epithelioma may extend peripherally, 
but in the course of time ulceration sets in, and, the hard, fibrous base giving way, 
the ulcer extends deeply, even attacking underlying bones. The ulcer when fully 
formed is characteristic, with hard, elevated, everted, purplish borders, the floor 
being covered with easily-bleeding granulations. The lymphatic ganglia in the 
neighborhood are often involved, especially in the later stages, and metastasis 
to distant parts may occur. The average duration of this form of epithelioma is 
said to be four years. 
(3) Deep-seated epithelioma may develop as a recurrence after the 
removal of one of the other forms, or it may be a primary growth. It 
is the latter which is here described. The 
tumor occurs most often in the mucous 
membrane, and particularly the tongue. It 
occurs also upon the skin. This form of 
epithelioma commences as a small, hard 
nodule deep in the submucous or subcu- 
taneous tissue. The growth enlarges, and 
the tissues covering it may for some time 
remain normal, but eventually adhesions 
occur, so that the skin or mucous membrane 
is no longer movable. The skin covering the 
growth is often florid and shows dilated ves- 
sels. After a variable time an ulcer forms, 
or the necrosis may occur more rapidly and a considerable portion of the 
growth may come away as a slough. A deep, irregular ulcerating cavity 
is left with hard edges. The progress of this form of epithelioma is 
more rapid than those already described, and sometimes in the course of 
a few months death may occur from dissemination or from marasmus. 
Mention must be made of a form of epithelioma which goes by the 
name of rodent ulcer. It is now agreed by most dermatologists that 
the significance of this name is purely clinical, there being no patho- 
logical grounds for separating rodent ulcer from other epitheliomata. 
This form of the malady is said to commence usually as a small brown- 
ish, rather soft nodule, generally found upon the upper two-thirds of 
the faces of elderly persons. After this has remained quiescent for a 
long time ulceration occurs. Though ulceration progresses slowly, its 
ravages may in the end be extreme, as the disease remains purely local, 
and thus does not readily terminate the life of the patient. After the 
Fig. 192. 
Epithelioma. 464 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
affection has fully developed it presents the appearance of a crateriform 
ulcer with slightly everted edges, the great distinction of rodent ulcer 
being that the amount of induration is insignificant as compared to the 
extent of ulceration. 
Etiology and Pathology.—Epitheliomata, like other forms of 
cancer, are most apt to attack those who have advanced beyond the 
middle of life, though it is probable that cancerous growths are more 
common in young people than was formerly taught. The male sex is 
much more frequently affected by epithelioma than the female. The 
factor which seems to be most potent is long-continued irritation of the 
epithelium in a certain region, as upon the lip by the pipes of smokers. 
Thus also is explained the cancer of the scrotum of chimney-sweeps and 
the epitheliomata of tar- and paraffin-workers. An epithelioma not 
uncommonly starts from a point which has been the site of some former 
pathological process, as a wart or a birth-mark or a scar. Epitheli- 
omatous lesions frequently develop in the wake of the disease known as 
xeroderma pigmentosum. Cottrell believes that syphilitic affections of the 
tongue form an especially frequent starting-point for epitheliomata. 
There is much reason to think that the true etiology of epithelioma is to be 
sought in some infective parasite, and the number of those who adhere to this 
view is constantly increasing. The parasite of cancer is regarded by most of those 
who believe in its existence as belonging to the class of protozoa. 
Epitheliomata consist microscopically of masses of epithelial cells surrounded 
and separated by bands of connective tissue. In some cases the epidermis is dis- 
posed in irregular bands and masses or lobules. The cells in the centre of such 
masses often become corneous, and by pressure assume a peculiar laminated ap- 
pearance, to which the term cancer-nest has been applied. In other cases the 
epithelium does not undergo the corneous change, and then presents an appear- 
ance more or less resembling gland-structure, consisting of epithelial processes 
surrounded by connective tissue, the epithelium often showing more or less of an 
attempt at a regular arrangement around the periphery of the processes. This 
last form of epithelioma is supposed by some to spring from the glands of the 
skin, but such an origin is probably rare. There has been much dispute among 
pathologists as to the true pathology of rodent ulcer. It is now almost universally 
acknowledged to be an epithelioma, opinion varying as to whether it is an ordinary 
epithelioma or an epithelioma springing from a sweat-gland or other structures. 
Diagnosis.—As a rule, the diagnosis of epithelioma is easy. The 
age at which it develops, the chronic ulcer with indurated edges, and 
late in the disease secondary adenopathy, all help to establish the true 
nature of the affection. The maladies with which epithelioma is most 
apt to be confounded are syphilis, lupus, and rhinoseleroma. 
A chancre might resemble an epithelioma, especially when it is found on the 
lower lip of an elderly man ; but with the chancre there is a history dating back at 
most for only a few weeks, while that of an epithelioma covers months; in chancre the 
lymphatic ganglia are involved early in the course of the sore, but in epithelioma 
only at a late date; in chancre the induration is apt to be much larger in compar- 
ison to the ulcer than in epithelioma; and finally, if doubt still remains, it will 
be settled in a short time by the occurrence with a chancre of a roseola. 
A gumma of the tongue might closely resemble a deep-seated epithelioma of 
that organ, but the course of the gumma is more rapid, there are other signs of 
syphilis, and the lymphatic ganglia are not involved, as they are at a very early 
date with this form of epithelioma. When the gumma has broken down, the ulcer 
left is more undermined at the edges than the epitheliomatous ulcer: it has not 
much, if any, infiltration at the base and edges, and does not show the fungous 
growths which are usually a conspicuous feature of epithelioma. 
It is hardly likely that the ordinary form of lupus vulgaris could be mistaken SURGICAL DISEASES OF THE SKIN. 
465 
for epithelioma. There is, however, one form of cutaneous tuberculosis (t. verru- 
cosa) which somewhat resembles the papillary epithelioma, but the situation of the 
lesion, the history, the absence of induration and of tendency to ulceration in 
tuberculosis verrucosa, and, finally, a microscopical examination, ought to decide 
the question. ( Vide Chapter XXVI.) 
The differential diagnosis of epithelioma and rhinoscleroma will be considered 
under the latter disease. 
Prognosis.—Epithelioma is always to be regarded as of grave prog- 
nosis on account of the liability to recurrence after attempted removal, 
yet the outlook may be relatively good or bad. The prognosis is made 
worse bv such circumstances as the situation of the growth on mucous 
membranes, by the early rapid growth of the tumor, by early lymphatic 
involvement; it is also rendered better if the growth is situated upon 
the skin where any operation for its destruction may be freely carried 
out, by the superficial character of the epithelioma and its slow growth, 
and by the absence of lymphatic involvement. 
Treatment.—It may be said that it is exceedingly questionable if 
any treatment for epithelioma beyond the local treatment is of avail. 
Lassar has recently spoken of apparent curt effected by the internal 
administration of arsenic, together with the hypodermic injection of the 
drug into the tumor. Coley, and more recently Emmerich and Scholl,1 
have made use of injections of the toxins of the streptococcus of erysip- 
elas in some inoperable cases of cancer with apparent cure, but as yet the 
method is in a strictly experimental stage. 
The local treatment of epithelioma consists of eradication, complete 
and thorough. If the growth is so situated that an abundance of tissue 
can be spared, the knife is the most convenient mode of removal. The 
incision must be made, both in depth and circumference, wide of the 
apparently diseased area, so as not to leave any cancer-cells from which 
the malady can be reproduced. Caustics, when properly applied, form 
one of our most efficient modes of destruction of epitheliomatous 
growths. To be effective their application must be thorough, for used 
with a timid hand they are worse than useless, serving only to goad the 
cancer to more rapid growth. 
A great many caustics have been used for the purpose of destroying epitheli- 
omata. The most important are arsenic, zinc chloride, pyrogallic acid, and caustic 
potash. The first is the most generally useful, especially as it exerts a selective 
action, destroying the cancer-cells more readily than the healthy tissue. Its use 
has certain limitations. For instance, it cannot well be used on the mucous 
membrane of the mouth, for fear of poisoning, nor about the eyelids, on account 
of the impossibility of exactly controlling the amount of destruction caused by 
the remedy. It should always be made a rule for the physician himself to apply 
arsenic, and the patient should be seen at frequent intervals during the use of the 
drug. In the treatment of epithelioma arsenic is used most frequently in the form 
of a paste. There are a number of such pastes in use, but the one preferred by 
the author is that introduced by Bougard. The formula for it is—Wheat flour, 
starch, ad. 30 grammes; arsenic, 0.5; hydrarg. sulph. rub., 2.5 ; ammonii muri- 
atis, 2.5; zinci chloridi, 30; hot water, 45. The first six ingredients are finely 
powdered, and then the zinc chloride, dissolved in the water, is added while the 
powder is stirred. 
In practice a portion of the paste is spread on a cotton cloth large enough to 
extend slightly beyond the cancerous sore. This is applied and allowed to remain 
on twenty-four hours. It is a good plan to see the patient within twelve hours, as 
the action of the paste is more rapid in some cases than in others. There is a 
1 Dent. med. Woch., April 25, 1895. 466 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
notable difference in the sensations of patients during the use of this paste, some 
complaining of excessive pain, others speaking of it as trifling. The result of the 
application is the formation of a slough involving the epithelioma and quite a 
severe inflammatory reaction in the surrounding tissues. This inflammation has 
the advantage that it is very likely to act in an unfavorable way upon any out- 
lying cancer-cells which have escaped actual destruction. Under poultices such 
as the unguentum vaselini plumbicum spread on cloth the slough soon separates, 
leaving a healthy granulating cavity which usually rapidly cicatrizes. Should any 
of the epitheliomatous tissue have escaped the first application, others should he 
made as soon as the fact is ascertained. The zinc chloride alone may be used in 
a similar way as a paste. 
Pgrogallol is a remedy which is appropriate for small growths. It is advisable 
first to scrape away the epithelioma with the curette, and then apply for several 
days a 25 per cent, ointment of pyrogallic acid, putting on fresh ointment eacli day. 
Caustic potash is used in the stick form. This is bored into the tissues till the 
requisite destruction is accomplished, and then the further action of the caustic is 
stopped by applying a weak acid. 
The galvano-cautery may be very well used in the destruction of epitheliomata, 
especially when small ones are to be dealt with. 
Darier1 has recorded cures from the following method: The tissue is first 
cleared of all crusts. Then a solution of one part of methyl blue to ten parts of a 
mixture of equal parts of alcohol and glycerin is applied. The cancer-cells are 
stained blue, and to these masses a 5 per cent, chromic-acid solution is then applied. 
This process is repeated at frequent intervals. 
The list of the various procedures which have been recommended in the treat- 
ment of epithelioma might be almost indefinitely prolonged. The sum of the 
whole matter is, that to-day the proper treatment is destruction. The means 
we adopt for this purpose will depend on the size and situation of the growth and 
the willingness of the patient to consent to the advice of his surgeon. 
Paget’s Disease (vide Chapter XXVI., Group VII.; also Chapter 
XIV., Vol. II.).—Paget’s disease most frequently attacks the breasts of 
women in the middle period of life, but it may atfect other parts of the 
body, and the male sex as well. Crocker has seen it upon the scrotum, and 
a case has been reported in which the affection attacked the nose. The 
malady usually begins upon the nipple of one breast, and looks at first like 
an ordinary eczema. There is more or less crusting, and when this is 
removed a raw, red granular-looking skin is exposed from which exudes 
a glairy secretion. The area involved slowly extends, the border remaining 
sharply defined and often a little raised. The base of the inflamed skin 
usually presents a thin infiltration, and scattered over the surface a few 
small islets of a pearly-looking epidermis can often be seen. It is com- 
mon to find the nipple gradually retracting. The malady may not 
extend much beyond the nipple or it may attack the skin of the whole 
breast. In a case recently seen the skin of a large portion of the 
anterior aspect of the thorax had become affected. 
There are itching and burning from the beginning. At the end of a 
few months, or in some cases only after many years, the disease enters 
upon its last stage, that of cancerous degeneration. This manifests 
itself either by the appearance of epitheliomata on the affected area or 
by the formation of an ordinary scirrhus of the breast. 
Microscopical examination of the affected skin shows that the super- 
ficial layers of the epidermis are thinned or wanting, while there is a 
decided down-growth from the deeper layers, and in some places alveoli 
of epithelial cells can be found. Thin states that the first cancerous 
changes occur in the lactiferous ducts. Darier has recently described 
1 Brocq, Journ. Cat. and Gen.-urin. Oct., 1894. SURGICAL DISEASES OF THE SKIN. 
467 
certain bodies which may be seen in the epidermis in Paget’s disease. 
These bodies are two or three times the size of the surrounding epidermic 
cells, and consist of a double-contoured cell-wall, within which is a mass 
of protoplasm containing several nuclei. Darier supposes that these 
bodies are psorosperms, and that the irritation of their presence causes 
the changes noted. The bodies may be found in scrapings which have 
been soaked in liquor potassse. 
The importance of an early diagnosis cannot be over-estimated. 
The affection which Paget’s disease most resembles is eczema of the nip- 
ples. Paget’s disease usually develops after the menopause, eczema 
during lactation. The surface exposed on removing the crusts in Paget’s 
disease is of a brighter red and more granular than that of eczema, while 
the border is more sharply defined. In eczema there is not the infiltra- 
tion noted in Paget’s disease, and scrapings do not show the peculiar 
bodies described above. 
Treatment.—When seen in its early stages or before the diagnosis 
can be established soothing applications should be made just as though 
one were treating an eczema. When we are quite sure of the nature of 
the malady, energetic treatment should be resorted to. We may scrape 
away the diseased tissue with the curette and then apply a strong (30 
per cent.) solution of zinc chloride for several hours, afterward dressing 
antiseptically. A zinc-chloride paste may be used instead of the solu- 
tion, or an ointment containing 30 per cent, pyrogallol may be applied 
for two or three days until a sufficient destruction has been accomplished. 
When malignant growths have formed excision of the whole breast must 
be performed. 
Carcinoma Cutis.—Besides epithelioma, there are two varieties of 
carcinoma of the skin—the lenticular and the tuberose forms. Some 
authors recognize a pigmented form also, but it is to-day generally 
thought that most of these cases are really sarcomata. 
Lenticular Carcinoma.—Lenticular carcinoma nearly always develops 
secondarily to a primary carcinoma; for instance, of the breast. The 
first evidence of the affection is the appearance of a number of white or 
pale-pink papules of a firm consistency, from a shot to a pea in size. 
The skin upon which these papules are situated may retain its normal 
color or may be of a violaceous hue and present dilated capillary vessels. 
The papules gradually increase in number, and coalesce to form larger 
nodules and plaques. In some cases large areas of skin become thick- 
ened and hard, constituting the cancer en cuirasse. The lymphatics may 
be so obstructed by the growths that the limbs become much swollen. 
The patient falls into a state of profound cachexia, and usually dies in 
a comparatively short time. If life is sufficiently prolonged, some of 
the nodules may ulcerate and fungous granulations may form. In a case 
of the author’s the microscope showed that the nodules were made up 
of masses and bands of epithelial cells lying apparently in the lymphatic 
spaces of the skin. 
Carcinoma Tuberosum.—This form of cutaneous cancer is rarer than 
that just considered. It occurs upon any part of the body in the form 
of hard, nodular masses from a marble to a small apple in size, and of a 
brownish or purplish color. There are usually many such nodules on 
the body. In a case of the author’s there were fully a dozen nodules 468 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
situated upon a dense mass lying in the subcutaneous tissue of the back, 
and conveying to the finger the sensation that a flat mass of wood was 
being felt through the skin. The tendency of the tumor is to break 
down into fungating ulcers which rapidly exhaust the strength of the 
patient. 
All treatment, thus far, has proved futile in carcinoma cutis, and 
the only ray of hope for such patients lies in the suggestion noted under 
Epithelioma, that some cases of malignant cutaneous growths seem to 
have been cured by the toxiues derived from the erysipelas germ. 
Sarcoma Cutis.—Sarcoma of the skin presents so many clinical 
varieties that it is extremely difficult to give a general description of the 
affection. Cutaneous sarcoma may be primary or secondary; one tumor 
may be present or many; the growth may be pigmented or non-pig- 
mented. 
Melanotic Sarcoma.—This is the most frequent form of sarcoma, and 
usually has its origin in a pigmented mole. From the mole a spongy, 
Fig. 193. 
Fibro-sarcoma of hands. 
fungating, black tumor develops. In the course of a few weeks or 
months, generally first in the neighborhood of the original growth, SURGICAL DISEASES OF THE SKIN. 
469 
numbers of small, firm, pigmented masses appear. These small tumors 
coalesce into large masses, ulceration occurs, the lymphatics become 
involved, and, after having become more or less generalized over the 
skin, the sarcoma attacks internal organs. The course of this form of 
sarcoma is usually rapid. Hutchinson has described a special form of 
melanotic sarcoma under the name melanotic whitlow which commences 
as a chronic onychitis with a faint pigmentation; gradually a slightly 
pigmented, fungating tumor develops, and then the sarcoma becomes 
generalized. Histologically, these tumors are very vascular round or 
spindle-cell sarcomata, with giant cells in some parts of the growth. 
There is also always more or less pigment to be seen both in and between 
the cells. 
Idiopathic Multiple Pigmented Sarcoma.—This form of the disease 
was first described by Kaposi: it is very rare. It generally occurs in 
middle-aged males, and first manifests itself as reddish-brown or plum- 
colored, pea-sized tumors, which are tender on pressure and are accom- 
panied by spontaneous pain. The growths occur on the flexor or extensor 
aspects of the hands or feet. The tumors increase in number and run 
together to form plaques. In addition to this, the hands, feet, and 
eventually the limbs, fall into an elephantiasic condition on account of 
a diffuse, board-like infiltration in the skin. 
The tumors rarely ulcerate, but they often undergo involution, leaving pig- 
mented scars. In the course of two or three years the tumors have usually begun 
to develop upon the face and trunk. After this the downward course is more 
rapid. The tumors may form upon the mucous membranes. Sooner or later 
dysenteric symptoms, haemoptysis, fever, and marasmus terminate the scene. After 
death the internal organs, and especially the large bowel, are found to contain 
nodules similar to those in the skin. Histologically, this form of growth looks 
like a small-cell sarcoma into which many hemorrhages have occurred. The pig- 
mentation is due to the hemorrhage, and really it would be more correct to class 
this affection among non-pigmented sarcomata. Multiple pigmented sarcoma may 
in its early stages very much resemble a large papular syphilide, except for its 
more limited distribution. In the later stages some cases bear a resemblance to 
the affection known as mycosis fungoides. 
Non-pigmented Sarcoma.—Non-pigmented sarcoma may be multiple 
or single, primary or secondary to a malignant growth of some internal 
organ. The tumors may be seated in the subcutaneous tissue or in the 
skin itself. The skin is sometimes normal in color, but more often of a 
bluish hue. Several tumors may run together to form large plaques, 
followed by ulceration. The disseminated form of non-pigmented sar- 
coma seems to be far less malignant than the pigmented form. 
Localized non-pigmented sarcomata of the skin may follow a blow or 
develop from a nsevus or other skin-lesion. The growth rarely attains 
a size larger than an orange. The skin over the tumor may be normal 
in color or of a darker hue. After a variable time ulceration occurs, 
and secondary tumors form in the skin, viscera, or lymphatics. It 
should be mentioned that in both leukaemia and pseudo-leukcemia tumors 
and plaques of infiltration, sarcomatous in their histology, may develop 
in the skin and other organs. 
The treatment of pigmented sarcomata after dissemination has 
occurred is futile. If the primary growth is removed thoroughly at an 
early date, there may be some chance of cure. Ho treatment has suc- 470 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
ceeded, in the great majority of cases, in curing idiopathic multiple pig- 
mented sarcoma, but the author has seen a case recover spontaneously, 
and Kohner claims to have brought about a cure by the use of arsenic. 
Arsenic administered hypodermically in gradually increasing doses has 
cured a number of cases of multiple non-pigmented sarcoma. The 
local sarcomata should be removed as soon as the diagnosis is made. 
Reference has already been made to the employment of erysipelas toxines 
in carcinoma. It has been used apparently with some benefit in inopera- 
ble cases of sarcoma. 
Tuberculosis of the Skin.—To-day no one doubts that the tubercle 
bacillus is capable of causing grave troubles in the skin. It is still a 
question as to where the limit of the various clinical forms which are in 
reality tuberculous should be drawn. Already it is shown that most 
cases of what was called papilloma are in reality tubercular infections. 
The same has been shown for many apparently simple chronic ulcers. 
Many are contending to-day for the tubercular nature of lupus ery- 
thematosus, and there can be no doubt that there are cases of tuberculosis 
of the skin which are clinically indistinguishable from it. ( Vide Chap- 
ter IX.) 
At present there are at least four well-recognized clinical forms in 
Fig. 194. 
which tuberculosis of the skin may occur ; Lupus vulgaris, tuberculosis 
cutis, tuberculosis verrucosa, and scrofuloderma. 
Lupus vulgaris. SURGICAL DISEASES OF THE SKIN. 
471 
Symptomatology.—Lupus vulgaris, as a rule, commences in child- 
hood and upon the face. Often the first evidence of the disease will be 
two or three small red-brown spots upon the cheek. They may be 
slightly raised, on a level with the skin, or depressed. Slowly these 
spots enlarge and take on a semi-transparent “ apple-jelly ” look. These 
are the well-known lupus tubercles, and it is by variations in their size 
and course that all the clinical manifestations of lupus are formed. The 
tubercles are much softer than the surrounding tissue, as may be ascer- 
tained with a blunt probe. Gradually more and more tubercles appear, 
and in the course of months, or more often years, by coalescence, a brown- 
red patch is formed, somewhat raised, thickened, and covered with a cer- 
tain amount of thin scales. In the border of such a patch it is nearly 
always possible to distinguish typical lupus-tubercles. From this point 
the lupus pursues one of two courses. It may break down and ulcerate. 
This is especially liable to happen when any of the mucous orifices are 
involved in the ulceration : all the soft parts down to the bone may be 
destroyed, but the bones are hardly ever attacked. The ulcers heal, 
usually after having existed for a long time, and scars of various sorts, 
from a thin to a much-banded scar, result. After the apparent healing 
has lasted a long time it is very common to see lupus-tubercles again 
making their appearance in the scarred area, and the process again runs 
through the course described. While the ulceration is going on at the 
central portion of the patch the border has been slowly extending by 
the growth of new tubercles. 
In some cases or in some parts of a patch ulceration does not occur, 
but interstitial absorption in the lupus-tissue occurs, and gradually the 
area becomes atrophic, covered with the scaling epidermis, and depressed 
below the surrounding level. 
Lupus may affect any part of the body, but the scalp, upper eyelids, forehead, 
palms, and soles are notably exempt. 
There are certain clinical variations to which descriptive terms have been 
attached. When the borders of two or more contiguous patches join in a serpen- 
tine figure, the appearance is called lupus serpiginosus. If the surrounding parts 
are affected with a sort of elephantoid state, or if the margin of the patch is much 
raised, it is spoken of as lupus hypertrophicus. Sometimes the lupus ulcer 
becomes filled with fungoid granulations—lupus papillaris verrucosus. Leloir has 
described a form of tuberculosis of the skin under the title lupus vulgaris ery- 
thematodes which very closely resembles lupus erythematosus. This clinical type 
should not be forgotten : it is not uncommon ; the author has seen several cases. 
Quite frequently lupus attacks the mucous membranes, spreading from the 
adjacent skin. Lupus of the nose sometimes starts in the mucous membrane of 
the nares, where it occasions crusting, being mistaken for eczema, and its true 
nature becoming manifest only after it has spread to the skin. Owing to the 
nature of the tissue, lupus of the mucous membrane does not present lupus- 
tubercles, such as are seen in the skin, but this lesion is replaced by a papillary 
growth. These growths form plaques which may undergo absorption or ulceration, 
just as happens in the skin. 
Tuberculosis Cutis.—The affection to which this appellation has been 
given has been seen only in persons affected with tuberculosis of some 
internal organ, and is rare. The disease occurs as chronic ulcerations 
at muco-cutaneous junctions, as the mouth or anus. The ulcers are 
shallow, with ragged borders. The floor is filled with granulations 
which secrete a thin, purulent material which may dry into crusts. At 
times small yellow miliary nodules can be seen scattered over the lesion. 472 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
This form of cutaneous tuberculosis does not always come on late in the 
course of the general infection, but may at times be one of the earliest 
signs, and some cases of ulcers of this class have been reported in which 
the skin-trouble seems to have been primary and tuberculosis of internal 
organs secondary. Often these ulcers are extremely painful. They 
may continuously enlarge, or, having reached a diameter of an inch, 
stop there. They show no tendency to heal. 
Tuberculosis Verrucosa.—This affection was formerly known as ver- 
ruca necrogenica. It occurs usually upon those who handle dead per- 
sons or animals or those who have come in contact with the secretions of 
patients affected with tuberculosis. The early appearance of the lesion 
may vary considerably, but as it develops a marked tendency to papil- 
lary hypertrophy is noted. The common sites of the affection are the 
knuckles, backs of the hands, elbows, and knees. In a well-developed 
lesion which is still extending there is an erythematous zone outside the 
patch. The patch is covered with a crusty-looking growth, often with 
pustules between the excrescences. The area may be small or it may be 
large enough to cover the back of the hand. There is little tendency 
to ulceration. Sometimes spontaneous involution occurs, but usually the 
lesion slowly extends. At times the centre becomes atrophic, while the 
circumference is still extending. Beyond the local trouble this form of 
tuberculosis is not, as a rule, serious, but a few cases are reported in 
which generalization occurred. The course of the affection is very 
chronic, the lesions frequently lasting many years. 
Scrofuloderma.—This term is applied to certain lesions originating 
in the subcutaneous tissue in scrofulous subjects, and involving the skin 
secondarily. The lesions usually commence in lymphatic ganglia, es- 
pecially those of the neck. A doughy, painless swelling is formed. 
After a time the skin assumes a bluish hue, and finally breaks at one 
or more points, giving exit to a sanious material and leaving an ulcer 
with ragged, undermined edges. At other times the origin is not from 
a lymphatic ganglion, but from a nodule in the subcutaneous tissue. The 
ulcer is extremely slow in healing, and may last for years. In some 
cases the patient is exhausted by the protracted suppuration, more es- 
pecially as accompanying this condition there are usually other affec- 
tions present to which the strumous are liable. After the ulcers have 
healed scars remain, usually traversed by bands and ridges. 
Etiology and Pathology.—The active agent in the causation of 
all the forms of tuberculosis of the skin is the tubercle bacillus. It is 
likely that this nearly always gains entrance into the tissues by inocula- 
tion after birth, so that heredity plays a less prominent part in our ideas 
of skin-tuberculosis than it once did. It is nearly always in children 
that we see lupus developing, but too much stress must not be laid on 
this point, as it may first appear in the late years of life. According to 
the observation of Leloir, pulmonary tuberculosis forms a frequent com- 
plication of lupus, though this is denied by many authors. 
In all forms of cutaneous tuberculosis we find histologically certain 
elements. These are the tubercle bacilli and the nodules of granulation- 
tissue containing giant cells. In tuberculosis verrucosa there is a hy- 
pertrophy of the papillae and a corresponding thickening of the epi- 
dermis. SURGICAL DISEASES OF THE SKIN. 
473 
Diagnosis.—Although the recognition of a typical case of lupus 
vulgaris ought to be very easy, yet a great deal of confusion prevails, 
if we judge by the number of cases of epithelioma and other affections 
in which a diagnosis of lupus has been erroneously made. The cardinal 
points to bear in mind are—the origin, usually in childhood, the great 
chronidty of the affection, and the presence of the characteristic soft 
lupus-tubercles, which are nearly always found at the periphery of the 
involved area. The differential diagnosis between lupus and the late 
syphilides is perhaps most difficult. The syphilitic ulcer runs a much 
more rapid course than does lupus, often doing more damage in a few 
weeks than lupus does in as many years. The edges of the syphilitic 
ulcer are apt to be more sharply cut. It is common to find multiple 
syphilitic lesions, while usually but one patch of lupus is present. 
Syphilis often attacks bones, and the lesions are often covered by large, 
thick crusts and give rise to an offensive discharge. The history of a 
previous infection or of previous syphilides can frequently be ob- 
tained with the syphilitic affection. Finally, with antisyphilitic treat- 
ment the lesions of syphilis heal readily. The ulcer described as tuber- 
culosis cutis can be distinguished from syphilis by the fact that it occurs 
in persons suffering from tuberculosis of internal organs, that it is very 
chronic, and that it often presents scalloped borders. 
None of the tubercular lesions should be mistaken for epithelioma if we re- 
member the peculiarities of the latter affection, its hard and everted borders, and 
the age at which it occurs. The microscopical examination would decide the 
question. 
It may be a matter of great difficulty at times to decide as to the true nature 
of verrucose tuberculosis of the skin. It may somewhat resemble a patch of 
eczema, but the tuberculosis verrucosa is more chronic, more abruptly defined, and 
presents ulceration and scarring, which are never seen with an eczema. 
A word may be in place as to the value of the tubercle bacillus in diagnosis of 
skin-tuberculosis. When it can be demonstrated, it is of course conclusive evi- 
dence, but a failure to find it cannot be considered as negativing the diagnosis, 
since it occurs in very small numbers, and thus easily escapes detection. 
Prognosis.—All forms of skin-tuberculosis are characterized by a 
tendency to recurrence even where a cure seems to have been effected. 
This is especially true of lupus. Tuberculosis verrucosa and scrofulo- 
derma give a better hope of permanent cure. If left alone, lupus nearly 
always slowly extends, causing hideous deformities, but rarely complete 
involution has occurred. The prognosis of tuberculosis cutis is that of 
the tubercular affection which it complicates. 
Treatment.—Since it is almost universally admitted that tuber- 
culosis of the skin is acquired by direct inoculation, it becomes of the 
highest importance to use every prophylactic precaution, especially with 
those who are supposed to be predisposed to tuberculosis. This includes 
avoidance of exposure, careful attention to all wounds, especially when 
they are known to have been exposed to tuberculous secretions, and care- 
ful and prompt cleansing of the unbroken skin when it has come into 
contact with any tuberculous matter. 
Internal treatment can be of avail only in so far as it improves the 
general condition of the patient. In this way climate also may exercise 
a beneficial effect. 
Thus far, we have no specific treatment. Tuberculin has been by 474 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
many discarded. Thiosinanhn, much lauded in certain quarters, lias 
proved inefficient in the author’s hands. The true treatment of skin- 
tuberculosis is local. 
Caustic agents have been used for a long time in the treatment of lupus. This 
method is not so much used now as surgical means. Only a few of the caustics 
will be mentioned here. Arsenical pastes (such as Bougard’s, for which see Epi- 
thelioma) are valuable because they have a selective action, destroying diseased 
tissue more rapidly than the healthy. The paste should be applied on cloth, 
removed in twelve hours, and applied again if necessary. Pvrogallic acid has a 
selective action, and may be used in an ointment, 3j to §j, spread on cloth and 
applied fresh twice a day till a sufficient effect has been produced. Nitrate of 
silver is useful, and with some dermatologists it is the favorite caustic; the solid 
stick should be used, boring it into the soft lupus tissue. Pure lactic acid applied 
to ulcerated lupus on lint, the surrounding skin being protected by an ointment, 
has frequently yielded excellent results: the applications last half an hour, are 
frequently painful, and must be repeated. Salicylic acid, either in plaster mulls 
with creosote added, as recommended by Unna, or made into a paste with glycerin, 
often gives good healing, especially in the more superficial forms of the disease. 
Elsenberg1 lias reported favorable results from the use of parachlorophenol. The 
area affected is first washed with alcohol and ether, and then pure parachloro- 
phenol, heated till it melts, is painted on: this is somewhat painful. An ointment 
composed as follows is then applied : Parachlorophenol, lanolin, vaseline, powdered 
starch, ad. 3iiss.—M. After ten or twelve hours this is removed and an iodoform 
salve substituted. In two days the parachlorophenol may be applied again, and 
so the treatment continued till cicatrization occurs. 
Of the various surgical methods of treatment, excision is the one 
which theoretically should yield the best results, but its use has been 
restricted in past years on account of the large wounds which it neces- 
sitates. Thiersch’s shin-grafting has done a great deal to obviate this dif- 
ficulty. This is the best treatment for tuberculosis verrucosa and for 
the enlargements of the lymphatic ganglia which lead to scrofuloderma. 
The method which is most generally used in treating lupus is no doubt 
curetting. A sharp spoon is used, and all the lupus tissue is scooped 
away as thoroughly as possible: the surface should then be cauterized 
with carbolic acid or ziuc chloride. A great portion of the affected area 
usually heals after such a procedure, but some nodules will appear again, 
and must be scooped out again or treated in some other way. 
Multiple incision of the lupus area has been strongly urged by Vidal. The 
incisions should be made very close together, and usually two series of cuts are 
made at right angles. The theory of cure by this method is, that the vessels which 
nourish the new tissue are destroyed. The operation must be frequently repeated, 
and generally produces healing in a large part of the patch. The few remaining 
nodules are usually best treated in some other way. 
The actual or the galvanic cautery may be used with advantage after curetting 
in place of a chemical caustic. This method may be also primarily used to destroy 
the lupus tissue either by puncture or by scarification. It is of special value in 
treating single lupus nodules. The galvanic cautery forms an excellent means of 
destroying tuberculosis verrucosa and for cauterizing the ulcers of scrofuloderma. 
Electrolysis forms a convenient method for destroying nodules that have formed 
in the scars after any of the above-mentioned methods. A needle, affixed to the 
negative pole of a twenty-cell galvanic battery, is repeatedly thrust into the nodule 
till its destruction seems accomplished. 
Iii treating an ordinary case of lupus it often happens that we get 
the best and most rapid results by a combination of these methods, using 
at some stage, for example, a chemical caustic, and then one of the sur- 
1 Med. Week, July 20, 1894. SURGICAL DISEASES OE THE SKIN. 
475 
gical procedures, or vice versa: what combination of procedures is best 
for each case must be determined by the judgment of the surgeon. 
The treatment of the ulcerous lesions of scrofuloderma will depend 
somewhat upon the condition of the patient, as well as upon the nature 
of the disease. It is advisable, if possible, to curette the ulcers, to lay 
open all sinuses, to cauterize with carbolic acid or chloride of zinc, and 
then to dress with iodoform. Where such severe means cannot be under- 
taken, the ulcers may be dressed with a paste made of salicylic acid and 
glycerin, to which has been added 1-2 per cent, of carbolic acid. Chaul- 
moogra oil internally and also as an ointment is recommended by 
Crocker. 
Erythema Induratum.—Under the title erytheme indure des scrofu- 
leux Bazin has described a malady which most often occurs in young 
girls of a scrofulous habit. The disease first manifests itself as one or 
several hard, pale indurations in the skin, which can be more easily felt 
than seen. The indurations are most usually found on the legs, and a 
favorite site is just below the bulge of the calf. When a number of 
lesions are present they may coalesce into brawny patches. In the course 
of time the skin over the nodules becomes red and then violaceous. 
Involution may occur after a considerable time, or the indurations slough 
out, leaving deep indolent ulcers, which are very slow in healing. There 
are no symptoms of constitutional disturbance, but there are often 
severe pains in the limbs. Its chronicity, the small number of lesions 
present at first, and the absence of fever distinguish this affection from 
erythema nodosum. The disease is most often mistaken for syphilitic 
gummata, but the absence of a syphilitic history, absence of other syph- 
ilides, the evolution of the disease, and finally the failure of specific 
treatment, should determine the diagnosis. 
In the way of treatment all these cases demand tonics, cod-liver 
oil, and good hygiene. The patient should be placed at rest with the legs 
elevated. When ulcers have formed, dressing with stimulating powders, 
such as iodoform, and the application of antiseptic dressings with firm 
bandaging, are most appropriate. In any case the healing is slow. 
Rhinoscleroma.—Rhinoscleroma is a parasitic lesion commencing as 
a painless induration, usually situated at the edge of the alee nasi or 
upon the upper lip. It grows very slowly, and there is no tendency 
toward involution. The skin over the growth may be unchanged or it 
may present dilated blood-vessels or may have a dark reddish color. To 
the touch the mass has a peculiar wooden hardness. The tumor has a 
lobulated appearance. Between the lobules the skin may crack, giving 
exit to a thick yellow discharge which dries into crusts. The affection 
may occur in the palate, pharynx, or trachea. It causes usually no sub- 
jective sensations, unless by its increase in size it interferes with respi- 
ration. In some cases pressure on the growth causes exquisite pain. 
The disease is rare, but in some portions of Russia is almost endemic. 
Anatomically, the growth is granulation-tissue, scattered through which are 
very large cells: in these cells short, thick encapsulated bacilli are found. These 
are the specific cause of rhinoscleroma. The long duration of rhinoscleroma, and 
the fact that it shows no tendency to break down, distinguish it from other 
growths with which it is apt to be confounded, such as syphilitic nodules or 
epithelioma. 476 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
There is little encouragement to operative interference, as thus far 
after removal the growth has always recurred. Lang seemed to get 
good results in one case by the internal administration of salicylic acid, 
and at the same time injecting the drug into the tumor. In case respi- 
ration is interfered with, a part of the growth may be removed or a hole 
may be drilled through it to permit breathing. (Fide Fig. 19.) 
Actinomycosis.—Actinomycosis is another parasitic disease rarely 
involving the skin primarily. ( Vide Chapter VIII.) The affection is 
most commonly seen in the subcutaneous tissue of the jaws, though other 
regions may be affected : for example, in certain tropical countries one 
variety of actinomycosis is not uncommon affecting the feet, constituting 
the malady called podelcoma. After an incubation-period which is not 
determined, the disease commences as one or more hard, lumpy tumors 
about the jaw. As they enlarge and approach the surface the skin over 
them become violaceous in appearance, and finally breaks down, often at 
several points. The sinuses thus formed discharge a sanious pus, float- 
ing in which may usually be found the actinomycotic granules, small, 
yellowish bodies composed of the ray fungus. 
The malady is of extreme chronicity, and as a rule the health is not deterio- 
rated, as it would be in the case of a malignant growth of the same size. The 
lymphatics are not involved. The affection sometimes becomes generalized by 
breaking into a blood-vessel. 
The disease is most likely to be mistaken for sarcoma, from which it can be 
differentiated by the demonstration of the actinomycosis or ray fungus. For this 
purpose it is easiest to examine the granules. The fungus consists of a dense net- 
work of fine mycelia, scattered in the interstices of which are many coccus-like 
bodies. The extremities of some of the mycelia are expanded into club-shaped 
masses : this was once thought characteristic of the parasite, but is now regarded 
by many as simply the result of a degenerative change. It is supposed that the 
fungus frequently enters the body through carious teeth. 
Not long since it was thought that the only treatment consisted in 
total extirpation of the diseased tissue. Where this was impossible in- 
cision of the sinuses, with subsequent scraping and cauterizing, was 
recommended. Recently it has been shown that potassium iodide, 
administered as in syphilis, is almost a specific, and a number of cures 
by this means have been reported from various parts of the world. 
Cysticercus Cellulosus Cutis.—The cysticercus of the tsenium 
solium is occasionally found in the subcutaneous tissue, where it forms 
tumors from a pea to a marble in size, round, and covered by unaltered 
skin. In the early stages the tumors are tense and elastic, but in time 
may undergo calcareous change. Usually several tumors are found, 
most commonly on the back. 
The diagnosis is often impossible to make except by removing one 
of the tumors and puncturing the sac and examining the fluid for the 
booklets. Echinococcus-cysts have been found in the skin, where they 
form fluctuating tumors. 
Guinea-worm (Filaria Medinensis).—The Guinea-worm is a white 
worm one-tenth of an inch in diameter and from two to three feet long. 
It is found in a great many tropical countries. The embryo probably 
enters the body in the drinking-water, and passes from the intestines to 
the skin, under which it develops. This applies only to the female worm, 
the male never having been discovered. When fully developed the SURGICAL DISEASES OF THE SKIN. 
477 
worm can be felt like a string coiled up. Inflammation more or less 
intense is excited, and a vesicle forms which breaks, allowing the head 
of the worm to protrude. 
Sometimes the reaction set up by the parasite is violent, resulting in phlegmon 
or even gangrene. This is said to be common when the worm has been broken in 
attempted extraction. Worms have been seen in almost all parts of the body, but 
by far the largest number have been found in the foot. Usually a single worm 
exists in an individual, but sometimes many are present. 
The time-honored treatment for Guinea-worm consists in gentle 
traction performed by winding as much of the worm as protrudes each 
day about a bit of stick. This method is tedious, and recently means 
which would seem better have been suggested. Christie has recom- 
mended the destruction of the worm while still under the skin by elec- 
trolysis. Emily1 recommends injecting into the worm as it lies under 
the skin a solution of bichloride of mercury. The worm is killed and 
absorbed without further trouble. 
Perforating Ulcer.—The so-called perforating ulcer is probably nearly 
always secondary to some nervous lesion which involves the integrity of 
the trophic function. (Vide Chapter IV.) It is most commonly seen 
with tabes dorsalis, leprosy, and syphilis. The appearance of the lesion 
varies. It is nearly always a sinus. Sometimes the orifice presents a 
bunch of flabby granulations, while at other times there is about it a 
dense ring of hypertrophied epidermis like a corn. The lesion is usually 
seen on the foot and at points where pressure is naturally greatest, as 
the metatarso-phalangeal joint of the big or little toe. This suggests 
that the ulcer may be caused by traumatism. Very frequently the sinus 
leads down to dead bone, and joints are often disorganized. Usually 
there is no pain attending a perforating ulcer and the region around 
may be anaesthetic. 
The course of the disease is slow. If rest of the part is secured, it 
will heal, but breaks out again on using the foot. 
The only affection which resembles perforating ulcer is a suppurating 
corn, but in the latter there is pain and the skin about it tender, and, 
besides, it readily heals. 
The treatment of this affection is unsatisfactory. Healing may be 
accomplished by rest and the use of stimulating antiseptics, but if the 
foot is used the disease is almost sure to recur. Amputation of the foot 
has succeeded, but sometimes the ulcer reappears in the stump. Stretch- 
ing the nerves which supply the part, together with free opening of 
the sinus, has been recommended and used in cases where the malady 
affected lepers. 
Onychia.—The term onychia is. applied to any inflammation of the 
nail-matrix. The inflammation may be associated with some lesions of 
the nervous centres, as in Morvan’s disease. There is an onychia which 
is of syphilitic origin. The most important and the only phase of the 
affection that will be discussed here is onychia maligna. This is an acute 
phlegmonous inflammation of the matrix which is most commonly seen 
in ill-nourished children of strumous habit. The affection commences 
with throbbing pain in the finger. There is a sero-sanguinolent exuda- 
tion under the nail, which becomes of a dull, opaque color, is lifted from 
1 Arch, de Med. nav., June, 1894. 478 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
its bed, and curls up at the edges. It usually separates, leaving a 
sloughy surface which cicatrizes with the formation of a deformed nail. 
The inflammation may spread to the tissues about the nail, constituting 
a paronychia, which may result in the loss of the last phalanx. 
The treatment consists in such general measures as the condition 
of the patient demands, together with appropriate local applications. At 
first cold-water compresses give relief. As soon as fluid has collected 
beneath the nail the pain is best relieved by splitting the nail : if it is 
loose, it should be removed, as recovery is thus hastened. The surface 
left is to be treated with antiseptic dressings on ordinary surgical prin- 
ciples. CHAPTER XXVIII. 
BURNS, SCALDS, AND FROST-BITES, AND THEIR TREATMENT. 
John Parmenter, M. D. 
To the old classification of burns and scalds, which regarded the 
depth only of the destructive effect, should be added another which 
takes cognizance of the superficial extent as well. It is a well-known 
clinical fact that a deep burn of limited extent is far less serious than one 
quite superficial, bid covering a large area. Furthermore, there does not 
seem much justification for clinging to the elaborate classification of 
Dupuytren, who divided burns into six groups according to the depth 
of the lesion, for from a practical standpoint the surgeon knows how 
difficult it is to estimate the depth of a burn at the time of its occur- 
rence. As burns and scalds differ only in causation and appearance, it 
will be understood that what applies to one is equally true of the other, 
and therefore, to all intents and purposes, the terms may be used inter- 
changeably. 
Definition.—A burn is the lesion resulting from the application of 
concentrated dry heat; a scald, from the application of hot or boiling 
liquids or steam. Corrosive fluids cause lesions very similar in many 
respects to those produced by dry or moist heat. 
Classification.—Burns and scalds may be divided into three 
groups: 
(a) Burns of the First Degree.—These may have hyperaemia and 
swelling for their chief characteristics. The skin becomes more or less 
reddened from capillary dilatation, followed by a serous exudate, which 
is ordinarily slight in amount. These phenomena may last for a few 
hours and entirely disappear. Occasionally, in persons with a delicate 
skin, desquamation occurs. 
(b) Burns of the Second Degree.—To the hyperaemia and swelling are 
added vesication. The blebs vary in size and contain serum clear or 
light in color, and lie between the horny layer and the rete Malpighii. 
The time of their appearance varies from a few minutes to some hours. 
The swelling is greater than in burns of the first degree. The pain is 
also more marked, especially when the vesicles are opened and their 
covering removed. 
(c) Burns of the Third Degree.—These include all lesions involving 
the entire thickness of the skin, with or without the underlying tissues. 
They vary, therefore, from partial destruction of the skin to complete 
charring of all tissues. An eschar is formed which may be dry or 
moist according to the individual case, and possessing varying shades of 
color from gray to black. 
Burns and Scalds. 480 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
The skin surrounding the eschar is often more or less blistered, and sometimes 
is puckered from the drying process to which it has been subjected, and when this 
occurs the skin so contracted may be considered dead. The eschar begins to sep- 
arate after four or five days, the process lasting from two to three weeks or even 
more in certain cases. Suppuration then follows, and when the defect is exten- 
sive cicatrization occurs only after weeks and months. These are cases in which 
the cicatrices play such an important role afterward, and claim the surgeon’s 
attention either from deformities or functional disturbances occasioned by them. 
General Considerations.—These injuries, where at all extensive, 
even though superficial, are peculiarly fatal, and have always been 
justly dreaded by the surgeon. The young and the old, delicate women 
and drunkards, are more prone to die than healthy adults. Few live 
when more than one-quarter of the body surface has been burned. 
Burns involving the thorax or abdomen are particularly fatal, owing to 
the shock and to sequel® to be mentioned later. In cases dying within 
a few hours after injury no characteristic post-mortem appearances have 
been discoverable, so that numerous theories have been advanced to 
explain the lethal action of burns. We may mention only a few: 
(a) Destruction of Red Blood-corpuscles.—These being essential to respiration 
and metabolic activity, these processes are hindered by their diminution, or else, 
having given up their haemoglobin, this latter may destroy the white blood-cor- 
puscles and produce an excess of fibrin-ferment, with subsequent coagulation of 
the blood in the vessels. This theory is in accord with the post-mortem findings 
in certain cases where an excess of haemoglobin was found in the kidneys, these 
organs being hvperaemic and studded with necrotic foci. The more or less com- 
plete anuria so often observed in these cases can thus be explained by the lesions 
in the kidneys. 
(b) Over-heating of the blood, with subsequent cardiac paralysis. 
(c) Excessive irritation of the nervous system, with resulting reflex diminution 
of vascular tone. 
(d) Thrombi and emboli from the blood-plaques, which, added to the increased 
adhesiveness of the blood-corpuscles, cause stoppage of the circulation. 
(e) Ptomaine-poisoning, the ptomaines being formed from the products of 
decomposition which have escaped destruction by the burn. 
(/) Noxious chemical substances formed by the action of heat upon substances 
within the skin and then absorbed. It has been alleged that hydrocyanic acid is 
produced in this way, and the resemblance between the symptoms of fatal burns 
and poisoning by this acid have been adduced in support of the theory. It is 
much easier to explain the cause of death when this follows after three or four 
days, but, as this properly belongs to the sequelae of burns, it will be considered 
elsewhere. 
Symptoms.—These vary with the situation, extent, and the time 
following the receipt of the burn, and with the age, bodily vigor, and 
temperament of the individual. Given a case of extensive superficial 
burn involving a third or more of the body-surface, we shall find symp- 
toms of shock the most prominent feature. Usually there is great pain, 
although in very bad cases this may be absent. The patient complains 
of great thirst and is more or less completely prostrated. The skin- 
surface is cold and clammy, the face pale, the temperature subnormal; 
the mouth and tongue are dry; the pulse is small and thready ; the 
respiration shallow and panting; the mind may be clear, but commonly 
delirium supervenes, followed by stupor and coma. The rigors and 
cramps frequently seen in adults are increased to convulsions in children. 
Should the patient survive the following twenty-four to forty-eight 
hours, the phenomena of shock are succeeded by those of reaction and 
inflammation. In this stage the temperature rises, the pulse becomes BURNS, SCA IDS, AND FROST-BITES. 
481 
fuller and more bounding, the respiration more regular, but hurried— 
symptoms which are due to the pain and reflex irritation, and also to 
the absorption of decomposition products. It is in this stage that the 
more dangerous complications arise which so commonly cause a fatal 
issue. These will vary with the situation and extent of the burn. 
Chief among these may be enumerated the following: pleurisy, pneu- 
monia, pericarditis, meningitis, cerebritis, peritonitis, duodenitis, and 
intussusception. Their importance justifies a brief consideration of 
some of them individually. 
(a) Pleurisy, Pneumonia, and Pericarditis.—These may be considered together, 
as they are very commonly associated. They may be explained by the internal 
congestion or the septic products resulting from the burn. They appear usually 
about the fourth or fifth day, sometimes earlier and frequently later. The symp- 
toms and treatment are similar to those in other adynamic forms of these diseases. 
(b) Meningitis and Cerebritis are not Uncommon.—They occur most frequently 
in cases of burn in children, and ordinarily appear soon after the accident. The 
usual treatment for these diseases is to be employed. 
(c) Peritonitis and Intestinal Inflammation.—These, too, follow a fairly regular 
course, and are to be treated symptomatically. Of the abdominal complications, 
duodenal ulceration is one of comparatively frequent occurrence and quite diffi- 
cult to explain. According to some, the ulceration is due to destruction of the 
epithelium by formate of ammonium and the further injury of the mucosa by 
the intestinal juices ; according to others, to the mingling of certain decomposition 
products with the bile, the mixture exciting inflammation and ulceration in the 
duodenum. However this may be, this complication often causes death from 
hemorrhage or perforative peritonitis. The symptoms are often most obscure, as 
pain, tenderness, diarrhoea, even vomiting and hemorrhage, may be absent, and 
yet perforation occur. The condition is not always fatal, however, as cicatrized 
ulcers are frequently found in persons who have died from other complications. 
Opiates form the basis of treatment. 
Acute nephritis is another justly-dreaded sequel, the pathology of which has 
been previously alluded to. It is, in our experience, usually fatal, and for its 
relief a hot bath or digitalis poultice to the lumbo-dorsal region produces the best 
results. 
The third stage usually begins after the second week, and is charac- 
terized by suppuration and septic phenomena. This stage acquires signif- 
icance in proportion to the extent of the surface injured and to the 
inefficiency of the treatment employed, as, for instance, where septic pus 
is allowed to remain in contact with a granulating surface, which it 
quickly erodes and deepens. Should the patient survive the many com- 
plications which belong rather to this than to the preceding stage, he 
may finally succumb from pyaemia, amyloid changes, and resulting 
exhaustion. Among the important complications of this stage may be 
found— 
(а) Tetanus— This may occur in the preceding stages, but most often appears 
at this time. ( Vide article on Tetanus.) 
(б) Arthritis occurs where the burn has extended to the region of the capsule, 
through which, by extension of the sloughing, the joint becomes invaded and sub- 
sequently inflamed. That this inflammation does not always of necessity follow is 
well illustrated by a case now under the writer’s care, in which, following a burn 
from a sky-rocket, the capsule of the metacarpo-phalangeal articulation of the left 
index finger was opened some weeks after the injury through ulcerative action. 
The joint was thoroughly washed out and the capsule stitched. Union was imme- 
diate, and perfect joint-action followed, and has so remained. Ordinarily, how- 
ever, the loss of the joint may be expected to ultimately occur. Here, as else- 
where, an antiseptic regimen helps in preventing ulcerative action or mitigates it 
when fully established. In other respects the treatment is that of joints suppu- 
rating from other causes. 482 
AFFECTIONS OF THE TISSUES ANI) TISSUE-SYSTEMS. 
(c) Hemorrhage from ulceration extending into some vessel sufficiently large 
now and then causes serious and fatal results. When a burn occurs over import- 
ant vessels the possibility of hemorrhage should always be borne in mind, and 
measures taken to prevent it from becoming excessive. For instance, when upon 
an extremity the patient should be shown where and how to compress the vessel 
until aid comes. Other expedients will suggest themselves in individual cases. 
(d) Cicatrices and their diseases. 
Cicatrices are the mod common sequelae of the third stage. They not 
only produce frightful deformity, but they may also impair the function 
of the afflicted part, so that extensive operations are often necessitated for 
their removal. This portion of the subject will be treated elsewhere in 
this work, so that we shall content ourselves here with a word as to their 
prevention. Rigid asepsis from the beginning should be aimed at. 
Unfortunately, only too frequently this must of necessity be imperfect 
or wellnigh impossible to attain, but this should not deter us from doing 
our best along these lines. Early shin-grafting by Thiersch’s method 
should be resorted to. This measure, when done in a timely and proper 
way, is a most efficient one in preventing cicatricial contraction. Where 
and when feasible the part should be systematically moved, the natural 
motions being imitated so far as possible. Proper posture during sleep 
is a most important, but usually neglected, prophylactic measure. 
Cicatrices may undergo various changes of a pathological nature. 
Among these is ulceration. This is not infrequent in scars from burns 
occurring in tuberculous, syphilitic, or even badly-nourished individuals. 
It may occur years after the formation of the cicatrix. As such cicatrices 
usually depend upon some depraved constitutional state, the indication 
is to build up the general health with tonics, nourishing food, and an 
existence as hygenie as possible. Locally they may be treated with 
solutions of nitrate of silver, 5 grains and upward to the ounce. Alum 
(one teaspoonful to a goblet of water), alcohol, port wine, and other 
astringents may be used with advantage. 
Carcinoma, especially epithelioma, is comparatively frequent in scars 
following extensive burns. The writer has had occasion to amputate the 
lower extremity three times for such cause, and has seen a few cases in 
the practice of other surgeons. 
The treatment is removal of the affected area or, if an extremity, 
amputation at a suitable point. 
Painful scars occur not infrequently, and are usually due to pressure 
upon some nerve by the contraction of the cicatrix. The pain may be 
very great. The therapeutic indication is to free the nerve, which may 
be done subcutaneously or by the open method. Often, however, the 
cause does not depend upon the involvement of a nerve, and must be 
treated upon general principles—by tonics and antineuralgic agents. 
Some cases cannot be relieved by any known expedient. 
Prognosis.—In estimating the outcome of a case of burn certain 
conditions deserve consideration: 
(а) Superficial Extent of the Burn.—As has been previously said, 
when more than one-third of the entire body-surface has become in- 
volved death almost invariably occurs, and within a few hours. 
(б) Location of the Burn.—When covering, in large part, the thorax 
or abdomen, burns are particularly prone to be followed by pulmonary 
or visceral complications, which only too often are fatal. BURNS, SCALDS, AND FROST-BITES. 
483 
(c) Children and Aged Persons bear the Shock of Burns badly.— 
When children survive the stage of collapse, in our experience they 
bear the complications of the second and third stages about as well as 
adults. 
{d) Sex.—Women, with their more delicate organization, suffer more 
shock proportionately than males. 
Of the two, burns are more fatal than scalds in a given number of 
cases. 
The prognosis regarding the local condition depends rather upon the 
depth of the burn, the kind of tissues involved, and the situation ; thus, 
a burn causing entire destruction of the skin in the antero-lateral region 
of the neck, about the axilla or groin, or about joints generally pro- 
duces more functional disturbance and deformity than one of equal 
severity upon the back or abdomen. 
Treatment.—This is both constitutional and local. 
Constitutional treatment in cases of severe burn, with symptoms of 
shock and collapse, resolves itself into judicious stimulation, alleviation of 
pain, and later the use of tonics and restoratives, together with improved 
hygiene. 
Diffusible stimulants, such as alcohol and ether, may be given hypo- 
dermically, by rectum, or by mouth where the patient can swallow. 
External warmth, particularly the hot (100°-104° Fahr.) bath, aids 
these stimulants. 
Strychnia and digitalis, in appropriate doses (gr. of the former and 15 minims 
of the latter), to be repeated in two or three hours if necessary, may be advan- 
tageously used. Where the collapse is less marked and the pain excruciating it 
is good practice to immediately anaesthetize the patient, and then administer mor- 
phia in doses of from \ to J grain subcutaneously. The morphia can thus be 
given in smaller doses and renders more efficient service than when its effects are 
offset by the pain. In some cases auto-transfusion and the subcutaneous injec- 
tion of normal (0.6 per cent.) salt solution does great service. 
Local Treatment.—The kind and amount of treatment varies 
with the kind and degree of burn. The burns caused by corrosive 
chemicals may be in part neutralized by agents having an opposite 
chemical reaction or a mechanical effect. This, however, is only true 
when treatment can be instituted immediately or very soon after the 
receipt of injury. 
Burns of the first degree require little or no treatment. Cooling 
applications, such as cool water, lead-water, starch-water, a saturated 
solution of sodium bicarbonate, and the like, form the most soothing 
applications. Powders, in the form of starch, dermatol, zinc oxide, 
flour, fuller’s earth, and many others may be used, but ordinarily are 
not so grateful as lotions. Flexible collodion makes an admirable 
dressing, and is especially useful about the more mobile parts of the 
body, such as the neck, face, etc. 
A domestic remedy of great efficiency in burns of even the second degree is 
molasses, which is best put on by soaking bits of blotting-paper about J an inch 
by 2 inches in it before laying them evenly upon the entire surface. They must 
overlap each other, and when sufficiently dry an excellent covering is obtained 
for the part. Any excess of molasses at the edges may be wiped away and dry 
powder dusted upon them. Thus applied, molasses excludes the air, is soothing, 
and prevents decomposition, sugar being an excellent antiseptic. 484 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
Burns of the second degree may be effectually treated by the means 
first mentioned. In addition, the blebs frequently require attention. 
As a rule, they may be left for a few days (three or four) without treat- 
ment, as the raised epidermis and serum protect the underlying sensi- 
tive surface. When, however, blebs form from the action of corrosive 
fluids, the serum will be found of an irritating character and should be 
evacuated early. How this is to be done has been already explained 
in Chapter XVII. under the Management of Blisters. 
For burns of the third degree, where they are at all extensive, no 
single procedure compares in value with the hot bath (100° Fahr.). It 
may be continued for days, and even weeks or months. It gives instant 
relief from pain by protecting the burned surface from the air, and for 
a similar reason it tends to prevent decomposition. When pus is 
formed it is washed away immediately, and thus a fairly aseptic condi- 
tion of the burned surface is maintained. Above all, in the early stage 
it vigorously combats the collapse which is so often present. 
For lesions of the third degree, but comparatively local in extent, 
the first indication is to carefully disinfect them with solutions of 
bichloride 1 : 2000 or carbolic acid 1 : 40, and to cut away all tissue 
actually dead. To do this effectually an anaesthetic is usually required. 
Indeed, the anaesthetic should be given before the removal of the clothing— 
which, in passing, it may be said, should be removed with the utmost care, in 
order that the epithelial covering may be preserved as far as possible. In the 
majority of cases the use of some antiseptic powder is preferable to ointments as a 
dressing. Powders are more apt to remain antiseptic, and their power to prevent 
suppuration is certainly greater. An excellent powder for this purpose is one 
containing iodoform 1 part and boric acid 7 parts. It should be sterilized before 
using by steaming for fifteen to twenty minutes. It can be used generously, with- 
out fear of iodoform-poisoning, except, possibly, in the more extensive burns in 
young children, where the hot bath is usually indicated. Zinc oxide, bismuth, 
and other similar powders have been used and praised. 
If ointments are used, a good formula is one containing equal parts 
of the ointment of oxide of zinc and of naphthaline, to which maybe 
added 5 per cent, of iodoform. 
Unguentin, prepared bv the Norwich Pharmacal Company, is also a soothing 
and antiseptic dressing. Carron oil, consisting of equal parts of lime-water and 
olive oil, was formerly a favorite dressing, but is now supplanted by other and 
better preparations. 
Whether powder or ointment be used, over all a thick layer of anti- 
septic gauze and cotton should be applied and bound firmly to the part. 
The dressing should not be disturbed until loosened by the discharges. 
In the less extensive burns oftentimes a single dressing will suffice, a 
dry aseptic scab having been formed, under which healing goes on 
without incident. The prevention of scars has already been alluded to 
in a previous paragraph. 
Burns from Lightning1.—These vary from mere reddening of the 
skin to the most severe forms. Coexisting with these are usually found 
pathological conditions of even more importance which scarcely come 
within the scope of this chapter, and the subject may be dismissed with 
the statement that, so far as the burns are concerned, what has already 
been said upon the subject in general applies equally to similar lesions 
due to lightning. BURNS, SCALDS, AND FROST-BITES. 
485 
Frost-bites. 
Frost-bites result from the application of cold of an intense degree 
for a time sufficiently long to arrest the circulation. They may be divided, 
like burns, into three degrees, and have a striking similarity to them. 
The first degree is characterized by superficial erythema; the second, 
by the formation of vesicles; and the third, by eschars. 
As a rule, the parts most distant from the heart suffer most—viz. 
parts of the hands and feet, the nose and ears. (It is interesting in this 
connection to note the immunity from freezing possessed by certain ex- 
posed parts, such as the eyelids and eyeballs.) 
Pathology.—When a part is exposed to cold, contraction of the 
blood-vessels, followed by retarded circulation, is the first phenomenon 
to be noted. Depending upon the intensity of the cold and the dura- 
tion of exposure, this contraction may proceed to complete obliteration, 
when the exposed surface becomes white in color. (This can be easily 
demonstrated experimentally with the ether spray when used as a local 
anaesthetic.) If, now, warmth be applied, dilatation of the vessels, with 
severe pain, stasis, thrombosis, and even gangrene, follows. 
Among other changes that have been noted are rupture of the vasa vasorum 
and interstitial hemorrhage, ascending neuritis and degeneration of the nerve- 
tubules, leading frequently to muscular atrophy, trophic ulcers, etc. 
Symptoms.—These are both constitutional and local, varying with 
the degree and duration of exposure to cold. 
Constitutional Symptoms.—In extreme cases these are manifested by 
a subnormal temperature, difficult respiration, slow pulse, dilated pupils, 
which react sluggishly, incoordination, apathy, and a tendency to sleep, 
which is so irresistible that the individual will consciously lie down to 
certain death. 
Local Symptoms.—The first degree is characterized by a deep-red 
color and more or less evident swelling in the affected tissues. The 
retarded circulation is shown by the slowness with which the color 
returns after its dissipation by pressure. The part may become more or 
less painful as warmth is applied; usually only itching is present. This 
degree of frost-bite, frequently repeated, leads to the well-known con- 
dition of chilblains. 
In frost-bite of the second degree the color becomes of a deeper red or 
bluish tint, and the part is more or less covered with blebs. These may 
break, leaving ulcers which are extremely slow in healing. Indeed, 
frost-bites of the second degree are usually more intractable than burns 
of the same degree—i. e. the vitality of the tissues is more depressed. 
In the third degree the part becomes dark blue in color or marble- 
like, is anaesthetic, and is covered with blebs. Soon gangrene, local or 
general, supervenes, followed frequently by sepsis, producing general 
disturbance. 
Treatment.—This will vary according to the extent of surface in- 
volved and the degree of the freezing. 
The treatment when a large portion of the entire body is frozen con- 
sists in the gradual application of warmth. This is done by putting the 
patient in a cold room, rubbing him with a sponge soaked in cold water, 486 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
later putting him in a cold bath (60° F.), the temperature of which is 
gradually raised to 90° in the succeeding three or four hours. 
Stimulants may be given subcutaneously, or, in cold water, by mouth 
where the individual can swallow. (Large, hot enemata should not be 
used, as thrombosis and gangrene of the bowel may be easily induced.) 
Vertical suspension of the part (the extremities, for instance) should be 
resorted to early. When pain is severe it may be mitigated by the appli- 
cation of cold in some form, as the snow-poultice, ice-bags, or cold wet 
cloths. Artificial respiration should be practised, and continued for a 
long time, even though its effects are not at first apparent. 
Local Treatment.—The treatment of a part is conducted along lines 
similar to those just considered as applicable to freezing of the entire 
body. The restoration to a normal temperature must be gradual; 
therefore snow or ice should be first used and followed by warmer appli- 
cations. Dry rubbing of the part is also useful. When ulceration has 
occurred, it may be treated as in the case of burns with any of the vari- 
ous antiseptic powders or ointments previously mentioned. Where the 
frozen surface is extensive, the continuous bath may be used with great 
advantage, and for the same reasons that indicated its use in burns. 
Its temperature will of course be regulated by circumstances. We 
have in mind here the bath as used after reaction has been finally estab- 
lished. When the part becomes gangrenous we should redouble our 
antiseptic precautions, and when a line of demarcation has formed 
between the living and dead tissue, remove the latter. In the case of an 
extremity this means amputation or disarticulation. Where suppura- 
tive cellulitis occurs it must be met promptly with free incisions, disin- 
fection, and thorough drainage in the usual way. CHAPTER XXIN. 
THE MUSCLES, TENDONS, AND TENDON-SHEATHS, BURSJE, 
AND FASCIAE. 
Herbert L. Burrell, M. D. 
Malformations . 
Congenital muscular deformities are met with occasionally. They 
are always due to either the absence of certain muscles or to the pres- 
ence of supernumerary muscles. The absence of the pectoral muscles 
is recorded. 
Webbed fingers, or syndactylism, is a congenital fusion, more or 
less perfect, of two or more digits. It is not very rare ; it often occurs 
in more than one member of a family, and frequently recurs in succeed- 
ing generations. It is due to the grooves in the hand of the foetus fail- 
ing to become clefts. The “ webbing ” may involve two or more fingers 
in one or both hands, the union being partial or complete. The indi- 
Fig. 195. 
Webbed and supernumerary fingers 
vidual fingers in form are frequently perfectly normal. They may 
be joined in three ways : first, by a narrow or wide web of skin and 
connective tissue; second, they may be in close apposition; and third, 
the bones of two fingers may be fused together either partially or 
throughout their length. The usefulness of the hand is often but little 
impaired. Supernumerary fingers not infrequently occur in conjunction 
with syndactylism (Fig. 195). 
487 488 
AFFECTIONS OF THE TISSUES ANI) TISSUE-SYSTEMS. 
Treatment.—If the bones of any two fingers are united through- 
out their length, it is unadvisable to attempt to separate them. The 
old operation for this deformity consisted in merely dividing the web 
Fig. 196. 
Congenital defects: “ webbing” of lower extremity. In lumbar region a pendulous lipoma resem 
bling a rudimentary tail (Wolff). 
from top to bottom, and in trying to prevent the fingers from reuniting. 
This method has been practically abandoned, because it is impossible 
to prevent a portion of the web from re-forming, and, on account of 
Fig. 197. 
Showing operation for webbed fingers : (1) and (2), incisions for flaps ; a, b, and c, sections of flaps 
before and after suture. 
cicatricial contraction, separation of the fingers is incomplete. A good 
method of treatment is to first make a small permanent opening between 
the bases of the fingers. This opening may be established by keeping MUSCLES, TENDONS, TENDON-SHEATHS, ETC. 
489 
in it an elastic ligature or a silver wire, with the ends attached at the 
wrist until the edges are united. After these edges are well covered 
with epithelium the remainder of the web is simply cut through. 
The best operation, and the one generally used, is illustrated in 
Fig. 197. Two flaps are taken, one from the palmar surface of the first 
finger, and the second from the dorsal surface of the next, by incisions 
made along the median line of the fingers («•). By so doing two flaps 
are obtained, each of which is of the length of the finger and in width 
equal to a quarter of the whole circumference of one finger with the 
added width of the web (6). These flaps are freed so that the palmar 
flap of the second finger remains attached to the first finger, while the 
dorsal one from the first finger remains attached to the second finger. 
The flaps are then brought around each individual finger and sutured 
into position (c). Care must be taken to adjust the flaps and sutures 
accurately at the base of the fingers, and the fingers must be kept well 
apart by the dressing; otherwise a partial failure may occur. In case 
the bones are only united for a slight distance they may be cut or sawed 
apart. Other methods of treatment are sometimes described, but they 
do not differ essentially from those given here. 
Webbed toes are less frequently seen than webbed fingers. As the 
deformity interferes but little with the usefulness of the foot, and as the 
parts arc concealed from sight, operations are unnecessary. Should an 
operation be desirable, however, it would be done in the same manner 
as for webbed fingers. 
Webbed knee is a very rare condition. The femur and tibia are 
not fused, but the knee-joints are flexed by a web of skin and connec- 
tive tissue in the popliteal space. In one instance, where both knees 
were in this condition, a typical plastic operation corrected the deformity, 
but it was necessary to divide the outer and inner hamstrings. 
Surgical Injuries of Muscles and Aponeuroses. 
Aponeuroses are either thin, flattened, or ribbon-shaped structures serving the 
same purpose as tendons by attaching the broad flat muscles to the bones, or they 
are membranous, composed of interlacing fibres surrounding the muscles and pre- 
venting their displacement and being continuous with the muscle-fibres. They 
are rarely the seat of active disease or injury, but they are important in forming a 
barrier to the extension of inflammation and suppuration from one layer of tissue 
to another. A thorough knowledge of their arrangement is of great value to the 
surgeon, for they frequently impede the progress of inflammatory products toward 
the surface, and by so doing conceal and favor invasion of the deep structures. 
Punctured wounds and ruptures of the aponeuroses are the only ones which need 
surgical attention. The former may occur in any punctured wound of the skin, 
and does not require special treatment. The latter may give rise to muscular dis- 
placement or hernia, and the treatment is described below. 
Muscular hernia is the protrusion of a limited portion of the mus- 
cular substance through its ruptured fascia or aponeurosis. This occurs 
only during contraction, forming an elastic tumor which disappears dur- 
ing relaxation. It resnlts in impairment of muscular powers. 
The diagnosis is easily made and the wounded edges of the tear in 
the aponeurosis can be readily felt. 
Treatment.—In recent cases rest and pressure generally result in 
a cure. If necessary, the edges of the opening in the fascia should be 490 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
freshened and brought together by sutures. If the discomfort caused 
by a muscular hernia is only slight, an improvised pad or truss may 
relieve the patient. 
Injuries of Muscles. 
Muscles from their situation are frequently exposed to violence, yet 
they are not commonly injured, nor are they frequently the seat of 
surgical disease. They are liable to contusions, strains, ruptures, dis- 
locations, and wounds. 
Contusions may be slight or severe. A slight contusion, if it occurs 
in a healthy muscle, may be quickly recovered from. Severe contusions 
are accompanied by swelling and discoloration of the overlying skin. 
Inflammation, suppuration, and atrophy may ensue, the latter probably 
being the result of accompanying nerve-injury. 
Hsematoma of the sterno-mastoid muscle is a condition which is 
sometimes seen in apparently healthy children at birth or shortly after. 
It is usually a localized swelling in the body of the muscle, but the 
whole length of the muscle may be involved. It is thought to be due 
to pressure or to partial rupture of the muscles from traction during 
birth. It is always unilateral, and it disappears spontaneously in from 
two to six months. 
- Gaudier has reported two cases in infants where during vaccination a sudden 
muscular action, due to turning the head aside, ruptured some of the muscular 
fibres of the sterno-cleido muscle, and there resulted a hsematoma. These cases 
are unique, in that hsematoma has always been considered a condition arising 
through pressure or traction in delivery. 
A strain is a stretching of a muscle, with probably always a small 
amount of rupture of muscle-fibre. Strains are often followed, espe- 
Fig. 198. 
cially when they occur late in life, by troublesome pain resembling; 
rheumatism. Strains occur most frequently in the muscles of the back, 
Ruptured long head of left biceps muscle (case of Dr. George H. Monks). MUSCLES, TENDONS, TENDON-SHEATHS, ETC. 
491 
hips, shoulders, arms, and legs. They occur often as a result of violent 
muscular efforts. 
Treatment.—During the acute stage of either a contusion or a 
strain, rest to the affected parts is imperative. Hot fomentations or 
evaporating lotions are adjuvants to be used. As soon as the pain and 
tenderness diminish, massage, passive motion, liniments, and electricity 
may be applied. 
Subcutaneous rupture of healthy muscles and tendons is of com- 
paratively common occurrence; for example, in most cases of strain 
some rupture of the muscle ensues. 
Complete rupture of a muscle is rare. Rupture generally takes place 
in the tendon near the union with the muscle or at its insertion on the 
bone. The power of resistance of a healthy 
muscle is very great, and it is said that rup- 
tures occur only as the result of some invol- 
untary action and when the muscle is taken 
unawares. Rupture of either a muscle or 
tendon is accompanied by sudden, violent 
pain and loss of power. A distinct snap is 
almost always heard. There is usually, unless 
the affected muscle or tendon lies deeply, a 
marked depression between the severed ends. 
This depression, which is easily felt at first, is 
often masked by the accompanying swelling 
which quickly comes on, and is due to the 
extravasation of blood in the surrounding 
parts. The tendons of the biceps, the triceps, 
the deltoid, and the pectoralis major have 
been torn apart by violent exercise, in lifting 
or clutching at some object in falling; the 
sterno-mastoid from violent vomiting or ex- 
cessive traction in childbirth; the pronator 
radii teres and plantaris in lawn-tennis; the 
rectus abdominis and the internal and external 
oblique muscles in tetanus and from falling 
across iron bars; the tendo Achilles and gas- 
trocnemius on alighting suddenly from a 
height; the quadriceps extensor tendon, the 
ligamentum patellae, the biceps femoris, and 
rectus femoris by falling backward or forward 
on the ice; adductor longus in horseback 
riding ; semimembranosus in lifting; and the 
muscles of the perineum and sphincter ani in 
parturition. Following long and exhaustive 
illnesses, such as occur in typhoid, typhus, and scarlet fevers, the mus- 
cles and tendons lose their power of resistance and often rupture from 
the very slightest muscular force. 
The flexor and extensor tendons of the hand are ruptured at their 
insertions. This accident occurs frequently to ball-players. In violin- 
playing the extensor tendon of the middle finger of the left hand has 
been torn away. 
Fig. 199. 
Long head of biceps muscle 
which had ruptured, and had 
formed a new attachment in 
the bicipital groove. 492 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
Treatment.—In the simple forms of rupture the treatment consists 
of absolute rest in a position which gives the greatest degree of relaxation 
to the injured part and approximates as closely as possible the ruptured 
ends of the muscle and tendon. Compression by bandages and splints 
is used when necessary. The application of ice or anodyne lotions has- 
tens the absorption of the effusion and promotes early repair. When 
the function of the ruptured muscle or tendon is one of considerable 
importance, or it is obvious that the ruptured ends will not unite, it is 
necessary to suture the same by open incision under antiseptic precautions. 
The flexor and extensor tendons of the hand, the quadriceps and patellar 
tendons, and the tendo Achilles are the principal ones which require 
operation. Catgut or silk is used for the suture and the wound is closed 
without drainage, the limb being placed in the most favorable position 
for relaxation of the affected part. Contractures sometimes develop sub- 
sequent to muscular ruptures. This is due to the action of antagonistic 
muscles, as in congenital torticollis from rupture of the sterno-mastoid, 
or to contraction of the cicatricial tissue. 
Dislocations of muscles and tendons are caused by the laceration 
of their fascial and synovial sheaths. They are not frequently seen, and 
those tendons most liable to dislocate are the long head of the biceps 
from the bicipital groove, the peroneus longus, the peroneus brevis, the 
tibialis posticus, and the plantaris in severe sprains of the ankle-joint; 
the sartorius and quadriceps in severe sprains of the knee; and the 
extensor tendons on the back of the wrist, as well as the flexor carpi 
ulnaris in sprains of the wrist. The latissimus dorsi muscle may become 
displaced where it passes over the lower angle of the scapula, and is rec- 
ognized by the prominence of that portion of the bone. Dislocation of 
a muscle or tendon is recognized by acute pain, by a certain amount of 
loss of function in the part, and by the jumping of the tendon from its 
anatomical position on contraction. 
Treatment.—The tendon or muscle may be readily reduced by 
manipulation of the limb and by pressure, in the majority of recent 
injuries. The difficulty is to keep the tendon in position, and it is doubt- 
ful if a ruptured tendon-sheath ever unites. After replacing a tendon 
it should be held in its position by a dressing which maintains pressure 
at the point of dislocation while the injured part is placed in a relaxed 
position ; for example, in the peronei tendons this would be with the foot 
extended and abducted. If, after treatment in the above manner for 
several weeks, the dislocation persistently recurs, an operation for its cure 
is justifiable. Under full antiseptic precautions an incision is made, the 
lacerated edges of the sheath should be freshened and sutured together 
over the tendon, or, if the dislocation is out of a groove in the bone, the 
periosteum may be raised, the groove deepened, and the periosteum, with 
the sheath, sutured over the tendon. 
Wounds and sections of muscles and tendons maybe classified, 
in the same manner as wounds of other tissues, into incised, contused, 
lacerated, punctured, and gunshot. 
Treatment.—This is the same as is applicable to wounds of the 
same character in other tissues. The essentials are arrest of hemorrhage, 
thorough cleansing, the removal of all extraneous matter, and accurate 
approximation of the ends of the cut muscular fibres as far as it is pos- MUSCLES, TENDONS, TENDON-SHEATHS, ETC. 
493 
sible to attain by suturing with catgut or silk. If there has not been 
extensive loss of tissue, true muscular regeneration may occur and loss 
of function may not ensue. Absolute rest until union has taken place 
is essential. If kept free from sepsis, the gravity of these wounds is 
usually slight. Complete division of tendons is much more common 
than of muscles, and even at the expense of materially lengthening the 
original wound the cut ends must be found and carefully sutured. Con- 
siderable difficulty is often experienced in securing the divided tendons 
of the hand and forearm, and, when several have been severed, in 
adjusting the proper ends one to the other. If the wound has been 
allowed to heal without the tendon having been sutured, it is necessary 
to reopen the wound, find, freshen, and suture the ends, in order to 
restore power to the divided structure. In gunshot wounds there is 
usually only slight destruction of tissue: the muscles and tendons are 
partially cut through, apparently being separated and pushed to one side. 
These wounds should not be sutured, but cleaned, packed lightly with 
iodoform gauze, and allowed to granulate. 
Regeneration of Muscles and Tendons (vide Chapter XXII.).— 
Regeneration of muscular tissue takes place only to a limited extent 
after loss of substance. 
Normal increase in size of muscles occurs chiefly through the increase in size 
of the individual muscle-fibres. There is first seen an increase in size and num- 
ber of the muscular nuclei by division. These new cells or sarcoblasts are spindle- 
shaped, gradually lengthening out, and showing striations. Eventually, each one 
forms a muscle-fibre. In slight wounds and injuries the cicatrix may be entirely 
muscular, but when the loss of tissue is extensive the defect is largely filled by 
connective tissue. After section of a tendon, regeneration occurs in one of two 
ways: If the space in the sheath between the divided ends becomes filled with 
blood, a callus of granulation-tissue is formed around the tendon and sheath which 
gradually encroaches and absorbs the blood-clot. This in time becomes practically 
normal tendon-tissue. The process is accomplished by proliferation of the cells 
of the tendon itself and of the tendon-sheath. If the blood-clot is absent in the 
sheath, its walls come together and unite, in this way uniting the ends of the 
tendon. 
Diseases of Muscles. 
Myalgia is often known as muscular rheumatism or neuralgia, neither 
term being strictly correct. It is a painful affection of the voluntary 
muscles, and oftentimes dates from some strain or blow. It is charac- 
terized by sudden pain and is intensified by strain or exposure. It 
occurs most frequently in the muscles of the back and in the neck. It 
is occasionally found to depend upon some specific cause, such as syph- 
ilis, tuberculosis, lead-poisoning, or malignant disease. 
Treatment.—Subcutaneous injections of one-sixtieth of a grain of 
atropia into the body of the muscle are said to give prompt relief. 
Other remedies are massage, electricity, hot baths, dry heat, and the 
administration of salicylic acid and iodide of potassium. 
Functional Disorders of Muscles.—Temporary loss of muscular 
power, with or without spasmodic contraction, is a condition occasionally 
seen. It comes in muscles which have been overworked, subjected to 
any unusual strain or position, or. exposed to cold. A common example is 
writer’s cramp, in which the muscles of the hand are affected only when 
holding a pen. It begins gradually, but very soon the hand is com- 494 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
pletely disabled. A general nervous condition, with fatigue, predis- 
poses to its development. General systemic treatment, as well as 
complete rest and local massage with electricity, comprises the treat- 
ment. Various devices for its relief and prevention have been con- 
trived, the bracelet of Nussbaum, which allows the patient to continue 
his writing, being the most useful one. Another frequent form of cram]) 
is the excessively painful tonic spasm which comes on in the calves of 
the leg after over-exertion, as in mountain-climbing or after remaining 
long in one position. It sometimes attacks one when quiet in bed, 
probably caused by the foot being held in a particular position. The 
death of skilful swimmers may be due to attacks of muscular cramps 
of this description. 
Myositis and Inflammation of Muscles.—Hyperaemia in muscles 
mav be due to traumatism, inflammation, to extension from contiguous 
inflammation, or to an infection from the presence of micro-organisms. 
In muscle as well as in other tissue inflammation results in effusion, sup- 
puration, ulceration, and necrosis. The limited amount of inflammation 
of muscle which follows a simple contusion is characterized by an exu- 
date of serum and by cellular infiltration around and between the mus- 
cle-fibres. If the trauma is sufficient to do permanent injury to the 
muscle-tissue, and there is no infection to produce suppuration, cloudy 
swelling and coagulation-necrosis follow. The defects caused by this 
necrosis in the muscle-tissue are to a certain extent replaced by the 
proliferation of muscle-cells, as has been described under Regeneration 
of Muscles. If this necrosis is extensive, there is a considerable forma- 
tion of fine connective tissue in the muscle-substance. These simple 
forms of hyperaemia are known as myositis serosa and myositis fibrosa. 
Myositis purulenta is the suppurative and gangrenous form of in- 
flammation, which is always due to bacterial infection. It may be either 
acute or chronic, occurring in the form of abscesses or as diffuse sup- 
puration. It occurs in the course of compound fractures, in general 
septic infections, and in endocarditis, erysipelas, typhoid fever, and 
tuberculosis. 
Myositis ossificans is a peculiar form of inflammation in which 
plates of bone are developed in the substance of the muscles. It may 
occur in connection with the formation of callus in the bone after frac- 
ture and as a result of continued or frequently repeated irritation or 
traumatism. 
Rider’s bone is a small plate of bone in the adductor longus muscle 
of the thigh, forming as the result of knee-pressure against the saddle. 
Drill bone is a similar condition in the deltoid muscle, and is occasion- 
ally seen in soldiers. 
Treatment.—Complete excision of the deposit is called for if the 
symptoms produced are annoying. 
There is a more general form of muscular ossification known as 
progressive myositis ossificans, in which a large number of muscles in 
the body gradually become the seat of extensive bone-deposits. This 
may come on as the result of a slight blow or even without apparent 
cause. In the beginning small, hard nodules are felt, which increase in 
size and become true bone, branching out through all the muscles, espe- 
cially those of the back. If seen early in the course of the disease, MUSCLES, TENDONS, TENDON-SIIEATHS, ETC. 
495 
the deposits may be excised, but the severe cases are usually helpless 
from the inception of the disease. The etiology of this disease is 
obscure. It has been suggested that it is congenital and that it is due 
to the foetal development of bone not ceasing. 
Calcification of Muscles.—This is a condition in which there is a 
deposit of lime salts in the muscles. It may occur in two forms: first, 
as masses which are known as concrements, which merely lie in the body 
of the muscle, or, second, as a general infiltration into the muscle-fibres. 
The first form is the ultimate result of tubercular necrosis and abscess- 
formation. Only a part of the necrosed mass is absorbed : the re- 
mainder becomes caseous, then calcified, and is enclosed in a capsule of 
connective tissue. If this inspissated substance gives rise to trouble, it 
may be readily excised. The second form, which is more properly 
spoken of as calcification, is a genuine infiltration, and is exceedingly 
rare in muscles. It has been found in the muscles of the legs. 
Degeneration of Muscles.—The muscles, like other tissues, are the 
seat of various forms of inflammatory degenerations. Some of these 
constitute definite surgical lesions, others are the sequelae or manifesta- 
tions of general disease, while still others may be the result of poison- 
ing by arsenic, phosphorus, etc. 
Cloudy Swelling and Fatty Degeneration.—In cloudy swelling or 
granular degeneration there is an increase in the size of the cells due to 
the accumulation of fine granules in the protoplasm. 
The tissue macroscopically has a dull, cloudy aspect, and under the microscope 
the granules obscure the cell-nuclei, which become visible on the addition of acetic 
acid. This degenerative process may disappear and the cells return to their natural 
condition, or the granular material may break down and disappear. Fatty degen- 
eration may exist with cloudy swelling or may result from it. In fatty degeneration 
the drops of fat are seen in the cells, being formed probably by the destruction of 
cell-albumen. In normal tissue the muscle-cell contains no fat, although there is a 
certain amount of fat among the muscle-fibres. An increase of the latter is not 
fatty degeneration. Fatty degeneration occurs as the result of diminished oxida- 
tion, or it may result from anaemia, from various forms of acute or chronic poison- 
ing, from the acute infectious diseases, and from inactivity of the muscles following 
paralysis or ankylosis. 
Waxy degeneration of the muscles is a form of coagulation-necrosis 
in which the muscle-fibre in places becomes disintegrated and the con- 
tractile myosin coagulates into refractive homogeneous masses. The 
fibres enlarge and become transparent from the presence of colloid 
material in the cells. The striations disappear, their position being 
indicated by lines of separation in the refractive masses. This degen- 
eration may result in the destruction of individual muscle-fibres or of 
large areas of muscle, which are always incapable of repair. The 
muscle, to the naked eye, resembles the flesh of fish, having a dull, 
grayish color. Waxy degeneration of muscles occurs in consequence 
of long-continued febrile conditions; in the abdominal muscles after 
severe typhoid and puerperal fevers; in tetanus and after extensive 
bruising, crushing, or tearing. 
Amyloid Degeneration of 3fitscles.—Amyloid disease is one of the 
degenerative processes which more rarely attacks muscles than the other 
tissues. Not infrequently it occurs in the muscles of the heart, the 
tongue, and the larynx as a result of inflammatory processes. It 496 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
is characterized by the deposit of a peculiar albuminous material 
known as amyloid substance between the muscle-cells rather than in 
them. This results in cell-atrophy and loss of function. It follows 
extensive syphilitic lesions, and is a sequel to long-continued suppura- 
tion, especially tubercular and other infectious bone-processes. The dis- 
ease is generally regarded as incurable, and it is important that it be 
recognized by the surgeon. All authorities consider that extensive 
amyloid disease is a contraindication to operation. The writer, however, 
has successfully operated on a number of patients who have had amy- 
loid disease. 
Syphilis of Muscles.—Syphilis of the muscles is not rare. It may 
manifest itself at any time in the course of the disease, especially in 
the tertiary stage. It may appear localized as a gumma or as a diffuse 
syphilitic myositis. Gummata are found generally in the muscles of 
the legs, arms, and neck. The muscles of the tongue are frequently 
involved, and even the heart and diaphragm may be invaded. They 
occur as distinct rounded tumors in the body of the muscle, varying in 
size up to a pigeon’s egg or even larger. Three have been observed in 
one sterno-mastoid muscle. These swellings are frequently so hard and 
so well defined as to lead to an operation, and excellent surgeons have 
erred in attempting their removal. These syphilitic growths are usually 
of an unstable nature, there being an extravasation of leucocytes without 
the formation of granulation-tissue. The leucocytes perish by fatty 
degeneration; suppuration and ulceration ensue; small areas may be 
reabsorbed. In larger gummata there may be a central zone of casea- 
tion, surrounded by granulation-tissue which becomes transformed into 
connective tissue and causes the common depressed cicatrix of syphilis. 
The diagnosis is at times very clear, but gummata are frequently 
confounded with malignant growths; in fact, not infrequently the diag- 
nosis is established by the success of the syphilitic treatment. 
Syphilitic myositis may, as a rule, be differentiated from ordinary 
myositis by the history, by the less acute course of the symptoms, and 
by the peculiar swelling and induration of the affected muscles, usually 
spoken of as “ woodeny.” It is characterized by an exudation into the 
interstitial connective tissue and the sarcolemma. 
The walls of the vessels, especially the arteries, are likely to be involved. They 
are thickened and the lumen reduced in size or even occluded. The muscles of 
the neck are a favorite seat for specific myositis. The writer has recently seen a 
case where almost the whole length of one sterno-cleido-mastoid muscle was 
infiltrated by this process, causing a prominent swelling throughout the side of the 
neck and simulating deep cellulitis. In this instance an incision was made into 
the substance of the muscle with the idea that pus might be present : it was only 
when a small portion of the muscle was excised and examined microscopically 
that the diagnosis of syphilis was made. Permanent atrophy and contracture of 
the muscle frequently follows this disease. 
Syphilis of muscles, as a rule, runs a chronic course. In adults 
it occurs as a tertiary lesion, but in children, especially in infants, it 
may be one of the earliest manifestations of the disease. In addition 
to the above forms of muscular syphilis there is occasionally seen a 
form of syphilitic contracture of the muscles. It occurs chiefly in the 
flexors of the arm and forearm, but occasionally it is seen in the biceps. 
It begins insidiously with slight pains in the fleshy part of the muscle, MUSCLES, TENDONS, TENDON-SHEATHS, ETC. 
497 
soon accompanied by weakness and unsteadiness of action. Later there 
occurs a slowly-progressing contraction of the muscle itself. Occasion- 
ally the first symptom noticed is stiffness in the elbow-joint, extension 
becomes limited, and the forearm remains partially flexed, and, if the 
arm be forcibly extended, the muscle is found to be tense or prominent 
and in a state of spasm. There are no other distinguishable changes in 
the muscle than its shortening and tension. 
This condition has been frequently attributed to rheumatism, traumatism, and 
other causes, but in most cases a definite history of syphilis may be obtained, and 
the disease usually yields readily to treatment. It is due to a subacute inflamma- 
tion in the muscles. A very troublesome myositis is occasionally seen in the 
sphincter ani of syphilitic women, which gives rise to much pain and discomfort. 
All forms of syphilitic disease are amenable to a vigorous course of mercury and 
iodide, and in cases of doubtful diagnosis it may be well to defer other treatment 
until this has been tried. Undoubtedly many of the so-called rheumatic pains, 
indurations, and contractions in muscles are due to syphilis. 
Tuberculosis of Muscles.—Primary tuberculosis of muscles prob- 
ably never exists, and muscular tuberculosis of any character is of very 
rare occurrence. As a rule, it is secondary to tubercular disease of the 
surrounding parts, such as bone, tendons, etc. It may occur in general 
miliary tuberculosis, following the absorption of tubercle bacilli from the 
circulation. In the former case it is seen in the adjacent muscles—for 
example, in hip- and other joint diseases—or may give rise to tubercular 
cold abscess. Tuberculosis of the tongue is occasionally seen, and may 
readily be confounded with syphilis or cancer. 
Muscular contractures may be of two distinct varieties—the first a 
simple muscular rigidity or spasm, and the second a permanent non- 
relaxing muscular contraction. The former is nothing more than a spasm 
of the muscles set up by extrinsic causes, either traumatic or inflamma- 
tory. An example of the traumatic form occurs in fractures, and disap- 
pears when the fracture is controlled. Rigidity and spasm, which always 
accompany joint diseases, especially in the acute stages, are examples due 
to inflammation. This spasm and rigidity are the cause of the charac- 
teristic deformities in hip-, knee-, and elbow-joint diseases and of the 
limitations of motion found in the early stages. 
There is a rare form of permanent congenital contraction of the muscles of the 
fingers and toes which may involve several digits of either the hands or feet. Gen- 
erally, these contractions are in the position of flexion, but there may be hyper- 
extension. In some of these cases there seems to be a distinct hereditary history 
of such deformity. Defective development of the bones may accompany muscular 
contraction. 
Treatment should consist of massage and manipulation, to be followed in case 
of failure by forcible extension under ether and retention by splints. Finally, 
division of the muscle or tendon, or even amputation, may be required to relieve 
certain cases. 
Permanent muscular contractions are acquired as the result of many 
causes. A mild form follows prolonged rest in a constant position. 
This takes place when an arm has been confined for a long time, with- 
out passive motion, on an internal angular splint. This temporary 
acquired contraction is not at all uncommon following the treatment of 
fractures involving the joint, and massage, passive motion, and, if neces- 
sary, active motion under an anaesthetic, are indicated. Severe and pain- 
ful contractions of the muscles often follow the various infective inflam- 498 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
mations. Every surgeon not infrequently sees extensive and permanent 
contraction of the muscles of the hand and forearm following an infec- 
tive cellulitis which may have come from a small wound on one finger. 
The inflammatory process in these cases has penetrated to the muscle 
itself, and has caused an atrophy of the muscular fibres and an adhesion 
between the muscles and tendons themselves. 
Treatment sometimes seems almost hopeless. Massage and forcible 
extension, persisted in for a long time by surgeon and patient, result in 
some improvement; even repeated etherizations are at times necessary. 
Cicatricial contractures of muscles follow injuries, loss of substance, 
or burns, and the deformity is due to either the injured muscle itself or 
to the superior strength of the antagonistic muscle. In adults contrac- 
tions of the muscles are seen as late results of hemiplegic paralysis. 
They occur commonly in the flexor muscles of the arm and leg. These 
flexions can be partially overcome by passive or active motion, but can- 
not be permanently relieved by any treatment. 
Muscular Atrophy.—Simple muscular atrophy is a condition fre- 
quently seen by the surgeon and under a variety of circumstances. The 
most familiar form is due to rest or some prolonged illness, and is not the 
result of disease in the muscle itself. Atrophy does occur as the result of 
imperfect assimilation. It may be brought about by interruption of the 
local circulation or by disturbed innervation, either from injury to the per- 
ipheral nerves or the central nervous system. There is also senile atrophy 
which is due to the constant expenditure of force, causing a waste of tissue 
in excess of the power of regeneration. Atrophy is a diminution in the 
amount of the normal tissue, without any material change in the structure 
of the muscle itself (Chapter I., Consequences of Disturbed Nutrition). 
The atrophy of disuse follows the pressure and confinement by splints 
after fractures and dislocations. It is greater in that part of the limb 
above the injury than in that below. 
The atrophy which is seen as the early symptom in all forms of joint disease is 
not, as is generally believed, occasioned by the enforced disuse of the part. It is 
supposed to be due to reflex disturbances of the trophic nerve secondary to the dis- 
ease in the joint. Brown-S6quard believed that it was a direct irritation of the 
nerves independent of the trophic centres. Atrophy following lesions of the brain 
and cord and in wasting diseases, as typhoid fever and phthisis, may be from 
either disuse or malnutrition. In conjunction with the various forms of muscular 
degeneration which occur, particularly in syphilis, rheumatism, typhus fever, alco- 
holism, and lead-poisoning, there is always a certain amount of atrophy of the 
muscular fibres. 
Progressive muscular atrophy is a peculiar chronic affection cha- 
racterized by a wasting and loss of power of individual and groups of 
muscles. It is progressive, commonly hereditary, and apt to begin in 
the muscles of the hand. Excessive muscular exertion, combined with 
exposure to cold and dampness, is supposed to be a predisposing cause. 
While its pathology is not well understood, lesions have been found in 
the spinal cord in a number of cases. 
The treatment in all forms of muscular atrophy is practically the 
same. It consists mainly in attempting to restore the wasted tissues as 
far as possible to their normal conditions. This in many instances may 
be accomplished by passive motion, massage and rubbing of the parts, 
muscle-beating, baths, and electricity. These, begun early, not only keep MUSCLES, TENDONS, TENDON-SHEATHS, ETC. 
499 
the muscle well nourished, but at times seem to delay the progress of the 
affection. 
Muscular Hypertrophy.—Hypertrophy is an increase in the size of 
a part with retention of its normal structure. In muscle it is due to 
increase in size of the individual muscular fibres, and not to the forma- 
tion of new tissue, exoept perhaps to a very limited extent. True hyper- 
trophy of the muscles arises from their increased use and is essentially 
a physiological condition. 
Pseudo-muscular hypertrophy or pseudo-hypertrophic muscular 
paralysis was first described by Duchenne in 1858, and for a long time 
Fig. 200. 
Pseudo-muscular hypertrophy: case of Dr. E. G. Brackett, showing characteristic attitude of 
child. 
the disease was known more commonly under his name. It should un- 
questionably be classed under the neuroses, but as cases come to the sur- 
geon for treatment, and as it has always received a place in surgical 
literature, it deserves some notice here. It is a disease characterized by 
a great increase in size of certain groups of muscles, together with a 
diminution in their power and functional activity. At the same time 
there is also a diminution in the size of other muscles, together with a 
loss of power. 
The muscles most frequently involved are the extensors of the leg, those of the 
calves, the glutei and lumbar muscles, the deltoids, the triceps, and the infra 
spinati. The muscles of the face, neck, forearm, and hand are rarely affected. 
In the muscles which are apparently hypertrophied, as well as those in which 
there is atrophy, there is a general atrophy of the muscle-fibre itself, but in those 
that are hypertrophied there is a great increase in the connective tissue and fat, 500 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
by which, in the later stages, the muscle-substance is largely replaced. This 
increase in fat and connective tissue accounts for the apparent enlargement in the 
muscle itself. However, in the early stages there has been noticed a marked 
enlargement of a few of the muscle-fibres and an increase in the nuclei of the 
sarcolemma. The atrophy of the fibres and the replacement by connective tissue 
and fat seem to be processes which go on during the progress of the disease. 
The disease in many instances is probably congenital, and seems to be trans- 
mitted in a family through several generations. The disease may not be recog- 
nized until the child begins to walk, when it is noticed that it is clumsy in its 
movements and that it stumbles and falls easily. As the trouble advances the 
attitude in standing and walking becomes characteristic. The legs are wide apart, 
abdomen prominent, with a pronounced curve in the spine, while the gait has a 
peculiar waddling character. The muscles themselves feel hard, firm, and elastic. 
The diagnosis is usually not difficult when one considers the apparently 
robust appearance with the wreak condition and the attitude, gait, and size of the 
muscles. The disease occurs in males much more frequently than in females, and 
in the majority of cases appears in childhood, but it may develop exceptionally in 
young adults. The progress of the disease is slow but constant, the paralysis 
becoming general and increasing until the patient is bed-ridden, when he fre- 
quently dies of some intercurrent disease. 
Traumatic Muscular Paralysis.—Persistent paralysis of one or 
more muscles may occur as the result of direct violence to the muscle 
itself or to its nerve-trunk. The former is not common, but a patient 
is occasionally seen who, after a violent blow on the belly of a muscle— 
for instance, the biceps—has considerable contraction, followed by 
paralysis and atrophy. The more common form of muscular paralysis 
is a result of injury to the nerve, and it is seen in the arm following 
pressure upon the circumflex and musculo-spiral nerves. Examples 
of this occur in crutch paralysis from the continued use of crutches, 
from pressure during sleep caused by the weight of the body or head 
resting on the arm, from the arm hanging over the back of a chair, 
following dislocations at the shoulder-joint, and after fracture from the 
involvement of the nerve in the callus. 
Direct muscular action, as in throwing a ball, may cause the same thing. When 
the trouble is occasioned by the use of a crutch it usually may be recognized in 
time to avert serious trouble. It begins with numbness and tingling in the fingers, 
soon followed by muscular weakness and paralysis if the cause is not removed. 
The treatment is rubbing, massage, hot and cold douching, elec- 
tricity, and passive motion. The recovery is usually very slow, and 
months may pass before the patient shows any improvement. 
Dupuytren’s contraction is the name given to a condition not 
infrequently seen, principally in men of middle age, in which there is 
permanent flexion of one or more fingers, usually the third and fourth. 
It is due to a contraction of the palmar facsia. It has no English 
synonym, and ever since Dupuvtren first demonstrated that the 
deformity was due to contraction of the palmar fascia, and not to the 
flexor tendons, the disease has been identified with his name. It is a 
condition which is seen in men much oftener than in women, and, while 
it may affect either or both hands and any finger, yet the ring and lit- 
tle fingers are usually the ones involved, and often the two together. 
It is an acquired disease, and, although the etiology is still a mooted 
point, as widely different views of its origin are held, yet it is certain 
that different conditions bring about the same disease. It seems to be 
most frequent in people of a rheumatic or gouty diathesis, and especially 
where it is hereditary. The disease has been ascribed to repeated slight MUSCLES, TENDONS, TENDON-SHEATHS, ETC. 
501 
traumatisms to the palm of the hand, such as occurs in the use of par- 
ticular tools; again, to nervous and inflammatory causes. A few cases 
can be traced to syphilitic origin in which 
treatment begun early in the contraction 
has resulted in cure without operation. 
It seems probable that it arises as the 
result of a chronic inflammatory pro- 
cess which attacks the palmar fascia, 
and that various constitutional conditions 
may be responsible for its occurrence. 
Why the palmar fascia is singled out, 
and the reason that some of the fingers, 
and not all, are attacked, are not manifest. 
Fig. 201. 
It has been clearly demonstrated by many 
dissections that the fingers are held flexed by 
tight bands of fibrous tissue which are some- 
what enlarged continuations of the palmar 
fascia, and which are attached to the skin of 
the finger at various points. It should be re- 
membered in this connection that the palmar 
fascia normally is not sharply defined, but that 
it becomes lost in the integument along the 
fingers in close connection with the skin. 
Dupuytren’s contraction appears first 
as a small lump or band which can be 
felt in the palm near the base of the 
phalanx. This gradually becomes more 
evident; occasionally stiffness of the fin- 
gers is the first symptom observed by the patient. The condition devel- 
ops slowly, without pain or discomfort, and, if allowed to progress, as is 
usually the case, continues until the finger-tip is drawn into the palm 
and other fingers begin to be involved. It is a characteristic deformity 
not readily mistaken. The marked flexion of one or more fingers, its 
progressive character, strongly resisting all efforts of extension, its slow 
development without evidence of inflammation, the prominent band felt 
in the palm, the ability to flex the finger still farther, and the absence 
of cerebral or spinal disease, taken together, make the diagnosis com- 
paratively simple. 
Dupuytren’s contraction of palmar fas- 
cia, showing contracted fingers. 
Cicatricial contractions from wounds, burns, and palmar abscess and rheumatic 
ankylosis with contraction, all somewhat resemble Dupuytren’s contraction. The 
efficiency of the hand is much impaired late in the disease, but a thorough opera- 
tion relieves completely. 
The present treatment of Dupuytren’s contraction is wholly ope- 
rative, and is either by subcutaneous section or by open incision, with 
or without removal of the contracted fascia. Massage, forcible exten- 
sion, and apparatus have been abandoned as slow, tedious, and inefficient. 
By operation the contracted bands are divided subcutaneously with a 
tenotome at a large number of points, beginning as high up in the palm 
as they can be felt and continuing the incisions along the palm out on 
to the fingers. If the deformity is extensive, as many as ten or even 
twenty punctures may be necessary. The advantages of the subcu- 
taneous method are that it may be readily done under cocaine and the 502 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
resulting scar is slight, while it has the disadvantages of all subcutaneous 
operations. The open operation is the best, for by this means the deform- 
ing bands can be clearly identified. One method is by making one or 
more incisions through the skin and fascia, straightening the finger, and 
allowing the wounds to heal by granulation. The best way of operating 
is to expose the contracted fascia freely by making a V-shaped incision 
in the palm, removing by careful dissection all of the bands, and suturing 
the V flap of skin back into position. The fingers should be put on a 
splint, which is slightly flexed to avoid pain, for a few days. Then the 
fingers should be completely straightened and the splint worn continu- 
ously until the wounds are healed. For several weeks, even after heal- 
ing, the splint should be kept on part of the twenty-four hours—during 
the night if it is more convenient. 
Hammer-toe is a peculiar deformity characterized by a permanent 
flexion of one or more toes: the first phalanx projects upward, while the 
second and third phalanges are drawn downward, so that the tip of the 
toe sustains the pressure on the ground. An annoying callus resembling 
a corn usually forms over the joint, which projects above. In many 
instances it is supposed to be the result of continuously wearing too 
short shoes, the toes being held cramped in this position: the fibres of 
the plantar fascia attached to the lateral ligaments become permanently 
shortened. In some cases the condition seems to be hereditary. The 
condition often begins in childhood, and continues until the deformity 
becomes pronounced, giving rise to much inconvenience and annoyance. 
If treatment is begun before the flexion becomes rigid, the trouble 
may often be remedied without operation. The toes should be strapped 
by firm adhesive plaster to a stiff plantar splint of wood or tin, the 
plaster passing over the crest of the projecting joint and being renewed 
frequently. A slight gain over the deformity is acquired each time. 
The lateral ligaments and plantar fascia have been divided subcutane- 
ously and by open incision, with satisfactory results. Excision of the 
joint seems to promise a better result than amputation, for the latter to 
be effective must be near the metatarso-phalangeal joint. 
Lock or trigger finger is the name given to the peculiar and rare 
condition in which free flexion and extension of the finger is prevented 
and the finger is brought to a sudden stop while in motion. On extra 
effort being made, with an appreciable jerk the obstruction is overcome 
and the flexion or extension is completed. The condition may be due to 
a circumscribed thickening of the tendon, causing for a short space a 
disproportion between the size of the tendon and its sheath, or it may be 
due to a small fibroma formed on one of the synovial fringes, being 
caught between the tendon and its sheath. Strains and injuries, as well 
as gouty and rheumatic inflammations, are regarded as etiological causes. 
If after the usual means of treatment bv passive motion and rub- 
bing relief is not obtained, an incision should be made and the cause of 
the trouble excised. 
Inflammation of the Tendons and Tendon-sheaths.—The sheaths 
of tendons are synovial membranes which resemble very closely in 
structure and pathology the synovial sacs of the joints. Inflammation 
of a tendon is usually identical with, and occurs at the same time as, 
inflammation of its synovial sheath. The most frequent source of simple MUSCLES, TENDONS, TENDON-S1IEA TITS, ETC. 
503 
hypersemia in a tendon is a sprain or wrench in the neighborhood of a 
joint, or it may follow long-continued and excessive muscular exertion. 
This hypersemia is usually of a subacute character and is known as the- 
citis, simple teno-synovitis, or teno-synovitis crepitans, from the 
peculiar well-marked crepitating or creeping sensation which is often felt 
over the tendon while the muscles are in action. If the injury is severe, 
there is an acute effusion of a considerable quantity of serous fluid into 
the tendon-sheath and surrounding tissues. The location of the trouble 
is marked by an ill-defined swelling, often elongated and cylindrical in 
shape, which is more or less painful and is sensitive on manipulation. 
Muscular action causes pain and is accompanied by the soft crepitant 
feeling. In less severe cases there may be a history of slight sprain, no 
distinguishable swelling, pain during fatigue or on beginning motion, 
which largely wears away as the movements increase and the patient 
becomes accustomed to them. In such instances the diagnosis is made 
largely by the crepitation, which is apt to be more pronounced than in 
those cases where the effusion is considerable. 
This form comes on in the tendo Achilles and in the front of the ankle after 
long walks. The crepitation corresponds to a pleuritic rub, and is the result of a 
fibrinous deposit in the tendon-sheath, which becomes roughened when the tendon 
is moved. 
The tendons of the forearm, wrist, and hand are frequently the seat 
of the trouble. Here it is often started up by severe muscular exercise, 
as in ball-playing or rowing or by sprains. Synovitis of the wrist- or 
ankle-joint may be mistaken for thecitis. In the former the pain and 
tenderness are ditfuse, while in the latter they are elicited by direct 
pressure along the course of the tendon. 
The treatment is rest and immobilization by splints, with mode- 
rate pressure if there is swelling; later, massage and passive motion. 
In light cases, partial rest, tincture of iodine, blisters, douches, and light 
rubbing will give relief. The duration of the trouble may be from a 
few days to three or four weeks. 
A teno-synovitis not infrequently arises in the course of acute or 
chronic rheumatism and in gout. Should the trouble not yield readily 
to local treatment, salicylic acid and potassium iodide should be admin- 
istered. In connection with a post-gonorrhoeal arthritis the neighboring 
tendon-sheaths are often more or less involved. 
Welch has recently reported a case of gonorrhoeal rheumatism at the ankle- 
joint in which there was extensive suppurative inflammation of the tendon-sheaths 
of the extensor tendons of the toes. The sheaths were distended with pus from 
which cultures of the gonococcus were obtained. Specific inflammation of the 
tendons is not common. It occurs in the form of gummata which tend to soften 
and discharge, leaving ragged ulcers difficult to heal. 
Chronic teno-synovitis is probably in nearly every case a tubercular 
disease of the tendon-sheath. It may develop as a primary disease or 
secondarily to tuberculosis of a neighboring joint. Like tuberculosis 
in a joint, chronic teno-synovitis develops after some traumatism, as a 
sprain or contusion, and it is seen most commonly in adult life in labor- 
ing people. The great majority of cases develop in the tendons of the 
flexors of the forearm, while it is not of infrequent occurrence in the 
hand and in the vicinity of the knee and ankle. Its course is very slow, 504 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
often covering a period of two or three years, sometimes improving 
under rest and almost disappearing. When the patient returns to his 
customary occupation the disease soon recurs. The affection is always 
characterized by a flat or oval swelling along the course of the tendon, 
caused by the effusion into the tendon-sheath. Its slow development 
causes very little inconvenience beyond slight weakness and pain on 
exertion. The swelling may resemble more or less an hour-glass in 
shape from the confinement, in places, of the tendon beneath the annular 
ligament. The swelling may be distinctly fluctuating or it may be soft 
and elastic, while at times a peculiar feeling, simulating crepitation, 
indicates the presence of small, firm bodies very similar in appearance 
to rice-kernels. The disease tends to extend up and down the thickened 
tendon, to increase in size, and to attack neighboring tendons, and, when 
allowed to progress, even to invade underlying joints. When not 
primary in the tendon, it is the result of an extension from some joint 
in close proximity. There are two pathological forms of the disease. 
The one is a fungous form, distinguished by the growth of exuberant 
granulation-tissue of a gelatinous appearance surrounding the tendon 
on the inner side of its sheath. In the other form, known as hygroma, 
the inner surface of the tendon-sheath is covered with small growths 
which become detached, forming small, hard kernels known as rice- 
bodies. These rice-bodies are the result of a fibrinoid degeneration; 
that is, the degenerated villous growths, which are fibrinous in character, 
become lossened, forming free kernels. 
Until recently this form of disease was supposed to have no connection with 
tubercular disease. It is now distinctly established that these bodies contain 
tubercle bacilli. The same condition may be found in tubercular joint disease, 
where they develop from a fibrinoid degeneration of tubercular granulations on 
the synovial fringes. It is said that these small tubercular nodules never become 
caseous. Their structure is that of fibrous tissue with few nuclei and an occa- 
sional giant cell with tubercle bacilli. Their separation is due to the fact that 
they project from the surface of the sheath as small, hard nodules, and by rubbing 
of the tendon are gradually separated. Localized tubercular areas are sometimes 
seen in the tendons and tendon-sheaths. If the disease is allowed to run its course, 
suppuration ensues, forming sinuses involving the skin which eventually break 
down. These, with the resulting cicatrices, greatly impair the usefulness of the 
hand. 
The treatment of chronic tenosynovitis may be of two kinds— 
conservative and operative. The essential features of the former are 
rest, immobilization by suitable splints, and moderate pressure. If the 
disease occurs in the forearm, the arm should be placed upon a splint, 
bandaged with not too great pressure over wadding, and carried in a 
sling. While the disease very rarely disappears spontaneously, yet this 
treatment, if persisted in for a long time, together with careful atten- 
tion to the general physical condition, which is of the greatest import- 
ance, and the administration of tonics, iron and cod-liver oil, will often 
result in permanent improvement. 
The writer believes that this method should be first tried in all cases 
which are seen sufficiently early and in which the disease has not made 
such progress that already an operation is indicated. This applies espe- 
cially to such cases as are able to give up their occupation temporarily 
and devote themselves to the eradication of the disease. 
The operative treatment is more efficient in the majority of cases. MUSCLES, TENDONS, TEND ON-SHEA TITS, ETC. 
505 
When there is no marked thickening of the tendon-sheath and its con- 
tents are fluid, an aspirating needle may he inserted into the sac, the 
fluid drawn away, and an emulsion of iodoform injected. The emulsion 
should consist of a 10 to 20 per cent, mixture of iodoform in glycerin 
or olive oil, both ingredients being sterilized separately before being put 
together. This method of preparing the emulsion is said to prevent the 
dangers of iodoform-poisoning. This method of treatment will fre- 
quently result in a cure of the disease in the right class of cases. 
When an incision is made the part should be rendered bloodless by 
an Esmarch bandage; the sheath should be laid open throughout the 
whole length of its diseased portion, even if it is necessary to divide the 
annular ligament, in order to thoroughly evacuate and cleanse the walls. 
Efficient treatment must mean the complete removal of all tubercular 
deposit bv scissors and a sharp curette. Recognition of diseased from 
healthy tissue is often extremely difficult, but everything of a suspicious 
nature should be dissected out. This is especially true when the condi- 
tion is secondary to joint disease. If necessary, the diseased tendons 
should be removed, and if a large portion of tendon is destroyed, the 
space may be filled in by splitting a portion off either end of the healthy 
tendon, turning the ends up and down, and suturing them together. By 
so doing the function of the tendon is not greatly impaired. If the 
operation has not been an extensive one, after thorough cleansing of the 
wound it may be dusted with iodoform and closed. After a radical ope- 
ration the wound may be partially sutured together and packed with 
iodoform gauze. 
WThile the prognosis is usually favorable in primary tuberculosis of 
the tendon-sheath, yet relapses occur and the patient may succumb to 
general tuberculosis. 
Paronychia is an infective inflammation of the soft parts of the ends 
of the fingers, rarely in the toes, in the vicinity of, and often involving, 
the nail itself. It originates either in the skin itself or in the subcu- 
taneous cellular tissue. It is usually superficial, and is seen most com- 
monly in debilitated subjects, especially in children, after the exhaus- 
tive and infectious diseases, such as measles and scarlet fever. It occurs 
after a slight abrasion or wound of an infectious nature in healthy peo- 
ple and laboring men. Unless it is checked it spreads around and 
under the base of the nail, where the pus remains for a long time. 
It occasionally arises as the result of excessively broad or ingrow- 
ing nails. 
Another form of paronychia will only be mentioned here, which is 
of syphilitic origin, being one of the late cutaneous manifestations of 
the disease. The results in an irregular roughened condition of the nail 
and frequently its permanent loss. In paronychia the inflammation is 
generally of a low grade and the symptoms slight, but if the infection 
is acute or the condition of the patient is poor, the swelling may be pro- 
nounced, the pain severe, and the suppuration profuse, with the devel- 
opment of fungous granulations around and under the nail, resulting in 
its complete loss. Neglected or improperly treated cases last for weeks 
until the necrosed nail is thrown oft. 
The treatment is simple and always efficient if begun early. In- 
cision with a small bistoury and thorough evacuation of the pus may be 506 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
accomplished without an anaesthetic. This should be followed by rest 
and elevation of the part, with the application of hot antiseptic fomen- 
tations of weak creolin or corrosive sublimate, changed very frequently. 
If the inflammation has already spread beneath the nail, the diseased 
portion should be carefully trimmed away, but in this event the chances 
are strongly in favor of its total loss. 
Felon, or whitlow, is an acute infectious inflammation involving the 
deep tissues of the terminal phalanx of the fingers or thumb. It may 
originate in the soft tissues, the ten- 
dons or tendon-sheaths, the perios- 
teum, or even the bone. At the 
start it is always a circumscribed 
inflammation on the palmar aspect 
of the finger, and it is more frequent 
Fig. 203. 
Fig. 202. 
Suppurative thecitis of thumb. 
in women than in men. It usually appears to originate spontaneously, 
but is probably the result of some injury so slight as to escape unno- 
ticed. 
Felon of thumb. 
The symptoms of a deep felon are almost unmistakable. The 
pain is excruciating; there is persistent throbbing which is increased 
by motion, pressure, or a dependent position. The finger is swollen, 
hot, tense, and of a livid hue. Fluctuation is not obtained, because of 
the limited space in which the suppuration occurs, 
Treatment consists in prompt incision at the earliest moment to 
relieve tension by laying open the inflamed focns. This treatment 
should not be delayed in order to try abortive measures when once the 
diagnosis is clearly established. It is very rare that septic inflammation 
when once established can be aborted. Applications of tincture of 
iodine, nitrate of silver, and liquor plumbi subacetatis are recommended 
as abortive treatment, but the disease when recognized must be promptly 
relieved, for delay is dangerous. 
The incision may be made after applying a small elastic tourniquet around the 
finger and injecting a few minims of a 2 per cent, solution of cocaine into the base 
of the finger on either side. The incision should be made over the point of great- 
est tenderness, and should be carried through the soft tissues down to and through MUSCLES, TENDONS, TENDON-SHEATHS, ETC. 
507 
the periosteum. Oftentimes not any or not more than a single drop of pus will 
be obtained, but the pain and tension will be relieved and further spread of the 
disease will be prevented. The incision should be made promptly, even before 
suppuration has been established, and the dressing should be an antiseptic one for 
a few days, after which the wound may heal very quickly. It is remarkable with 
what little discomfort the operation may be performed under cocaine, and how 
quickly relief is obtained. 
The surgeon frequently sees neglected cases of felon which have 
opened spontaneously. These are very disagreeable cases to treat. The 
tip of the finger may be one mass of sloughing material, the periosteum 
destroyed, and the joint involved. It is hopeless to attempt to save the 
vrhole finger under such circumstances, but under efficient poulticing the 
inflammation may be reduced and the tissues brought into such a con- 
dition that an amputation may be performed later, and usually only the 
terminal phalanx sacrificed. 
The variety of felon known as shirt-stud or collar-button abscess should 
not be forgotten. It is a small collection of pus lying just beneath 
Fig. 204. 
Fig. 20o. 
Neglected suppurating thecitis resulting in 
palmar abscess. 
Same, dorsal aspect. 
the skin, connected by a small sinus with a large abscess beneath the 
deep fascia. The danger lies in the fact that the superficial abscess may 
be opened while the deep one is unrecognized and continues to extend. 
Pus extends readily in the finger, owing to the anatomical arrange- 
ment of the fibres, the connective-tissue fibres running perpendicularly 508 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
inward to the deep fascia, and when the pus reaches the tendon-sheath it 
extends without opposition along its channel. 
Inflammation of the thumb or little finger is much more likely to 
extend into the palm and up the forearm than if situated on either of 
the other three fingers. The tendon- 
sheaths of the first three fingers are 
closed sacs and extend only to the base 
of the fingers, while those of the thumb 
and little finger are continuous with the 
synovial membrane which encloses the 
tendons of the palm and passes beneath 
the annular ligament, extending for 
some distance up the forearm. The 
importance of thorough and prompt 
attention to a felon can scarcely be 
overestimated, for an important mem- 
ber is involved and the function of a 
hand or arm may be lost, and lives 
have been destroyed by neglect. 
Palmar abscess occurs either as 
the result of a suppurative lymphan- 
gitis or a thecitis of the flexor tendons 
of the fingers travelling upward, or it 
may be the result of direct local in- 
fection. 
Fig. 206. 
A favorite seat for infection is the cal- 
losities almost invariably seen in the palms 
of working-men over the heads of the meta- 
carpal bones. The broken skin over a blis- 
ter or a small crack in the surface of the 
skin, together with the presence of infectious 
matter, furnishes the soil and material for 
abscess-formation. This mode of infection 
is rather more likely to result in a superficial than a deep palmar abscess. The 
latter variety occurs commonly secondarily to suppuration in the tip of the thumb 
or little finger, where the pus has travelled along the tendon-sheaths into the syno- 
vial sac of the palm. The dense palmar fascia above, presenting a barrier to the 
exit of the pus, favors its spread along the tendons. 
Permanent contraction of fingers after 
palmar abscess. 
If the pressure be not relieved and an exit given to the pus, it may 
extend between the bones of the hand to the dorsal surface, or it 
usually finds its way under the annular ligament into the wrist, and 
frequently involves the muscles of the forearm. The pain and tension 
are always very great, while redness and inflammatory swelling are not 
pronounced symptoms because of the deep location of the suppuration. 
There is always, however, a characteristic oedematous swelling of the 
whole hand, which is described as a porky or boggy swelling. The fingers 
are stiff and held partially flexed. Fluctuation may or may not be 
obtained, but the other symptoms as described, of an acute nature, are 
sufficient to establish a positive diagnosis. There are usually considerable 
constitutional disturbance, temperature, anorexia, etc. 
Nowhere is an early operation of greater importance, and neglect leads 
frequently to the loss of function or complete loss of the hand. Surgi- MUSCLES, TENDONS, TENDON-SHEATHS, ETC. 
509 
cal anaesthesia is necessary for the operation. Incisions in the fingers and 
in the palm should be made parallel to the axis of the bone. Short, 
deep incisions are the rule, in order that the vessels may be more readily 
avoided. The palmar arch crosses the hand nearly opposite the web of 
Fig. 207. 
Diagram of palmar incisions. 
the thumb, and if incisions are made beyond this, no difficulty will be 
met with. It is better to avoid cutting the arch, but if cut it should be 
ligated. If the inflammation has spread extensively, the sinuses should be 
Fig. 208. 
Diagram of dorsal incisions. 
followed out and several short counter-openings made to secure thorough 
drainage. After prolonged irrigation with a hot antiseptic solution 
narrow strips of iodoform gauze should be inserted into each opening. 
The after-treatment should consist of a prolonged hot antiseptic bath daily in 
a vessel capable of admitting the whole hand and forearm. Large antiseptic 
poultices applied clear to the elbow should be changed frequently enough to keep 
them hot, and the arm should be raised on a pillow. Careful attention should be 
paid to the general condition of the patient, and stimulants and quinine adminis- 
tered as required. In very acute types of the inflammation it may sometimes be 
necessary to make a number of long parallel incisions, regardless of all anatomical 
structures, and even to cut the annular ligament. Permanent contractures of the 
fingers result, due to adhesions between the tendons and to cicatricial formations. 
Manipulation and massage, continued for a long time after recovery, aid somewhat 
in reducing the contractions. 
Ganglion.—In connection with the tendon-sheaths of the forearm 
and hand there occurs a small, rounded, elastic swelling which is known 
as a ganglion. It was first thought to be a localized dropsy of the 
tendon-sheath; hence as such it received the name of weeping sinew. 
Recently ganglia have been classed with the hygromata of the tendon- 
sheaths and bursae, and now are believed to be outgrowths from the syno- 510 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
vial fringe or follicle of joints, occasionally from the tendon-sheaths, and 
are regarded as a kind of new growth. The fluid which they contain is 
a sort of thickened synovial fluid, and usually does not communicate with 
the fluid of the tendon-sheath or joint. Another theory is that the gan- 
glion is a hernia of synovial membrane, occurring through a rent in the 
tendon-sheath, forming a closed sac. 
Ganglion is most common on the dorsum of the hand, but may occur 
on the foot or on the flexor tendons of the forearm. It is a small, oval, 
fluctuating tumor, causing no pain and very little inconvenience, except 
that there is slight pain when the arm is fatigued. 
Fig. 209. 
Ganglion of wrist. 
Treatment.—This is by rupture of the sac by pressure or treatment 
of the sac by operation. Where the ganglion is small the time-honored 
method of rupture of the sac by a blow from the back of a book may be 
tried. A simpler method is to superimpose the thumb over the tumor 
and by sudden pressure to rupture the sac. A splint and pad-pressure 
should be kept applied for ten days to a fortnight. A cure by forcibly 
rupturing the sac is not certain, but the method has the advantage of not 
injuring the patient. The treatment of the sac by operation may be carried 
out in several ways—by aspiration with a fine, hollow needle, with or 
without the injection of an emulsion of iodoform. In the larger tumors 
and in those where the simple methods of cure have failed the very sat- 
isfactory operation of excision of the sac by dissection may be done. In 
all of these methods it is necessary to apply a splint and pressure to 
the part in the after-treatment. 
Affections of the Bursje. 
The bursae are anatomical structures interposed between moving tissues to 
prevent friction, as in the case of skin or tendon over projecting bony surfaces. 
They are divided into two classes—the bursae mucosae and the synovial 
bursae. The bursae mucosae are simple enclosed sacs containing a clear, viscid 
fluid, situated in the subcutaneous areolar tissue in various parts of the body, as 
in front of the patella over the olecranon process, over both malleoli, and in other 
prominent places. These are also known as subcutaneous bursae. The synovial 
bursae are cavities of practically the same nature and structure found interposed 
between muscles and tendons where they move over bony prominences. They are 
similar to synovial membranes, and where they exist in the neighborhood of a 
joint they usually communicate with its cavity. Many bursae are present in the 
body at birth, but new ones are developed in consequence of friction or pressure 
occurring in unusual places. As the result of injury, pressure, excessive action, MUSCLES, TENDONS, TEND ON-SHEA TJIS, ETC. 
511 
and various diseased conditions, as tuberculosis and syphilis, bursae become 
enlarged, thickened, and at times suppurate. 
Acute bursitis is due ordinarily to external traumatism or excessive 
muscular exertion. It is an acute hypersemia of the bursal sac, giving 
rise to increased secretions which may be either serous, serofibrinous, or 
purulent. It gives rise to a superficial, rounded, more or less prominent 
fluctuating tumor. 
If the inflammation is not of a purulent nature, the symptoms are 
slight and are the result of physical discomfort from the presence of the 
swelling. When the bursitis results from a blow, the swelling comes 
on rapidly, with pain and tenderness, and there may be considerable 
blood poured with the eflusion into the sac, causing so-called hsematoma 
of bursae. When the inflammation is suppurative, which occurs only 
from infection, there are rapid swelling, redness, tenderness, and pain, 
with often considerable constitutional disturbance. Unless promptly 
arrested there is danger of extension to the surrounding tissues and the 
joint may be invaded. The location, extent, and shape of the swelling 
are sufficient to distinguish the disease from ordinary cellulitis. 
The general treatment is rest to the part, uniform pressure, and 
cold applications, together with aspiration if the effusion and swelling 
do not diminish. If pus is present, the sac should be freely laid open, 
curetted out, and packed to secure obliteration of the cavity by granula- 
tion healing. 
Chronic bursitis is not the mere continuation of the acute variety 
of the disease until it becomes chronic, but it is a distinct type of the 
disease which is known as hydrops or hygroma. It occurs usually as 
a painless, fluctuating swelling of slowly increasing size, with thickened 
walls due to a growth of villous or granulation-tissue, and containing a 
thick mucoid liquid. This villous growth at times undergoes a fibrin- 
oid degeneration, the degenerated portions breaking loose, giving rise 
to the rice-bodies which are found in chronically enlarged bursae. The 
number of these small bodies is often very large; as many as several 
hundred may be found in one sac. The whole process, in many 
instances at least, is essentially a tuberculosis, and in the rice-bodies are 
found tubercle bacilli. ( Vide Chapter XXXIII.) 
Hygromata of the bursce are said to be caused by growths of cartilage 
and by sarcomatous tissue. Chronic bursitis is often due to injury or 
mechanical irritation, and in rare cases it is ascribed to rheumatism or 
syphilis. There are many cases of tubercular disease of the synovial 
bursae which are secondary to a tuberculosis of a neighboring joint, and 
which on that account fail of recognition. It is of special importance 
that they be not overlooked in operations upon the joints. 
The diagnosis rests mainly upon the nature of the swelling, the 
slow chronic course of the disease, and the location of the trouble. In 
many instances when it occurs at the wrist-joint it cannot be distin- 
guished, except by operation, from chronic disease of the tendon-sheath. 
Occasionally the rice-bodies may be felt like small shot in the sac. 
Treatment other than operative is merely temporizing with the 
trouble, although there may occur instances in which rest of the part 
on a splint, with application of moderate pressure and counter-irritants, 
may be advisable at first and may result in temporary improvement. 512 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
The operation consists in incising the sac, evacuating its contents, 
thoroughly curetting out the interior, and irrigating with a 1: 1000 
corrosive-sublimate solution. If practicable, it is better to dissect out 
the sac. Packing with iodoform gauze secures permanent closure of the 
cavity by granulation. Over the hyoid bone a cystic tumor of a size 
requiring removal is rarely met with; it is a chronically enlarged bursa 
of the hygroma type. 
Simple Enlarged Bursae.—There are a number of bursae which are 
often enlarged. Several of them are of sufficient importance and fre- 
Fig. 210. 
Fig. 211. 
Enlarged prepatellar bursa (house- 
maid’s knee). 
Bunion in hallux valgus. 
quent occurrence to receive distinguishing names. Enlargement of the 
prepatellar bursa, commonly known as housemaid’s knee, is the most 
common form of enlarged bursa. It occurs as a prominent fluctuating 
swelling directly over the patella, painless unless inflamed, and is 
caused by the pressure incident to kneeling. It sometimes occurs in 
both knees at the same time, and its appearance is very striking and 
perfectly characteristic. It should be treated by aspiration followed by 
rest and pressure. When inflamed it must be incised. 
A bursa over the anterior aspect of the upper end of the tibia, 
between the patellar tendon and the tubercle of the tibia, is sometimes 
enlarged, and may be mistaken for synovitis of the joint. It may 
communicate with the joint and must be aspirated with care. A bursa 
over the tip of the olecranon process corresponds to housemaid’s knee, 
and is known as miner’s elbow from its frequency in that class of work- 
men. A subpatellar bursa has recently been described as occurring in 
football-players, supposed to arise from excessive exercise in kicking. 
Bursa) in the popliteal space beneath the tendons have been mistaken 
for aneurism as well as intra-articular disease. They are also likely to 513 
MUSCLES, TENDONS, TENDON-SHEATHS, ETC. 
communicate with the joint, and must be operated upon with caution. 
There is a deep bursa beneath the deltoid muscle which causes pain, 
swelling, and crepitation on motion when inflamed. A bursa under the 
tendo Achilles over the tuberosity of the os calcis causes pain and lame- 
ness when inflamed. A bursa occurring under the psoas tendon, 
between it and the edge of the pelvis, may communicate with the hip- 
joint ; also one between the great trochanter and the gluteus maximus is 
sometimes seen : both of these when enlarged and inflamed give rise to 
symptoms which simulate hip disease in its early stages. Enlarged 
bursae are also seen once in a great while in various other parts of the 
body; for example, over the tuberosity of the ischium, between the latis- 
simus dorsi and the angle of the scapula, in the palm, and in the calf of 
the leg. 
As a general rule, there should be but little difficulty in distinguish- 
ing bursae, but when they lie in close proximity to a joint, the diagnosis 
may occasionally be quite obscure and can be made only by careful dif- 
ferentiation. 
Bursae of New Formation.—The number of normal bursae in the 
body is very large, and is not by any means constant, even in healthy 
adults. As many as eighteen have been found in the vicinity of the 
knee-joint and fifteen in the dorsum of the hand. New bursce develop 
in locations where the tissues are subjected to constant pressure or fric- 
tion, usually over bone-prominences. They are formed in the soft con- 
nective tissue between the skin and underlying tissue, beginning at first 
as small, irregular cavities with a lining of atrophied connective-tissue 
fibres. The space develops slowly in size until finally it has a complete 
sac with a smooth-walled endothelial lining. Bursse are seen in various 
places on the body-—on the outer side of a club-foot, where the pressure 
is borne in walking; over the projecting spines of the kyphosis of a 
spinal caries ; on the ends of stumps after amputation when an apparatus 
has been worn. All of these are liable to become inflamed and cause 
serious inconvenience. A bursa forms over the sternum in shoemakers; 
over the head of the fibula in tailors, constituting tailor's ankle, from 
pressure caused by sitting on the floor with the legs crossed in front. A 
bursse forms over the first metatarsal bone in the deformity known as 
hallux valgus. This latter bursal tumor is commonly known as bunion, 
and always occurs as the result of wearing tight, improperly fitting, or 
improperly made shoes. It may be caused by the shoe being too loose, 
allowing the foot to slip back and forth, or more frequently it is due to 
a narrow-toed shoe causing the tip of the great toe to bend toward the 
outer side of the foot, thus bringing unusual pressure on the joint. A 
mild degree of bunion is present in many people who suffer very little 
inconvenience. There is usually slight tenderness in the part, and the 
swelling is quite likely to become acutely inflamed, in which case the 
skin becomes much reddened; there is constant pain with excessive 
tenderness, walking is very difficult, and it is impossible to wear a boot 
of any kind. Suppuration takes place in the bursa, which, breaking 
through the sac, invades the joint and other tissues and often starts up 
a cellulitis in the foot. Persons having bunions should not wear nar- 
row-toed shoes, but shoes with broad, rounded toes and a straight 
inner border. 514 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
Bunions which are slightly inflamed and in which there is some pain and dis- 
comfort are relieved until the acute symptoms have passed off and the inflamma- 
tion has subsided by wearing over the part a small, circular felt pad cut out in the 
shape of a washer. The pressure of the shoe comes against the pad, which sur- 
rounds the sensitive area. If the bursa is thickened and not inflamed, blisters and 
iodine may be applied to reduce its size. When the bursa is inflamed rest and 
cooling applications are indicated and may prevent serious trouble. Suppuration 
demands incision and antiseptic treatment, and if the joint is invaded partial or 
complete excision of the joint will be required. The removal of a bursa before 
any inflammation has occurred is the best treatment, and frequently it is necessary 
to combine with its removal a resection of the underlying joint. 
Tumors of Muscles.—Primary tumors of muscles are of compara- 
tively rare occurrence, and when found are treated as elsewhere. They 
may be located in the muscle itself or in its tendon. Aside from those 
of syphilitic or tubercular origin, which have already been spoken of, 
those of sarcomatous type are the most common, while fibrous myxoma 
and enchondroma are occasionally seen. Secondary infiltration or de- 
posit in the muscles is common when the growth originates in a neigh- 
boring part. This often occurs in the pectoral muscles from cancer of 
the breast. Primary tumors of muscles can be readily removed, and 
their recurrence depends on their malignancy. Secondary tumors should 
be operated on as a palliative measure. 
Parasitic cysts of muscles are rare. The trichina spiralis, the 
echinococcus, and the cysticercus are the three varieties of animal para- 
sites which occasionally occur in muscles. 
Trichinosis originates from eating underdone pork which contains the 
trichinae spiralis. These parasites develop in the intestines, penetrate the walls, 
and enter the circulation, or by a direct passage find their way into the muscles, 
where they remain. By their presence a myositis develops, resulting in exudation, 
which becomes encapsulated and forms a permanent cyst. 
The symptoms are pronounced: there is a muscular stiffness, with pain, swell- 
ing, and tenderness. The constitutional symptoms are high temperature, chills, 
delirium, and gastro-intestinal disturbance. The mortality is high, but undoubt- 
edly many mild cases recover. 
The diagnosis is confirmed only after abstracting a piece of the muscle with 
a small punch and subjecting it to a microscopical examination. 
The treatment consists of the employment of purgatives ; sedatives, ample 
nourishment, and stimulants are required. 
The echinococcus, or hydatid, and the cysticercus are seen even less 
frequently than the trichinae, which they closely resemble in character. 
They result from infection by taenia through the intestinal tract. Their 
presence in the tissues through irritation results in the formation of 
cysts. These parasites are not confined to muscles, but are found in 
any tissue or organ of the body. 
Tenotomy and Myotomy. 
These should be recognized as important surgical operations, as upon 
them depend largely the correction and removal of many deformities. 
They form a considerable proportion of the operative surgery of ortho- 
paedics, but are frequently very useful to the general surgeon. Myotomy 
and tenotomy will be treated as one subject, because the method of ope- 
rating is essentially the same. It is always advisable to cut the tendon 
when possible, and only in instances where the muscle has no tendon 
or the tendon is too short is the muscle itself divided. Tenotomy is MUSCLES, TENDONS, TENDON-SHEATHS, ETC. 
515 
indicated in all cases where there is permanent contraction or shorten- 
ing in a muscle or fascia, resulting in deformity which interferes with 
the usefulness or beauty of the part. In fractures occurring in the 
neighborhood of a joint persistent muscular spasm may interfere with 
maintenance of apposition of the fragments. This may readily be 
overcome by subcutaneous tenotomy. This is often true of the tendo 
Achilles in fractures about the ankle-joint. There are two ways of per- 
forming tenotomy—one by an open incision, the other subcutaneously. 
In general, it may be said that the open operation is desirable in 
dangerous localities and where there are several tendons to be cut, as in 
the case of contraction at the wrist-joint. The advantages in favor of 
subcutaneous tenotomy are its simplicity, greater rapidity in securing 
firm union, and minimum danger from infection by the small puncture. 
The operation of subcutaneous tenotomy is easily done, and there is little 
danger if a thorough knowledge of anatomy is possessed by the ope- 
rator, in order that important vessels and nerves may be avoided. The 
only instruments needed are two delicate knives, known as tenotomes, 
with straight blades about a half inch in length and an eighth of an 
inch broad—one sharp-pointed, the other blunt. Longer blades are 
unnecessary, except in rare instances where a muscle is to be divided. 
The curved tenotomy knives, while theoretically applicable to the curved 
surface of the tendon, are, in the experience of the writer, never neces- 
sary. The sharp-pointed instrument should be introduced through the 
skin near the tendon, and above or below it according as one desires to 
cut in or out. By cutting the tendon outward the skin is more likely to 
be punctured, while by cutting downward there is more danger of injur- 
ing adjacent and underlying structures. 
In the hands of skilful men, accustomed to the performance of tenotomy, the 
sharp-pointed instrument, which is designed merely to prepare the way for the 
blunt tenotome, is often used to divide the tendon. It is safer, however, to use the 
blunt instrument for this purpose, especially in the neighborhood of important 
structures. As the tendon is divided a creaking sensation is felt and the tendon 
gives way with a distinct snap. A common source of failure in this operation is 
due to the incomplete division of the tendon or its sheath. After the withdrawal 
of the knife the blood should be expressed from the wound and a simple antiseptic 
cb-essing applied for a few days. The technique of the particular operations for 
the various deformities requiring tenotomy will be found under their several 
headings. 
The open division of tendons is to be preferred in many cases : with 
the limb rendered bloodless and a clean incision over the tendon which 
is to be divided, it is very satisfactory to simply snip the tendon, with 
its sheath, with a pair of blunt scissors; no unnecessary damage is done 
to the surrounding parts, the divided skin is easily adjusted by a few 
sutures, and the wound is dressed antiseptically. 
Lengthening- of Tendons.—In certain cases where the contracted 
tendon is to be divided it may be advisable to lengthen it a certain def- 
inite amount. This may be done, as illustrated, by an incision along 
the middle of the tendon, which should be one-lialf as long as the 
required distanoe. The tendon is then cut through at either end of the 
middle incision and the ends sutured together. Another method of 
lengthening, especially applicable to old cut tendons where the ends are 
retracted and cannot be brought into apposition, is by splitting off a por- 516 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
tion of one or both ends of the cut tendon, turning it down, and suturing 
together the ends thus split off. 
Fig. 212. 
Showing methods (a) and (b) of lengthening tendons. 
Transplantation of muscles and tendons, in the absence or loss of 
Fig. 213. 
Illustrating transplantation of tendons in paralytic valgus (case of Dr. J. E. Goldthwait): A, before 
operation, with patient standing naturally, bearing weight on both feet; B, after operation, 
showing patient standing and bearing all of weight on left foot. 
tissue, has been proposed, and experiments have been made on animals MUSCLES, TENDONS, TENDON-SHEATHS, ETC. 
517 
with this end in view. It has been shown that such implanted tissue 
always becomes absorbed, but it is possible that such tissue may assist 
and hasten regenerative changes. Gluck has inserted strands of catgut 
to replace the loss of muscle, of tendon, and of nerve-tissue, with partial 
success. 
Dr. J. E. Goldthwait of Boston has recently suggested a new method 
of tendon transplantation or grafting, and several cases have been 
operated upon and reported by him. It is made use of in the treatment 
of some cases of infantile paralysis for the purpose of furnishing better 
mechanical support to certain partially paralyzed groups of muscles. 
The method consists of cutting the tendons of certain muscles and 
attaching them to others, and thus transferring the action of the muscles 
to other more important tendons. From the few cases which have 
already been operated upon the writer believes this to be a surgical 
procedure of considerable promise in the treatment of deformities 
resulting from infantile paralysis. CHAPTER XXX. 
INJURIES AND DISEASES OF THE LYMPHATIC VESSELS 
AND NODES. 
Frederic Henry Gerrish, M. D. 
The distribution of lymphatic structures is so extensive that, whatever a 
morbid process is or wherever it exists, it is almost sure to involve some of them. 
Although not commonly so regarded, the spaces enclosed by the great serous mem- 
branes are only prodigiously expanded areolm or lymph-spaces, and the deep layer 
of many mucous membranes is composed of essentially the same material as that 
which constitutes the most typical node, only in the one case it is diffused, and in 
the other gathered into a definite mass. Certain viscera are often included in the 
enumeration of the organs of the lymphatic system on account of the conspicu- 
ousness of characteristic elements in their structure. But this chapter wrill deal 
only with the affections of the lymphatic system in general, and with the most of 
those in which the principal feature is the involvement of lymphatic vessels or 
nodes, or both. 
It may not be amiss to call attention to the important part played by the lym- 
phatic system in many conditions of disease. Nearly everywhere there are minute 
spaces between the histological elements of which the tissues are built. These 
irregular, microscopic, and innumerable crannies are the beginnings of streams 
which flow unceasingly toward the central ends of the great veins which empty 
into the right heart: they are the finest rootlets of the great trees wdiose branchless 
trunks are the thoracic and the right lymphatic ducts. Some of these tiny spaces 
are exposed on every surface which is artificially made either by accidental or 
intentional wounds, and in such circumstances afford the best possible opportunity 
for the introduction of pathogenic micro-organisms into the system. But a breach 
of integument is not absolutely necessary for the admission of the germs of a 
disease, for lymph-spaces are so near the cutaneous and mucous surfaces that pro- 
longed contact, and especially contact with pressure, is often sufficient to effect the 
penetration of the intervening layers by the microbes and ensure their entrance 
into the lymphatic system. Thus, septic poisoning may come from immersion of the 
unwounded hands in the fluids of a cadaver at a necropsy, and syphilis may be con- 
tracted by the mere touch of the discharge from an initial lesion upon a moist and 
delicate part of the unbroken skin. While it is important, therefore, that we should 
search for an opening at the periphery of the set of lymphatic vessels which drains 
into the node or group of nodes whose involvement is a feature of the malady 
which we are investigating, we cannot always find evidences of even the slightest 
injury. To be adequately equipped for the study of lymphatic diseases one needs 
a high degree of familiarity with the anatomical relations of the vessels and the 
nodes to which they are tributary. 
Wounds of Lymphatic Vessels. 
Probably every cut into the tissues beneath the epithelial surfaces 
lays open minute lymph-vessels, and in amputations tubes of consider- 
able size are always severed. But almost never does any trouble ensue 
from such injuries alone. If a superficial vessel does persist in leaking 
through a wound, a delicate touch with a mild caustic and firm com- 
518 INJURIES AND DISEASES OF THE LYMPHATIC VESSELS, ETC. 
519 
pression with pad and bandage will usually speedily end the trouble. 
But when a great trunk is incised or otherwise opened, the surgeon has 
to deal with a lesion of the gravest kind. The thoracic duct is so deeply 
located that it is very seldom wounded, but when it is punctured the 
very inaccessibility which is ordinarily its protection interferes with, 
though it may not absolutely prohibit, direct treatment. Its contents 
escape into the whole surrounding region, causing chylous hydrothorax or 
chylous ascites, or both, or the fluid may distend the areolar tissue outside 
of the pleura and peritoneum or fill up the mediastinum. 
Possibly a cure may be effected by an abdominal section with drainage, 
adhesion of the lips of the duct resulting from the irritation occasioned 
by the necessary manipulations during the operation and by the presence 
of the drainage-tube. Suture of the opening in the thoracic duct seems 
not to have been attempted in the abdominal region, but it has been tried 
with success in the case of wounds close to its central extremity at the 
base of the neck. In this locality forcipressure and compression with a 
pad of gauze have yielded good results. 
Wounds of the right lymphatic duct are far less serious than those of 
the larger trunk, and, from its readier accessibility, are much more 
amenable to treatment. 
In conjunction with the means already recommended, and also when they can- 
not be employed, it is advisable to keep the patient perfectly quiet and on the 
lowest diet compatible with living. Fluid food shoidd be avoided as far as prac- 
ticable, with a view to preventing distention of the injured vessel. Death, which 
may be long delayed, will probably result from inanition, but a fatal result is not 
inevitable, a number of spontaneous recoveries having been reported. 
Inflammation of Lymphatic Vessels. 
Lymphangitis, as this disease is technically called, need not be de- 
scribed under several different heads, as has usually been the case, for we 
now know that all inflammation of lymph-vessels is of microbic origin, 
and may therefore drop the terms “ idiopathic ” and “ traumatic ” as 
being no longer descriptive. Lymphangitis is almost always secondary 
to some traumatism, but it may depend upon the passage of septic mat- 
ter through the unbroken integument. It may be induced by various 
micro-organisms. At first a thrombus is formed in a vessel; then pus- 
cells are seen in the walls, the epithelium is swollen or peeled off, the 
lymph is thick with desquamated cells and fibrinous clots, leucocytes 
and exuded lymph surround the tube, and the neighboring structures 
are inflamed. In tubercular inflammation characteristic deposits occupy 
the lumen. The process may terminate in complete resolution or abscess 
or occlusion. The related nodes are usually implicated. 
When only the minute vessels which form a fine network near the 
surface are involved the inflammation is called reticular ; when only the 
larger collecting vessels are concerned it is called tubular ; but both forms 
may coexist. 
The diagnosis of deep lymphangitis, where no superficial inflamma- 
tion is present, is not always easy; indeed, it is usually very difficult at 
first on account of the distance of the affected vessels from the surface. 
Clinically, we observe in mild cases of the tubular variety faint red 
lines in the skin coursing up the limb, which are felt to mark the location 520 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
of beaded cords. From these a bluish tint diffuses laterally, and the 
nodes soon become swollen and tender. Little pain is experienced if 
entire quiet is maintained. In severe cases all these symptoms are aggra- 
vated. Pain is acute, fever is high, oedema is marked, and in some sit- 
uations is very perilous. Later on pus forms in the nodes and areolar 
tissue, and in the worst cases there occur rigors, excessive thirst, difflu- 
ent abscesses in distant parts, restlessness, delirium, and death from sep- 
ticaemia. The termination of a case depends upon the nature and amount 
of the toxic material introduced, the condition of the patient, and the 
promptness and wisdom of the treatment. 
In the reticular form the inflammation shows itself in red, tender, 
cedematous patches, which may succeed each other up the limb, one fad- 
ing as a neighboring area blooms out. It is to be remembered that the 
inflammation of a vessel, superficial or deep, does not always pursue a 
course from periphery to centre : it sometimes works back in the opposite 
direction. 
Treatment must be both local and general. If there is a wound, 
thorough disinfection of it must be effected at once. Irrigation with an 
antiseptic wash may accomplish this, but if this is doubtful the wound 
should be laid open to give opportunity for perfect cleansing of the parts. 
For a surface application a hot antiseptic pack is best in the early stages ; 
for example, a corrosive-sublimate solution, 1 : 2000. A blister around 
the limb at a level proximal to the disease was much esteemed formerly 
—i. e. fighting fire with fire. If pus forms or is suspected, incise freely 
and let it out. Meantime the systemic condition must be regarded, the 
bowels and kidneys kept active, pain checked with anodynes, and the 
strength held up with easily digested food and other supportives. 
A considerable number of the most serious affections of the lymphatic 
system are caused by interference with the normal flow of lymph ; and, as 
many of these diseases have features in common, it will be well first to 
study the general subject, and then to consider in detail the specific 
manifestations, varying as they do according to their etiology, their 
situation, the size of the vessel involved, and the kind of tissues con- 
cerned. 
Occlusion of Lymph-vessels. 
Various conditions occasion occlusion, as thickening of the walls of the vessels 
from inflammation, the deposit of plastic material about the tube, the pressure of 
neighboring tumors, the presence of a morbid growth within the lymphatic, or the 
lodgement of a parasite in its lumen. Anything which arrests the current dams 
back the lymph upon the region which the vessel normally drains, unless the fluid 
can escape by some side channel; and this interference results usually in one or 
both of two principal changes. The first of these is dilatation of the vessels from 
the increased pressure of lymph within, and the other is saturation of the tissues 
on the distal side of the obstruction with lymph, and their consequent hyperplasia 
from over-nutrition. 
Dilatation maybe displayed over a minute area or in the vessels of an 
entire limb—there may result small vesicles or large cystic tumors; it 
may affect deep structures or superficial; its effect on health varies from 
the inappreciable to the destructive; and its amenability to treatment 
ranges between the facile and the hopeless. If the case is one of pure 
dilatation, the vessel assumes a beaded appearance when the valves hold, INJURIES AND DISEASES OF THE LYMPHATIC VESSELS, ETC. 
521 
and a cylindrical when they do not. The latter variety readily changes into 
the cystic when the inward pressure is concentrated upon a limited area, 
and causes a bulging of a part or the whole of the circumference. When 
a cluster of dilated vessels lie in contact, increasing pressure may cause 
such atrophy of their contiguous walls that ultimately perforations occur, 
and the mass of tubes becomes a sac with imperfect septa which are the 
remnants of the vessel-walls. Inflammation of a dilated vessel is a 
much more serious matter than the same process in normal conditions. 
The hyperplasia resulting from the constant overfeeding of the parts, 
which are flooded with lymph in cases of occlusion, is not observed in 
all of the tissues; but the white fibrous—the classical “ connective-tissue 
proper/’ the material which nature uses so largely in reparative pro- 
cesses and which is produced so readily—gluttonously appropriates as 
much as it can of the excess of nourishing material, and, having a 
greater capacity for growth than its neighbors, crowds them to such an 
extent by its augmented bulk that they are not able to take even their 
wonted quantity of aliment. As a consequence they suffer atrophy, 
while it undergoes hypertrophy. It is a case where the greedy avarice 
of the rapidly-breeding plebeian starves out the refined and sensitive, 
but necessary, patrician, with the usual result of fatal disaster to the 
community. 
Lymphangioma (vide Chapter XXVI., Group VI.) is a tumor of 
which the essential constituent is dilated lymphatic vessels. As a rule, 
it is congenital. It occurs most frequently on the neck, buttocks, back 
of thigh, groin, axilla, forehead, and in the mouth. It is painless, soft, 
and compressible. As the size of the tumor increases by further dila- 
tation of the vessels the connective tissue between them atrophies and 
disappears, and then the vessel-walls are thinned, and, to a greater or 
less extent, absorbed, so that free communication is established between 
the various tubes, and a lymphatic cyst is formed. Sometimes a con- 
tiguous blood-vessel is invaded by the same process, and, the contents 
of the two kinds of vessels being mingled, we have a hcemato-lymphan- 
qioma—that is, a tumor composed of blood-vessels and lymph-vessels. 
The so-called cystic hygroma of the neck is a cavernous lymphangioma. 
It occurs just beneath the occiput, is smooth, and is marked by a verti- 
cal median groove. Another variety of lymphangioma is lymph-varix. 
When this occurs as a superficial growth its favorite sites are the penis 
and the groin. It is often only a temporary formation, disappearing 
with the removal of the obstruction which has caused it. The deep 
varices are much more serious. They commonly occupy inaccessible 
positions in the abdomen. In the advanced stages they may be mistaken 
for hernise. 
Structurally considered, all the varieties of lymphangioma are benign 
growths, but in certain circumstances their presence may be a menace to 
life. Tlie continuous internal pressure to which their walls are sub- 
jected sometimes occasions spontaneous perforations, and the accidental 
application of external violence may produce the same effect. The 
leakage of lymph through such apertures is often enormous, and, while 
cases have been reported in which great loss of this fluid has been en- 
Lymphangioma . 522 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
dured without serious impairment of health, there is danger of the 
establishment of grave anaemia. A moderate but persistent discharge 
is called lymphorrhoea ; a large and continuous one, lymphorrhagia. 
Treatment of superficial varices should be directed to the removal 
of the cause if possible. The deep varices should be studiously let 
alone, for they cannot be wholly removed, and if wounded leak most 
alarmingly. Other lymphangiomata should be removed with absolute 
thoroughness if subjected to any treatment. 
Lymphcedema. 
Interference with the normal passage of lymph often results in its 
transudation in large quantity into the areolar tissue. This condition is 
called lymphcedema or solid oedema. It is distinguishable from the 
<edema which results from venous obstruction by its extreme density 
and persistence. Areolar tissue is so almost universally a constituent 
of the soft parts that lvmphoedema may affect a whole limb, which then 
becomes brawny, inflexible, and enormously swollen. If this condition 
exists a long time, permanent enlargement ensues from the growth of 
white fibrous tissue, and the part becomes not only useless, but an intol- 
erable burden. 
The treatment should aim to remove the obstructing cause, if 
practicable. If this cannot be done, firm, equable compression with an 
elastic bandage should be applied. This failing, nothing remains 
to be done short of removal of the affected part. Amputation-flaps 
may heal promptly, even though lymph oozes profusely from their cut 
surfaces at the operation. 
Sometimes we see cases in which there is no typical lymphangioma, 
varix, oedema, or lymphorrhoea, but 
for which we can account only on the 
ground of occlusion of lymph-chan- 
nels, as there is a monstrous growth 
of one or more members, obviously 
from such excessive nutrition as is a 
characteristic feature of this obstruc- 
tion. This condition is known as 
macromelia, but special names are used 
for the designation of the disease in 
different parts, as macrodactylia, mac- 
ropodia, macroglosgia, and macrocheilia, 
wherein the digits, the foot, the tongue, 
and the lips are respectively affected 
(see Fig. 166). 
The patient shown in Fig. 215 was 
affected in two fingers of one hand 
and three of the other, and in one leg, 
the part of the limb most overgrown 
being the great toe. 
The cause of the disease is un- 
known, and the only satisfactory treat- 
Macromelia. 
Fig. 214. 
Macroglossia (Neisser , INJURIES AND DISEASES OF THE LYMPHATIC VESSELS, ETC. 
523 
ment is amputation. (Vide also Chapter I., Tissue-Alterations due to 
Change in Nutrition.) 
Fig. 215. 
Macromelia (original). 
Chylocele. 
This disease resembles ordinary hydrocele in all of its clinical aspects 
with a single exception, which is rarely, if ever, recognized before 
operation. The fluid contents, instead of being clear, are milky, and 
failure to find translucency in a case supposed to be one of hydrocele 
should excite suspicion of chylocele. 
A positive diagnosis, however, can hardly be made, as the rare 
disease, spermatocele, presents a non-translucency with the candle-test. 
The fluid in chylocele is milky, and if allowed to stand cream rises to 
the surface. The lining of the sac may exhibit distended lymph-vessels, 
or at some point the mouths of several large channels connected with 
spaces of areolar tissue. Apparently the disease is due to an obstruction 
on the proximal side of some lacteal, but the pathology is not clear. 
Further observation may show this to be of filarial origin. 
Treatment for hydrocele is generally that appropriate for chylocele ; 
but in cases where milder means fail it will be well to lay open the 
vaginal tunic and ligate the enlarged and leaking vessels. 
Filariasis. 
Most prominent among the causes of serious obstruction of lymph- 
channels stands filariasis. The diseases which it induces are uncommon 524 
AFFECTIONS OF THE TISSUES ANI) TISSUE-SYSTEMS. 
in this country, but it lias already obtained a foothold in some of our 
Southern States, and the possibility of its wide dissemination gives a 
peculiar interest to the study of its history and manifestations. 
It is essentially a parasitic condition. In a typical case of filariasis 
the blood contains a multitude of worms of the nematoid class of the 
variety called filaria sanguinis hominis—the thread-like worm of the 
blood of man. The creature is sexless, one-eightieth of an inch long, 
not quite as wide as a colored corpuscle of the blood, and wriggles 
incessantly like a snake. 
The worm appears to be enveloped in a filmy, transparent sheath, within which 
the body is alternately extended and retracted with great rapidity, so that the 
impression is produced of the animal’s being furnished with a lash. This action 
does not cause locomotion, but makes little currents in the blood, by which the 
recognition of the parasite is facilitated. Many millions of these microscopic 
beings may exist in one patient. A most peculiar characteristic is their alternate 
presence in and absence from the blood. During the daytime the blood is free 
from them, but as night approaches they begin to appear, their numbers rapidly 
increase, and by midnight the blood swarms with them. From this hour they 
gradually disappear, and few, if any, can be discovered after six o’clock in the 
morning. Habitual reversal of the periods of waking and sleeping determines a 
corresponding change in the time of appearance of the parasites, and fever inter- 
rupts the regularity of their manifestations. The cause of the periodicity of their 
migrations is not known. 
These creatures are the embryos of a worm, the filaria Bancrofti, which lias 
lodged in a lymph-vessel. The male of the species is probably a close companion 
of the female. The latter is about three and a half inches long and one-ninetieth 
of an inch thick. It has a smooth body, a clubbed head, a slender neck, and a 
blunt tail. Its alimentary canal extends from the head nearly to the tail, but the 
greater part of the body is occupied by a bicornous womb which is crammed with 
embryos. The animal is viviparous, and its young, being borne into a lymph- 
channel, are carried by the current through the thoracic duct into the blood- 
vascular system. 
The method by which filarise are propagated is of practical interest. A female 
mosquito abstracts from a person who has filarial disease a meal of blood in which 
are many of these embryos. Several days are consumed in the digestive process, 
but a small proportion of the parasites not only escape destruction, but even 
undergo some development. The insect, led by instinct to deposit her eggs on the 
surface of some pool, ends her brief life by falling into the water, and the tenants 
of her frail body emerge into a medium exactly suited to their needs. In this they 
may attain a length of half an inch. If now they are swallowed by a human 
being whose thirst for water exceeds his discretion in the selection of it, they work 
their way, probably by boring through the intermediate structures, from the ali- 
mentary canal to some large lymph-vessel, in which they find the environment 
best adapted .to their comfort. They then steer against the current of lymph, and 
continue until they enter a vessel too small to permit further passage. Here a 
permanent lodgement is effected, and the creatures grow, develop, and breed in 
their snug quarters for years, setting up serious structural changes in the neigh- 
boring parts by the irritation of their presence. 
Several mature worms have been discovered in a single case. It is imaginable, 
however, that one of these helminths could produce pathological results of the 
gravest sort. While it is unquestionable that nearly all cases of the various dis- 
eases which are called filarial are really inaugurated by these parasites, it is pos- 
sible, on the one hand, that some other equally obstructive agency may produce 
identical results, and, on the other hand, it is known that filariasis may exist for a 
long time without serious interference with health. Both of these occurrences are, 
however, exceptions to a very general rule. 
No evil results are to be expected from the mere presence of the 
embryos in the blood, but the parents are terribly mischievous in their 
effects. Hypersemia, organization, and consequent stenosis, of the invaded INJURIES AND DISEASES OF THE LYMPHATIC VESSELS, ETC. 
525 
vessel are soon occasioned; the lymph is dammed back, the tube dilates, 
the walls burst or become hypertrophied, the whole region which was 
formerly drained by the occluded vessel is saturated and distended with 
the fluid, and the tissues undergo characteristic changes. Lymphangitis, 
lymphadenitis, lymph-varix, lymph-scrotum, chyluria, elephantiasis, phle- 
bitis, hcematuria, hydrocele, fever resembling malarial,—one or several of 
these are to be anticipated in such a case. 
It is useless to direct any medicinal agencies to the cure of filariasis. 
Even if we knew how to destroy and remove the unwelcome visitor, 
its extirpation would do no appreciable good, for the lesions produced 
by the presence of the worm would remain. Something of alleviation 
may perhaps be accomplished by rest, elevation of the affected part, the 
lowering of tension by the use of saline laxatives, a spare diet, and 
abstinence from liquids as far as possible. Operative procedures are 
sometimes available, and these will be mentioned when considering the 
separate diseases caused by filariasis. 
Our greatest reliance in our efforts to rid the community of the evils 
dependent on this parasitic condition must be placed on sanitary measures. 
If all drinking-water in filarial regions were to be subjected to thorough 
filtration and boiling, or to either of these processes, the further exten- 
sion of the condition would be effectually prevented. 
We now proceed to the consideration of the chief diseases produced 
by filariasis. 
ELEPHANTIASIS. 
No one who has seen a pronounced case of elephantiasis of the lower 
limb—a favorite seat of the disease—would think of questioning the 
fitness of the name, for the resemblance to the leg of the greatest of 
quadrupeds is instantly suggested. The disease is not common outside 
of the tropics, and yet cases are seen now and then in northern climes. 
As our knowledge of filariasis is quite recent, it is impossible to state 
whether or not most of the sporadic instances apparently originating in 
the temperate zone have had a filarial source. As the mature parasite 
has a marked preference for the lymphatics of the lower part of the 
body for residential purposes, the disease is rarely seen above the navel, 
and the lower extremities and the external genitals are the members 
usually affected. 
When the malady attacks the lower limb it commonly begins with 
an outburst of erysipelas in the toes. The manifestations are not 
unusual—pain, swelling, inflammation of lymph-nodes, systemic dis- 
turbance. Subsidence leaves the integuments thicker and harder than 
normal. After a variable period a second attack of erysipelas occurs 
over a wider area and disappears, and then another and another, and 
so on for many times, each leaving its mark in a contribution to the 
thickness of the skin and subcutaneous tissue, until the hypertrophied 
parts may be four inches thick. The limb is rarely involved above 
the knee. When the disease is well marked the skin is seen to be 
thrown into many ridges, the surfaces concealed in the intervening 
furrows being eczematous; foul and indolent ulcers are numerous; 
and cracks, oozing lymph, appear at many points. The skin may be 526 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
smooth or rough, hard or soft, and gray, brown, black, warty or 
knobbed, and a single case may display several of these peculiarities. 
The suffering of the patient is mainly due to the great weight of the 
member, but in some cases the pressure upon 
included nerves adds an element of very acute 
pain. 
The condition now established is a true hyper- 
plasia of the white fibrous tissue of the corium 
and subcutaneous areolar layer, in the interstices 
Fig. 216. 
Fig. 217. 
Elephantiasis of leg, scrotum, 
and penis (original). 
Elephantiasis of hand, acquired (Park). 
of which is a copious albuminoid deposit. The papillae are immensely 
enlarged. A section shows a white, homogeneous mass, moist with 
lymph, which leaks from every point, and almost as dense as cartilage. 
The blood-vessels are notably enlarged. Pressure and enforced inac- 
tivity have caused degeneration of the muscles, and the over-nutrition 
of the periosteum has resulted in abnormal growth of bone, usually in 
disfiguring protrusions. 
Treatment of the erysipelas should be conducted on the lines 
already prescribed for that disease, and the other incidental ailments 
are to be managed as when they occur in other circumstances. For the 
fully-developed elephantiasis numerous therapeutic recommendations have 
been made. Ilest, elevation of the limb, and fomentations contribute to 
the comfort of the part; compression with a rubber bandage may 
retard the growth and afford some relief for a time; anodynes and 
supportives to the general system are often manifestly demanded. But 
among real operative measures amputation alone is worthy of serious 
consideration, and must be resorted to if the disease is to be extirpated. INJURIES AND DISEASES OF THE LYMPHATIC VESSELS, ETC. 
527 
The results are generally all that could be expected. The Esmarch 
bandage is of conspicuous value in these eases. 
Elephantiasis of the external f/enitals stands next in order of frequency 
to that of the leg, and, allowing for the structural differences in the 
organs concerned, the symptoms and the tissue 
changes are substantially identical in the two 
localities. If only the scrotum is involved, its 
integuments so far outgrow the length of the 
penis that the latter may become lost to sight 
at the bottom of a conical pit. The superficial 
lymphatic vessels are apt to become varicose, 
Fig. 218. 
Fig. 219. 
Elephantiasis of scrotum 
(original). 
Elephantiasis of scrotum and penis (original). 
and, being ruptured, discharge so much fluid as to keep the skin moist. 
Ulcerations are common, and mortification of the mass may occur. The 
chief danger seems to be from septic infection. The greatest discomfort 
experienced is due to the bulk of the tumor and its weight, which may 
exceed that of the individual who bears it. The severe dragging on the 
inguinal structures not infrequently causes hernia. 
When the penis is the part principally affected, which is rather un- 
common, it may grow to a monstrous size. In Fig. 216, which exhibits 
a typical enlargement of one leg, the patient’s penis, measured around 
the curves, had a length of twenty-seven inches and a circumference 
near the scrotum of fifteen inches. This case and that represented in 
Fig. 218 belonged in Barbados, where the disease is so common as to 
have derived one of its names (Barbados leg) from the place. Fig. 219 528 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
is drawn from a photograph of a New England case in which penis and 
scrotum are about equally diseased. 
In females elephantiasis is far less frequent than in males. The 
genitalia involved are the homologues of the scrotum and penis—namely, 
the labia majora and the clitoris. 
The TREATMENT OF ELEPHANTIASIS OF THE GENITALS does not 
differ from that appropriate to the disease in other localities. Only 
complete ablation affords anything more than transient relief. The 
main peril is from shock, for hemorrhage, which formerly was most 
dreaded, is largely controllable by the Esmarch bandage. For some 
hours before the operation the parts should be elevated in order to drain 
them of fluids, hernise should be reduced, and hydroceles emptied. 
The neck of the tumor is to be constricted with the elastic band and 
provision made for compression of the aorta. The incisions are made 
along the dorsum of the penis and over the course of the cords, and 
these organs, with the testes, are dissected out and turned up on the 
abdomen. Wounding of the vaginal tunic is to be avoided. The per- 
ineal connections are then severed and the mass removed. as 
well as arteries, ought to be tied. 
LYMPH-SCROTUM. 
This is a form of elephantiasis, and often develops into the commoner 
variety. It generally is ushered in with fever, which is quickly fol- 
lowed by acute inflammation of the scrotum and of the lymphatic ves- 
sels of the groin. The skin is thickened and becomes peculiarly corru- 
gated, and its lymph-vessels dilate to such an extent as to constitute a 
set of large intercommunicating sinuses, with so little epidermal cover- 
ing that spontaneous or artificial perforation often starts a dangerous 
lymphorrhagia. The scrotal enlargement is more due to dilatation of 
lvmph-vessels than to hyperplasia of connective tissue. Usually there 
is intermittent leakage of lymph, and the bulk of the tumor may lessen 
during the discharge and increase during the interval. After the drain 
has continued for many years it may cease, and the scrotum gradually 
assume the characteristic appearances of ordinary elephantiasis. 
Filarise may be absent from the blood, even though constant in the voided 
lymph—a condition brought about by the lodgement of a worm in a vessel in or 
near the upper part of the scrotum. The inflammation which the parasite awakens 
extends to the nearest related nodes, the channels of which consequently become 
occluded, and thus the embryos are confined in the lymph on the distal side. 
Ablation is the only suitable treatment. 
This is a condition characterized by the presence of emulsified oil in 
the urine. There is usually no warning of its approach, but the onset is 
sudden, the urine assuming a milky look and becoming extremely abun- 
dant. Simultaneously there may be discomfort in the region of the 
urinary organs, with general depression and debility. The urine coagu- 
lates quickly, but the clot soon disintegrates, a layer of cream forms on 
the top, and rapid decomposition ensues. There is sometimes coincident 
hsematuria. Chyluria may continue many months, and then cease as 
CHYLURIA. INJURIES AND DISEASES OF THE LYMPHATIC VESSELS, ETC. 
529 
abruptly as it began. It is often associated with lymph-scrotum, and 
the discharge of milky fluid from the ruptured vesicles may alternate 
with the appearance of chyle in the urine. The condition of the gen- 
eral health varies greatly, but marked debility is common, due probably 
to the waste of a large amount of the digested materials which the lac- 
teals have absorbed. 
The pathology is obscure. Doubtless the disease is of filarial 
origin, for its geographical distribution is identical with that of other 
diseases of this class, and the embryos are almost invariably to be found 
in the blood and in the chylous urine. No other feature of the malady 
is as constant as their presence. 
Supportive measures are almost always demanded, but beyond this 
treatment nothing avails. 
Prognosis should be guarded. 
Inflammation of Lymph-nodes.—Now-a-days we have discarded the 
words “ idiopathic ” and “ diathetic ” as applied to this disease, for we 
recognize no spontaneity of cause to justify the first, and know that the 
cases which formerly seemed to warrant the second are started by material 
particles brought through lymph-channels from an infected area to a 
node. The microbes which set up inflammation in vessels excite the 
same process in nodes, and almost always lymphadenitis (the technical 
name of the disease) is caused by extension of the lymphangitis of some 
tributary. When this is not the case the cause is usually to be sought 
in infection from a more or less distant point, the poison being conveyed 
to the node through vessels which may receive no harm from the toxic 
agent to which they give passage. Nodes are very prone to take on 
inflammation, and this generally spreads to the areolar tissue in which 
they are imbedded. 
As acute inflammation of lymphatic nodes usually differs from the 
chronic form in etiology, course, and indications for treatment, the two 
will be considered separately. 
Acute Lymphadenitis.—A previously unnoticed node displays the 
classical signs of inflammation. The pain is not great if the adjacent 
parts are kept entirely quiet, and there may be absence of fever. If the 
inflammation is not checked, suppuration occurs. The node and the 
skin covering it soften, and when a cluster of nodes is concerned they 
may form a single abscess by confluence. Evacuation of the pus is suc- 
ceeded by rapid healing, but in depraved conditions of the system an 
idcer, or even a sinus, may remain and be unresponsive to treatment for 
a long time. Rarely acute inflammation terminates in the chronic form 
or in fibrous induration, caseation, calcification, or gangrene. 
Generally acute lymphadenitis is caused by the introduction to the node of 
some irritant material brought by lymphatic vessels. The principal pathological 
change observed is a vast increase in the number of cells, which block up the chan- 
nels, and thus make the node more than ever a catch-basin for particles floating in 
the current of lymph. 
Treatment must be prompt and active if the integrity of the node 
is to be saved. First, remove the cause if possible, seeking it at the 
periphery of the tributary vessels. Keep the inflamed part perfectly 
still. Reduce congestion by leeching or apply freely several times a day 
equal parts of carbolic acid and glycerin, or inject carbolic acid. The 530 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
last method has won much favor. Its value seems to depend less upon 
the strength of the acid than on the exact manner of its employment. 
Some surgeons use a 2 per cent, solution, others the liquefied acid, but 
all recommend the injection of all parts of the node. The needle of a 
hypodermic syringe is thrust nearly through the node lengthwise; it is 
then slowly withdrawn, and the acid is deposited all along its track— 
perhaps thirty minims if a weak solution is used, three or four if the 
strongest. Then firm pressure is applied. None of these measures are 
efficacious after pus has formed. When this stage is reached incision 
must be resorted to. If there are fibrous bands or adherent pus, curette 
the cavity, swab it out with a strong antiseptic, and pack it with gauze. 
When granulation has well begun healing may be expedited by a deep 
suture. The routine treatment of inflamed nodes with tincture of iodine 
is most undesirable. Iodine in any form probably does no good in acute 
lymphadenitis. 
Constitutional treatment, although of secondary importance, may be 
needed, and the careful practitioner will not forget the possibility. 
It is probable that a node is never thoroughly restored after having 
been inflamed. Its stroma is increased, it remains harder than is normal, 
and it has contracted adhesions to circumjacent parts. 
Chronic Lymphadenitis.—Before entering upon the consideration 
of this form of inflammation of lymph-nodes it is desirable to devote a 
little attention to the subject of scrofula, to which, in the minds of non- 
medical people, and also of a not inconsiderable part of the profession, 
this affection is due in a majority of cases. 
To deny the right of scrofula to a place in the nosology would until very recent 
years have been regarded as rank heresy. But my contention goes even farther 
than this, and challenges the propriety of considering scrofula as a demonstrable 
condition or even a tendency. Many years ago the domain of scrofula was undis- 
puted even over diseases which to the wider pathological information of to-day are 
so absurdly dissimilar, and so wholly unlike the morbid exhibitions which we have 
been accustomed to hear called scrofulous, that their inclusion under this head is 
amazing and grotesque. Think, for example, of placing in this category cancer, 
hereditary syphilis, chronic hydrocephalus, diabetes, rickets, intestinal worms, and 
lice! and yet all of them have been reckoned as forms of scrofula. In our times, 
however, we hardly hear of scrofula except in bones and joints and lymph-nodes, 
the last by far the most frequently. The question arises with great pertinency, 
Are not all of these affections displays of tuberculosis? Certainly the pathologists 
do not hesitate to answer affirmatively as regards the skeletal structures and almost 
all of the lymph-nodes, which have hitherto been considered scrofulous. The 
only doubt in the well-informed attaches to the condition of a minority of diseased 
nodes, in which neither tubercles nor the bacilli tuberculosis are found. These nodes, 
clinically, are in no manner distinguishable from those which are emphatically 
tuberculous, and often are directly contiguous with them. But, considering that 
tubercle requires a period of time for its developmental and another for its degen- 
eration changes, and that in both of these, and especially in the latter, the typical 
form is often wanting; and considering further that bacilli are not invariably 
detected in cases where we are positive that they must at some time have been, it 
seems not unreasonable to take these comparatively few cases out of their classic 
field and place them in that of tuberculosis. When this is done the province of 
scrofula is absolutely emptied. To be sure, the dictionaries still call it a tendency 
existing in some constitutions, but it is difficult to understand in what way this 
tendency is to be proved short of a pathologic demonstration, and when this is 
done there is no call to speak of a tendency, for there is an actual disease. The 
rational conclusion is that the term “scrofula” should be discarded as no longer 
useful. In a few years more it will not be necessary for a writer on lymphatic 
diseases to explain w'hy he omits a description of scrofula. INJURIES AND DISEASES OF THE LYMPHATIC VESSLES, ETC. 
531 
Chronic lymphadenitis may be, though it rarely is, a sequel of an 
acute inflammation. Almost always it originates in the entrance of bac- 
teria from the peripheral area drained by the affected node. These 
directly or indirectly excite inflammation of so low a grade that it often 
seems to have qualities which entitle it to be regarded as chronic from 
the outset. So deliberate is this process that it may consume many 
years before it runs its entire course, including its sequels. Its most 
characteristic feature is perverted growth of the connective tissues, which 
so hypertrophy as to destroy or crowd out the cellular elements and 
sometimes reduce the node to the condition of a fibrous lump. At other 
times the node attains a great size, in which case large cells are found to 
have developed. Many nodes in a locality are apt to be diseased at the 
same time, and often coalesce into hard, lobulated masses, which are 
always disfiguring, frequently cause suffering, and occasionally interfer- 
ence with important functions by pressure upon nerves, vessels, and 
other organs. These nodes, which are almost always the seat of tuber- 
culosis, undergo the degenerative changes incident to that disease, and 
with especial frequency caseation. The cluster of nodes is converted 
into a cheesy mass, which may long remain unaltered or rapidly soften 
and be partly discharged, the remainder acting like a foreign body and 
maintaining suppuration. AVlien spontaneous healing takes place the 
resulting scar is large, puckered, and unsightly. 
Chronic lymphadenitis is most common in the poorly nourished, espe- 
cially those of tuberculous or syphilitic parentage. It is very insidious 
in its approach, and the fact that a node is in trouble may not be sus- 
pected until an abnormal bulging is noticed on some part of the patient’s 
neck—the favorite locality of the disease, because the mucous surfaces 
of mouth, nose, and ear offer so much more extensive opportunities for 
the admission of septic germs than are available for the inguinal and 
axillary nodes. There is no pain, as a rule, and the growth may remain 
unaltered for a long period. 
Treatment must be both constitutional and local, the former being 
much the more important. Hygienic measures are most to be depended 
on—abundance of pure air and nourishing, easily-digested food, cloth- 
ing adapted to the seasons in turn, baths, suitable exercise, favorable 
climate. 
Unhappily, however, the majority of cases occur among people to whom such 
prescriptions are a mockery, to whom the exact antipodes of these conditions have 
constituted the entire environment and the most urgent invitation to the disease 
with which they are afflicted. Penury establishes the physical state which favors 
the development of the malady and an insurmountable obstacle to the adoption of 
the necessary means for its removal. Only the opulent can command the best 
constitutional treatment. We are driven, therefore, in a large proportion of cases, 
to depend upon medicinal remedies, and these are principally in the directly sup- 
portive class—tonics and stimulants, as cod-liver oil, iron, and the alcoholics, the 
last to be used with extreme caution. Arsenic, mercury, and iodine, of course in 
minute doses and in forms which are easily tolerated, have often seemed to aid in 
the correction of the constitutional perversity. 
Local treatment should vary according to circumstances. If the node 
is hard, some good may come from the application with gentle friction 
of some ointment containing iodine, iodoform, iodide of lead, or iodide 
of potassium. When this device causes soreness of the skin, its use 532 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
should be left off until the skin is restored, and then renewed. Pus 
should be given vent as soon as detected, and the incision would better 
be small. The cautery knife at a dull red heat is preferred by certain 
surgeons. One advantage of early opening is the probability of a less 
offensive scar than follows spontaneous evacuation of the pus. 
With a view to the substitution of harmless cicatricial tissue in the place of 
the morbid deposit, the centre of the node may be injected with a caustic, as two 
minims of a 10 per cent, chloride-of-zinc solution once a week or so, or three 
minims of equal parts of carbolic acid and glycerin. Puncture with the thermo- 
cautery will sometimes answer the same purpose, causing induration of the entire 
node. 
Particular caution should be observed in the local treatment of ingui- 
nal tumors, which are supposed to be chronically inflamed lymphatic 
nodes. In two patients I have found hernia which had been diagnosti- 
cated by the attending physician as lymphadenitis, and in one of these 
a small knuckle of intestine was gangrenous. 
When the tumor causes suffering by compression of nerves or ves- 
sels, or menaces life by interference with breathing or deglutition, 
nobody hesitates to advise removal. But these cases are infrequent, 
and concerning a cutting operation in the majority of cases the highest 
surgical opinion is divided. Of course every one would be glad to rid 
his patient of a mass which is probably tubercular, for infection of the 
system from the degeneration of these nodes may occur in any given case, 
though it certainly is not common. If there is only slight mobility of 
the tumor, nobody can tell how extensive a dissection may be necessary 
to remove it; and perhaps more harm than good comes from taking 
only a part away, for experience shows that such interference often 
excites more rapidity of growth in the remainder. There is a lack of 
information relative to the results of extirpating operations : the reports 
of them have been made too soon to justify conclusions as to their value. 
It is probably a safe rule to ablate masses which are freely movable, in 
order to prevent extension to neighboring nodes. Such operations are 
not difficult, as a rule, but when the tumor is not freely movable the 
case is far different. Then it is generally best not to use the cutting 
edge of the knife after the nodes are reached, for the vessels and nerves, 
and especially the jugular vein, are often so displaced, stretched, and 
obscured that they are apt to be mistaken for fascial bands and wounded 
in consequence. The fingers and blunt instruments are the safest imple- 
ments in these circumstances. Piecemeal removal is often most expe- 
ditious, and by far the best. 
Hodgkin’s Disease. 
There are not many diseases which have been called at one time by as many 
different names as that which we are about to consider, and its current titles are 
herewith presented, not as an illustration of the fertility of terminological inven- 
tion, but that the reader who has known this malady by any one of these appella- 
tions may be made aware of the subject of this section. Here are the names: lymph- 
adenoma., generalized lymphadenoma, lymphadenosis, lymphoma, adeno-lymphoma, 
malignant lymphoma, malignant multiple lymphoma, infective lymphoma, adenia, ade- 
nosis, progressive glandular hypertrophy, hxjperplasia of lymph-nodes, lymphosarcoma, 
multiple sarcoma, lymphatic anaemia, splenic ancemia, pseudo-leucocythcemia, pseudo- 
leukaemia. Unfortunately, some of these are used to designate more than one dis- 
ease, and their employment is, consequently, very confusing; and others, while INJURIES AND DISEASES OF THE LYMPHATIC VESSELS, ETC. 
533 
affecting to give pathological information, are really misleading. It has seemed 
wiser, therefore, in spite of well-grounded objections to eponyms, to call the affec- 
tion by the name of the observant physician who first gave an account of it, until 
a concise and correct descriptive title can be agreed upon. 
Hodgkin’s disease is more frequently seen in the young, and espe- 
cially males. Its first manifestation is the enlargement of some super- 
ficial nodes, generally in the cervical region. They are not painful or 
tender, do not adhere to the skin or to each other, and show no tend- 
ency to caseation or suppuration. The spleen is a little enlarged and the 
general vigor impaired. There is a suggestion of anaemia, but the only 
observable alteration in the blood is a 
slight diminution in the number of the 
colored corpuscles. The case can cer- 
tainly be made out to be neither cancer 
nor tuberculosis, and arouses but little 
suspicion of sarcoma. 
The enlargement of the nodes pro- 
gresses—if slowly, the tumor is prob- 
ably hard; if rapidly, soft. Those in 
the arm-pits and groins are affected next 
after the cervical, and other groups fol- 
low suit. The only suffering comes from 
debility and depression of spirits, which 
are constant, and from fever, which is 
frequent. The blood may lose three- 
quarters of its colored corpuscles, but 
the colorless are not diminished. The 
skin is pallid and waxy and the mucous 
membranes are blanched. Variations 
in appetite are observed from anorexia 
to voracity. 
In a year or two every node in the body 
is enlarged: the neck has ceased to be a 
constricted part and bulges hideously; 
the axillae are stuffed with tumors; the 
groins protrude and the lymphatic col- 
onies in the great cavities are correspondingly affected. Pressure produces 
results which vary according to the organ involved, and is responsible 
for pain, paralysis, perverted respiratory action, and interference with 
digestion and circulation. Death is due to exhaustion. 
Post-mortem examination shows no formation of pus, no caseation, 
no breaking down of any kind. The nodes composing each separate 
group have become fused, the lymphoid tissue between them having in- 
creased and banded them together. They display increased vascularity 
and hypertrophy of tissue, the cellular elements being overgrown in the 
soft masses and the fibrous in the hard. Small, irregular lumps of new 
lymphatic tissue are scattered abundantly throughout the spleen, and 
the lungs, liver, kidneys, stomach, and intestines may contain similar 
deposits. 
This is the history, in brief, of a pronounced and clear case of Hodg- 
kin’s disease, but deviations from this type are not uncommon, and the 
Fig. 220. 
Hodgkin’s disease (Park). 534 
AFFECTIONS OF THE TISSUES ANT) TISSUE-SYSTEMS. 
future may prove that some of the so-called varieties are really different 
diseases. The most confusing (alleged) variety is that in which there is 
not merely a relative but an actual increase in the number of leucocytes in 
the blood The difficulty in interpreting this condition, so opposed to 
that which is usual, is at least diminished bv observing that this multi- 
plication of colorless corpuscles is 
coincident with that form of hyper- 
trophy of the spleen in which there 
is not only the typical, characteristic 
overgrowth of the lymphatic ele- 
ments, but also an augmentation of 
the pulp ; and this change in the pulp 
is the cause of the leucocythsemia. 
Thus we have developing in the 
same patient Hodgkin’s disease with 
its loss of colored corpuscles, and 
splenic leucocythsemia with its , 
vicious gain of colorless corpuscles. 
Occasionally there is no enlarge- 
ment of the spleen. It would be 
interesting to know if the other 
viscera, which are usually affected 
in advanced stages, are equally ex- 
empt. Sometimes the disease begins 
in the deep nodes, and then an early 
iliagnosis is wellnigh impossible. 
Diagnosis cannot be made until 
the appearance of enlargement of 
nodes. The principal differences 
between Hodgkin’s disease and leu- 
:*ocytl)8emia (with which, as we have 
seen, it is at times associated) are, 
first, that in the former anosmia is 
not pronounced until after the lym- 
phatic hypertrophy, but in the latter 
anaemia is the first thing noticed; 
second, in Hodgkin’s disease the splenic enlargement is slight until that 
of the nodes is very great, but in leueoeythcemia the spleen is the first 
organ to show increase in size. 
Fig. 221. 
Hodgkin’s disease (Park). 
There is little danger of confounding Hodgkin’s disease with carcinoma, as the 
latter almost never starts in the nodes. Tuberculosis of the nodes is attended 
with slowness of growth, earliness of agglutination, and a marked tendency to 
degeneration and the formation of pus—none of which phenomena are seen in 
Hodgkin’s disease. Some authors declare that it cannot be discriminated from 
sarcoma, but in Hodgkin’s disease the enlargement is purely hyperplastic, “while 
such tumors only are to be regarded as sarcomatous w7hich in type have nothing in 
common with the mother-tissue” (Winiwarter). The microscopic*examination 
of a bit of the growth cut out for this purpose would easily determine this point. 
The recent discovery that the blood-leucocytes are not of one kind, 
but of five or more varieties, may be the key which is to unlock some 
of the mysteries of this disease, which needs to be studied anew from 
the point of view of this addition to our knowledge. INJURIES AND DISEASES OF THE LYMPHATIC VESSLES, ETC. 
535 
In the treatment of Hodgkin’s disease almost all drugs which 
have been tried have proved to be worthless. Arsenic alone seems 
worth a trial, as some tumors have diminished during its administration 
and a number of complete cures have been reported. As large doses as 
can be borne without toxic effects should be given. The general 
strength must be upheld in every possible way. 
Local treatment does not promise much, if any, more than medicinal. Injec- 
tions, massage, inunctions, compression, and blistering have all been tried fruit- 
lessly. The propriety of operation always comes up for discussion. If the diag- 
nosis has been made early—when, for instance, only a single and accessible group 
of nodes is involved, the spleen apparently normal, and the ansemia slight— 
removal of the mass should be practised; for, while this procedure cannot be 
warranted to exempt the patient from extension of the disease, it is usually 
attended with little peril, and it gives him the chance of benefit possibly resulting 
from the extirpation of a tumor which if allowed to remain may cause infection 
of the entire system. In order to do any good the removal must be thorough. If 
the disease has become general, operation is not to be thought of, except for the 
removal of such masses as mechanically cause suffering or interference with vital 
processes; and always in such a case it should be plainly stated by the surgeon 
that nothing curative can be hoped for from the operation, but merely temporary 
palliation. 
Sarcoma of Lymph-nodes. 
Although the cases are very rare, it seems to be fairly settled that 
sarcoma may affect lymph-nodes as a primary affection. 
The diagnosis is not always easy—in fact, may not be possible until 
the node has been removed and subjected to microscopic examination. 
The treatment is, of course, ablation. CHAPTER XXXI. 
SURGICAL INJURIES AND DISEASES OF THE VEINS. 
James M. Holloway, M. D. 
Anatomy and Physiology.—The veins exceed the arteries in length, calibre, 
and number. Like the arteries, they are composed of three coats—an inner serous, 
a middle fibro-muscular, and an outer fibrous, these being closely connected by 
cellular tissue. The serous coat is continuous with the membrane that forms the 
capillary vessels and lines the arterioles and venules. The fibro-muscular middle 
coat endows the vessel-wall with feeble contractile force, and aids the outer coat in 
securing elasticity and resistance against sudden or prolonged blood-pressure. 
Valves do not exist in all veins, being present for the most part in those requir- 
ing the support of the column of blood against gravity and the pressure on large 
vessels within the abdomen due to physiological and pathological changes or over- 
growths occurring therein. These valves vary in number and location in the 
vessels—e. g. in the superficial veins of the lower extremities. Bennett,1 during a 
series of observations made under his direction, discovered remarkable facts in this 
regard. 
This will account for the pathological conditions to be noticed elsewhere. 
Further observations showed that the valves are sometimes either entirely absent 
or defective congenitally, causing hypertrophy of one or both of the lower extrem- 
ities, and also rarely of the upper extremities. 
The circulation of the blood in the veins is for the most part centrifugal, and 
is not, as a rule, influenced directly by the force of the heart. Nevertheless, the 
heart’s action constitutes a powerful factor, aided by peripheral capillary circula- 
tion, endo- and exosmotic currents, and muscular action. 
Owing to numerous small branches given off from the larger vessels, and con- 
necting them with each other, the superficial and deep veins are constantly inter- 
changing their contents, and thus modifying the blood-pressure to an extent 
sufficient to prevent over-distention under ordinary conditions. Along with the 
veins and in close connection with them are found either nerve-trunks (with the 
venae comites) or filaments of nerves that penetrate the muscles and supply the 
contents of the cellular planes. 
The intimate anatomical relation of the lymphatic system to the veins demands 
recognition when treating of surgical affections of these vessels. 
Hyperjemia of Veins. 
This condition is a consequence of trauma, not only of the walls of 
the vessel, but of the adjacent or surrounding tissues. Contusion, punct- 
ure, or laceration of a vein, if not treated preventively, will be more 
or less speedily followed by swelling, induration, plugging, discoloration, 
and decided tenderness. If circumscribed, the elevation of temperature 
will be strictly local, and not always appreciable except by a surface 
thermometer. The surgeon rarely encounters such a case, because of its 
seeming insignificance. When called he finds that the hyperaemia has 
536 
1 London Lancet, 1889, p. 1073. SURGICAL INJURIES AND DISEASES OF THE VEINS. 
537 
extended upward along the course of the vessel quite a distance from 
the site of the injury. The vein can be outlined by the swelling and 
discoloration, and the pain and fever indicate a constitutional disturb- 
ance. Hypersemia of veins is a prominent feature in the clinical course 
of a sprain in which preventive measures have not been employed or 
have failed. All of the structures about the joint are more or less 
involved; there is a general discoloration of the skin, the hue deter- 
mined by its natural pigment. The veins are usually, in such a case, 
outlined by their fulness and the darker arborescent streaks. After the 
hypersemia has subsided the mottled skin oftentimes remains to indicate 
the effusion of blood and the enfeebled venous flow through these super- 
ficial vessels. Frequently clotting occurs during the active hypersemic 
state, and the vein is obliterated, leaving indurated masses that are 
likely to be mistaken for lymph-nodes or fibrinous deposits. These 
phenomena, observable upon the superficial, occur as well in the deeper 
parts, and may be properly cited as one of the causes of nutritive dis- 
turbances, pathological degenerations, and the formation and growth of 
neoplasms. 
The treatment of hypersemia of veins demands physiological rest, 
support by dry or wet, warm, hot, or cold compresses of cotton or 
wool, and the supporting effect of concentric compression by bandages. 
Anodyne and astringent lotions may be added to these when pain and 
tenderness exist. A lead lotion with opium, an evaporating or stimu- 
lating lotion—e. g. distilled extract of witch-hazel, tincture of arnica, 
or the balsam-apple in rectified spirits—may be substituted. Compres- 
sion by cotton batting or wool and the bandage supports, eases and favors 
resolution and the return circulation. 
Phlebitis. 
Inflammation of Veins (Sepsis).— Wounds of veins are the most 
frequent direct cause of this condition. The absorption of septic fluids 
from contiguous structures that are septic is the common indirect cause. 
Oftentimes, in either case, the lymphatic system is considerably affected, 
so as to render it difficult to decide as to their causal relation. The 
walls of the veins become swollen and less resistant, the serous coat is 
congested, the valves are less mobile, and the blood clots readily from 
stasis and the admixture of septic fluids. The parts directly within the 
area of the septic state become boggy, discolored, and more or less ten- 
der, the pain being burning and lancinating. The tendency is toward 
the formation of diffuse collections of pus in the adjacent structures. 
The constitutional disturbance is alarming; the asthenic state is 
present; all the essential signs of fever are manifest; the pulse soon 
becomes feebler and less regular than in the sthenic fevers; the respira- 
tion is sighing; the skin is frequently bathed in profuse sweats; the 
countenance expresses concern; and the secretions from the intestinal 
tract and the kidneys are scanty. There is a general sepsis that may 
terminate more or less speedily in death by asthenia or by the formation 
of septic abscesses in the lungs or liver or brain. On the other hand, 
the patient may recover by elimination of the septic matter through 
intestinal drainage and free diuresis and diaphoresis, or by the formation 
of conservative depots of pus in the cellular planes. 538 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
Treatment of Phlebitis (Sepsis).—The preventive treatment 
should be the aim of the surgeon—viz. when possible remove all for- 
eign substances, blood-clots, etc. that will act as local irritants, establish 
and maintain free drainage, and employ aseptics and antiseptics. The 
technique will be suggested by each individual case. Should, however, 
these precautions have been neglected or have failed because of incom- 
pleteness in their application, no time should be lost in the thorough 
removal of the cause when practicable, and in the employment of con- 
stitutional treatment to lessen the gravity of the sepsis, and at the same 
time sustain the patient against the asthenic state so likely to prove 
fatal. Free incisions where the parts are boggy and tense, irrigation 
with sterilized carbolized water, the bichloride solution; after, drains of 
gauze or tubing, dusting with iodoform and boric acid, and over all 
aseptic and antiseptic gauze, the object being to prevent those putrefac- 
tive changes that result in the production of ptomaines and toxins. 
These for the local condition. For the constitutional state, already 
present, free drainage bv the intestinal tract and kidneys is to be secured 
by small doses of calomel repeated at intervals of a half hour or hour, 
to he followed by small doses of Rochelle or Epsom salts until free pur- 
gation and diuresis occur. At the same time milk, broth, eggs, and 
wine or whiskey should be judiciously administered. Special attention 
should be given in such cases to the administration of from one-thirtieth 
to one-twentieth of a grain of strychnine hypodermically every four or 
six hours, to which may be added, when required, digitalin and nitro- 
glycerin. 
In cases of recovery the area of the local septic state is recognized 
by a persistent swelling and induration, upon the subsidence of which, 
under appropriate treatment by bandages, massage, and the hot and 
cold shower, the superficial veins may be outlined by irregularity and 
cordiness. 
Varicose Veins (Varices). 
There is no doubt about the dilatation of the calibre of the veins that 
are in a varicose condition. Nevertheless, veins that are dilated are not 
necessarily varicose. A difference between varicose and dilated veins is 
therefore recognized. This consists in the condition of the valves. In 
the former (varix) the valves are insufficient; in the latter (dilatation) 
they are not. In the former the walls are irregularly thinned, length- 
ened, and tortuous; in the latter the walls are more or less thickened. 
A notable example of this is observed in varicocele that is present on the left 
side in fully 10 per cent, of adults. Here the veins are valveless, and when rolled 
between the fingers and thumb or compressed, furnish the well-recognized sensa- 
tion of a hag of fishing worms. When excised for the radical cure of varicocele 
the walls are always found uniformly and sometimes enormously thickened. 
Insufficiency of the valves is caused by a stretching of the wall of 
the veins so as to separate the thin free edges, leaving an interspace that 
permits of regurgitation of the blood in a direction opposite to the nor- 
mal current. In consequence the column of blood has no longer sup- 
port against gravity, and does not flow normally into collateral channels 
when interrupted in its more direct course. This valvular insufficiency SURGICAL INJURIES AND DISEASES OF THE VEINS. 
539 
is a potent factor in progressively thinning the vein-walls and adjacent 
skin, and increasing the danger of their rupture subcutaneously or 
through the attenuated overlying skin or mucous membrane. Short of 
this, the pressure-effects of varicosities are liquid or semi-solid oedema ; 
pain due (1) to the sense of fulness where stasis (congestion) results; 
(2) to pressure upon filaments of nerves or nerve-trunks; (3) to disturb- 
ances of nutrition, causing eczema, ulceration, overgrowth, more or less 
permanent pigmentation, the formation of thrombi and their degeneration 
into phleboliths. 
Causation of Varicose Veins of Lower Extremities.—(1) 
Thrombins of large veins following an attack of typhoid or other long- 
continued fever; (2) injury of pelvis or thigh 
or leg, lessening nutritive powers; (3) local 
pressure of pelvic or abdominal tumors or 
fecal accumulations (the latter affecting the 
left limb); (4) long-standing occupation, affect- 
ing the long superficial internal saphena; (5) 
congenital defect in the arrangement of the 
valves, as noticed in the paragraph on the 
Anatomy and Physiology of the Veins, as 
recorded by Bennett. 
Constipation and pregnancy, especially the 
latter, aggravate the varicosity, the former 
being questionable as an exciting or aggravat- 
ing cause. Occupation is not usually an ex- 
citing cause, but persons who are compelled 
to maintain the erect posture during long 
watches, during great heat, or are subject to 
frequent slight injuries have a tendency to 
varicosity very much aggravated. Age is not 
a determining cause, for in many instances 
the presence of varicosities is not discovered 
until far advanced. The disease is rarely 
noticed in persons under twenty-one years 
unless abdominal obstruction exists—a very 
rare occurrence. The tendency to the affec- 
tion increases under certain limitations after 
adult life, and is much more common in old age in both sexes. 
It is important to emphasize the statement that a deficiency in the arrange- 
ment of the valves and their integrity accounts for the presence or absence of vari- 
cose veins in persons of similar occupations, and in one or the other leg of the same 
person, whether male or female. 
The complications of varicose veins of the lower extremities, as 
given by Bennett,1 are hemorrhoids, varicocele, varix over pubes, labial 
varix in female, ulceration and eczema, persistent solid oedema (lymph- 
oedema), recent thrombus, old thrombus, valgus. 
Except pregnancy as a cause, more men suffer from varicose veins of the lower 
extremities than women. Simultaneously the deeper and superficial veins are 
often affected, while the superficial veins alone are often involved. When the 
deeper veins escape, pain is not a prominent feature, only a feeling of fulness and 
heaviness. 
Fig. 222. 
Congenital varices (Park). 
4 1 London Lancet, 1889, p. 1074. 540 
AFFECTIONS OF THE TISSUES ANI) TISSUE-SYSTEMS. 
Varicose veins of upper extremities are caused by occupations requir- 
ing over-use—washerwomen who work daily and use their hands instead 
of wringers; men who work at brick-kilns pitching the brick in the 
erect position, and, after burning, loading wagons; tennis- and base- 
ball-players can be named. 
The early symptoms are pain in a muscle or group of muscles in 
unusual localities of the arm, usually attributed to sprain. To diagnose 
such a case slight compression with a bandage around the arm near the 
axilla will speedily bring to view conspicuous varicosity. To prove the 
correctness of the opinion, apply a roller bandage and the movements 
will be made without pain ; afterward direct the patient to wear an 
appropriate elastic stocking. 
In extreme cases the same treatment may be resorted to as is 
applicable to veins of the lower extremities. 
Symptoms of Varicose Veins of Lower Extrem ities.—Incipient.—Crampy 
pains upon rising, passing off, and late in the afternoon a sense of ful- 
ness and heaviness, with more or less dull pain in one or both legs. 
Inspection rarely reveals varicosity of the superficial vessels, except 
perhaps a few slight varicosities near the saphenous opening, upon the 
outside of the thigh, in the popliteal space, on the fibular side of the 
leg, or behind the ankles. These may be altogether absent. In some 
cases slight oedema of the foot or ankle comes on later in the evening, 
enough only to be noticed because a loose shoe then feels too tight. 
When the patient applies for relief during the early stage of the affection, it 
must be differentiated from gout or rheumatism. Later on, even if the patient 
has been properly advised, the superficial veins become enlarged and can be readily 
outlined. Then the diagnosis is easy. But in the latter stage the crampy pains 
upon rising no longer give trouble, and another train of symptoms appears. Heavi- 
ness and fulness of the limb are present in all positions except the recumbent. In 
some the sitting or standing posture causes greater pain, including a restlessness 
that forces the patient to move about. For a while the muscular effort causes the 
blood in the veins to flow more freely and relieves the pressure, but fatigue 
increases the pain again, and relief is only obtained by elevating the limb or lying 
down. 
In many cases of extreme varicosities of the lower extremities observed in 
hospital practice the writer has called attention of students to the singular fact 
that the patients denied having any pain except a sense of fulness. Numbers of 
these have been members of the street-cleaning gang in this city for over twenty 
years; they have very large tortuous veins, eczema, serous or lymph-oedema, and 
some have ulcers. All of them remember the pain formerly experienced. In 
such cases the writer has taught that the pain is due to pressure usually of the 
enlarged deeper-seated vessels (comites) upon the nerve-trunks. He acknow- 
ledges, however, that the significance of the varicosity of the deeper veins was not 
fully appreciated nor understood until after a careful study of Bennett’s1 lectures 
on this subject. 
Varicosities of the deeper veins are more commonly recognized now 
than formerly. When elderly laborers or women who are multiparous 
are able to pursue their usual vocations without much pain, the inference 
is warranted that their varicosities are confined largely to the superficial 
veins. Pain in the vicinity of superficial varices is commonly due to 
pressure upon filaments of nerves, not to any disturbance of the main 
branches. The sense of fulness and heaviness that is experienced is 
due to the general stasis in the foot and leg. The eczema and itching 
1 London Lancet, loc. cit. SURGICAL INJURIES AND DISEASES OF THE VEINS. 
541 
are due to the effusion disturbing the function of innervation in the 
sensory branches distributed to the skin. The ulceration and resultant 
ulcer are due to the bursting of a vein, to the wound of the cuticle by the 
Fig. 223. 
Fig. 224. 
Varicose ulcers. 
Varicose ulcers (original). 
finger-nails employed to allay or modify the itching after lying down, 
to an accidental contusion or abrasion, to the presence of a phlebolith 
that causes molecular death by pressure or by becoming septic. 
Treatment of Varicose Veins of the Lower Extremities. 
—Support by the perfect elastic stocking or by the roller bandage is 
sufficient to ease the crampy pains upon rising and prevent the heavi- 
ness and fulness and slight oedema of the early or incipient stage. More 
radical treatment should be resorted to after the condition has advanced. 
Multiple ligation of the prominent veins, either subcutaneously or 
through incisions in the overlying skin, has proven effectual in many 
instances. But under the present aseptic and antiseptic method nothing 
short of excision of the internal saphena and prominent tortuous groups 
of veins below the knee can be recommended. 
The writer has been afforded recent opportunities for testing the value of this 
method, and can highly recommend it. The operations were done in hospital and 
private practice, upon males and females between the ages of twenty-five and 
twenty-six years. 
The technique, simple but tedious, is as follows: While the patient 
is standing encircle the upper third of the thigh by a rubber cord, tight 
enough to obstruct the venous flow, but short of compressing the artery. 
While an anaesthetic is being administered, the internal saphena and 542 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
veins below the knee, that were not easily outlined before, now become 
prominent. As soon as the parts have been thoroughly cleansed and 
protected by sterilized towels, an incision through the skin, six or eight 
inches long, should be made parallel to the internal saphena, but not 
directly over it. This precaution is taken to avoid wounding the vessel 
by misdirected pressure upon a blade of uncertain keenness. When the 
incision through the skin has exposed the subcutaneous cellular tissue, 
the knife must be laid aside or its handle only employed. With it and 
the fingers the vein and its variable number of branches must be teased 
out of their bed, and so thoroughly exposed that each branch and the 
proximal and distal end of the main vessel can be ligated. 
Thus far, only chromicized catgut has been employed. It is much less easily 
handled than silk or kangaroo tendon, but has been sufficiently firm before its ab- 
sorption to effectually close the vessels. An expert assistant aids greatly in the 
dextrous jjerformance of the operation, for the curled condition of the dry catgut 
forms quite an obstacle to the facile threading of the blunt curved needle em- 
ployed in the ligation, and wetting of the ligature by the oozing renders it so slip- 
pery that the compression forceps are needed to tighten the knot. 
After the vessels have been secured they are excised by the scissors. 
Then, after cleansing the parts by wiping, not by irrigation, the edges 
of the skin-wound should be accurately coapted by silkworm-gut or 
catgut sutures. 
Occasionally the undue pressure of silkworm gut will cause necrosis along its 
track and defeat a perfect union. As a rule, it answers and is sufficient, but the 
clirornicized catgut is recommended, and if buried will, in from seven to ten days, 
leave the parts entirely free from foreign substances and firmly united. After the 
internal saphena has been disposed of, it is covered with an aseptic binder, and the 
large varices below the knee are excised or left untouched according to the judg- 
ment of the operator. It is safer for the success of the operation, however, if the 
more prominent ones are removed, unless there is a varicose ulcer or an extensive 
eczema, especially that form of the latter usually called weeping eczema, in which 
the desiccation of the exuded serum leaves large crusts: under such conditions it 
is difficult to maintain strict asepsis and antisepsis. 
After the wound or wounds have been closed dust freely with iodoform or a 
mixture of iodoform and boric acid (1 part to 3), and cover with sterilized iodo- 
form or borated gauze; then carefully bandage the entire limb firmly and evenly. 
The patient should be required to remain in bed ten days with the limb slightly 
elevated. Careful attention to regimen should be enjoined. Unless the tempera- 
ture rises to the fever-point or pain occurs in the limb or at the site of the wounds, 
the dressing should not be removed until it is necessary to cut the coapting stitches. 
If catgut has been employed exclusively, the wound-dressing need not be examined 
for ten days. The limb should be carefully bandaged for a month or six weeks 
after the patient leaves the bed. 
Under extraordinary circumstances, not likely to occur often, liga- 
tion of the femoral vein or one or more of the venae comites of the leg 
is suggested when the method named above has failed to cure the vari- 
cosity. When the disability can be clearly attributed to a varicose 
state of the deeper veins and the subcutaneous veins are not plainly 
apparent, the writer would advise ligation of the deeper veins. Under 
the improved and constantly improving methods for doing thoroughly 
clean surgery this advice is deemed proper. It is given without hesita- 
tion since the experiments of Trzebicky and St. Karpinski in 1893 on 
the ligation of femoral veins.1 
1 American Journal of the Medical Sciences, vol. evi. p. 606. SURGICAL INJURIES AND DISEASES OF THE VEINS. 
543 
The operation of Schede has the same idea in view—cutting off the 
column of blood from above—but does it more effectually than any of 
the other methods. It is simply a circumcision of the entire leg at 
about the junction of the upper and middle thirds, dividing the skin 
and subcutaneous tissues down to the deep fascia, tying the bleeding 
points, and then sewing up the incision. 
Treatment of Varicose Ulcer. — Palliative. — The various 
methods commonly employed are intended to arrest the ulcerative process 
(first stage), or to stimulate it in the stage of arrest (second stage), or con- 
duct it, steadily through the stage of repair (third stage). These methods 
have been considered fully elsewhere. Whatever plan of treatment suc- 
ceeds in aiding the ulcer to heal leaves the limb in such a condition, on 
account of the varicosity, as to render reopening of the ulcer or the 
formation of others, under very slight exciting causes, probable. There- 
fore the only radical method by which a cure may be effected is to first 
excise or obliterate the main trunks that are varicose. Then the most 
effective plan is thorough curettage, loosening the edges of the ulcer with 
the handle of a scalpel, and aseptic and antiseptic dressing with proper 
support. If so large a portion of skin has been destroyed as to pre- 
vent contraction, skin-grafting will hasten cicatrization. 
In a case recently operated upon the writer excised six inches of the internal 
saphena from the middle third of the thigh, and at the same time curetted a weep- 
ing ulcer of the leg that nearly encircled the limb. At the time of the operation 
the affected limb was one-third larger than its fellow. The subsidence of the 
limb and rapidity of repair that followed were marvellous. 
The eczema and weeping that cause so much itching and distress in 
such cases before operation for radical cure can be lessened, and some- 
times be made to disappear temporarily, by elevation at night and skilful 
bandaging during the day, the parts having been dusted with boric acid, 
bismuth, iodol, aristol, iodoform, oxide of zinc, or admixtures of these 
in proper proportions. 
The globular varix that occurs oftenest at or near the saphenous 
opening is not always a dilatation of the saphena. Bennett describes 
two kinds that are dilatations of smaller collateral vessels—viz. (1) the 
subcutaneous, that is the more globular in shape and, under the thinned 
skin, is darker; (2) the subfascial, that is flattened by the denser fascia 
lata, its color being less dark because of its depth. Neither kind can be 
emptied by pressure, rebounding when digital compression is withdrawn. 
When these give rise to pain by pressure upon minute filaments of 
nerves, removal is the proper treatment. A curvilinear incision half 
around the tumor will expose it readily, and in the subcutaneous variety 
will lessen the danger of cutting into the tumor. 
Landerer’s method of treating varicose veins has not been sufficiently 
employed in this country to determine its value. Its simplicity is con- 
spicuous, and if successful, even as a palliative measure, deserves prompt 
recognition in dealing with a class of cases that are not to be operated 
upon for a radical cure because of old age, visceral degenerations, preg- 
nancy, or those necessities of life demanding continuous occupation. 
It consists in the pressure on the saphena above or below the knee by a 
“parabolic spring carrying a cushion filled with glycerin or water,” 
attached to a garter that fits so loosely as not to constrict the limb. 544 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
The inventor claims remarkable results by this method, an interesting review 
of which, bv Dr. J. P. Warbasse, may be found in the Annals of Surgery (vol. xx., 
1894). 
• The pulsation of veins, as in exophthalmos, is due to defective or dis- 
turbed innervation, improvement under effective treatment being fol- 
lowed by lessening of the pulsation or its disappearance. Sudden occlu- 
sion of a large vein by plugging or its gradual obliteration by pressure 
of an overgrowth causes rapid oedema (effusion) or more gradual lymph- 
oedema. 
An illustrative case of the former (as recorded by the Paris correspondent of 
the London Lancet, vol. i., 1894) was a sudden plugging of the superior vena cava. 
An instance of the latter was observed by the writer in a case of carcinoma of 
the axillary lymphatics after amputation of the breast. The entire upper extrem- 
ity on the affected side became enormously enlarged, and so indurated that firm 
pressure with the fingers or bandage failed to produced pitting. 
Rupture of varicose veins is sometimes attended bv profuse hemor- 
rhage, and death has resulted. It always causes alarm to the patient 
and those around. To arrest the bleeding, elevate the limb and apply 
pressure with the finger until a compress and bandage can be applied. 
The flow of blood is mainly from the distal end, but, it is asserted, the 
proximal end also bleeds. 
This is one form of erectile tumor. It is usually congenital, but quite 
often acquired. It involves the skin and mucous membrane, and is 
found in the subcutaneous and submucous tissue. Naevi are discovered 
post-mortem in the liver and some other internal organs. They are 
situated more commonly on the head and face and in the cavities of the 
nose and mouth, pharynx, and nasopharyngeal space. 
Venous Njevus. 
The writer has recently examined a well-defined venous nsevus in the pharynx 
of a lady aged twenty-six years that had not attracted attention until about one 
month ago, when a hemorrhage led to its discovery. 
The upper and lower lips, the tongue, the orbit, and the scalp are 
frequently the seat of the affection, and the dark claret stains or port- 
Fig. 225. 
Congenital venous naevus (original). 
wine marks in the skin of the face and neck and upon the eyelid, usually 
called mother’s marks or birth-marks, and attributed to maternal impres- SURGICAL INJURIES AND DISEASES OF THE VEINS. 
545 
sions during intra-uterine life, are true venous nsevi. They vary in 
size from the head of a pin to masses of relatively large size and dif- 
fused over large surfaces of skin, or form large tumors of divers shapes. 
Fig. 225 represents a subcutaneous nsevus of the arm of a young lady, who 
stated to the writer that it was congenital and had increased with the growth and 
development of the arm. Until examined carefully it resembled a mass of tortuous 
varicose veins. Some of these tumors pulsate; others do not. Some of them can 
be emptied by firm pressure; others are elastic, and the blood can only be dis- 
placed, owing to the thickness of the walls of the caverns and the amount of inter- 
vening hypertrophied connective tissue. 
Certain forms of carcinoma and sarcoma resemble venous nsevi in 
appearance, density, and anatomical arrangement, while distinct nsevi 
form a part of such malignant growths. Many venous nsevi (the smaller 
varieties) disappear spontaneously after birth, the blood-supply having 
been cut off; others increase in size, many of them outstripping the nor- 
mal growth of the structures containing them. In some the growth is 
so rapid as to injure by pressure-effects, by closing more or less com- 
pletely the cavities—e. g. obstructing one nasal cavity or lessening the 
calibre of the pharynx, thereby causing difficult deglutition. 
Lennox Browne1 reports varices of the throat and under the tongue, the former 
causing overgrowth of adenoid tissue and giving rise to tenesmus similar to that 
from piles in the rectum. 
Turbinal ncevi are likely to be mistaken for nasal polypi, from which 
they differ only in color and the absence of a pedicle. The deep-blue 
color of venous nsevi when very superficial renders their diagnosis easy, 
but when erectile tumors are under the scalp or under thick skin or 
mucous membrane elsewhere, it is not always possible to decide whether 
they are venous or arterial. Especially is this the case when the tumor 
pulsates, and upon being easily emptied by pressure rapidly refills. 
From the capillary nsevi of the skin, the diffused variety, the predomi- 
nance of the special vessels dilated can be decided by the color. From 
cirsoid aneurism the distinction is made by the absence of a bruit and a 
pulsation synchronous with the heart. 
Treatment of Venous (vide Chapter XXVI., Angei- 
oma).—For the smaller circumscribed variety, that tends to disappear 
spontaneously, painting with collodion will so constrict the growth as to 
lessen its size and finally cut off the blood-supply. For the claret stains 
tattooing offers a method of cure that will reward the patient one. For 
the circumscribed increasing tumors on unexposed parts of the body and 
upon the scalp the ligature, inserted subcutaneously and made to transfix 
and surround the mass so as to cut off the blood-supply, will effect a cure 
without disfigurement. 
The injection of coagulating agents is only named to be condemned. The writer 
was present many years ago when an unsightly nsevus of the upper lip was injected 
with a solution of persulphate of iron. The tumor solidified with wonderful quick- 
ness, and then afforded favorable opportunity for excision and a subsequent plastic 
operation to restore the lip. This suggestion was disregarded, and the patient died 
ten days afterward from tetanus. 
Excision offers a means for the cure of mevus, especially in those 
that do not pulsate and are situated under the skin. The bulbous cau- 
1 London Lancet, Jan., 1893, p. 177. 546 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
tery, after applying or injecting cocaine, is applicable to naevi on the 
tongue. The safest and least destructive method is electrolysis. 
Marshall1 presents this plan of treatment so graphically that it is copied here: 
“Electrolysis.—By its use we get (1) an operation which gives no after-pain; (2) 
it is free from danger; (3) there is no bleeding; (4) the scar is white, and does not 
tend to contraction in loose structures like the eyelids. In adopting this plan it 
is necessary at once to recognize the fact that it is not usually expeditious in its 
action: this is its chief drawback, because parents are apt to clamor for some 
obvious effect to be produced, and are loath to wait with patience for the gradual 
fading of the naevus, by which we get our best results. Occasionally naevi may be 
cured at one sitting without sloughing, and they may speedily diminish, but this 
is in my experience uncommon, and it is not wise to attempt to obtain so rapid an 
action, because the chances are against the effect being good. Stop the growth and 
be content to wait is the better method, reattacking if development takes place or 
its subsidence is long delayed. I always use the positive pole, with one or more 
needles according to the size of the growth and its situation. The needle (or 
needles, as the case may be) is moved about systematically to attack the growth in 
various parts. This is done without withdrawing the needle after it has remained 
long enough in one spot to produce some effect. It is wiser at first to work well 
away from the surface of the tumor, especially in raised naevi, which are very florid, 
to avoid risk of destroying the thin covering. The circuit is completed by attach- 
ing a rheophore to the negative pole : by this we avoid an unnecessary puncture, 
and I find that the process is equally effectual. I have not yet succeeded in find- 
ing a good means for insulating needles, and the scar left by the negative needles 
is brown and very disfiguring. I prefer to use the positive instead of the negative 
pole, because it is slower in its action, and therefore less likely to lead to slough- 
ing, and the bleeding on withdrawal of the needle is much less troublesome. The 
objection to the scar left by the negative needle has already been referred to. The 
number of cells used, I find in my notes, varies somewhat, but my usual custom 
is to commence with five Leclanche cells, and increase according to the effect pro- 
duced. Ten cells are generally sufficient, but in deep subcutaneous naevi I have 
applied twenty cells. The amount of tension caused must be carefully gauged, 
cutaneous naevi being capable of standing very little. Change in color to a dusky 
hue is a good guide to judge when it is requisite to stop the current. I arrived at 
the conclusions detailed here by testing the number of cells and their effect on 
naevi on the trunk, where scarring was of less importance. On withdrawal of the 
needle all that is required is, to rotate it before pulling, to free it, and then paint 
the orifice with collodion.” 
1 London Lancet, 1889, p. 73. CHAPTER XXXII. 
SURGICAL INJURIES AND DISEASES OF THE ARTERIES, 
INCLUDING ANEURISM. 
Duncan Eve, M. D. 
Structure.—In considering the Surgical Diseases of the Arteries it will suffice 
to state, briefly, that their most important structural features consist of a thin 
inner coat composed of an epithelioid lining resting on an elastic base of no con- 
spicuous thickness, the intima, continuous with the endocardium, the inner coat of 
the veins, and composing the entire coat of the capillaries; of a thick middle coat, 
the media, composed partly of muscular fibres disposed for the most part trans- 
versely, and partly of stout elastic elements, this being the thickest and most 
important of all three coats; and of an outer coat, the extima, consisting chiefly of 
elastic elements intermixed with an increasing amount of white connective tissue, 
this being the strongest and most dense of the three, the connective-tissue bundles 
being disposed for the most part longitudinally, and containing a number of con- 
nective-tissue corpuscles and a relatively large amount of elastic fibres. In many 
arteries bands of plain muscular fibres are present in this coat also, running for 
the most part, but not exclusively, in a longitudinal direction. Blood-vessels for 
the nourishment of the arterial tissues (vasa vasorum) are demonstrable in the 
larger arteries, being most abundant in the outer coat, but penetrating for some 
distance into the middle coat. Nerves, chiefly non-medullated fibres, may be 
traced through the outer coat into the middle coat, appearing to end in connection 
with the muscular fibres. Blood-vessels have not been demonstrated in the intima. 
These features are possessed by all arteries. As a general rule, the muscular 
element bears a larger proportion to the elastic element in the smaller arteries, 
they being more conspicuously muscular and the larger arteries more elastic. The 
several arteries of the body differ, however, to some extent in minor features, such 
as the relative disposition and amount of muscular and elastic elements in the 
middle coat, the amount of muscular tissue in the outer coat, and the proportion 
of white connective tissue present; in the aorta a considerable quantity of white 
connective tissue is present in the middle, and even in the inner coat, as well as 
the outer coat. While all three coats, and especially the middle coat, contribute 
to give an artery its characteristic elastic properties, expanding under external 
pressure and contracting when the pressure is removed, it is the middle coat, which 
by means of its circularly-disposed muscular fibres, by their contraction, narrows 
and constricts, and by their relaxation permits the widening of, the vessels. The 
outer coat increases the tensile strength and resisting power of the vessel. The 
importance of the inner coat is centred in its epithelioid lining, smooth and offer- 
ing but little if any obstacle to the onward flow of the blood, and being specially 
influenced thereby ; the outer and middle coats deriving their nutrition from the 
vasa vasorum; and, possibly, the inner coat being entirely dependent on the current 
of blood flowing through it. 
The arteries in their distribution are included in a loose areolar investment 
which separates them from the surrounding tissues and is called a sheath. Around 
the principal vessels this sheath is an important structure: it is composed of 
areolo-fibrous tissue, in which white connective tissue is far more abundant than 
the yellow elastic elements, the sheath being much less elastic than the artery, so 
that when an artery is cut completely across with its sheath, by elastic shrinking it 
contracts within the latter. The sheath is continuous with the fascia of the region 
in which the artery is situated, and from its blood-vessels are derived the vasa 
547 548 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
vasorum; it also contains the accompanying veins, and sometimes a nerve. The 
sheath is absent in the cerebral and certain other visceral arteries. 
The whole of the arteries proceed from a single trunk, the aorta, from which 
they are given off as branches, and divide and subdivide, usually dichotomously, 
to their ultimate ramifications. From the aorta the branches, for the most part, 
pass off at right angles, but in the limbs usually at an acute angle, and in some 
instances, as in the viscera and elsewhere, at an obtuse angle. In the division of 
an artery into its branches the combined area of the two is somewhat greater than 
that of the single trunk; and if the combined area of all the branches at the 
periphery of the circulation is compared with that of the aorta, it will be seen that 
the arterial blood is flowing through a conical space, with the apex at the aorta 
and the base at the periphery. 
Communications between arteries are very free and numerous, and increase in 
frequency with the diminution of the size of the branches, so that through the 
medium of minute ramifications the entire body may be considered as one uninter- 
rupted circle of inosculation or anastomosis. This increase of frequency of anas- 
tomosis with the smaller arteries counteracts their greater liability to impediments 
existing in, or obstructions developing within them, than in the larger vessels. 
Where freedom of circulation is of vital importance, as in the brain, this com- 
munication shown in the circle of Willis is remarkable, as it also is in the com- 
munication of the branches of the coronary arteries of the heart, being also quite 
a prominent feature in the alimentary canal, around joints, and in the hand and 
foot. Upon this free communication existing everywhere throughout the arterial 
system is based the curative principle of the ligation of the larger arteries: the 
ramifications of the branches given off above the ligature inosculate or anastomose 
with those proceeding from the trunk or its branches below, these communicating 
branches enlarging and forming a collateral circulation, first demonstrated in a series 
of beautiful preparations made by Sir Astley Cooper showing several large branches 
performing the duty of a single obliterated trunk. Under the stimulus of increased 
blood-pressure through the branches by the arrest of the flow of blood through the 
trunk a true hyperplasia of the various coats and hypertrophy of the branches 
result. Nothnagel and Recklinghausen explain the growth and increased devel- 
opment of the branches by the increased rapidity of the blood-current within 
them, and the increased amount of nutrition thus brought about. The more blood 
that passes through a vessel in a given time, the greater amount of nutritive mate- 
rial supplied to the wall of the vessel. 
Malformations and Malpositions. 
“ Defects of development in the large arterial trunks ” (Ziegler) “ are 
of grave import.” Thus, e. g., absence or imperfection of the septum of 
the aortic bulb, the aorta and the pulmonary artery arising from a single 
stem, or abnormal position of the septum, the aorta being displaced to 
the right or in extreme cases arising from the right ventricle ; perma- 
nent patency of the ductus arteriosus—a defect at one point being to a 
certain extent compensated for by an abnormality at another. 
Simple atrophy of the walls of arteries is observed in connection 
with general marasmus and atrophy of individual organs. After ampu- 
tation of a limb the arteries usually become smaller. 
The principal arteries, those requiring correct surgical knowledge, as a general 
rule have definite and analogous positions and like relations in different individ- 
uals. Anomalies of position, course, and distribution are by no means infrequent, 
and are fully considered in special and general works on anatomy, want of space 
precluding their consideration here. This must ever be kept well in mind by the 
surgeon, as well as the possibility of the occlusion of original trunks by emboli, 
thromboses, previous surgical operations and injuries, and the development of col- 
lateral branches in the vicinity. L. Testut of Lyons,1 in his monograph on mus- 
1 Les Anomalies musculaires considerees au point de vue de la ligature des arteres, O. 
Doin, Paris, 1893. THE ARTERIES, INCLUDING ANEURISM. 
549 
cular anomalies which are of importance to the surgeon, states that the large 
arteries which he has found to be occasionally covered by supernumerary muscular 
bands are the brachial, axillary, subclavian, internal mammary, popliteal, pos- 
terior tibial, and peroneal. He has met with no muscular anomalies which would 
affect the ligature of the carotids, radial, ulnar, iliacs, femoral, or anterior tibial, 
and has, consequently, left them out of consideration. 
Thrombosis. 
The circulation through the arteries being so active and energetic, a 
coagulation from stagnation is not likely to occur. A change in the 
inner wall of an artery is the commonest cause of thrombosis, but this 
is a matter of degree; and if the circulation remains vigorous, even a 
considerable change of surface will not necessarily produce coagulation. 
When the circulation is sluggish it is more apt to occur. 
In atheroma, subsequently to be considered, calcareous plates are often found 
which, in some cases by absorption of the inner coat or its destruction or disap- 
pearance, come into contact with the blood-stream and result in a deposition of 
fibrin thereon. This is most frequently noticed in the aorta, but it may occur, 
though more rarely, in smaller arteries, and cause complete obstruction of them; 
the consequences of which in the arteries of the brain or heart are very important 
or even fatal. This process is with difficulty to be distinguished from embolism, 
which will subsequently claim attention. 
Virchow attributed coagulation of blood in a living vessel to a slowing of the 
current, but it has been shown that blood may be kept stagnant in a vessel by two 
ligatures, and coagulation will not result if the vessel is kept aseptic and unin- 
jured. Slowing of the current with these conditions accompanying will result in 
coagulation, as will in less degree injury to the wall of the vessel, roughness of its 
inner coat, introduction of a foreign body, or septic infection, without change in 
the current; yet if the retardation of the latter occurs, it is more certain. The 
blood-plaques or third corpuscles are important factors in the coagulation of circu- 
lating blood. With irritation, roughness of the intima, etc., with or without re- 
tarded current, the blood-plaques rapidly leave the current of the stream and accu- 
mulate at the point in question, and numbers of leucocytes are also arrested and 
become attached thereto, thus forming a viscous mass projecting from the wall into 
the lumen of the vessel, the fibrin of the blood having an affinity for the accumu- 
lation of blood-plaques and leucocytes, binding together the mass, in which may 
be entangled red corpuscles. A clot, once formed, has a tendency to enlarge by 
coagulating the blood in contact with it. Coagulation beginning at one side of a 
vessel may spread until the vessel is blocked. 
Thrombi are spoken of as “ (1) 'parietal, and (2) obstructive, accord- 
ing as they are attached to the wall of a vessel or occupy its whole 
lumen. The one kind may, of course, pass into the other, but the 
structure of those which are at first parietal is different from that of 
those which are formed by coagulation of the whole column in a vessel.” 
“1. Parietal thrombi are always formed of successive layers. The 
first layer (as Zahn has observed during life in the transparent part of 
frogs) is formed of leucocytes with a little fibrin; on this another layer 
is deposited, and so on. For some reason, not yet understood, the suc- 
cessive layers are often different in color, some consisting entirely of 
leucocytes and fibrin, others containing red corpuscles also, producing 
an appearance like the structure of an agate. This laminated structure 
is traceable to the last in such thrombi, and is often obvious to the 
naked eye—for instance, in the layers of clot inside an aneurism. Some 
parietal thrombi are almost wholly composed of fibrin and leucocytes, 
and are known as 1 white thrombi.’ Some layers may be transparent or 550 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
hyaline, but generally there is a large quantity of a finely granular 
substance known as molecular fibrin. 
“ 2. Obstructive thrombi, consisting of the whole mass of the blood, 
will at first precisely resemble ordinary clots formed out of the body, 
but undergo certain changes. 
“ These changes are: In the first two or three days the thrombus 
becomes firmer and drier from loss of the serum squeezed out of it in 
contraction. Next it becomes somewhat adherent to the wall of the 
vessel. Later on the blood-pigment diffuses out of the corpuscles, and 
the whole clot becomes tinged of a reddish-brown color from altered 
haemoglobin or haematoidin. This is, however, absorbed, and the clot 
becomes partly decolorized, especially in the central portions. The loss 
of color is good evidence of the age of the clot. 
“ What may be considered a natural or healthy end of this process 
is the so-called ‘ organization of the thrombus.’ It becomes gradually 
replaced by a mass of connective tissue, which either converts the vessel 
into a fibrous cord or else becomes channelled and allows it to become 
pervious again.” 1 
It is an unsettled question as to whether the coagulum is an active or passive 
agent in this organization. The most satisfactory view is, that it becomes organ- 
ized by young tissue growing into it from the vessel-walls, the vasa vasorum push- 
ing their radicals on through the middle coat, beyond the intact, or more probably 
the injured or defective, intima, or its site, into the clot, developing connective or 
cicatricial tissue, disintegrating and absorbing the clot, in some instances leaving 
spaces in the newly-formed tissue, which has a spongy consistence, forming 
channels through which the blood may again circulate. 
However, another transformation of the thrombus may occur, or 
what is known as softening-. The fibrin and leucocytes disintegrate 
into a fatty mass, which forms a slimy fluid of pulpy or creamy consist- 
ency in the inner layers of the thrombus, and it is thus broken up. 
The microscope shows this to be granular matter with shrivelled and 
degenerated leucocytes. Rarely, the number of the cells is so great as 
to present an appearance very similar to pus, pus itself only developing 
under septic influences. 
The result of this softening is, that (1) the softened matter may pass 
into the blood without injurious consequences, the only result being that 
the channel of the vessel is opened up ; (2) a fragment may be carried 
on into some smaller vessel, which it will obstruct, forming an embolus; 
(3) the matter may contain septic material (pus), producing general dis- 
ease or setting up suppuration or necrosis at the point where it becomes 
ultimately lodged. Fragments of thrombi may be detached by the 
force of the blood-stream, by movement or some mechanical accident 
without softening, and be carried off to be lodged elsewhere as an 
embolus. 
Emboli may be formed from other substances than a blood-clot. 
When tissues containing fat are broken down by injury or disease, 
drops of fluid fat enter the circulation, and may be lodged in the 
branches of the pulmonary arteries and capillaries. Emboli are simple 
or mechanical and specific, the one producing only the effect of obstruc- 
tion. the other general or localized septic infection. Simple obstruction 
1 Manual of General Pathology, John Frank Payne, M. D., 1888. THE ARTERIES, INCLUDING ANEURISM. 
551 
of an artery by an embolus is generally indicated by the suddenness of 
the symptoms, referred to the part beyond the obstruction. In most 
cases the obstruction is increased by the extension of a thrombus from 
the embolic mass. The column of blood both in front and behind the 
embolism is brought to a state of rest and coagulates. This also occurs 
in partial obstruction. 
The embolus is most frequently arrested at the bifurcation of an artery, and 
secondary thrombi may extend into the branches. Vegetations carried away from 
the aortic valves, lodging in the middle cerebral artery, with or without subse- 
quent thrombosis, suddenly developing hemiplegia, aphasia, and other symptoms 
showing a morbid condition of that part of the brain supplied by this arterial 
branch, constitute a by no means uncommon form of cerebral embolism. In the 
same condition of the aortic valves there may be sudden and painful obstruction 
of the femoral artery, the embolus lodging at the giving off' of the profunda, the 
limb becoming cold, pulseless, and subsequently gangrenous. 
“ If the main artery of a limb be blocked,” says Payne, “the anastomosis may 
be perfect enough to restore the circulation after a time, so that no permanent 
effects follow. If the anastomosis be insufficient, we get, in the external parts, 
gangrene.” 
If an artery going to an internal organ is blocked, there will in many cases be 
sufficient lateral anastomosis to restore the circulation; but if a terminal artery 
is occluded, the consequences are very apt to prove serious by reason of rapid 
necrosis (softening), slow necrosis (wasting), or a hemorrhagic infarction. 
Emboli only move in the direction of the blood-current in the arteries. 
The treatment of thrombosis and embolism is mainly prophylac- 
tic. Their thorough consideration is of importance in the treatment of 
surgical diseases and the pathology of the arteries.1 In some instances 
the production of a thrombus is essential. Care should be taken, how- 
ever, in all cases that the thrombus does not give rise to embolism. The 
parts therefore should be kept perfectly at rest, with as slow and easy 
pulsation as possible, until organization or absorption of the thrombus 
occurs. 
Arteritis. 
Inflammation of arteries as a result of extension from the tissues 
adjacent is of common occurrence; however, they are more resisting 
than many other tissues; thus in hospital gangrene, now rarely seen, 
they are the last of the soft parts to yield to the destructive invasion, 
and have been often seen completely uncovered or lying loosely in a 
mass of necrotic and sloughing material, still serving the important 
purpose of carrying the vital fluid on to more distant parts. In malig- 
nant disease the walls of the arteries may be thickened even to the 
extent of occlusion by irritative hyperplasia, or blocked by clot, thus 
preventing serious hemorrhage in many instances as the process of ero- 
sion advances. It is yet an open question whether acute arteritis occurs 
as a primary affection. A few doubtful cases have been recorded in 
which severe pain and tenderness existed along the course of an artery, 
in some instances accompanied by a certain degree of redness and swell- 
ing. The diagnosis has been made, but, a favorable termination occur- 
ring, pathological proof demonstrating its existence is wanting. 
Each coat of an artery may be separately involved; thus we have 
'periarteritis, mesarteritis, and endarteritis, these distinctions being more 
1 For more thorough consideration of the pathology of thrombosis and embolism see 
p. 32 et seq., Chap. II., “Surgical Pathology of the Blood.” 552 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
important in a pathological point of view than for curative treatment at 
the hands of the surgeon. Mesarteritis is generally an accompaniment 
of endarteritis, fibrous deposits hiking the place of normal elements and 
muscular fibres as they gradually disappear in the middle coat. The 
changes rarely extend to the same 
degree in the intima, but here and 
there the normal tissue may be com- 
pletely replaced by cicatricial or 
fibrous tissue. Periarteritis, usually 
secondary in character and due to 
extension from surrounding lesions, 
results in fibrous thickening and 
condensation of the outer coat. The 
thickening may be diffused or ag- 
gregated into coarse bands or nodes 
—periarteritis nodosa of Kussmaul 
and Maier—or destructive ulceration 
may occur. In destructive inflam- 
mation and ulceration of the arterial 
coats the lumen of the vessel is gen- 
erally occluded by a thrombus before 
perforation occurs. Should throm- 
bosis not develop, severe and some- 
times fatal hemorrhage may arise if 
the artery be of sufficient size. 
Acute arteritis is a rare surgi- 
cal disease, and is due to infectious 
material or to toxic embolus lodged 
in the vessel. The internal coats 
Fig. 226. 
Fig. 227. 
Arteritis and periarteritis nodosa; small 
artery from peritoneum: b, thin mus- 
cular layer; c, adventitia; k, thrombus 
(Fletcher). 
Cross-section of same artery : a, thickened and 
confused intima and media ; c, zone of leuco- 
cytic invasion, at / merging into surrounding 
connective tissue (Fletcher). 
become swollen and infiltrated with pus-cells. The suppurative pro- 
cess may extend to the other coats of the artery and surrounding parts, 
and may result in abscess. 
Syphilitic arteritis may occur, either as an independent disorder or 
as part of a local syphilitic affection. The intima and adventitia are THE ARTERIES, INCLUDING ANEURISM. 
553 
thickened by fibrous hyperplasia or diffused cellular infiltration. The 
media may be but little altered, or here and there atrophied and fibrous. 
The thickening of the coats may be so extensive as to almost or entirely 
occlude the lumen of the vessel. 
Tuberculous inflammation is very common in arteries running 
through organs or tissues involved in tuberculous infiltration. Tuber- 
cles and diffused patches may appear in their walls, and if the granu- 
lomatous focus becomes caseous, the vessels undergo the same changes, 
rupturing or giving rise to hemorrhage, unless prevented by a previously 
formed thrombus. 
External injuries of the soft parts may result in hyperse'mia and congestion of 
the arterial coats, attended by throbbing pain along the course of the artery in- 
volved, subsequently subsiding or developing localized atheroma. Ziegler says: 
“ Purulent arteritis, issuing in suppuration and destruction of the wall of an artery, 
is generally a secondary process occurring within suppurating wounds and ulcers. 
Inflammation and necrosis extend by continuity from the surrounding tissues to 
the vessel, destroying first the adventitia and then the other coats. The wall 
appears thick and yellowish or gray in color; the intima is turbid, yellowish or 
grayish, and infiltrated with pus. Often the brittle or rotten vessel gives way and 
hemorrhage follows. Secondary hemorrhage in wounds, haemoptysis in phthisical 
lungs, hemorrhage from cancerous ulcerations, etc. are all of this nature; and in 
the same way fatal bleeding may occur from suppurative inflammation of the um- 
bilical cord in infants. At times, as in tuberculosis, the necrotic process takes on 
a caseous character. Sometimes purulent arteritis with necrosis is due to the 
entrance of irritant matters into the blood, as happens in embolism when the 
emboli are virulent or infective. When the destructive process spreads from the 
vessel to the neighboring tissue abscesses are formed. The pus-corpuscles which 
in these processes accumulate in the substance of the vessel-wall are in part 
derived from the vasa vasorum, in part from surrounding vessels. 
Patty degeneration occurs in the inner coats of arteries, especially 
the aorta, carotids, and cerebral arteries, developing small, rounded or 
angular whitish spots, which are elevated slightly above the surface, the 
fatty changes first taking place in the connective-tissue corpuscles, and 
subsequently the intermediate substance softening, the masses of fat- 
granules falling apart and being carried away by the blood-current, 
leaving velvety-looking depressions. 
Calcification, most frequently met with in the peripheral arteries, 
occurs chiefly in the middle coat, and consists of a deposit of earthy 
matters, mostly calcium phosphate, with a little carbonate, forming 
plates, rings, or tubes, known as laminar, annular, and tubular calcifica- 
tions. The result is a deficient supply of blood, owing to a narrowing 
of the lumen of the vessel and want of contractility. When it is exten- 
sive enough to entirely occlude the vessel, gangrene may result. It is 
often readily detected in superficial arteries, as the radials, by the finger 
placed on the vessels, which feel hard, rigid, and unyielding. Calcifi- 
cation occurs chiefly in cases where the nutrition of the cell-wall is 
impaired and when degeneration of tissue has already taken place. It 
is a very common sequel of fatty change, and also of atheroma or scle- 
rosis. The calcareous matter is deposited in the intima as well as the 
media. In the former it is mainly the atheromatous patches which 
become calcified, forming definite and cohering plates which may be 
removed entirely. When in the media the whole vessel may be con- 
verted into a hard and rigid tube, noticed most frequently in the larger 
and middle-sized arteries of the trunk and limbs, the inner surface often 554 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
having a ribbed or corrugated appearance, from which, if the intima is 
peeled off (which may be readily done), it is seen that the ridges spring 
from the middle coat, the intima being more or less atheromatous. The 
deposit of ossific matter in the arterial coats—ossification—occurs but 
rarely. 
Atheroma, also known as arterio-sclerosis (chronic arteritis?), is a 
degeneration of the arteries, fatty and atheromatous, usually attended 
with thickening of the intima, later also of the media. It is a process 
common to age, when it is found attended with other evidences of senility, 
as the arcus senilis, atrophy of the kidneys, and general atrophy, and is 
an expression of involution. 
The condition is developed in maturity and youth by errors and excesses in 
diet, alcohol, syphilis, rheumatism, and gout; hence the expression that has been 
used, that “ a man is as old as his arteries.” One-half or more of the cases of 
atheroma have been known to have been preceded or accompanied by rheumatism 
or gout, the former occupying by far the larger proportion of the two. It may 
occur in any condition which raises the pressure in the arterial system, as hard 
work, luxury, and a sedentary life. It arises also in cases of retention of toxic mate- 
rials, as in diabetes, uraemia, and gout. It occurs more frequently in males than 
in females, in the old than in the young. Those vessels subjected to the greatest 
strain suffer first, as, in the order of frequency, the ascending aorta, its arch, the 
descending aorta, the splenic, iliac, and crural, the coronary, cerebral, uterine, 
brachial, radial, and ulnar arteries. The disease process shows itself first as simple 
thickening of the intima, and is followed by fatty degeneration, with the deposit 
of calcareous matter, often by subsequent ulceration and cicatrization. The first 
changes may be so slight as to be scarcely noticeable, but soon the internal surface 
becomes roughened and irregular, and opaque yellowish patches are seen here and 
there. The patches consist of a rapid proliferation and multiplication of the cells 
of the subendothelial tissues, which may become so numerous as to push the endo- 
thelial cells before them, encroaching upon the lumen of the vessel even to the 
point of obliteration ; and the endothelial cells themselves are in many cases the 
seat of a true hyperplasia. 
Atheroma occurs in two forms, nodular or localized—mostly seen in 
the aorta and larger vessels—and the diffused. 
In the nodular form there are seen upon the inner lining of the 
artery grayish or yellowish elevations presenting an appearance not 
unlike cartilaginous plates, the edges either abrupt or gradually sloping. 
In size these sclerosed spots vary from small points to that of an inch 
or more in diameter, and may be so numerous as to thickly stud the 
intima. Later, degenerative changes or necrotic softening occurs within 
the plates, and they are then composed of soft, grumous, molecular mate- 
rial, developing into 'atheromatous abscess, which may rupture on the sur- 
face of the intima, discharging its contents, leaving an irregular necrotic 
area, the atheromatous ulcer, often covered with fibrinous deposits ; the 
final change being calcification, which may occur in the base of the 
atheromatous ulcer or in the plates before rupture. True ossification has 
occasionally been observed. The media and adventitia may be thicker 
than normal, the former presenting more or less calcareous infiltration. 
In other instances, especially when localized dilatations of the vessel are 
present, the middle and outer coats are thinned and degenerated. Fibrin- 
ous thrombi are apt to form on the ulcerated surfaces. 
The diffused form of atheroma is most often met with in the 
smaller arteries, being frequently seen in strongly-built, muscular men 
whose work has been laborious and who have been much exposed. The THE ARTERIES, INCLUDING ANEURISM. 
555 
arteries are thickened and dilated, and at the same time lengthened, so 
that they become more or less tortuous. The intima presents spots of 
a dull-white appearance, but not distinct nodules; and there may also be 
areas of degeneration. The subendothelial tissue is greatly thickened: 
and the muscle-fibres in the media variously degenerated, sometimes dis- 
tinctly fatty or necrotic,, at other times converted into hyaline material, 
all resemblance to muscular tissue being lost. The adventitia is thick- 
ened and dense. 
Taking the well-known etiological factors of atheroma, dissipation, excesses, 
errors in diet, rheumatism, gout, syphilis, etc. and toxic conditions of the blood, 
thereby interfering with perfect nutrition of the intima, developing excessive and 
possibly defective cell-proliferation of the subendothelial tissue, and imperfect 
development of the endothelial cells, are of paramount consideration. Laborious 
work, excessive muscular effort, with or without exposure, increasing the cardiac 
force, also interfere with the proper nutrition of the intima. Strain is very gen- 
erally accepted as a sufficient cause for the production of changes in the vessels, 
whether it results from the repeated and sudden increase of blood-pressure incident 
to excessive muscular effort, or from the repeated overfilling of the blood-vessels, 
due to excessive alimentation of the bon vivant. Mental strain and anxiety may 
also have a like influence. 
Contusions and external injuries, having a temporary influence upon the intima 
of an artery, which may be perpetuated to the development of local atheroma from 
traumatism, the hyperaemia, instead of subsiding, may so interfere with the nutri- 
tion and development of the endothelial cells as to result in atheroma. 
Hypertrophy of the heart, which so uniformly results from atheroma, occurring 
independently of this condition, driving the blood on more forcibly, may so inter- 
fere with normal nutrition of the intima at certain localities as to be a causative 
factor. 
Alanus observed sclerosis of the temporal and radial arteries in a young man 
under forty years of age, temperate, but a vegetarian. Raymond saw it in a num- 
ber of young monks, vegetarians; and Treille remarked it of the inhabitants of 
Bombay and Calcutta, who live largely if not exclusively on rice. According to 
Galen, “ vegetable food injures the blood-vessels and precipitates the changes of 
age.” 
In the early stages of atheroma, when the elasticity of the aorta and other 
arteries has been impaired by degeneration of the media and adventitia, there is 
increased demand upon the heart, and in consequence hypertrophy is commonly 
present. The weakened arteries are prone to undergo dilatation, with formation 
•of aneurism. Thoma limited this period to about a week's duration, this being 
the date preceding the compensatory thickening of the intima; after which aneur- 
isms are less likely to be developed. 
Symptomatology.—Degenerative changes may be shown in autopsy 
which were unsuspected during life, owing to the mildness or indefinite- 
ness of the symptoms. So few of the arteries involved are within reach 
of tactile investigation, and early diagnosis is of such importance, that 
it is necessary to carefully consider even slight changes in any clinical 
phenomena in order to arrive at a correct conclusion. We may first find 
indications from the pulse : its tension may be high, although the hard- 
ening of the artery may amount to nothing, but sometimes we find the 
one accompanying the other, the radial being felt as a hard, rigid cord, 
which can be traced up the arm to the brachial and axillary. The pulse- 
wave is rather slow from want of elasticity of the vessel, the sphygmo- 
graph showing a short up-stroke with broad summit, and slow, gradual 
descent. The loss of elasticity and increased blood-pressure may also 
be indicated by the tortuous character of the temporals, and sometimes 
by the radial and brachial. 
Hypertrophy of the left ventricle is early manifested by increased area 556 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
of cardiac dulness and augmented force of the systolic sound. The 
second sound of the heart heard over the root of the aorta is decidedly 
accentuated and ringing—a natural result from increased arterial pres- 
sure, or, more properly, resistance. Dilatation may follow hypertrophy 
with its usual train of symptoms. 
The detection of atheroma at the wrist is not positive information as to its 
existence elsewhere, and autopsy will sometimes show serious lesions of internal 
arteries when those more superficial are normal; yet we may usually look for 
arterial lesions when we find obvious changes at accessible points. 
One of the most important regions affected is the brain, indicated by headache, 
vertigo, or syncopal seizures, or cerebral hemorrhage due to the rupture of an 
atheromatous vessel or miliary aneurism, or embolism or thrombosis followed by 
impairment of memory, weakness of intellect, etc., due to cerebral softening. 
When the cerebral vessels are involved an interesting diagnostic point is an oph- 
thalmoscopic examination, which shows pulsation of the retinal vessels, dilated 
veins, and whitish spots of degeneration of the retina. 
Kidney-changes are common, and may follow or precede the arterial lesion. 
The symptoms of contracted kidney—urine increased, diminished specific gravity, 
a small amount of albumen with hyaline casts—may be found. 
Treatment.—It is generally accepted that organic changes in the 
arteries, as elsewhere, offer but little if any promise as regards curative 
treatment. However, Bartholow, with others, has claimed that the 
double chloride of gold and sodium has the power of absorbing connec- 
tive-tissue growth, and hence is useful in arterio-sclerosis. Others have 
claimed benefit from iodide of potassium, whether due to syphilitic lesion 
or otherwise. Billings claims that Basham’s mixture, or tr. ferri alone 
or with dilute phosphoric acid and glycerin, has given good results ; 
with Huchard he also places stress upon milk as a diet. 
Prophylactic measures and means to stay further invasion are of greater import- 
ance. Of the utmost necessity is the avoidance of those diseases, habits, and 
customs which have been known to be productive of this condition. A quiet, well- 
ordered life, free from mental and bodily strain, avoidance of excesses in eating 
and drinking, as well as excesses in muscular exertion, are essential, together with 
good hygienic surroundings and a sufficiency of sleep at regular hours. Complete 
attention to the eliminatory organs, clean and freely-acting skin, and proper work on 
the part of the kidneys and bowels must not be lost sight of, and the patient should 
be thoroughly instructed as to the details of his daily life. If the heart’s action 
should seem to be excessive as a result of high arterial tension, it may be modified 
by a cautious use of the nitrites, amyl, nitro-glycerin, etc. Bleeding may prove 
beneficial in some instances. When the heart’s power shows indication of failure 
cardiac stimulants may be resorted to, but with the utmost caution for fear of 
rupture of the cerebral or other weakened vessels. 
Aii aneurism is a tumor filled with blood and communicating with 
the lumen of an artery. With this general definition we have several 
material modifications. 
A true aneurism is one in which the walls of the sac are formed by 
the coats of the vessel, of which one at least is intact. It may be sac- 
cular, sacculated, or sacciform, consisting of a pouch projecting from one 
side of the vessel and communicating by a small or large opening with 
the latter. It may rupture and become diffused. A hernial aneurism 
is one in which the inner coat or the inner and middle coats are pro- 
jected through the outer coat; it may be sacculated or may rupture and 
become diffused. A cylindroid, tubular, or fusiform aneurism is formed 
Aneurism. THE ARTERIES, INCLUDING ANEURISM. 
557 
by a uniform dilatation and growth involving the whole circumference 
of an artery; it may rupture and become sacculated or diffused. A 
dissecting aneurism is one making its way between the coats of the 
artery; it may be sacculated, may rupture, and be a diffused or false 
aneurism, and yet again become circumscribed. A traumatic aneurism 
is one produced by a wound, traumatism, or injury of an artery from 
within or without, and may be diffused or circumscribed ; or arterio- 
venous, constituting aneurismal varix, in which the blood is poured into 
an adjoining vein ; or a varicose aneurism, through an intervening aneur- 
ismal sac, and then into the vein. Nearly all traumatic aneurisms and 
all diffused aneurisms are false aneurisms, having no arterial coat around 
them. Arterial varix is a single dilated and tortuous condition of 
smaller arterial vessels and capillaries. 
Aneurisms are thus, from an etiological standpoint, divided into trau- 
matic and spontaneous or endogenous. 
External aneurisms include those outside the visceral cavities, and 
are named from the vessel affected, as carotid, popliteal, etc.; and internal 
aneurisms are designated by the cavity in which they occur, as tho- 
racic, those of the thoracic aorta and its branches, including cardiac 
aneurism, a partial sacculated dilatation of the heart; abdominal, of the 
abdominal aorta and its branches; pelvic and intracranial, the latter 
including orbital aneurisms. Internal aneurisms are also designated by 
the name of the vessel involved. 
They all present certain clinical phenomena in common : (1) The 
development of an elastic pulsating tumor, which is diminished in size 
by pressure on the tumor or the artery on the proximal side of it, and 
increased in size by pressure upon the artery on the distal side; (2) 
aneurismal murmur or bruit, heard over the tumor; (3) signs of pressure, 
as absorption of neighboring parts and tissues, even bone; pain and 
paralysis from pressure by the tumor on adjacent nerves. 
Results of Aneurism.—An artery involved in aneurismal dilatation 
never returns to its normal state ; the dilatation, if changed at all, tends 
steadily to increase. The Avails become thinner and Aveaker, and, Avhile 
the irritation may develop an increase of tissue in the Aucinity, it is 
unable to furnish an efficient substitute for the loss or attenuation of the 
original arterial coats. The sac ultimately gives Avay at some point, and 
in the case of aortic and other dilatations affecting the larger vessels 
fatal hemorrhage ensues. Fatal cerebral hemorrhage or apoplexy, and 
haemoptysis in pulmonary tuberculosis, may result from the rupture of 
minute or miliary aneurism. An untreated aneurism may also cause 
death by pressure on important parts, by inducing syncope or by causing 
gangrene. 
Spontaneous cure—unfortunately, a rare termination—may be 
effected in ways, and the modes of treatment subsequently to 
be considered are but imitations of nature’s methods: 
(1) The most frequent method is by the gradual deposit and subse- 
quent consolidation of laminated coagula, and is seen almost exclusively 
in sacculated aneurisms and arteries of the second or lesser magnitude, 
the dilatation forming a diverticulum in which the blood circulates 
more sloAvly, and the morbid condition of the intima in addition faA’or- 
ing the formation of a coagulum in successive layers, thus encouraging 558 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
the separation of fibrin and the consequent formation of a laminated 
clot. Stanley observed an aortic aneurism spontaneously cured in this 
way. This mode of cure is imitated in the medical treatment of 
aneurism, as well as the surgical treatment by pressure on the cardiac 
side of the aneurism, by flexion, and to a certain extent by Wardrop’s 
operation. 
(2) The artery below the sac may be plugged by an embolus from the 
previously formed coagulum, or the artery above the sac may be 
occluded by an embolus from the heart or another aneurism, the former 
being imitated by Brasdor’s operation and the treatment by manipula- 
tion ; and the latter by Anel’s method. 
(3) Irritation of the sac may cause coagulation within, and is imitated 
by direct pressure, galvano-puncture, and the injection of irritating 
fluids. The clot formed in this way is apt to be soft, and may subse- 
quently disintegrate. 
(4) Finally, bv suppuration and gangrene previously occluding the 
artery and extruding the sac as a slough. This is the method of the 
“ancient cure,” or the operation of Antyllus, which practically is an 
excision of the aneurism. 
When spontaneous cure results the sac becomes firm and contracted, the pul- 
sation and bruit disappear, the circulation being carried on by collateral branches. 
It is only in comparatively small arteries that we may expect complete oblitera- 
tion spontaneously by filling up of the sac with cicatricial tissue, the formation of 
such tissue probably being preceded by the occurrence of a thrombus in the sac, 
subsequent organization of the thrombus, and the development of collateral cir- 
Fig. 228. 
Chronic endarteritis: a, media of obliterated vessel; l, elastic tunic (media); e, interna; c v, 
fibrous connective tissue occupying original lumen ; a', a", inflamed nerves ; v, healthy nerve; 
v, arteriole with vegetating endarteritis ; scl, sclerotic tissue (Letulle). 
dilation. In large aneurisms we frequently find large, firm, laminated, partly 
decolorized or mottled thrombi more or less completely occupying the cavity. At 
various points we may find evidence of partial proliferation of the elements of the 
intima in contact with the thrombi, leading to the development of fibrous tissue ; 
but such thrombi rarely if ever undergo complete organization, affording but an THE ARTERIES, INCLUDING ANEURISM. 
559 
imperfect defence against rupture, as the blood may find its way between the 
thrombus and the vessel-wall, and the thrombi may undergo softening, disintegra- 
tion, and even liquefaction; sometimes calcareous salts are deposited, and they 
become calcified. In rare and occasional instances of fusiform or tubular aneurisms, 
even in comparatively large arteries, observed principally in the aorta and the 
larger branches, laminated thrombi may also entirely fill the cavity of the 
aneurism, leaving a canal for the passage of the blood, and by hyperplasia and 
hypertrophy the different tunics become greatly thickened and increased in 
strength and density, the effect of gradual and long-continued interstitial deposits 
of fibrous tissue, resulting in spontaneous cure. 
Etiology.—The development of an aneurism is due invariably to 
pre-existent disease or injury of the arterial coats, sclerosis or atheroma 
Fig. 229. 
Aneurism of an artery from the pia mater, of mycotic-embolic origin: a, adventitia; h, hyaline 
intima covered with thrombi; r, red thrombi (Eppinger). 
being the commonest cause. Sacculations are especially apt to occur 
when the intima and media are simultaneously affected by active disease 
or degeneration. Affections of the adventitia may lead to aneurism 
when they are such as extend to the media and occasion muscular 
degeneration there. These conditions all diminish the elasticity and 
strength of the arterial wall, so that the pressure of the blood causes it 
to stretch and give way. We usually find the intima wanting or highly 
atheromatous, the muscular elements of the middle coat being lost 
altogether or fatty and degenerated, the elastic fibres showing granular 
change. The intima or media, or both, may here and there be wanting 
entirely, while the adventitia is usually thickened and infiltrated with 560 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
exudations. According to the Ponfick,1 emboli consisting of calcified 
endocarditic vegetations may lodge in the Avail of an artery—possibly 
of the brain, for example: there they work or bore their way into the 
tissue of the Avail until it at length gVes AA’ay and a sacculation is 
formed. 
Age has an important influence on the occurrence of aneurism. We find by 
far the majority of cases occurring about the middle period of life, the decade 
from thirty to forty years of age being that in which we have by far the greater 
frequency of occurrence of atheromatous degeneration, while at the same time the 
heart has not lost any of its impulsive force; there are more frequent calls upon 
the entire muscular development for periods of increased alid extraordinary exer- 
tion, and when the degenerated vessels, enfeebled and inelastic, becoming exposed 
to powerful causes of distention, may readily give way or be dilated at some one 
weakened point. After the age of forty the heart’s action, as well as general 
muscular force, gradually becomes weakened, and we find the frequency of occur- 
rence gradually decreasing. Aneurism is rare before the age of puberty, the few 
occasional cases being rather surgical curiosities. Erichsen says that “ Svme 
mentions a case of popliteal aneurism in a boy of seven Hodgson had a prepara- 
tion of a carotid aneurism in a girl of ten, and Schmidt a case of spontaneous 
aneurism of the radial artery in an infant eight weeks old. R. W. Parker, after a 
careful search of medical literature, only found 15 cases recorded as occurring 
under the age of twenty. Gross says that “ men suffer from aneurism more fre- 
quently than women, but in what proportion has not been determined.” The 
same principles influenced by age govern sex. Occupation also has its bearing, 
and we find a greater frequency of occurrence in those subjected to occasional 
over-exertion of muscular and cardiac force. Climate also has its influence, and we 
find a greater frequency in cold than in hot countries: it is not so much locality 
and meteorological influences, however, as it is the habits of the people that predis- 
pose to it. Cachexy, induced by any cause, as syphilis, rheumatism, gout, errors and 
excesses in diet having a tendency to develop structural changes in the arterial 
coats, is of importance as a factor. Embolism is an occasional cause, noticed most 
frequently in the popliteal artery, producing first obstruction in the calibre of the 
vessel, and then softening, disintegration, and dilatation of its walls. 
The direct and exciting causes are limited to blows, ivounds, 
violent muscular strains, or increased cardiac impulse even from mental 
excitement or other causes. The degenerated coats may give way under 
the influence of a direct blow or concussion, or severe muscular exertion 
or inordinate force of ventricular contraction unduly stretching the 
inelastic vessel. 
Varieties.—Various classifications have been observed by different 
authors. I can but regard the following as being full and complete, 
and more in accordance with the general features presented, simple, and 
readily understood: 
1. Sacculated or Sacciform Aneurism : 
This may result in— 
A. Hernial aneurism ; 
B. Diffused aneurism, the latter being a form of 
False aneurism. 
2. Cylindrical, Tubular, or Fusiform Aneurism. 
3. Dissecting Aneurism : 
This may become— 
1. Sacculated; 
B. Diffused and false aneurism. 
C. Circumscribed aneurism. 
1 Virch. Arch., vol. lviii. THE ARTERIES, INCLUDING ANEURISM. 
561 
4. Traumatic Aneurism. 
This may be— 
C. Circumscribed, 
B. Diffused; 
D. Arte) do-venous, 
/. Aneurismal varix, 
(j. Varicose aneurism, 
e. False aneurisms. 
5. Arterial Yarix and Cirsoid Aneurism. 
6. Aneurism by Anastomosis, or Angeioma. 
(1) Saccular Aneurism.—Of the two grand divisions, according to 
this classification, we find the saccular the most frequent. It essentially 
consists of a formation of a pouch, bag, or sac connected with the side 
of the affected artery. It may even develop from some point of a cylin- 
drical or tubular dilatation or aneurism. It is capable of assuming a 
great variety of forms, the most common being globular or ovoid—in 
rare cases, conical, elongated, or irregularly flattened. It may vary 
materially as regards dimensions, in some instances not being larger 
than a hazel-nut; in others it is as large as the fist or even the head of 
the patient; in general, however, so long as it remains a simple saccu- 
lated aneurism it is not larger than an orange. 
The attachment of the tumor to the artery is commonly by a narrow footstalk, 
but in some instances it is by a broad and extended base, in which case it is not 
unusual for the artery to suffer serious compression during the progress of the 
tumor. The orifice of communication in the first method of attachment is pro- 
portionately small, with smooth and well-defined margins. In the latter it is 
always much larger, its edges irregular, sometimes quite shreddy and ragged, as if 
the vessel had been rent or torn. The internal and middle tunics may terminate 
abruptly at the margins of the sac or may extend into its cavity, and serve for, at 
least, a partial lining. By the rapid proliferation of tissue in the adventitia and 
media there is usually such a blending of the various elements that the separa- 
tion of the several coats in an aneurism of large size becomes very difficult if not 
impossible. So long, however, as the external coat remains intact, it may be 
regarded as a simple sacculated tumor. 
The first thing that happens is the loss of tensile strength of the middle coat 
through pre-existing disease of it and the intima, or possibly a rent, fissure, or 
crevice, which gradually enlarges under the influence of the impelling current of 
blood, and thus permits the corresponding portion of the elastic adventitia to be 
converted into a pouch. This pouch, originally composed exclusively of the adven- 
titia, would be very weak and unable to withstand the shock of blood driven into 
it. Nature, however, comes to the rescue, and under the influence of irritation, 
caused by pressure of the developing tumor, pours out both in the adventitia and 
adjacent tissues plastic matter: this effusion rapidly becomes organized, blending 
the tissues together in a firm and more resisting mass. Under the same influences 
there may be more or less proliferation of the muscular elements belonging to the 
media, as well as, in some cases, the interior being lined, if not with a perfect, yet 
a fair ensemble of the intima. “ Such aid, then,” says Gross, “ is wise and need- 
ful, and, fortunately, always comes into play at an early stage of the disease,” the 
yielding of the arterial coats, the pressure of blood within, and the pressure of the 
tumor on adjacent structures developing sufficient irritation from the rapid effu- 
sion of plastic exudates and the proliferation of cellular and other elements. 
Gross further says: “ When the periosteum contributes to the formation of the 
sac, as it occasionally does in aneurism of the thoracic aorta, the walls of the tumor 
may be partly earthy, or even partly osseous.” 
Hamilton 1 says : “ It is possible that an aneurism may be sacculated without 
a lesion of either the internal or middle coats of the artery; that is, like the fusi- 
form aneurism, it may be formed by a dilatation of all the coats. This condition, 
however, can never obtain except in the case of small aneurisms, and even in these 
1 The Principles and Practice of Surgery, p. 197, 3d ed., 1886. 562 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
cases its occurrence must be regarded as altogether exceptional. In almost all 
cases one or both of the internal coats have given way, and the sac is composed 
only of the external coat, with such adventitious coverings as a certain degree of 
inflammatory action may have provided.” 
The sac varies in thickness, in different cases and under different 
conditions, front the fourth of a line to the fourth of an inch thick, or 
even thicker, at some points as the tumor develops the sac becoming 
much thinner than at others. Usually the sac is quite tough, and in 
cases of long standing is composed of various strata, grayish, whitish, 
or drab-colored, consisting of fibres intersecting eacli other in all direc- 
tions. The outer surface is rough and irregular; the inner, if at first 
smooth, subsequently becomes rough and encrusted with fibrinous con- 
cretions. Notwithstanding the thickness of the sac and the reparative 
effects of nature by means of plastic exudation, owing to the absence 
or deficiency of the muscular fibres it gradually dilates under the con- 
tinued influence of the inflowing blood-stream, and at one or more points 
manifests a disposition to yield, and at length gives way, the activity 
Fig. 230. 
Multiple aneurisms of the mesenteric arteries (Eppinger). 
of the absorbent vessels, according to some writers, exceeding those of 
repair. 
The sac always contains, even at an early period of formation, fibrinous masses, 
that not only strengthen the tumor, but aid in its obliteration, and in rare instances 
its spontaneous cure. They are arranged in concentric layers or laminae piled one 
upon the other, and closely connected with one another and with the wall of the 
sac. Their color and density vary according to age of development, the outer and 
older being pale and yellowish and of a firm, fibrinous consistency, while the inner 
ones, of more recent date, resemble very much an ordinary blood-clot; in thick- 
ness they range from one-fourth of a line to that of a sheet of paper, and may 
number several hundred in an aneurism the size of an orange. The diminished 
movement of the blood in the sac, and the altered conditions of the sac-wall 
from that of normal endothelium, cause the deposition of fibrinous material in 
which is entangled both white and red blood-cells, and, as the fibrin contracts after 
deposition, the red corpuscles are squeezed out or disintegrate and again mingle 
with the fluid blood, the leucocytes, or a part of them, and the fibrin remaining, to PLATE XVII. 
Large Aneurism of Aorta, showing Lamination of Clot in the Effort at 
Consolidation. (Specimen in Museum of the Medical Department, Univer- 
sity of Buffalo.) THE ARTERIES, INCLUDING ANEURISM. 
563 
subsequently become organized into a lamina. In the older layers no corpuscles 
are distinguishable, but much fatty and granular matter is found, the result of 
their disintegration. In fusiform aneurisms, in which the flow of blood is rapid 
throughout the dilatation, adhesion takes place with difficulty, while in sacculated 
aneurisms, the movement of the blood being retarded, laminated fibrin is nearly 
always deposited. It will afterward be shown that modes of treatment by which 
the flow of blood in the sac is retarded are of the greatest importance. 
(A) Hernial aneurism, or aneurismal hernia, is of so rare occurrence 
that its existence has been questioned. Among the older writers, Haller, 
Dupuytren, Breschet, and others have given particular descriptions of 
it. It is saccular in form : the outer and middle coats having yielded 
to erosive or other destructive action, the inner coat is pushed out in the 
form of a thin translucent cyst. 
Pressure on adjacent tissues oc- 
casions interstitial plastic de- 
posits, strengthening the sac. 
Soon, however, under the in- 
11 uence of continued blood- 
pressure from within, it will 
burst and result in a diffused 
or circumscribed hemorrhage, 
which subsequently may be 
walled in by adventitious ma- 
terial, forming (e) a false an- 
eurism. 
(B) Diffused Aneurism.—A 
sacculated aneurism may give 
way under erosive action or the 
influence of increased pressure 
from within, the effect of violent 
cardiac impulse, muscular ex- 
ertion, or severe compression. 
Only a small quantity may es- 
cape, and if it should coagulate 
very firmly; the clot so formed 
may serve for a time as an effec- 
tual barrier against further loss. 
Most generally, however, the 
hemorrhage is extensive, and 
the newly-extravasated blood, 
mingled more or less with coag- 
ula of recent formation and not 
firmly adherent to each other 
and the wall of the sac, speedily 
coagulates, gradually assuming 
a greater degree of consistence if the patient survives any length of time, 
this additional pressure by irritative action rapidly producing the effu- 
sion of plastic matter and the proliferation of cellular tissue around the 
mass, walling it in and forming a new sac of increased dimensions. 
None of the arterial tunics forming part of the sac, it is one of the forms 
of (e) false aneurism. 
(2) Tubular aneurism is an abnormal dilatation of an artery, all the 
Fig. 231. 
Aortic aneurism: f, sternum displacing clavicle; e, 
aneurism involving root of innominate (Cooper). 564 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
coats being expanded throughout the circumference of the vessel. It 
most frequently occurs in the aorta, though sometimes met with in the 
cranial and other vessels. It is not a mere fusiform dilatation of the 
artery, for there are elongation, thickening, and degeneration of the walls. 
The elongation of the artery may be as marked as the dilatation, and is 
always very considerable, an undue space being observed in cases occur- 
ring at the aortic arch between the innominate, carotid, and subclavian, 
its walls likewise being thickened, nodulated, and rugged. In some 
instances several dilatations are observed in the same vessel, with inter- 
vening healthy spaces. It rarely grows to be of great size, and scarcely 
ever ruptures unless a sacculated aneurism is developed from some por- 
tion of it. It rarely contains laminated coagula, but may give rise to 
great discomfort, and often becomes serious from pressure upon important 
organs. 
(3) Dissecting- aneurism, originally described by Shekelton, in which 
the sac is situated in the wall of the artery between its coats, is one in 
which the intima has given way bv reason of atheromatous or other ero- 
sion, and the blood dissects or makes its way by splitting up the media. 
It may burrow for some distance through the media, and at some point 
may push out the adventitia, forming a saccular aneurism, or, bursting 
through an eroded spot, may be extravasated into the tissues, resulting 
in the diffuse form. It may also burrow through the middle coat for a 
distance, and reopen into the lumen of the artery through a more distant 
atheromatous patch of the intima : in this form it may last for years and 
the patient may live indefinitely, or it may form a blind pouch within 
the media: failing to push its way through the adventitia or intima, a 
sac is thus formed in the substance of the middle coat which may become 
chronic, but which will at last push its way through the external coat 
and rupture. The arterial coats often appear soft and sodden as if mace- 
rated, and are easily separated. 
Two conditions are essential for its production : (1) an atheromatous condition, 
destroying the intima and the innermost layers of the media; and (2) there must 
also be a general softening of the middle coat, rather than a blending or matting 
together of its tissues by plastic exudation, with want of cohesion between the 
tunics. The rupture usually takes place in a longitudinal direction along the 
middle coat, and may often extend to a very considerable distance. The aneurism 
may reach from the end of the aorta to the iliacs, or from the aorta to the bifur- 
cation of the carotids. It occurs almost exclusively in the aorta and its principal 
branches—in those arteries in which yellow elastic tissue is most abundant in the 
media. In some instances, when the blood re-enters the vessel through the intima, 
the new channel becomes lined with a dense smooth membrane, resembling closely 
the intima, from which it is separated as by a septum, and has been erroneously 
described as a double aorta. A dissecting aneurism may be sacculated, circum- 
scribed, or diffused, and so constitute a false aneurism. 
4. Traumatic Aneurism.—In an oblique, indirect, or small punc- 
ture of an artery the blood may partly escape from the wound, and partly 
be extravasated in the adjacent tissues; or, clot forming sufficiently to 
prevent the further escape of blood externally, we may have extravasa- 
tion within ; and in some instances the external wound may have been 
closed by plaster or bandage ; the lesion of the artery remaining patent, 
the blood is forced out into the tissues. There may have been no exter- 
nal solution of continuity, yet the artery may have been punctured, 
lacerated, or torn across completely by fragments of bone, violent con- THE ARTERIES, INCLUDING ANEURISM. 
565 
fusion, strain, or twist of the part, by the injury of a dislocation, or the 
efforts of the surgeon at reduction. 
(C) Circumscribed Traumatic Aneurism.—The blood, extravasated as 
above, may become surrounded and limited by plastic exudation; this 
by gradual development of fibrous tissue, after the nature of cicatricial 
tissue, may be sufficiently firm to prevent further diffusion, but not 
strong enough to resist the distending force of the cardiac contractions, 
and it steadily increases in size—not by a process of stretching, as it 
does not become uniformly thinner in proportion to its increase in size, 
but by a constant growth of new fibrous tissue. As the aneurism in- 
creases, however, the growth of fibrous tissue becomes less perfect, and 
eventually too soft to withstand the pressure of the blood, and the sac 
may rupture and the aneurism again become diffused or fatal hemor- 
rhage result. Circumscribed traumatic aneurism most usually occurs 
from injuries to the smaller arteries, as the temporal, facial, palmar, 
plantar, radial, and ulnar. 
Another form of circumscribed traumatic aneurism occurs but rarely, 
and is due to a small puncture of a large artery, as the carotid or axil- 
lary. At first the hemorrhage may be quite free, subsequently arrested 
by pressure; the external wound as well as that in the arterial coats 
may heal by cicatrix. This, being weaker than the normal arterial tis- 
sues, may, after several weeks or months, yield to the pressure of the 
blood, and a distinct sac, formed by the yielding of the cicatrix in the 
external coat and the arterial sheath, results, with no effusion of blood 
into the surrounding tissues, this being the only form of traumatic aneur- 
ism that possesses the features of a true aneurism. 
Fia. 232. 
Traumatic aneurism of axillary artery (Park). 
(B) Diffused traumatic aneurism exists when the blood forced out is 
onlv limited in extent by the resistance of the surrounding tissues and 566 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
coagulation in the network of areolar tissue. It has no sac, its boundary 
is ill defined, and it has a constant tendency to extend under the pres- 
sure of the fluid blood, which is continuously forced into the interior of 
the mass. 
(D) Arterio-venous Aneurism.—In former days, when general vene- 
section was so frequently resorted to, it was by no means uncommon for 
the adjacent artery as well as the vein to be wounded. When a con- 
tiguous artery and vein have been perforated, 
adhesion may take place between the two ves- 
sels at the site, the communication between 
them remaining pervious; a portion of the 
arterial blood is thrown directly into the vein 
at each pulsation, the vein being dilated into 
a fusiform pouch with thickened coats. Com- 
municating veins may also become enlarged, 
nodulated, tortuous, and thickened, constitut- 
ing (/) aneurismal varix. 
In some instances the openings in the artery 
and vein are not directly in communication, and 
a diffused or circumscribed aneurism, with its 
sac formed by plastic effusion and develop- 
ment of fibrous tissue, is formed between the 
two vessels, into which the blood is poured 
before reaching the interior of the vein, form- 
ing a varicose aneurism, which is a traumatic 
aneurism to which is added the conditions of 
aneurismal varix. In some instances the open- 
ing into the vein becomes closed, and the tumor 
is converted into a circumscribed traumatic 
aneurism. 
(5) Arterial Varix and Cirsoid Aneurism. 
—This is a peculiar dilatation occurring in the 
scalp, and next in frequency in the hand, although other parts, as 
the tongue, viscera, bones, etc., may be involved. The artery is 
dilated, elongated, and tortuous, very much like a varicose vein. 
True aneurismal pouches sometimes form as large as the end of 
the finger or thumb. If a single artery is involved, it is known as 
arterial varix, and if a number of arteries, held together by connective 
tissue, are so affected, it is termed cirsoid aneurism. The structure of 
the arterial walls in the beginning shows no change, although subse- 
quently they become thinned during the process of dilatation and elong- 
ation. Some authors have argued that this is not properly an aneurism, 
but, having some of the peculiarities pertaining thereto, it is deemed 
best to consider it in connection therewith. It is especially the middle 
coat which is most affected, becoming pale, soft, and thin, the artery 
now resembling a vein in structure. The dilatation is commonly sym- 
metrical, so that the circumference of the artery is uniformly dilated ; 
in other cases, however, this not being the case, we have pouches and 
unequal saccular dilatations. As the artery elongates it becomes tortu- 
ous and serpentine, sometimes even spiral. It is rarely limited to a 
single trunk, several trunks and their branches being involved. These 
Fig. 238. 
Arterio-venous aneurism at bend 
of elbow : a, brachial artery; 
b, radial artery; c, basilic vein; 
d, median basilic vein ; c, an- 
eurismal sac ; /, dilated vein 
(Lenoir). THE ARTERIES, INCLUDING ANEURISM. 
567 
growths rarely occur in infancy, generally making their appearance in 
early adult life as the result of a bruise or injury, causing, as some sup- 
Fig. 234. 
Cirsoid aneurism (Bruns). 
pose, a paralysis of the vasomotor nerves. The tumor is irregular in 
shape, compressible, bluish in color, and pulsating. 
(6) Aneurism by Anastomosis, or Angioma.—While not properly 
a neoplasm, but rather a morbid change affecting a vascular area in 
which the arteries become dilated and convoluted and the intervening 
tissues subject to atrophy, its consideration here is proper, although by 
some it is not considered as an aneurism. The tumor pulsates, and 
feels under the fingers like a knot of moving worms. In some instances 
it originates in congenital defects, and at times leads to erosion of 
bone; in other cases it is evidently the result of mechanical injury. 
The walls of the dilated arteries are thickened. It differs from cirsoid 
aneurism in that the capillaries are dilated and the skin is involved. It 
will generally be noticed that the arteries leading up to it, though at a 
considerable distance, are tortuous and dilated, with thin and distended 
coats, pulsating forcibly, constituting the condition of cirsoid dilatation. 
The temperature of the part may be somewhat elevated. 
Symptomatology and Diagnosis.—The leading symptoms in exter- 
nal aneurisms are usually sufficient for a ready diagnosis. The devel- 
opment of a tumor in the course of an artery, ovoid or globular, except 
in the case of diffused or tubular aneurisms, soft and elastic to the 
touch, is usually well defined. This, if taken in connection with pulsa- 
tion and a well-marked bruit, forms pathognomonic phenomena not 
likely to be mistaken for anything else. However, if the tumor is not 
of recent formation, it may be firm and resistant from accumulation of 
more or less organized coagula within and density of the sac. The fluid 
nature of the contents is usually perceptible. A cystic or other tumor, 568 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
located over the course of an artery may receive an impulse therefrom, 
which, however, would be likely to disappear if placed in a dependent 
position, or, if it is lifted up from the artery, the impulse in such case 
being more of a lifting, heaving character, in a line drawn from the 
centre of the artery to the centre of the most salient point of the tumor; 
while in aneurism it is eccentric, expansive, and centrifugal, being felt 
with almost equal force over the entire circumference of the tumor. In 
case of a tumor over a large artery the impulse usually increases with 
the size of the tumor, and in aneurism it naturally decreases. In grasp- 
ing the tumor between the ends of the fingers applied to both sides its 
expansive character in aneurism is quite apparent. The pulsation is 
more forcible in an aneurism in which there is but little laminated 
fibrin, and as this increases the pulsation loses its expansile character, 
being converted into a dull thud, and in some cases is lost entirely. 
When pulsation is ill defined it may be increased by elevating the limb 
or compressing the artery below the tumor. Firm pressure above the 
tumor will cause the pulsation to cease, and the size of the tumor may 
be somewhat reduced by pressure at the same time over the tumor. 
Taking the pressure from the artery suddenly, the blood will rush into 
the tumor and distend the sac by a sudden stroke more or less expansile 
in character. 
The bruit or murmur accompanies the pulsation, and may vary mate- 
rially in different instances, as was first noticed by Ambrose Pare, and 
is caused by friction and ricochetting and tumult of the blood passing 
into and out of the dilatation. It is usually loud, rasping, and blowing 
—loudest and roughest in tubular aneurisms. Occasionally in sacculated 
aneurisms the bruit is double, and in cases of aortic regurgitation we 
may have a diastolic murmur in fusiform aneurism from the backward 
flow of blood in the large vessels. In many cases the bruit is entirely 
or occasionally absent, especially in sacculated aneurisms with small 
mouths, in those that are distended with coagula and blood, and in more 
quiescent states of the circulation. In the latter case exciting the circu- 
lation by muscular exertion or otherwise may develop a bruit that at 
other times may not be detected. Elevating the limb may slightly 
reduce the quantity of blood in the sac, and render perceptible a bruit 
too feeble to be detected otherwise. Pressure over the artery leading to 
the sac will usually cause cessation of bruit. 
In encephaloid tumor, soft sarcoma, and growths of naevoid tissue we may have 
reduction of volume by pressure, and the distinct impulse of blood may be felt on 
its removal, the tumor returning to its original size with a soft swelling pulsation, 
and there may also be a loud and distinct bruit. These tumors are not so distinctly 
circumscribed: they are soft, spongy, and elastic, not having the sensation of fluid 
met with in some forms of aneurism, or of solid coagula as found in others; and 
the bruit is either soft, blowing, and more prolonged, or possibly sharp and super- 
ficial ; the pulsation also is not so distinct, and is more of the nature of a general 
swelling or heaving of the tumor than a distinct thud. The location of such 
tumors, if in a situation not occupied by an artery of sufficient size, as the head 
of the tibia, the side of the pelvis, etc., may solve the difficulty; but if such a 
tumor is located over or under an artery of large size and in the usual site of an 
aneurism, the diagnosis may be extremely difficult. An abscess located over an 
artery and in a favorable site for aneurism may present diagnostic difficulties.' The 
history of the case, impossibility of diminishing the size of the tumor by pressure 
over it or on the artery on the proximal side, its want of circumscription, its fluc- 
tuation, and a distinct heaving up and down, instead of the eccentric and expansile THE ARTERIES, INCLUDING ANEURISM. 
569 
pulsation pertaining to an aneurism, may serve to elucidate. Glandular or thyroid 
swellings over the carotid, or similar conditions elsewhere at the root of the neck 
or in the groin or popliteal space, may likewise present difficulties. If solid, they 
are usually nodulated and irregular in outline, and can be frequently moved to 
one side of the arterial site or lifted up from it by passing the fingers beneath ; yet 
care must be taken not to mistake them for a consolidated aneurism undergoing 
spontaneous cure. Difficulty is especially apt to occur in aneurisms that have 
become diffused, either spontaneously or as a result of traumatism, that may not 
pulsate, have no bruit, are elastic, softened, and diffluent to the touch, and over 
which the skin may have become inflamed and reddened. It is only by the most 
careful attention to the history of the case and by skilful manipulation that a cor- 
rect diagnosis can be arrived at. Withdrawing a part of the fluid contents by the 
cautious use of a small aspirator needle may fail to elucidate the case satisfactorily, 
for the aneurism g,nd abscess may exist coincidently, or the artery and abscess 
may communicate as a result of erosive action. 
Rheumatism and neuralgia have been mistaken for aneurism, and vice versd, 
especially in internal aneurisms. The pain in aneurism is not only lancinating, 
but intermittent, as well as continuous, aching, boring, and burning. In many 
cases of popliteal aneurism the patient first complains of rheumatic pain in the 
knee, and it is a good rule whenever complaint is made of obscure pain in the 
knee-joint, persistent in character, to examine the popliteal space, as well as similar 
pain in the back, side of the head, neck, or arm should occasion a careful scrutiny 
of the neighboring large vessels. 
The skin over an aneurism may be healthy or natural in color, though 
it is stretched : as the aneurism grows it may become discolored, thinned, 
and even ulcerated, and suppuration may occur in the subcutaneous 
areolar tissue. Muscular weakness, stiffness of the part, and a tired 
feeling are accompaniments. 
Venous congestion and oedema from compression of the deep-seated 
veins, and in some cases a varicose condition of the superficial veins, 
and even gangrene and superficial sloughing from obstruction to the 
returning circulation, are among the effects sometimes present, the tend- 
ency to gangrene being increased by the pressure of the sac upon its own 
or neighboring vessels. Pressure upon nerves not only gives rise to 
lancinating pain, but also to interference with the functions of important 
parts, as hoarseness and spasmodic dyspnoea from compression of the 
recurrent laryngeal, dyspnoea and uncontrollable eructation from pres- 
sure on the pneumogastric, and facial paralysis, deafness, ptosis, strabis- 
mus, and blindness in cases of intracranial aneurism. Pressure upon 
secreting glands or their ducts may cause trouble from interference with 
their functions, death from asthenia and progressive emaciation having 
occurred from pressure upon the thoracic duct prior to rupture of the 
sac. Serious consequences may ensue from pressure upon important 
viscera, or dyspnoea and cough from compression of the trachea, bronchi, 
or lungs; dysphagia from pressure on the oesophagus; or hemiplegia as 
a result of an intracranial aneurism. Serious consequences result from 
pressure upon bones and joints; the flat bones, as the ribs and sternum, 
and even the bodies of the vertebrae, may be eroded, or caries and 
destruction of an articulation may ensue. The erosion of bone by an 
aneurism is usually attended by a distressing sensation of boring or 
burning pain, as in the vertebral column in cases of aortic aneurism. 
When an aneurism becomes diffused by rupture of its sac the tumor 
loses its defined outline, rapidly becomes much larger, and the pulsation 
and bruit may become weak or disappear. The part becomes cedematous, 
cold, and livid from venous congestion; pain is suddenly increased, and 570 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
syncope may occur. The swelling becomes hard from coagulation, and 
in some rare cases consolidation of clot, condensation of areolar tissue, 
and plastic effusion may limit its further extension, and so grave a result 
has resulted in spontaneous cure. Generally, however, the swelling 
increases, with or without pulsation, and the case ends in gangrene or 
external hemorrhage from giving way of the superjacent tissues. In 
other cases rupture of the sac leads to wide extravasation of blood into 
the tissues, with shock and pain, faintness and syncope from loss of 
blood from the general circulation, and death at no distant day from 
exhaustion or gangrene. 
Diffused traumatic aneurism is, as Gross remarks, a collection of blood in the 
tissues of the part, differing only from a wounded artery in there being no exter- 
nal communication. The diagnosis can usually be readily made by reason of the 
oblong, somewhat pyriform swelling, elastic and fluctuating, and, if the opening 
into the artery is large, we may have well-marked pulsation, thrilling, purring or 
jarring, and bruit, although in some cases one or both may be wanting; the pul- 
sation of the artery beyond the wound is either diminished or wanting. At first 
the skin over it is natural in color, but gradually becomes bluish, and thinned by 
pressure. Circumscribed traumatic aneurism in the clinical phenomena presented 
differs but little if at all from the forms already given. In all cases we may expect 
to find the pulsation in the artery beyond the aneurism diminished. 
General Treatment.—Measures to prevent further increase of 
the dilatation, the formation of organized coagula, and the obliteration 
of the sac pertain to the domain of therapeutics as well as surgery, and 
surgical means may be greatly enhanced thereby. In some instances 
they constitute the sole reliance, the object being, first, to lessen the 
force of the cardiac impulse, and so diminish the eccentric pressure of 
the blood; and, second, to modify the condition of the blood so as to 
dispose to the deposition of fibrin. Perfect rest, in bed if possible, and 
a limited diet, avoiding irritation or indigestible food and stimulants, 
with a restricted quantity of liquid, as well as mental quiet, are of the 
greatest importance. 
General venesection, originally introduced by Valsalva as a means of removing 
plethora and reducing irritability of the heart and the force of its action, may be 
advantageously employed in suitable cases. Valsalva combined with it a reduc- 
tion of food and drink just within the starvation point. The rest-treatment, or the 
method of Tuffnel of Ireland, who first published his experience in 1875, has for 
its object the reduction of the watery elements of the blood and an increase in its 
solid constituents, and combined rest, regimen, and restrictive diet, with some reme- 
dial agents. Recumbency is the principal element of cure, and must be rigidly 
maintained for at least three months. His diet may be summarized as follows : 
Breakfast.—Two ounces of bread with a little butter and two ounces of milk. 
Dinner.—From two to three ounces of meat without salt and four ounces of 
milk; for a portion of the milk an ounce or two of claret may be substituted. 
Supper.—The same as the breakfast. 
With this he gave lactucarium to quiet the patient, resorting to opium if needed 
to relieve pain. He claimed that no remedial agent would so lessen the heart’s 
action, without injury or danger, as rest in the recumbent position. He also gave 
compound jalap powder at intervals to reduce the quantity of the blood by with- 
drawing the serum. 
Iodide of potassium, from its effect of increasing the deposition of 
fibrin, lias been largely used bv various reliable observers, and it has 
evidently been productive of good even in cases not due to syphilitic 
disease of the artery. Given in doses of from 5 to 30 grains three 
times a day, alone or combined with the bromides, suffering lias been THE ARTERIES, INCLUDING ANEURISM. 
571 
relieved, there has been diminution in the size of the sac, and in some 
cases a cure has been apparent. Gallic acid, plumbi acetas, and chloride 
of barium have been recommended. Veratrum viride, aconite, and 
digitalis have also been claimed as advantageous: the two former, by 
modifying the heart’s action, will doubtless be beneficial, although 
danger will likely attend the use of the latter by its effect of increasing 
ventricular systole. Langenbeck and Plagge have recommended the 
use of ergotine hypodermically. 
S. Solis Cohen in two cases of aneurism at the root of the neck, pre- 
sumably carotid, used hydrated calcium chloride in doses of about a 
drachm a day, in combination with rest. Marked improvement was 
demonstrated in one case, no change in the other. Marked improve- 
ment was also observed in a case of innominate aneurism under his care 
at the Philadelphia Hospital two years ago by similar measures. 
These remedies, or some of them, judiciously used, will in all cases 
materially aid purely surgical procedures, and in cases when operative 
interference is questionable or directly contraindicated will at least 
prove beneficial if not curative. 
Operative Measures.—First in importance is ligation, whether by the 
“ old method ” of Antyllus, extirpation and ligation of all vessels be- 
longing to the sac ; AneVs operation, or proximal ligation in the imme- 
diate vicinity of the sac; Hunter’s method, or proximal ligation at a 
distance from the sac; Brasdor’s procedure, of distal ligation below the 
sac; or War dr op’s modification of the same, by ligature of one or more 
of the principal branches given off from the artery below the sac. In 
all cases a proper preparation of the patient by rest, attention to diet 
and the emunctories, should not be lost sight of, and an effort to estab- 
lish in advance the collateral circulation by compressing for a few hours 
daily the artery involved should not be neglected. 
Dr. Joseph RansohofF of Cincinnati, in a short paper contributed to the Am. 
Med. Ass’n., June, 1893, on “Extirpation of Aneurisms,” gave the following con- 
clusions : 
“ 1. Extirpation is the ideal method. It should be resorted to unless there are 
weighty reasons against it. 
“ 2. In aneurisms of the forearm and legs no other method should be adopted. 
“ 3. Aneurisms which have suddenly grown large from subcutaneous rup- 
ture of the sac, and those in which rupture is pending, should be subjected to 
extirpation. 
“ 4. In recent traumatic aneurisms the injured vessel should be divided be- 
tween ligatures; when a sac has formed it should be excised. 
“ 5. When other methods have failed, extirpation should be tried before resort 
is taken to amputation. 
“ 6. In arterio-venous aneurisms extirpation should be practised if any opera- 
tion is indicated. 
“ 7. Proximal ligation is to be reserved for cases of idiopathic or spontaneous 
aneurisms in Avhich the age of the patient or an enfeebled condition from other 
causes would make a prolonged operation hazardous, and for cases in which the 
position of the tumor precludes the possibility of extirpation.” 
Nearly forty years ago Mr. Syme suggested that in aneurism of the 
carotid, axillary, gluteal, and iliac arteries, in which the Hunterian 
method is not admissible, the sac should be freely opened, its contents 
turned out, and the artery ligated above and below. In several in- 
stances following the suggestion he was brilliantly successful, the last 
one being an aneurism involving the external iliac, his incision into the 572 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
sac extending for six inches, and six pounds of blood and fibrin were 
turned out; the common, external, and internal iliacs were ligated, 
with recovery of the patient. As regards effectiveness, extirpation has 
many advantages, but is, unfortunately, not admissible in some cases. 
Hunter’s method, although claimed as a modification of Anel’s, but 
originated independently, is next in value. One of its advantages over 
the latter is that we are more likely to find sound arterial tissue at a 
distance from an aneurism than in its immediate vicinity. These two 
methods, as well as extirpation, are often excluded by reason of the site 
of the aneurism and the vessel or part of it involved. 
In ligation in the immediate vicinity of the sac we are less apt to 
have maintenance of the circulation in the tumor by development of the 
collateral circulation, and as a result rapid but imperfect coagulation. 
In the Hunterian method we may have secondary hemorrhage at the site 
of the ligation, return of pulsation from too free development of collat- 
eral circulation, including the sac, sloughing of the sac, and gangrene of 
the limb. 
Brasdor’s operation aims to produce entire arrest of circulation in the 
sac, and Wardrop’s modification a partial arrest. In addition to the 
same risks pertaining to Hunter’s method, we are liable to have further 
distention of the sac or rupture of the sac or artery. It is limited to 
particular cases, as aneurism at the root of the carotid or of the innomi- 
nate. The conditions and relations of each particular aneurism and the 
vessels involved are to be thoroughly and carefully considered, and the 
most suitable method resorted to. 
Ligation is indicated in cases in which the trouble is active and pro- 
gressive, in locations in which pressure and flexion are not applicable, in 
any cases in which other less dangerous modes have been tried unsuc- 
cessfully, in cases where a sacculated aneurism has suddenly become 
diffused or opened into an articulation, or where it has opened or is 
about to open externally, and in traumatic aneurisms. It is contraindi- 
cated when other methods, as pressure, flexion, etc., offer a reasonable 
hope of cure; in the presence of any complication, as extensive cardiac 
or arterial disease; the prevalence of erysipelas, which would likely 
affect the wound, or other circumstances incurring too great a risk ; and 
by the locality of the aneurism being such that from the proximity of 
anastomosing branches or from any other cause the operation would be 
unsuccessful. Multiple aneurisms, though usually, are not always a 
contraindication : two aneurisms occurring in the same artery may be 
cured by the single operation, or a double popliteal by operation on both 
femorals. Their occurrence, however, suggests extreme caution. 
Recurrent pulsation usually occurs after ligation within twenty-four hours, 
though sometimes not for four or five weeks, and still more rarely at an interme- 
diate period. It usually disappears as consolidation takes place, though a fatal 
result may occur from sloughing of the sac. It is generally satisfactorily treated 
by elevating the limb, with moderate pressure over the sac. Enlargement of the 
sac without pulsation may result from reflux of blood on the distal side. If exces- 
sive, it may lead to gangrene, hut generally coagulation occurs, converting the 
aneurism into a solid tumor. The treatment of hemorrhage at the point of liga- 
tion, sloughing, or rupture of the sac is by elevation of the limb, careful pressure, 
mechanical or digital; this failing, cutting down on the bleeding point and liga- 
tion above and below, or ligation of the main artery at a higher point, or amputa- 
tion, must be resorted to. THE ARTERIES, INCLUDING ANEURISM. 
573 
Suppuration of the sac may occur in from a few days to several 
months after ligation. We first have heat, pain, pulsation, and discol- 
oration of the skin : the latter, becoming thinned, at length gives way, 
and the contents of the tumor, softened, broken down, and mixed with 
pus, are discharged through the aperture in the form of a dark, purplish- 
brown fluid mixed with masses of soft dark coagula or drier laminated 
fibrin. The escape of this matter may be accompanied by a sudden 
gush of fluid arterial blood, carrying off the patient at once, or it may 
occur in small -quantities, ceasing and recurring from time to time, grad- 
ually producing fatal exhaustion. It is most liable to take place between 
the third and eighth weeks, though in one case recorded by Sir A. Cooper 
it took place so late as the eighth month. If unaccompanied by hemor- 
rhage, it requires only the treatment of an abscess, proper precaution 
being made to arrest hemorrhage should it occur during evacuation. 
If accompanied by hemorrhage, the case is quite serious. Evacuation 
of the sac by free incision, clearing out the cavity, and packing with iodo- 
form gauze, held in place by graduated compress and roller bandage, may 
serve to permanently arrest the flow of blood, and will in all events give 
time to resort to more effectual means if needed. Ligation of the bleed- 
ing vessel is of doubtful utility; the softened and disintegrated vessel 
would be apt to give way. A ligature applied nearer the centre of cir- 
culation also is doubtful in its results: the circulation below, already 
embarrassed by the previous ligature and by suppuration and distention 
of the sac, may be so interfered with as to result in gangrene, or else the 
collateral circulation, if of sufficient activity to maintain vitality in the 
parts beyond the sac, will also keep up the hemorrhage from the artery 
or the sac. More certain results are offered by amputation of the limb 
if the aneurism is so situated that it can be done, or control of the 
hemorrhage by means of the actual cautery in other cases. 
Acupressure and temporary ligature have been successfully used in a 
few cases, not sufficiently numerous to demonstrate any superiority over 
the ligature, and resulted in cure by temporarily arresting the flow of 
blood through the sac and consolidation of its contents. 
Compression as a means of cure may be instrumental or digital— 
directly over the tumor or indirectly over the artery above or below 
(proximal or distal), or by means of the elastic bandage. In either 
event proper and careful precautions to favor occlusion should precede 
and accompany the effort. The irritability of the heart and general 
system should be controlled by anodynes and sedatives, and the patient 
placed in a comfortable bed and his position secured by well-adjusted 
pillows and mattresses. In irritable and uncontrollable patients it is 
not advisable. 
Various instruments for this purpose have been devised, or the sur- 
geon may improvise one to suit the special indications of the case. 
Tuffnel has devised a very ingenious compressor, composed simply 
of a truss-spring and pad, with straps to keep it in place and to increase 
the force of pressure by being tightened. 
Signoroni’s tourniquet and Lister’s aorta-compressor are applicable 
in certain situations. 
A conical weight, held in position by means of a leather socket, a bag of shot 
suspended over the artery, as successfully used in Bellevue Hospital, New York, 574 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
may be used. It is not necessary, as was formerly supposed, to make such com- 
pression as to entirely occlude the artery, but just sufficient to simply arrest pulsa- 
tion in the sac, without completely arresting the flow of blood through it, and 
thus induce the deposition of laminated coagula. After recovery the sac is gen- 
erally entirely filled up, but in some cases the channel remains, through which the 
normal circulation is carried on. Instrumental pressure has given better results in 
aneurism below the middle of the thigh than elsewhere, and is not so applicable 
in the carotid, iliac, subclavian, and axillary arteries, although aneurisms in the 
groin have been successfully treated by compression of the external iliac or abdom- 
inal aorta. 
The rapid-pressure treatment, by completely arresting the flow of blood through 
the sac by instrumental pressure both above and below the sac, and kept up for 
several hours, the patient being partly or wholly under the influence of an anaes- 
thetic, while a valuable addition to the means of treating abdominal aneurism, is 
not so satisfactory in other situations. 
Direct pressure, for obvious causes so dangerous and uncertain, and 
distal pressure, are now rarely resorted to, but both may prove valu- 
able adjuncts to proximal compression. Before applying the instru- 
ment the part should be well shaved and dusted with talcum or other 
powder, and if an extremity is involved a soft roller should be carefully 
applied. In order to keep up continuous pressure, at the same time 
prevent the skin from being chafed or the soft parts beneath the pad 
from sloughing, it is best, if applicable, to adjust two instruments, the 
one above the other, a little distance apart, so that one can be tightened 
and the other temporarily loosened. The more continuously the pressure 
is kept up the greater certainty of effective results. It must be main- 
tained carefully for a variable period. In some instances the tumor has 
solidified in a few hours, in others in two or three days, and it has been 
protracted from time to time for two or three months before cure has 
resulted. Barwell gives the longest period at seven weeks, and the 
shortest twenty-four hours. 
Digital compression may be employed as an exclusive method of treatment or 
as an adjuvant to instrumental. If used exclusively, it requires several relays of 
competent assistants, relieving each other at periods of from ten to thirty minutes 
or longer in proportion to their powers of endurance, and it may be by the fingers 
or thumbs alone, or aided by a weight added to the hand or finger, or by means 
of a suitable compress. It is most applicable to arteries at the root of the neck, 
in the orbit, or elsewhere in cases in which an instrument cannot be adjusted. 
In all cases of instrumental compression it is well to secure complete 
distention of the sac by a few minutes’ distal compression. Careful 
elastic pressure over the sac during the whole course of treatment by 
compression is advised. 
Compression has its disadvantages. It is sometimes unbearable bv 
reason of pain, tedious in protracted cases, and occasionally fails. If 
venous congestion, great oedema, and pain are markedly increased, it 
should be abandoned if satisfactory results are not obtained in three or 
four days, and in exceptional cases in even a shorter time, and the 
Hunterian or other method resorted to. In the event of its failure the 
chances of cure by ligation may have been enhanced by the partial or 
complete development of the collateral circulation while being tried. 
The elastic bandage and tourniquet have been successfully used in some 
cases of aneurism of the extremities. The bandage is tightly applied 
from the fingers or toes up the aneurism, lightly over the sac, and tightly 
again above it; then the elastic tourniquet is secured, which should be THE ARTERIES, INCLUDING ANEURISM. 
575 
removed before the bandage, and instrumental or digital compression 
kept up for three, six, or twenty-four hours afterward, even if all pulsa- 
tion in the tumor has ceased. The elastic bandage should be kept on 
for about an average of one and a half hours : it has been kept on for 
three to live hours without serious results. The limb must be kept warm 
by enveloping it in wool and the application of external heat to about 
100° F. If the bandage be kept on longer than an hour, an anaesthetic 
or a full morphia hypodermic may have to be used. It effects a cure by 
causing stasis of blood in the sac and adjoining portions of the artery. 
It may fail from want of coagulability of the blood, and may result in 
gangrene from blood-stasis in the limb, venous thrombosis, or embol- 
ism from subsequent washing away of the clot or a part of it. It is not 
applicable to aneurisms that are large, have thin walls, containing fluid 
blood with no laminated clot, or are rapidly increasing in size. 
Flexion, by bending the limb on itself, is limited to arteries low in 
the popliteal space or below in the leg, or in the arm below or at the 
bend of the elbow, and is further limited by pain and the insupportable 
annoyance due to confinement of the limb in one position. Although 
occasional temporary relaxation has been permitted, it has sometimes 
even then effected a cure. The limb is carefully bandaged as high as 
the knee or elbow, and then the extremity forcibly flexed upon the 
joint and maintained in position by a few secure turns above the joint 
or secured by a strap. It should be kept up for several days or a week 
or longer, and may precede or alternate with digital or instrumental 
compression in suitable cases. 
Galvano-puncture, first employed by Phillips some sixty years ago, 
was but little resorted to until recently, when it has been warmly advo- 
cated by French and Italian surgeons, the object being to decompose 
the blood in the sac by means-of galvanism, and thus secure its coagu- 
lation. 
Erichsen advises ten or twenty Leclanche cells, with needles, both insulated to 
near their points with vulcanite or gum elastic, introduced into the sac on opposite 
sides, a current of high tension and somewhat low intensity being maintained for 
twenty or thirty minutes. Tillmanns uses a Stohrer’s zinc-carbon battery, a fine 
sterilized needle ten centimetres in length being introduced into the sac connected 
with the positive pole, while the cathode or negative pole is connected to a metal 
plate on the opposite side of the tumor. The length of the sitting is only from 
five to ten minutes, and the current is gradually increased by rheostat and dyna- 
mometer from twenty to thirty milliamperes. Bastian and others advocate the 
introduction into the sac of the positive pole only: the clot forming about the 
negative is soft and frothy, and but little good can result from it. A single appli- 
cation rarely suffices, and several are needed on different days to secure satisfactory 
results. It possesses no advantages over ligation or compression, and may result 
in sloughing, hemorrhage, or embolism. Its use is restricted to those cases, such 
as internal aneurism and others, not amenable to other methods, being positively 
contraindicated in diffused aneurisms. 
Injections into the sac of perchloricle of iron, ergot, and other reme- 
dies have been used in some cases with success, but the dangers from 
inflammation, gangrene, rupture, and embolism are far too great. 
Manipulation, by kneading and squeezing the tumor in order to break 
up coagula that may have formed with the hope that a fragment may 
effectually plug the distal side of the artery, is both dangerous and 
uncertain : the embolus is not under control, and may lodge where it 576 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
will do serious injury. Esmarch, Teale, and Tillaux have mentioned 
such results from the necessary manipulations during the examination 
of an aneurism. 
Acupuncture and the introduction of foreign bodies from without, coils 
of horsehair, catgut, and iron wire, to secure the formation of coagula, 
are also of questionable propriety, and should never be resorted to if 
more certain methods are available. Macewen’s method of irritating 
the interior of the sac by means of a sharp needle, and thereby inducing 
the formation of white thrombi, has sometimes proved successful, the 
effort being to induce infiltration of the sae-wail with leucocytes from 
the blood-stream, and their segregation at the point of irritation. 
The irritation should be evenly applied over as much of the interior of 
the sac as,,possible, and at times, the needle being held lightly with its 
point impinging on the opposite surface so as to allow the current of 
bipod to play on it, shifting to other positions at intervals of a few 
minutes. The time required to irritate the entire sac varies from a few 
hours to forty-eight hours. It may be necessary to repeat the operation 
at intervals for weeks or even several months. 
Special Aneurisms.— Thoracic aneurism presents symptoms that 
are far from uniform, being due to pressure upon surrounding struc- 
tures, and influenced by location, form, size, rapidity of formation, and 
direction of growth; being liable also to materially change during its 
progress. The symptoms are not in proportion to external manifesta- 
tions : the more an aneurism tends in an inward direction, the greater 
the degree of suffering and disturbance, which may be intensely aggra- 
vated prior to any external manifestations. In some cases these may 
be very indefinite, with no physical signs whatever. Erosion of the 
sternum or ribs occurring, it may be readily apparent. Abnormal local 
sensations are usually present, such as pain varying in character and 
intensity ; heat, weight, and fulness with throbbing; cutaneous tender- 
ness and hyperaesthesia being common. W hen pressing backward the 
pain may be gnawing or grinding, owing to destruction of the vertebrae. 
Pressure-symptoms, occasioning interference with nervous and other 
functions, are to be closely studied. Aphonia, dyspnoea, or dysphagia 
may be manifested early or late. The general system may suffer mark- 
edly, and we may sometimes have a striking appearance of illness, com- 
bined with anaemia or a sallow, cachectic look, distressed and wan 
expression, without positive diagnostic phenomena. Gastric disturb- 
ance from pressure upon the pneumogastric or sympathetic nerves, and 
dysphagia, if oesophageal stricture and organic disease can be eliminated, 
are important symptoms. Head-symptoms with disturbed sleep may 
also occur. 
Local bulging is dependent upon the site involved. If in the as- 
cending or transverse portion of the arch, the prominence will be in 
front and to the right or left of the manubrium, occupying the re- 
mainder of the arch and the descending portion; the bulging will be 
posteriorly, generally to the left of the spine and occasionally to the 
right, and may become quite extensive. In shape it tends to be 
rounded and conical, and involves the ribs and spaces equally. Pul- 
sation, if expansile, heaving, and throbbing, with or without enlarge- 
ment, and synchronous with the cardiac systole, is an important sign : it THE ARTERIES, INCLUDING ANEURISM. 
577 
may be markedly undulatory, and sometimes a thrill is felt; it is some- 
times double, and occasionally is mainly diastolic. • If the patient is 
made to sit up with the head inclined forward, and the cricoid cartilage 
is grasped firmly between the index finger and thumb and drawn forci- 
bly upward, putting the trachea on the stretch, a distinct and well- 
marked tugging sensation is felt, originally described bv Surgeon-major 
Porter as tracheal tugging. Dulness upon percussion of a dead, putty- 
like character, extending beyond the cardiac areas, may be elicited over an 
aneurism, which is also to be discriminated from other mediastinal growths 
by exclusion or other characteristic phenomena. This is but one link in 
the chain formed by other symptoms. Auscultation may reveal nothing 
or only indefinite sounds. The most important is a rough murmur, 
usually systolic, sometimes double, and in rare instances only diastolic. 
Gross says that “ it is more like the purring of a cat than the clear 
murmur of the first sound of the heart, and it is still further defined 
by the presence of a peculiar tremor or vibratory movement.” 
Occasionally a systolic murmur is heard over the trachea, or even at the pa- 
tient's mouth when open. The heart may be pushed downward to the left: if the 
aneurism is behind, this organ may be so pushed forward that the chief impulse is 
observed at the base. The left ventricle may be enlarged, and aortic valvular dis- 
ease is often present. Examination of the respiratory organs may reveal func- 
tional or organic disease of the larynx; displacement, compression, or interference 
with the entrance of air into one or both lungs; consolidation or destructive 
changes in them; bronchial catarrh on one or both sides, or bronchiectasis from 
pressure by the tumor. Dr. W. C. Glasgow of St. Louis, Mo., claims to have no- 
ticed a systolic thud in the brachial artery synchronous with the cardiac systole. 
The radial pulse may be delayed or absent on one side, or it differs in force on the 
two sides, and its dicrotism may be materially influenced. An aortic aneurism is 
not only capable of influencing the pulse by its direct effects upon the circulation, 
but by obstructing the main arteries by pressure and by closure of their orifices 
by torsion or clot. Osier says that a large aneurism of the descending aorta may 
cause complete cessation of pulsation in the abdominal aorta, femoral and periph- 
eral arteries of the lower extremities. 
As regards the form of aneurism, there is more diffused pulsation in 
fusiform aneurism, above as well as below the clavicle, well-marked 
thrill, rough, prolonged, rasping, whizzing or whirring murmur, sys- 
tolic, louder along the arch than over the aortic orifice, and less promi- 
nence of pressure-signs. 
The duration of thoracic aneurism may be only two or three months, 
or it may exist for as many years. 
In the TREATMENT little is to be hoped from surgical interference, 
and our main reliance is upon therapeutic measures. Ligation on the 
cardiac side of the tumor is out of the question : an operation on one or 
more of the branches after Wardrop’s modification of Brasdor’s opera- 
tion has not been as yet attended with results sufficiently satisfactory to 
justify very urgent recommendation, nor does acupuncture or galvanism 
offer encouragement. Should spasmodic closure of the glottis threaten 
to suddenly cut short the patient’s life, opening the larynx or trachea is 
justifiable, as would be an opening into the stomach for the introduc- 
tion of food in the event of distressing dysphagia. 
The Innominate Artery.—Aneurism of this artery usually pre- 
sents a pulsating, globular tumor behind the right sterno-clavicular 
junction : in addition to pain, we may have oedema of the right side of 578 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
the face and arm, laryngeal cough, dyspnoea, and dysphagia. The 
tumor will All more or less the hollow above the sternum, rising as high 
as the lower margin of the cricoid cartilage; the sternal end of the 
sterno-mastoid is first pushed forward and subsequently the clavicular 
portion. The upper part of the sternum, the clavicle, and costal carti- 
lage of the first rib may be pushed forward without the development of 
a tumor in the neck. Dulness on percussion around the sterno-clavicular 
articulation and pulsation of the first intercostal space are apparent. 
Bruit may be absent or very variable in character; the cardiac sound 
may be projected well up into the antero-inferior triangle of the neck. 
The pulsation in the carotid and radial on the right side is less than on 
the left, in many cases before the appearance of tumor. Enlargement 
of the superficial veins of the neck and upper extremities is a frequent 
accompaniment. Pain is not limited to the tumor, but may radiate into 
the neck or arm, over the shoulder and upper part of the chest. En- 
trance of air into the right bronchus may be interfered with. The 
muscular power of the right arm may be impaired. Pressure upon the 
sympathetic may occasion turgescence from dilatation of the vessels, 
and sweating on one side of the face. 
Treatment.—In addition to a thorough attention to therapeutic 
measures, distal ligation only is admissible, limited to ligation of the 
subclavian alone, the carotid alone, or consecutive ligation of both ; or 
galvano-puncture or acupuncture may be tried. 
In subclavian aneurism the tumor extends externally to the clavic- 
ular origin of the sterno-mastoid muscle, reaching the posterior triangle 
of the neck : it becomes more elongated transversely than vertically; 
the bruit is propagated more toward the axilla than the neck, and re- 
mains the same on compressing the carotid; the radial pulse is enfeebled, 
and the limb painful, cedematous, and incommoded in its movements. 
Medical and hygienic measures of treatment, with compression 
judiciously applied, are the most promising. The distal operation 
alone is applicable to aneurism existing in the first or second portions 
of the vessel, the Hunterian being limited to aneurism occupying the 
outer third, when the artery can be secured outside or between the 
scaleni muscles. 
Ligation of the innominate, first practised by Mott, was successfully done by 
Smyth of New Orleans, who also tied the carotid and vertebral. Ligation on the 
proximal side and immediate amputation of the arm have been advised, and are 
perhaps justifiable in so grave a condition. The N. Y. Med. Record of Aug. 17,1895, 
lias the following: “A man was recently on exhibition in London whose innominate 
artery was tied by Mr. Coppinger, at the Mater Misericordiae Hospital in Dublin, 
in January, 1893. The operation was for the relief of aneurism of the subclavian 
artery. He was exhibited shortly after the operation in Dublin, and later at New- 
eastle-on-Tyne. The man is now fifty-nine years of age, and is in excellent health. 
It is claimed for him that he is the only living example as yet exhibited in Europe 
of cure of subclavian aneurism by innominate ligature.” Ligation of the innomi- 
nate has also been recently done by Burrell of Boston, with temporary success. 
Axillary aneurism, either idiopathic or traumatic, from the laxity 
of the surrounding tissues is prone to development and liable to become 
inflamed. Venous congestion and oedema of the forearm are likely to 
ensue. Delayed radial pulse on the side involved and severe pain from 
pressure on the brachial plexus are features. 
Ligation of the axillary has been done, yet the statistics of ligation THE ARTERIES, INCLUDING ANEURISM. 
579 
of the third part of the subclavian have been more favorable, the first 
method being more after Anel’s, the latter the Hunterian, method. Syme 
and Morton removed the arm at the shoulder-joint for hemorrhage and 
gangrene of the subclavian at the second part. Proximal pressure 
before resorting to ligation should be faithfully and carefully tried. 
Aneurisms of the arm, forearm, and hand offer nothing peculiar 
in their clinical features. 
When the upper part of the brachial just below the axilla is involved, 
digital compression or flexion may be tried. Instrumental pressure is 
apt to be very painful, and the smallness and cylindrical form of the 
humerus make it difficult of satisfactory application. If these fail, the 
operation of Antyllus is likely to be preferable to the Hunterian. For 
aneurism lower down or for either of the branches, if compression fail, 
the Hunterian operation can be tried. For traumatic or arterio-venous 
aneurism at the bend of the elbow extirpation is preferable. Aneurism 
of the hand if not relieved by pressure should be extirpated. 
Aneurism of the common carotid presents a considerable degree 
of difficulty in its diagnosis, having in more than one instance been mis- 
taken for aneurism of other vessels, solid cysts, abscesses, or other tumors 
by careful and experienced surgeons. Dilatation of the internal jugular 
vein, which may receive a pulsatory movement from the heart or the 
vessel, is distinguished by its softness and compressibility, the lack of 
expansile impulse, its situation, rather behind than in front of the mas- 
toid muscle, and pressure upon its distal portion effacing it. In aneur- 
ism of the aortic arch, innominate, and subclavian the delayed impulse 
at the radial should aid in the diagnosis. 
Ligation of the common carotid has been attended with a considerable 
degree of mortality, in many cases death resulting from cerebral or pul- 
monary sequela?. If the aneurism is located low down, the proximal 
operation may be impossible, and ligation of the innominate for cases 
occurring on the right side is far too serious. Digital compression may 
be unavailable, and the only resort is to the old operation, the distal ope- 
ration by Brasdor’s method, or Wardrop’s modification, one of the latter 
methods being preferable from the possibility of mistaking aneurism of 
the arch or the innominate for one of the common carotid. Galvanism 
and acupuncture are worthy of consideration. 
Aneurism of the external carotid, from the shortness of this vessel, 
rarely occurs without involving as well the upper portion of the common 
artery at its division. The tumor will be found under the angle of the 
jaw about level with the cricoid cartilage. Paralysis of the tongue on 
that side and aphonia and dysphagia have been met with. 
Ligation of the common carotid, or the external on its proximal side, 
is likely to be followed with failure on account of the extent of anasto- 
mosing vessels. Morris advised as well ligation of the principal branches 
of the external on the distal side of the tumor—an exceedingly diffi- 
cult measure. Digital compression, galvanism, or acupuncture may be 
successful. 
Aneurism of the internal carotid external to the skull presents but 
little difference from it at the point of bifurcation or the upper part of 
the external, the tendency being to extend inward toward the pharynx 
rather than outwardly. 580 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
If digital compression, medical treatment, and other milder means 
fail in giving relief, ligation of the common carotid, although extremely 
unfavorable, may be resorted to. 
Intracranial aneurisms are usually formed by dilatation of the 
whole calibre of the artery rather than a saccular development. Pres- 
sure-effects upon the soft and yielding brain-tissue show themselves 
prior to giving way of the bony encasement. The symptoms are quite 
equivocal: an aneurism of large size may exist at the base of the brain 
without any symptoms whatever. “ The most reliable ” symptoms, 
Fig. 235. 
Aneurism of right internal carotid (Peacock). 
according to Gross, “ are apoplexy and hemiplegia, buzzing noises in 
the ears, deafness, dizziness, vertigo, and pain in the head, circumscribed 
or diffused, intermittent or continued, increased by motion, and accom- 
panied by peculiar morbid sensations,” coming on suddenly without pre- 
monition or arising gradually and imperceptibly, A loud rough or 
whizzing noise, heard by the patient on one side of the head and by 
auscultation, has in a few instances served for diagnosis. 
Operative measures are limited to ligation of the carotid when diag- 
nosis is satisfactory. 
Intraorbital aneurism frequently first manifests itself by a loud snap 
or crack felt in the orbit or head as if something had given way. Con- 
gestion of the conjunctiva, difficulty in opening the eyelids, a feeling of 
tension or pain in the orbit, a loud whizzing noise, increased on stoop- 
ing or lying down, more or less exophthalmos, and pulsation of a throb- THE ARTERIES, INCLUDING ANEURISM, 
581 
bing character, with loud whizzing bruit, may serve to distinguish this 
affection. 
If* digital compression should fail to relieve, ligation of the common 
carotid should be resorted to, the exigencies of the case and clearness of 
diagnosis justifying it. 
Aneurism of the vertebral artery is of extremely rare occurrence, 
and the symptoms quite obscure, a pulsating tumor situated in the course 
of the vessel, not commanded by pressure on the lower part of the caro- 
tid, being somewhat distinctive. 
If pressure, etc. fail to cure, ligation of the artery near its origin is 
the only resource. 
Aneurism of the Abdominal Aorta.—Pulsation is more distinct 
than in thoracic aneurism : pressure-effects are less marked, from the 
yielding character of the abdominal viscera and walls. The tumor is 
immovably fixed, dull on percussion, and gradually increases in size and 
firmness with its age. The pain, at first slight, gradually becomes more 
severe, especially in the vicinity of the coeliac, solar, and hypogastric 
plexuses, and may be quite neuralgic—pain of a boring nature, burning, 
more fixed and attended with sympathetic disturbance when the verte- 
bra? are involved. It must be discriminated from solid or other growths 
of the pancreas, malignant and other growths of the omentum, stomach, 
colon, or mesentery, hydatids of the liver, intestinal concretions, indu- 
rated faeces, abscesses of the abdominal walls, and abnormal pulsations 
of the aorta from anaemia, neuralgia, or inflammatory reaction. With 
the bowels thoroughly emptied and abdomen relaxed, examination in 
the recumbent position on a firm table, and also with the patient placed 
on the hands and knees, if carefully done, may serve for diagnosis, 
especially if the expansile character and distinct bruit over the inferior 
dorsal or lower lumbar vertebra? or the tumor direct is present. 
Although ligation has been resorted to, it is out of the question, and 
our reliance is entirely on therapeutic measures, with or without com- 
pression, in the latter event anaesthesia for several hours being essential. 
Aneurisms of the hepatic, gastro-epiploic, and mesenteric arteries 
are extremely rare, yet it is important to make a correct diagnosis to 
at least prevent erroneous measures of treatment. In aneurism of the 
hepatic artery the tumor is fixed, and in the two latter forms more or 
less movable from side to side, the pulsation being maintained. The latter 
are usually circumscribed and more or less globular, and may be accom- 
panied by bruit. From pressure upon the liver or gall-bladder jaundice 
may occur, and pressure on the pancreas may result in phenomena of 
imperfect digestion, pain, eructation, flatulence, and vomiting; in some 
instances hsematemesis existed. 
Inguinal Aneurism.—Aneurism of the common iliac is extremely 
rare, it being much more likely to develop from the external iliac or 
upper part of the femoral. It is usually circumscribed, though some- 
times tubular, rarely diffused. When first noticed it is small, soft, and 
compressible, attended with pulsation and bruit and but little pain or 
tenderness. It rapidly enlarges, and may seem lobulated from con- 
striction by the fascia under which it lies. Increasing in size, oedema 
of the limb will arise from pressure on the saphena and femoral veins, 
and pain occasionally in the thigh and leg from pressure on the anterior 582 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
crural nerve. Pulsating tumors of bone must be excluded by careful 
examination. In no case should thorough treatment by pressure, etc. 
be omitted; and in the event that the external iliac or the common 
iliac can be reached above the sac, ligation may be attempted. Tf Syme’s 
procedure, after the “old method,” is deemed advisable, firm pressure 
on the abdominal aorta during the operation should not be neglected. 
Fro. 236. 
Sacculated aneurism of femoral artery (Parmenter). 
Aneurism of the profunda femoris is only likely to be mistaken 
for pulsating tumor of the femur. If compression carefully applied 
does not succeed, the surgeon must use his discretion whether ligation 
of the external iliac or the common femoral is most suitable. 
Aneurism of the superficial femoral and popliteal presents no 
special clinical features, and the suggestions made in the general con- 
siderations of treatment do not here need repetition, more than the brief 
mention in the following order of preference : compression, digital, by 
flexion, or instrumental, and the Hunterian method of ligation. In 
diffused popliteal aneurism amputation may be a question for con- 
sideration. 
Aneurisms of the leg- and foot are somewhat rare, and do not 
require special consideration; their diagnosis and method of treatment 
will be readily suggested by what has heretofore been submitted. 
Aneurisms of the Internal Iliac Artery and its Branches.— 
Erichsen has only recorded one instance of aneurism of the internal 
iliac and one of the pudic, so rarely have these vessels been involved. 
Gluteal and sciatic aneurisms, both traumatic and idiopathic, have 
occasionally been observed, the former more frequently than the latter. 
Erichsen says that “ gluteal aneurism has generally been found situated 
at the upper part of the great sciatic notch, but may extend over a large 
portion of the buttocks. Sciatic aneurism lies more deeply, and a por- 
tion of the sac may be within the pelvis.” They vary in size from a 
slight swelling to a tumor as large as a child’s head—are accompanied 
by strong pulsation, whirring and buzzing murmurs, sciatic pain, and 
possibly local paralysis. 
The diagnosis is somewhat difficult, and abscess, soft sarcomata, 
cysts, and sciatic hernia must be eliminated. 
Various methods of treatment have been suggested, as opening the THE ARTERIES, INCLUDING ANEURISM. 
583 
sac and ligation of the vessels, ligation of the internal iliac, injection of 
coagulating fluids, or galvano-puncture. Pressure on the cardiac side 
of the tumor is impossible. 
Cirsoid aneurism (vide Chapter I. Vol. II.) and angioma present 
clinical features that are quite definitive, yet the treatment is in many 
cases unsatisfactory. If detected early and while small, thorough re- 
moval by incision, the lines of incision being carried wide of the tumor, 
or the thermo- or galvano-cautery, should be resorted to. In other 
instances the ligation of the afferent vessels may succeed; the injection 
of coagulating fluids after the method of Broca, who used perchloride 
of iron, preventing the passage of the styptic beyond the desired area by 
pressure with a leaden ring, attacking the tumor in sections by dividing 
it into lobes by means of rubber tubes; or the nitrate of silver, as sug- 
gested by Bigelow; coagulation by electro-puncture or ligation of the 
main vessel. Two or more of these methods may be combined. CHAPTER XXXIII. 
INJURIES AND DISEASES OF THE JOINTS AND JOINT 
STRUCTURES. 
Joseph Ransohoff, M. D. 
General Considerations. 
There enter into the formation of every joint two or more bones held together 
by a capsule which is strengthened by ligaments. Within there is contained a 
quantity of synovial fluid sufficient only for the lubrication of the joint-surfaces. 
Even in so large a joint as the knee it does not normally exceed two or three 
cubic centimetres. Joint and capsule are supplied by blood-vessels and by sen- 
sory nerves. The latter are always derived from a source common to the supply of 
the muscles which act upon the joint. The synovial membrane covers only the cap- 
sule. The articular ends of the bones are smooth, covered with cartilage, and sup- 
ply none of the synovial fluid. Within the joints that are most subject to pressure, 
to violent concussion, and to frequent movements there are fibro-cartilages, which 
by their borders are attached to the capsule, thereby affording the joint additional 
strength, reducing shock, and increasing the range of movements. Such carti- 
lages are found in the temporo-maxillary articulation, the acromio-clavieular, the 
wrist- and the knee-joints. . To the outer side of the joints, but often connecting 
with them, there are found bursae, which play an important role in the gliding of 
the tendons over the joints, and are often significant in the injuries and diseases 
of the joints proper. The capsule of the joint, made up of strong fibrous tissue, 
is capable of resisting great pressure without rupture. Rupture of the capsule can 
only occur from direct violence or in consequence of degenerative changes inci- 
dent to disease. In the distention of the capsule a separation of the articular 
ends of the bones does not ordinarily ensue. The position of a limb depends some- 
what, but not altgether, upon the degree of distention of the joint with fluid. 
Experimental distention of a joint invariably causes it to assume a position mid- 
way between flexion and extension. In inflammatory conditions, chronic in cha- 
racter, this position is maintained uniformly, not owing to the distention of the 
joint by fluid, but because of the greater strength of the flexor muscles over the 
extensors, and the proneness of the latter to atrophy more quickly than the for- 
mer. In hemorrhage into a joint or acute distention thereof by serous exudation 
the limb is often maintained in the extended position. The synovial membrane, 
being of the nature of a serous tunic, reacts rapidly to irritation, to the presence 
of foreign bodies, to injury, or to effusion of blood. The entrance of blood into a 
joint is of significance, since every injury to the joint may be associated with more 
or less hsemarthrosis. When small quantities of blood are introduced into a joint, 
becoming mingled with the synovial fluid, coagulation does not ensue : even when 
large effusions of blood result, as in the knee, coagulation of the entire effusion 
never takes place. Some coagula will be deposited upon the articular surfaces, 
become imbedded in an endothelial layer proliferated from the normal synovial 
covering, and in the course of time undergo organization. The greater quantity 
of the coagula will, by very slow process, often continuing through months, 
remain floating within the fluid substratum and ultimately undergo absorption. 
Contusion.—The simplest injury to a joint is the contusion result- 
ing usually from direct violence, such as a fall or a blow. Very rarely, 
Injuries of Joints. 
584 INJURIES AND DISEASES OF THE JOINTS, ETC. 
585 
as in the case of the small joints of the hand and wrist, is it the result 
of indirect violence. When severe, contusion often makes itself mani- 
fest by hemorrhages into the periarticular tissues, which may, in the 
course of twenty-four hours, permeate the subcutaneous layer and 
appear in the form of ecchymoses of greater or less extent. In the 
severer forms of contusion considerable hemorrhage into the interior of 
the joint takes place. 8'welling of greater or less extent, with loss of 
the normal joint outline, will make easy the recognition of the condi- 
tion. Pain, as a rule, is not very severe, the inconvenience of the joint 
movement and tenderness on pressure being the only subjective symp- 
toms complained of. In extensive hemorrhages into the joint slight 
rise of temperature may result during the first twenty-four or forty- 
eight hours. 
The TREATMENT of contusions consists of rest, evenly applied band- 
ages, and elastic compression. If much pain be complained of, appli- 
cations of ice during the first twenty-four or forty-eight hours will often 
give great relief. After the lapse of two or three days passive move- 
ments should be made and systematic massage of the joint practised. 
Sprain.—A sprain is always the result of indirect violence, and is 
produced when the movements of a joint are carried beyond their physio- 
logical limits, but stop short of a permanent displacement of the articular 
ends—that is, dislocation. A sprain may thus be said to be the pro- 
dromal stage of a dislocation. Excessive muscular action may likewise 
produce a sprain. In many individuals the presence of a sprain pre- 
disposes to recurrence of the condition from apparently trivial causes. 
In the majority of sprains there is a stretching of the capsule and of 
one or more of the ligaments. In severe cases there is a rupture of one 
or both of these, with consequent laceration of blood-vessels, and often 
nerves. Hemorrhage into the joint and the periarticular structures is 
almost always present. The ligaments, as a rule, if torn, give way at 
the point of insertion rather than in their continuity. This is made 
manifest in milder cases, not by tenderness to pressure over the articu- 
lar line, but at some point above or below, corresponding to the point 
from which the ligament was torn. In the tearing of a ligament from 
its osseous attachment particles of bone are not infrequently brought 
away with the detached fibrous structure. In severe cases the bone may 
be denuded of its periosteum for a considerable distance. 
In the sprains of childhood and adolescence this condition, owing to the 
greater flexibility of the bone, is not uncommon. In adults, on the other hand, 
the extreme limit of the sprain is the tearing away of a greater or less fragment 
of bone to which the ligament, placed upon the stretch by the trauma, has been 
attached. It is in this way that fractures of the lower end of the radius and of 
the lower end of the fibula may be considered as severe forms of articular distor- 
tion. They are sometimes known as sprain-fractures. In severe sprains the seg- 
ment of capsule opposite that which is put upon the stretch may be pinched 
between the articular surfaces, which are by the sprain more closely approximated 
to each other than normally. It is in this way that in severe sprains of the 
ankle pain is felt on both sides of the foot. In very severe cases a rupture of the 
muscles surrounding the joint may ensue. This, however, is quite uncommon. 
When it results, the muscle gives way along the line of its attachment to the 
tendon. 
The SYMPTOMS of a sprain are—pain, swelling, ecchymosis, and 
limitation of joint function. The pain at the moment of accident is 586 
AFFECTIONS OF THE TISSUES ANI) TISSUE-SYSTEMS. 
often very severe, leading at times to syncope. When an examination 
of the joint is made the tenderness will be found most marked over the 
articular line and over the insertion of the ruptured ligament. The swell- 
ing varies greatly in different cases, since it depends upon the hemor- 
rhage within and about the joint. In mild cases it is limited to the 
periarticular structures, appearing in the form of ecchymoses within 
the course of two or three days. The ecchymoses, owing to ruptures 
of muscles, are often found at points considerably removed from the 
affected joint. The ecchymosis following a sprain is often found at a 
distance far removed from the joint without rupture of muscle. Often 
the only ecchymoses seen in sprains of the shoulder appear after the 
lapse, sometimes, of many days at the point of insertion of the deltoid. 
As a rule, the swelling attains its maximum within the course of 
twenty-four hours. In many cases, however, the hemorrhage into the 
joint produces a reactional hydrarthrosis, which reaches its maximum 
in from a week to ten days. The degree of periarticular or intra- 
articular swelling depends entirely upon the extent of damage done 
to the ligaments and the joint-capsule. 
The frequency with which joints are subject to sprain varied with their nature. 
The enarthrodial joints, in which the range of movement is widest, are least 
subject to sprains. On the other hand, joints of the hinge variety are more fre- 
quently the seat of such lesions. Sprains occur, therefore, most often in the 
ankle, the knee, the wrist, and the small joints of the hand. 
The clinical history of a sprain varies with the conditions pro- 
duced by it. In some cases, characterized by the stretching of the lig- 
aments without laceration, the pain and swelling speedily subside, and 
after a few days or a week the joint-functions are restored. In severer 
cases, where hemorrhage into the joint and periarticular swelling indi- 
cate extensive laceration, the progress toward recovery is often very 
tedious, and months may pass before a final restitution to the normal 
condition takes place. In the severest cases circumscribed tender areas, 
thickening of the joint-capsules, or chronic hydrarthrosis may leave the 
joint permanently impaired. Atrophy of the muscles is often found to 
follow upon severe sprain during the first two weeks, and is the result 
of the injury to the articular nerve-filaments. This condition is often 
irreparable. 
Extensive hemorrhage into a joint is always significant of a tedious recovery, 
and frequently renders unfavorable the prognosis, so far as complete restoration 
of joint function is concerned. In subjects with a tendency to diathetic, and par- 
ticularly to tubercular, disease a sprain is often the exciting cause of chronic 
joint disease. 
Treatment.—In the treatment of sprains absolute rest should be at 
once secured. Elevation and suspension of the affected limb at a right angle 
will often relieve the pain at once. This position conduces to the arrest 
of hemorrhage and, by rapidly depleting the veins, facilitates the absorption 
of the already effused blood. To further hasten absorption compression 
by an elastic bandage may be considered as of prime importance in the 
treatment of sprains. Cold applications are often of value for the relief 
of pain. To these may be added the lead and opium wash, or a solution 
of chloride of ammonium and opium, or an ichthyol ointment. Internal 
administration of opiates may become necessary when pain cannot be INJURIES AND DISEASES OF THE JOINTS, ETC. 
587 
otherwise alleviated. To secure absolute rest immobilization of the joint by 
means of plaster-of-Paris, starch, or silicate-of-sodium bandages is often 
indicated. The indiscriminate use of fixed dressings must, however, be 
condemned, since their unnecessarily prolonged use may lead to irreme- 
diable stiffness of the joint. It is preferable to resort to the use of 
splints, which can be removed daily if required. After the subsidence 
of the acute symptoms of the sprain the main object of treatment 
must be that of the restoration of joint f unction. Efforts in this direc- 
tion should never be delayed beyond the second week. The chief agents 
in attaining this end are passive movements and massage methodically 
applied. In the severest forms of sprains, in which the intra-articular 
effusion is not absorbed by this treatment, recourse must be had to 
aspiration of the joint. 
In sprains which are not relieved by one or other of these methods of treat- 
ment, singly or combined, counter-irritation by means of blisters, or, preferably, by 
ignipuncture, often answers admirably. When there is any thickening under an 
especially tender point recourse should be had to free incision. In a few cases 
hemorrhagic cysts have been drained or granulation masses removed with a curette, 
thereby permanently relieving the symptoms. The writer recently drained with 
success such a subfascial cyst as large as a hazelnut. It was over the trochanter, 
and directly under a point which had been extremely tender during two years fol- 
lowing a sprain of the hip. 
Penetrating Wounds.—The injuries of joints hitherto considered 
may prove serious to the function of a limb, but being subcutaneous 
they never, per sc, jeopardize either limb or life. In strong contrast to 
these, therefore, are the wounds in which communication is established 
between the external air and the joint interior. Penetrating wounds, 
particularly of the larger joints, like the knee, the hip, the shoulder, 
and the ankle, may and often do become among the gravest of the 
injuries to which the body is subject that are not immediately fatal. 
The gravity of penetrating joint wounds depends not upon the mere opening 
of the synovial membrane, but on the introduction into the serous cavity at the 
time the wound is inflicted or subsequently of morbific matter, which in many 
cases produces a septic inflammation, always dangerous to limb and often to life. 
That the mere penetration of a joint is free of danger is displayed daily in the 
operating-room. Aspiration, puncturing with a trocar, free incision for the 
removal of foreign bodies, with the proper precautions as to asepticism, involve 
no danger. A wound of the synovial membrane heals by primary union as does a 
wound of the skin. The great danger of infection of a joint from a penetrating 
wound lies in the complicated construction of many of the joints, the difficulty in 
securing adequate drainage, the communication normally present between the 
joint and surrounding bursae, and the ease with which the connective-tissue planes 
about the joint are involved in the diseased process. 
Penetrating wounds of the joint may be divided into the incised, the 
'punctured, the lacerated, and the gunshot injuries. In very many 
instances the wound is complicated with more or less extensive injury 
to the surrounding structures, particularly the bones, the larger blood- 
vessels, and the nerve-trunks. For practical purposes simple incised 
wounds may be differentiated from the complicated forms, for in the 
latter the opening of the serous cavity is less significant than the con- 
comitant injury to bone, blood-vessel, or nerve. In civil practice the 
injuries most frequently seen are of the punctured or incised variety. 
The shoemaker thrusts an awl into his knee or the woodman sinks his 
axe into ankle or knee; the mechanic occasionally thrusts a pointed 588 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
instrument into the wrist-joint. The wound of communication, it will 
therefore be seen, varies very much in its size, being often so small as to 
be just perceptible, or large enough, on the other hand, to afford a view 
of the joint interior. In the latter instance the diagnosis is, of course, 
simple; in the former, on the other hand, it may be difficult to recog- 
nize the penetrating nature of the injury, and often it is impossible. 
Symptoms.—Cardinal signs indicative of penetrating joint injury 
have been said to be the outflow of synovial fluid, pure or mixed with 
blood, and in the absence of this the rapid filling up of the joint-cavity 
with blood. Neither of these signs is pathognomonic. The opening of 
a periarticular bursa or of a tendon-sheath will permit the outflow of a 
fluid closely allied to the synovial. When the perforation is small the 
opening in the joint closes, and will allow no permeation of fluid through 
the wound tract. The accumulation of fluid within the joint, on the other 
hand, will often attend contusion of the joint without perforation. It 
is not uncommon, for example, to find, in consequence of falls upon the 
knee, a contused and lacerated wound of the periarticular structures, 
followed by haemarthrosis without penetration of the joint. 
In compound fractures of the epiphyses joint penetration may often 
be suspected, but is rarely subject to demonstration until, in neglected 
or badly treated cases, the joint reacts to septic infection. When the 
diagnosis cannot be otherwise established, the careful use of a steril- 
ized probe may bring certainty. In small punctured wounds the dis- 
placement of the tract between muscles and tendon-sheaths will often 
render the search futile. If indications arise demanding a positive 
diagnosis, an enlargement of the wound under anaesthesia and explora- 
tion of its course must be made as the preliminary step of the proper 
operative treatment. 
Punctured and small incised wounds of even the largest joints are 
not, as a rule, attended by severe constitutional disturbance. A man 
with a punctured knee may follow his vocation for a day or two without 
any marked local or general disturbance. In the lacerated wounds, on 
the other hand, there is, as a rule, very great depression. Being often 
associated with fracture or dislocation and accompanied by profuse 
bleeding, the shock manifested is often extreme. 
The clinical course of these injuries depends wholly on the 
presence or absence of primary wound infection. In the latter even 
large wounds heal per primam without local or general reaction. The 
continued outflow of synovia for several days, while it jeopardizes so 
fortunate a result, does not annul it. 
In the presence of infection the course will be determined, to a large degree, 
by the nature of the infection, the facility for drainage, and the treatment insti- 
tuted. The introduction of the less virulent pus-formers into punctured wounds 
may be followed by a period of quiescence varying from two days to a week. The 
vascularization of the synovial tunic is then made evident by a serous articular 
effusion, which speedily becomes turbid and contains flakes of lymph. The joint 
and periarticular tissues become reddened, disfigured, painful, and tender. Often 
a chill announces the inception of the suppurative process. In evidence of sys- 
temic toxicsemia there is a continuous fever with morning remissions, which con- 
tinues while intra-articular pus-retention exists. In these milder forms of traumatic 
synovitis, if ample opportunity for drainage is afforded, the integrity of the joint 
may still, to a large extent, be maintained. The outflow of the pus through one 
or more openings reduces the intra-articular tension, the discharge in the course INJURIES AND DISEASES OF THE JOINTS, ETC. 
589 
of a few weeks becomes reduced to a minimum, the cartilaginous covering may 
even be left intact, and the joint saved with a fair degree of function. 
In the cases of grave infection, with insufficient drainage, the joint 
structures soon undergo changes that place them beyond repair. The 
synovial membrane becomes greatly thickened, the surrounding liga- 
ments become softened, the cartilage covering the bones raised at first in 
areas, then separated altogether from the underlying bone. The joint 
structures thus become almost altogether unrecognizable. Communica- 
tions are established between the pus-cavity into which the joint has 
been converted and the bursae originally communicating with the joint 
tendon-sheaths overlying them. In this way a joint abscess finds its 
way to the surface, often in as many as from three to six places removed 
from each other by considerable distances. While this process in and 
about the joint is going on the limb becomes often enormously swollen, 
the general septic manifestations are very marked, and, unless relief is 
afforded, death may sooner or later occur. But even in such unfortunate 
cases life and limb are often preserved after protracted suppuration, last- 
ing at times for many months. 
As in wounds of the soft part, those of joints that are primarily infected with 
the more malignant pus-formers (the streptococcus infection), if left to themselves, 
often run a more rapidly fatal course. From the very beginning the general 
manifestations of sepsis are graver. Within twenty-four hours of the injury the 
joint is already enormously tumefied. Within forty-eight hours the discharges 
are slightly putrid, and often an examination of the joint reveals free gases in the 
interior. In these cases ascending phlebitis of the deeper veins often leads to rap- 
idly spreading gangrene of the extremity. In one case, seen by the writer, of a 
wound of the knee with such grave primary infection gangrene had developed 
within twenty-four hours ; within thirty hours the gangrene had spread to the hip, 
ending fatally within thirty-three hours from the infliction of the injury. Between 
these extremes in the clinical course of penetrating wounds of the larger joints 
there are all degrees in rapidity and virulence of symptoms consequent on infec- 
tion. 
In penetrating wounds of the smaller joints, particularly of the 
hand and foot, owing to their greater simplicity the local and general 
manifestations are proportionate to the size of the joint injured. 
Whereas, as a rule, the function of the joint involved is permanently 
restricted, the infection remains localized and limited, and life is rarely, 
threatened. But even in this regard caution in prognostication is essen- 
tial, since the extension of disease to parts far removed from the pri- 
mary injury occasionally ensues. 
The treatment of penetrating wounds of the joint must have for 
its objects—first, the securing of primary union through the prevention 
of infection; and, second, the treatment of the traumatic arthritis when 
the infection has already taken place. To meet the first condition is 
simple when the diagnosis is clear. Like wounds in other parts, joint 
wounds must be thoroughly cleansed. Unevennesses of the surface and 
contused edges must be removed by clean incisions, and the joint should 
be thoroughly explored for parts of the vulnerating body which have 
possibly remained imbedded in it. To accomplish this the wound into 
the joint may without fear be very much enlarged. The joint-cavity is 
then to be thoroughly irrigated with a sublimate solution of 1 :1000. 
If there has been much oozing, a silkworm-gut strand may be left for 590 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
drainage. The wound is closed by sutures and the joint, being asepti- 
cally dressed, kept at rest. 
When the diagnosis of joint penetration is in doubt, the treatment 
should depend largely upon the facilities for aseptic exploration at the 
command of the surgeon. Without such facilities it is probably wiser 
to await the development of symptoms indicative of infection before 
resorting to operative interference. When the surgeon has control of 
his surroundings it is advisable, as in cases of doubt pertaining to pen- 
etrating wounds of the abdomen, to enlarge the punctured or incised 
wound, to trace it to the joint-capsule, and, if this be found to be pene- 
trated, to treat it as in the cases just considered. With the first evi- 
dences of septic infection, in either class of cases, the treatment must 
consist of the antiseptic management of the joint interior. By this is 
meant a free incision for the removal, through drainage, of the contents 
of the diseased joint and antiseptic irrigation of the joint interior. In 
proportion as these objects are sought early or late the integrity of the 
joint will be more or less maintained or entirely lost. For the drainage 
of joints that are already suppurating, nothing excels rubber drainage- 
tubes of considerable calibre. 
These tubes ought not be drawn directly through the joints between the bony 
surfaces, since the latter would by pressure make thorough drainage impossible, 
and the pressure upon the cartilage by the tube would, perforce, if long continued, 
produce a localized pressure-necrosis. Irrigation in these cases must usually be 
made at least once, and often twice, in twenty-four hours, until suppuration is very 
materially diminished. With subsidence of the joint distention, the reduction of 
periarticular inflammation, and of purulent discharge the frequency of the irriga- 
tion may be lessened. The drainage-tubes should not often be removed, at least 
in the early history of the case, since their return might be rendered difficult 
through the retraction of the aperture in the fibrous capsule. As the case pro- 
gresses toward recovery they should from time to time be removed and shortened as 
occasion requires. 
Iii the management of traumatic suppurative arthritis regard must be 
had to the position of the limb with a view to probable future ankylosis. 
Left to itself, a suppurative arthritis of the knee will invariably leave 
the limb much flexed; of the elbow, the arm slightly so. An early 
regard for the position to be attained is therefore an essential element 
of treatment. 
When the penetrating wound of a joint is only one feature of a com- 
plicated trauma, the question of primary excision, or even of amputation, 
may arise. For uncomplicated wounds of the joint neither of these ope- 
rations is primarily indicated. In cases of compound dislocation with 
fracture into the epiphysis, particularly in the upper extremity, a pri- 
mary excision will often save a useful limb. The same is true of com- 
pound dislocations of the ankle. In compound dislocations of the knee 
the force producing it is necessarily so great as to make the joint injurv 
of secondary importance. In these cases primary amputation must, as 
a rule, be resorted to. 
Gunshot Injuries. 
Gunshot wounds of the joints are always lacerated and contused, and 
for this reason alone afford a better soil for infection. In the wounds 
made by larger missiles there is always added considerable injury to the INJURIES AND DISEASES OF THE JOINTS, ETC. 
591 
epiphyseal ends of one or both of the contiguous bones. In these 
wounds the epiphyses are often shattered beyond repair, and the larger 
vascular or nerve trunks are often involved to a degree calling for im- 
mediate amputation. A gunshot wound of a larger joint by a ball of 
large calibre, when left to itself, often pursues a rapidly fatal course. Of 
271 joint injuries in the Russo-Turkish war, tabulated by Reyher, 146 
proved fatal; mortality, 54 per cent. From the very first day the joint 
becomes tender, the slightest movement giving rise to excruciating pain. 
The integuments become discolored, the veins are distended, and gas- 
formation in and about the joint rapidly takes place. The constitutional 
symptoms accord with the degree of the local infection : the temperature 
ranges between 103° and 105° F., the sensorium becomes obtunded, 
delirium develops, and the patient, if unrelieved, often dies, in from 
three to five days, of acute septicaemia. In the gunshot wounds of 
joints made by small-arms, as seen in civil practice, the symptoms are 
far less pronounced. They accord with those described of the milder 
infected wounds that are penetrating from other sources, but even in 
these, owing to the damage done to contiguous bones and the presence 
of foreign substances, the symptoms develop more rapidly. In wounds 
produced by the larger missiles fired from modern arms there is usually 
perforation, under which circumstances, as in gunshot injuries elsewhere, 
the wound of entrance is smaller than that of exit and has a tendency 
to contract. The wound of exit is larger, often gaping, and on explo- 
ration presents detached spieulse of bone. In wounds made by missiles 
of small calibre perforation of the larger joints is not common. The 
missile may rarely be found loose between the joint surfaces. Often it 
is found firmly imbedded in the epiphysis after having produced more 
or less splintering. 
The DIAGNOSIS OF gunshot injuries of the joints by larger mis- 
siles is always simple. The probe, or preferably the finger, thoroughly 
sterilized, can be made to freely enter the joint-cavity and detect the 
damage done. In the injuries produced by balls of small calibre the 
diagnosis is likewise, as a rule, easily made. The outflow of synovia 
mixed with blood, the rapid filling of the joint with fluid, the crepitus 
detected by manipulation, the impairment of joint motion due to the 
presence of the missile or fragments of bone, make the diagnosis clear. 
There are, however, cases in which doubt must obtain, as in the cases 
of other than gunshot wounds in the vicinity of joints. In doubtful 
cases nothing but an exploratory incision will lead to positive diagnosis. 
This should always be done, except in wounds made by the smallest-cal- 
ibre revolvers or rifles. These ordinarily do little damage, the force propel- 
ling being slight, and they rarely carry before them particles of infected 
clothing: if left to themselves, primary union or healing under a blood- 
clot ensues, as in similar wounds of the soft parts. In wounds by larger 
missiles, even those from large revolvers, the source of wound-contami- 
nation is chiefly in particles of clothing penetrating with the ball. The 
latter as it comes from the manufacturer has been shown to be almost 
sterile; the temperature to which it is raised in its course and by impact 
is insufficient to sterilize the foreign substance which it carries into the 
wound before it. In three out of five pistol-shot wounds of the knee 
recently recorded particles of clothing were found in the track of the wound. 592 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
Wounds of the joint made by the larger projectiles of war, propelled with 
great force, and particularly those of modern pattern, are almost always per- 
forating. 
In joints with subtendinous pouches, like the elbow and the knee, 
joint penetration not infrequently occurs without injury to the bone. A 
similar penetration may occur, for example, from a wound in the antero- 
posterior axis of the knee without injury to bone when the leg is flexed 
at an angle of about 140° against the thigh. 
Treatment.—The course of a wound is mapped out by the hands tof 
him who first sees it. This is particularly true of gunshot wounds of 
joints. Except when profuse hemorrhage calls for immediate care the 
first attention should be limited to the application of an antiseptic dress- 
ing. More should not be done until the best possible facilities are 
afforded for antiseptic and aseptic manipulations. Above all things, 
probing with finger or instrument can only be harmful unless every pre- 
caution toward surgical cleanliness is observed. Conservatism in the 
sense of antisepsis and immobilization is indicated in cases of smaller 
wounds, such as are seen in civil practice. In all other gunshot injuries 
of joints conservatism is probably most favored by primary operative 
treatment. Delay until the manifestations of infection compel a tardy 
interference entails disaster to life and limb more often than in joint 
wounds from other causes. This has been established beyond a reason- 
able doubt. 
Of 46 gunshot injuries of the larger joints treated antiseptically primarily, 6 
■ended in death; mortality, 13 per cent. This primary treatment included anti- 
septic occlusion, immediate drainage, and primary excision. In 78 cases treated 
by antiseptic means after infection had occurred the mortality was 54 per cent. 
■(Revher). 
According to the varying conditions found, recourse must be had to 
■exploration and lavage of the joint, atypical excision, or amputation. In 
civil practice the latter would rarely be demanded; even in military 
practice it will probably be reserved for the complicated injuries, of 
which the joint penetration is only one element. Extensive injury to 
to the soft parts, comminution of both epiphyses and fracture extending 
into the diaphysis, injury to larger nerve and vascular trunks, are the 
conditions demanding primary amputation. As for severe injuries from 
other causes, amputations of the lower extremity, other things being 
equal, will be oftener demanded than those of the upper. In the 
smaller wounds seen in civil life, when the diagnosis is clear the facili- 
ties for asepticism should determine the course ; without them, an expect- 
ant treatment limited to thorough cleansing of the wound and immo- 
bilization should be trusted to rather than exploration. 
With facilities for aseptic work at hand even the smaller wounds seen 
in civil life should be subjected to immediate exploration. The wound 
should be enlarged and the site of joint penetration thoroughly exposed. 
When it is required for further manipulation a free incision into the cap- 
sule must be made. With the parts so exposed the course of the ball can 
ordinarily be easily followed. If' it has ploughed its way into an epiphysis, 
the canal should be enlarged with chisel and sharp spoon until it is 
found and dislodged. Loose spiculse of bone are to be removed with 
the forceps and uneven projections chiselled away. An atypical resec- INJURIES AND DISEASES OF THE JOINTS, ETC. 
593 
tion may thus be made. Particular care must be given to the removal 
of foreign substances carried in with the missile. If in perforating 
wounds the manipulations have brought the operator near the distal 
side of the joint, a counter-opening should here be made. Ample 
facility for drainage is the condition on which success depends. After 
such atypical resection fair joint motion is often retained. If both 
epiphyses are injured, it is probably wiser to make a formal excision 
with the view to obtaining ankylosis. 
The suggestions here made for the early operative treatment of gunshot 
injuries tend toward an ideal which is within reach in civil practice. The 
statistics of our Civil War and of the Continental wars of 1866, 1870, and 1877 
speak strongly in favor of non-interference in gunshot injuries of the larger joints. 
These statistics belong to the preantiseptic period of surgery, and are of historical 
value only. It is probable that with the increased facilities for surgical cleanli- 
ness on the field and, above all things, in military hospitals, the danger of wound 
infection following operative interference will be greatly reduced, although never, 
probably, for reasons that are apparent, to the degree that it has been in well- 
appointed civil hospitals. 
Diseases of Joints. 
Diseases of joints which result from irritation or infection may be 
divided into the acute and the chronic. The division can also be made 
according to their primary or secondary development, and, finally, 
according to the end-product of the process into the serous or purulent on 
the one hand, and the dry or plastic on the other. Exact differentiation 
between the various types is often a matter of considerable difficulty. 
As elsewhere, an acute disease of a joint often retrogrades slowly, 
becomes the subject of exacerbations, and eventuates in a chronic 
disorder. 
In point of pathology, differentiation is also at times difficult. As in 
cases of pleurisy with effusion it is at times impossible to state just when 
the serous becomes converted into a purulent exudate, so in inflammatory 
or subinflammatory diseases of the joint the differentiation is often im- 
possible. Furthermore, as in the intrathoracic disease just referred to, 
the disappearance of the serous effusion will leave a fibro-plastic material 
as the only vestige of pre-existing disease, or, as we may have a fibro- 
plastic disease of the pleura unchanged at any time, so we may have 
inflammatory diseases of the joint converted from the serous into the 
plastic, or one that remains plastic throughout the entire course of the 
disease. Again, as elsewhere, differentiation between lesions of the 
joints that are purely the result of irritation—mechanical, as from 
injury, chemical, as from a deposit of uric-acid salts—or the purely 
infective is difficult to make. For practical purposes, therefore, the best 
division possible of acute diseases of joint structures under the circum- 
stances given is into— 
(a) The simple serous synovitis. 
(b) The simple purulent synovitis. 
(c) The dry synovitis. 
(d) Acute suppurative arthritis. 
Simple Synovitis with Effusion.—Acute serous synovitis is the 
commonest form of joint disease. As a rule, it is the result of a con- 
tusion, but may arise without any known cause. In point of frequency 594 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
the joints involved are the knee, the elbow, and the ankle. Among the 
joints less frequently involved are the hip, the shoulder, and the small 
joints of the extremities. The pathology of the disease is limited to 
changes in the synovial membrane in which the usual manifestations 
of irritation and inflammation develop according to the cause producing 
the disease. 
When this affection is the result of an irritation such as is produced by a 
trauma, the, presence of a blood-clot, the pinching of the synovial folds, or 
irritation from chemical causes, such as occur in gout and in some cases of gonor- 
rhoea, there is a congestion of the synovial membrane, the vessels are injected, 
the entire surface reddened, particularly about the line of attachment to the 
articular cartilages. These undergo no change, and by their pearliness are 
therefore in strong contrast to the reddened synovial surfaces. From these there 
is effused at first an increased quantity of synovia, and soon the exudate becomes 
closely allied to the serous effusion found elsewhere. Clear at first, it has a tend- 
ency to become turbid from the admixture of disintegrated epithelial cells and of 
leucocytes. The turbidity is often increased by the presence of blood-disks from 
minute hemorrhages into the joint-cavity. Within the exuded fluid flocculi of 
fibrin in greater or less abundance are usually found. These may be attached to 
the synovial fringes and to the more dependent portions of the joint, or they may 
be floating about in the free exudate. 
In mild cases of synovitis the condition described lasts from a week 
to ten days, when, by the gradual absorption of the exudate and the 
return of the distended vessels to their natural condition, the joint 
resumes its normal appearance and function. In other cases absorption 
goes on very slowly, or it may altogether fail to take place, under 
which circumstances we have established the condition known as 
hydrarthrosis, the chief feature of which is the effusion into the joint. 
Simple Purulent Synovitis (Synovitis Catarrhalis Purulenta).— 
In less favorable cases or in consequence of improper management the 
exudation increases often to enormous proportions. Its character may 
also change : turbid at first from the admixture of few cellular elements, 
these increase until the exudate assumes a purulent character. ■ The 
rapidity with which the effusion becomes purulent is at times so great 
that the synovitis in these cases seems to be purulent from the beginning. 
Except for the latter, the condition of the joint interior does not vary 
at first in the simple purulent form of synovitis from the serous. 
Particularly in children, as Volkmann and Krause have shown, there may be 
a purulent effusion into the joint without destruction of the articular surfaces 
or permanent impairment of synovial membrane, joint-capsule, or ligaments, pro- 
vided spontaneous perforation occurs or an early outlet be made for the discharge. 
Dry Synovitis.—In certain cases of acute synovitis the fluid exuded 
may be very small in quantity or altogether absent. In proportion the 
flakes of fibrin are greatly increased, until they may appear as a con- 
tinuous layer covering the articular surfaces and forming a deposit of 
varying thickness on the synovial membrane and cartilages. The fibrin 
thus thrown out shows remarkable tendency toward organization. The 
smooth, glistening character of the serous surfaces is lost. In its place 
there are masses of fibrin, often unevenly disposed and by joint move- 
ment often drawn into shreds of unequal length and adherent at one or 
both ends. If ankylosis do not occur, these shreds may speedily 
become detached and present themselves in the form of many small INJURIES AND DISEASES OF THE JOINTS, ETC. 
595 
bodies the size of a pea or bean, round or ovoid, and consisting of con- 
centric rings of fibrin—rice-bodies. In other cases the joint surfaces are 
speedily welded together by the organization of the exuded lymph. 
Ankylosis may sometimes follow these acute dry synovitides with 
remarkable rapidity. 
Acute Suppurative Arthritis.—The conditions above described are 
superficial, and do not involve, even if long continued, the integrity of 
the joint structures. Acute suppurative arthritis, however, being always 
an evidence of grave infection, is almost from the first destructive in its 
tendency. Although in the beginning the lesions are limited to the 
synovial membrane and the product may be but a serous effusion, there 
soon follows purulent distention of the joint. In addition to the syno- 
vial lining the cartilages participate in the morbid process. They lose 
their pearly hue and assume a reddish or even blue tinge. Blood- 
vessels appear within them, and absorption, often in patches, takes 
place, the subjacent bone thereby becoming exposed. Shreds of car- 
tilage are often raised in areas, become necrotic, and are thrown off into 
the joint-cavity. The ligaments become softened and permeated by 
small purulent foci; the joint becomes loosened and devoid of function. 
Displacements of the articular ends of the bones are therefore of early 
and frequent occurrence. Caries of the articular ends, extending for a 
greater or less distance into the epiphyses, results. The periarticular 
structures, bursse, and tendon-sheaths take part in the suppurative pro- 
cess. Abscesses communicating with the joint occur and develop in 
different places. They are often far removed from the part primarily 
involved. Unless adequate treatment is instituted the destruction of 
the joint invariably follows. If the limb is saved, the suppurative pro- 
cess gradually subsides through the drainage given by fistulous forma- 
tions or by surgical treatment. The joint-cavity is almost always 
obliterated. Ankylosis, fibrous or bony, is an almost inevitable result. 
Symptoms.—The superficial position of most of the joints facilitates 
the recognition of a simple synovitis. Except in the joints deeply seated, 
like the shoulder and the hip, the four cardinal symptoms of inflamma- 
tion can be easily recognized. In the latter joints only are we called 
upon to look to other than the characteristic symptoms for recognition 
of the condition. As has been said in the symptomatology of joint 
injuries, the patient first complains of pain, which, as a rule, is propor- 
tionate to the rapidity of the joint distention with fluid. Generally the 
pain is complained of in the joint itself. Only in exceptional cases, as in 
the hip, it is felt in a part far removed. With the pain there is associ- 
ated more or less tenderness, often felt at one or more points along the 
articular line rather than over the entire area. In cases of traumatic 
origin the reason for this is apparent. In other cases Volkmann has 
ascribed these special points of tenderness to the deposit beneath them 
of fibrinous material. It is more probable, however, that these special 
points of tenderness correspond to the attachment of ligaments or dupli- 
catures of the synovial membrane, which are stretched by unequal ten- 
sion of the effusion in the joint when pressure is made over them. Where 
pain is not complained of when the limb is at rest, it will often be found 
to be very severe when any effort at motion, voluntary or passive, is 
made. The swelling is the most marked feature of a simple synovitis. 596 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
Often within twenty-four or forty-eight hours it is sufficiently developed 
to have effaced all of the normal outlines of the joint. 
The grooves on both sides of the patella, the supra- and infrapatellar depres- 
sions, are often thus early effaced and distinct fluctuation manifested. The patella 
with a little tap of the finger can be made to strike the anterior intercondyloid 
depression from which it has been lifted by the serous effusion (ballottement). In 
the ankle the swelling is most and soonest marked below the malleoli and in front 
of the joint. In the elbow the grooves between the olecranon and condyles soon 
become obliterated, and often the swelling is marked between the head of the 
radius and the outer condyle. In the wrist the swelling makes itself soonest 
apparent beneath the styloid processes of radius and ulna, and the antero-posterior 
diameter of the joint becomes to the naked eye greatly increased. The effusion 
into the shoulder-joint, as a rule, manifests itself by a greater fulness and by 
increased antero-posterior measurement. Except through the axilla effusion into 
the joint cannot be easily mapped out, because of the thick muscular covering 
upon its outer anterior and posterior surfaces. For the same reason effusions into 
the hip are also recognized with great difficulty. Occasionally a tumefaction in 
front of the joint or to the outer side and behind the trochanter gives positive 
evidence of joint effusion, and a sensation of deep fluctuation may occasionally be 
obtained. 
The development of an acute synovitis is very frequently, although 
not always, associated with definite change in the position of the limb. 
For the most part, one midway between flexion and extension is assumed, 
and maintained throughout the entire course of the disease. The knee 
becomes flexed upon the thigh, the foot becomes placed in the position 
of talipes equinus, the hip becomes flexed and abducted. When the 
shoulder is involved the arm is held close to the side of the body; in 
disease of the elbow the forearm is extended at an angle of 140° ; in 
disease of the wrist there is a slight drop, the fingers are maintained 
almost in extension, and the hand somewhat flexed on the forearm. The 
assumption of these positions has been accounted for through the fact 
that by them an equal pressure on different part of the joint surface is 
secured, since they are positions taken by the joints when injected experi- 
mentally. This explanation does not obtain in cases of synovitis, since 
in some of great distention with serous fluid no faulty position is assumed. 
In every case of purulent synovitis this tendency to contracture makes 
itself apparent early, as it does also in cases of tubercular disease, to be 
hereafter considered. It is exceedingly probable, therefore, that the 
contracture is a reflex phenomenon manifested only when, from the 
nature of the disease, prolonged fixation, in the position in which exten- 
sors and flexors are equally favored, is to be maintained for a long time. 
The symptoms hitherto considered are far more important than the 
remaining cardinal symptoms of redness and heat. In simple serous 
synovitis redness, as a rule, is altogether absent. In the purulent form 
it is present only when preparations are making toward spontane- 
ous perforation. When synovitis is the result of joint contusion the 
reaction following periarticular injury is often causative of a redness far 
in excess of that which follows the synovitis alone. In joints super- 
ficially placed, like the elbow, the knee, and the wrist, a local elevation 
of temperature of from one to two degrees may usually be recognized. 
The general condition in cases of simple serous synovitis is commonly not 
influenced by the disease. Extensive effusions may take place in the joint without 
other than local symptoms. This is particularly true of the synovitis which is the 
result of an irritation such as a primary trauma will produce. As has already INJURIES AND DISEASES OF THE JOINTS, ETC. 
597 
been stated, the absorption of blood may elevate the temperature one or two degrees, 
but after two or three days the temperature returns to the normal. 
In cases of suppurative synovitis the general symptoms reflect the 
greater gravity of the local condition. With the systemic absorption 
of the products of inflammation the usual accompaniments of toxaemia, 
chills and continuous fever, coating of the tongue, and anorexia, are 
found. 
The general symptoms of acute suppurative arthritis are proportionate 
to the severity of the local condition. Almost from the beginning the 
temperature rises from three to five degrees, and continues with morning 
remissions until vent is given to the inflammatory products or until 
death ensues from exhaustion. The fatality of this condition has already 
been referred to in the section on Penetrating Wounds of the Joints. 
In the dry form of synovitis many of the local symptoms of the 
serous and purulent variety are absent. Pain and tenderness are often 
very marked, and out of all proportion to the swelling, which, as a rule, 
is slight. In these cases the tendency to faulty position is very early 
developed. When efforts at motion are made crepitus is felt. Move- 
ments of the patella upon the front of the femoral condyles may like- 
wise elicit such joint crepitus. When the latter is insufficient to be felt 
it is distinctly audible when the ear is placed over- the joint and the 
articular surfaces are moved upon each other. Passive movements are 
more painful than in the synovitis with effusion, and the pain associated 
therewith increases with the tendency to the formation of adhesions. 
The latter may form as early as the first week, and be firm enough to 
demand the anaesthetizing of the patient for their severance and the 
correction of the concomitant deformity. The general symptoms in 
cases of acute dry synovitis are often out of proportion to the severity 
of the local condition. 
Etiology.—The etiological factors of acute diseases of the joints 
may be divided into the traumatic and the non-traumatic. The former 
have been sufficiently considered under the head of Joint Injuries. 
Without the history of a trauma, acute inflammation occasionally devel- 
ops without any recognizable cause. Non-traumatic joint inflammations 
are often secondary to lesions in the vicinity of the joint. Acute inflam- 
mations of the joint-structures also often develop by extension from 
disease in the vicinity. 
Chronic osteitis, periarticular abscesses, epiphyseal osteomyelitis, or erysipelas 
of an extremity may by extension of the process involve a joint in the vicinity. 
Suppurative disease in the tendon-sheaths of the hand and foot are not infrequently 
the cause of acute destructive inflammation of joints. Direct perforation of the 
joint-capsule from the outside does not ordinarily take place in this process, but it 
is through the slow invasion of the capsule by the pus-formers from without that 
the disease is grafted on the joint interior. 
A tubercular nodule in the epiphyses by breaking into the joint will speedily set 
up a synovitis which at first is serous. Many of the non-traumatic inflammations 
of joints are but the manifestations of systemic involvement, and may therefore be 
called infective. Pyaemia, puerperal fever, gonorrhoea, the acute exanthemata, rheu- 
matism, and gout, ali have, as frequent complications, one or other form of acute 
joint disease, limited according to the severity of the local infection either to the 
synovial membrane or deeply involving the structures entering into the joint 
formation. 
The synovitis of pyaemia and puerperal fever is ordinarily characterized by the 
involvement of more than one joint, either simultaneously or in succession. The 598 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
joints affected are usually the larger ones, like the knee and shoulder. Generally 
the joint effusion is purulent from its inception. The pus when evacuated is 
usually thin and flaky, but often is very foul. The acute exanthemata—with which 
for present purposes might be classed typhoid fever—which most frequently are 
followed by synovitis in their relative order are variola, scarlet fever, measles, 
and typhoid fever. As a rule, the joint complication develops during the period 
of convalescence, and, except in the case of variola, is ordinarily serous in its 
character. In variola, however, suppuration of the joint is not at all uncommon. 
In the suppurative processes of joints which occasionally accompany the acute 
infectious diseases the specific microbe of the individual disease has not been found 
in the joint effusion. The staphylococcus aureus has been most frequently observed, 
and in graver infections the streptococcus. In the arthritis following typhoid fever, 
the hip is more frequently affected than any other joint. Occasionally suppuration 
does not take place and complete recovery may ensue. More frequently, however, 
the joint lesions leave in their wake ankylosis or spontaneous dislocation. In 43 cases 
of joint disease from typhoid fever collected by Keen, 30 were subjects of spon- 
taneous luxation, of which 27 were of the hip, 2 of the shoulder, and 1 of the 
knee. The synovitis which is the chief symptom of rheumatism is sufficiently 
characterized by the rapidity of the joint effusion, its serous character, and, above 
all, by the periarticular swelling and redness and the number of joints that are 
simultaneously or successively involved. 
Gouty synovitis is but a manifestation of the general condition. It 
is serous, limited, usually to the metatarso-phalangeal joint of the left 
foot, associated with extensive periarticular swelling and redness. 
Through the soft' parts, after the subsidence of the acute disease, 
nodules of calcareous deposit can often be felt within and about the 
joint structures, more or less defacing the joint outline and limiting mo- 
tion to a varying degree. The subjective symptoms of pain and of tender- 
ness are far in excess of the local underlying conditions. Both rheu- 
matic and gouty synovitis are further characterized by their tendency to 
become subacute and even chronic. The structural changes involve the 
cartilage, ligaments, and periarticular structures. Both of these forms 
of synovitis, but particularly the gouty, are characterized further by 
their tendency to recur. 
Post-gonorrhoeal synovitis, when it develops, usually appears during 
the period of greatest activity of the primary urethral disease. In the 
great majority of cases, therefore, it will be found before the end of the 
third week. Immunity from a synovitis, however, does not exist until 
the complete cessation of the discharge. 
While it is uncommon, gonorrhoeal synovitis occasionally develops as a com- 
plication of what appears to be an insignificant gleetv discharge. (See Chapter 
XI.) Special predilection is shown for the knee. Of 209 cases tabulated by 
Lagrange, the knee was affected in 83, the ankle-joint in 32, fingers and toes in 23, 
the hip in 16, the wrist in 14, the shoulder in 12, and the elbow in 11. That all 
joints may become involved is shown by this tabulation, to which the temporo- 
maxillary, the sacro-iliac, and the sterno-clavicular joints afford a contingent. As 
a rule, gonorrhoeal synovitis affects one joint at a time, but it may be polyarticular. 
It appears more frequently in men, but does not altogether spare women. 
Closely allied etiologically to gonorrhoeal synovitis is what might be 
termed urethral synovitis. Occasionally the passage of a sound or a 
catheter in a urethra apparently normal is followed by a joint affection 
indistinguishable from that under consideration. 
The relation of gonorrhoeal synovitis to the primary disease is not clearly 
understood. Most careful observers like Kammerer, Petrone, and Bousquet have 
found the pathogenic diplococcus of Neisser in the exudate removed from a 
gonorrhoeal synovitis. Per contra, in the hands of many observers the search INJURIES AND DISEASES OF THE JOINTS, ETC. 
599 
has been negative. The discrepancy may be due to the fact, as Kammerer 
has pointed out, that it is only during the height of the disease that the specific 
germ of Neisser can be found. In a very recent case of gonorrhceal synovitis he 
discovered the diplococcus; on making an artlirotomy on the same case eighteen 
days later the search proved negative. Usually gonorrhceal synovitis is serous in 
its character; very rarely it becomes suppurative. In the latter cases ordinary 
pus-formers have been found more frequently by all investigators than the specific 
gonococcus. 
The diagnosis of gonorrhceal SYNOVITIS is not difficult when 
the presence of the primary disease is known. From ordinary rheuma- 
tism it may be recognized by its being mono-articular, by the low range 
of temperature, the absence of the profuse sweating and heavily-loaded 
urine characteristic of rheumatic disease. Gonorrhoeal rheumatism (as 
it is too often misnamed), as a rule, retrogrades slowly toward recovery. 
Often, however, the effusion becomes permanent. In other cases the 
plastic material thrown out tends toward the formation of fibrous anky- 
losis. Most ankyloses of the knee that are not the result of tubercu- 
losis or trauma in young male subjects owe their origin to gonorrhoeal 
infection. Syphilis very rarely produces primary acute articular disease. 
Occasionally during the eruptive stage joint pains are complained of. 
Serous effusions do not occur frequently, and are almost altogether 
limited to the knee. Ordinarily, the joint complications of syphilis are 
secondary to gummatous deposits in the epiphyses. In the hereditary 
syphilis of early life multiple joint lesions of this nature are often seen. 
Treatment.—The treatment of acute inflammation of joints has a 
fourfold object: First, the limitation of the inflammatory process; sec- 
ond, the removal of the products of inflammation ; third, the prevention 
of deformity ; and fourth, the restoration of full physiological function. 
(1) Among the methods of curtailing inflammation may be mentioned, 
in the first place, position and rest. In inflammation of the larger joints 
of the upper, and of necessity of the lower extremities, the patient must 
be put to bed. In diseases of the knee, the ankle, the elbow, and the 
wrist the limb should be suspended at nearly a right angle. The disad- 
vantage given by position to the arterial circulation is often of itself suf- 
ficient to cut short an attack of synovitis. Unfortunately, in inflamma- 
tory conditions of the hip and of the shoulder these advantages cannot be 
obtained. Rest should further be secured by placing the part upon a 
proper splint, and the circulation should be as far as possible controlled 
by the application of an elastic bandage. As elsewhere, this should 
not be directly applied to the skin, which would speedily macerate, but 
over one or two thicknesses of gauze. When the tenderness and pain 
will not admit of such pressure the application of an ice-bag or astrin- 
gent lotions, sugar of lead and tincture of opium or the chloride of 
ammonium, will be of service. The general condition of the patient 
in the simple form of synovitis rarely requires any special attention. 
(2) For the removed of the products of inflammation the preparations 
of iodine, of mercury, and of lead have been used from time immemo- 
rial, but with rather doubtful results. The repeated use of blisters and 
of the hot iron will not infrequently, in cases that have passed through 
the acute stage, cause a speedy and permanent reduction of the joint 
swelling. To further facilitate the removal, and at the same time ensure 
joint fixation, fixed dressings, like the plaster-of-Paris, the starch, and 600 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
the silicate-of-soda bandage, have been highly recommended. Their use, 
however, should be limited to ten days or two weeks at a time, after 
which an inspection of the joint is necessary to forestall the development 
of ankylosis. Very effective in hastening absorption of serous products 
of inflammation is massage. When methodically applied once or twice 
daily, and followed by the use of elastic compression, it will remove the 
great majority of synovial effusions. As auxiliary to the local treatment 
very great faith may be placed in the internal administration of the 
iodide of potassium. When, notwithstanding the procedures here de- 
scribed, the effusion continues, recourse should be had to aspiration of 
the joint. This should not be delayed more than two or three weeks, lest 
the relaxation of the periarticular structures leaves the joint in a per- 
manently weakened condition. The aspiration should always be done 
with the strictest aseptic precautions, a large needle being used and an 
oblique puncture being made through the overlying soft parts. All of 
the fluid of course cannot be removed by aspiration. The removal of 
only a part, however, will relieve the intra-articular tension to a degree 
compatible with the function of absorption by the synovial membranes. 
In not a few cases, particularly of the subacute variety, the tendency to 
the reaccumulation of fluid is great. When one or two aspirations have 
failed, a permanent cure can ordinarily be secured by the injection into 
the joint-cavity of two or three drachms of a 5 per cent, solution of car- 
bolic acid. This injection should preferably be made through a large 
trocar, the joint being distended with as much of the solution as it will 
hold, when all but two or three drachms are allowed to come away 
through the cannula. In cases of pyoid effusions relief will not ordi- 
narily be obtained without this treatment. 
In cases of suppurative arthritis efficient drainage must be secured at 
the earliest possible moment. It is only by early and efficient drainage 
that the joint function can in a measure be saved. 
In very many instances the removal of the entire synovial membrane 
and as much of the articular ends of the bones as may be diseased 
(arthrotomy) would prove the best conservatism practicable. It is only 
in the exceptional cases of acute articular suppuration that recourse must 
be had to amputation. 
(3) Deformity is to be prevented by giving the limb a proper position 
from the very beginning, and one which, in the event of ankylosis, would 
leave it most useful. The knee should therefore always be kept extended, 
the elbow at nearly a right angle, and the wrist midway between prona- 
tion and supination. In diseases of the hip the leg is to be extended. 
As the tendency to deformity often manifests itself early, it may be 
already present when the case first comes under observation. At any 
cost this should be corrected as soon possible, either by gradual exten- 
sion or, if need be, forcibly under general anaesthesia. By the use of 
proper support the recurrence of the deformity can ordinarily be ob- 
viated. 
(4) Restoration of function is the most difficult achievement in the 
treatment of acute joint diseases. It can be met only by properly con- 
ducted passive movements, instituted as soon as the height of the inflam- 
matory action has been thoroughly passed. The restoration of joint 
function must be particularly cared for in cases of synovitis which early INJURIES AND DISEASES OF THE JOINTS, ETC. 
601 
manifest a tendency toward joint fixation. Such are the dry synovitides 
and those which complicate gonorrhcea and the acute exanthemata. In 
these cases the use of an immobile dressing for two or three weeks will 
often permanently impair joint movement. Where it is already impaired 
passive movements and massage are most serviceable in restoring joint 
function. 
Chronic Diseases. 
Hydrarthrosis.—This term is used to designate a serous effusion into 
a joint with a tendency to chronicity. Strictly speaking, it is not a dis- 
ease, but a result common to many conditions in and about the joints. 
Often in its inception it is the result of an irritation or an inflammation, 
the acute synovitis having become chronic. On the other hand, the 
effusion is often the result of changes in the vicinity of joints. 
A tubercidar or gummatous nodule in an epiphysis or a sarcoma of the epiphys- 
eal end of the bone will occasionally be associated with a serous effusion into the 
adjoining joint-cavitv. Chronic articular rheumatism and osteoarthritis are also at 
times associated with joint effusion, although, as a rule, in these cases the hydrar- 
throsis is limited in extent. Retarded circulation that in other parts produces an 
oedema will at times be followed by hydropic effusion into the joints. The local 
retardation of circulation, such as occurs in phlegmasia alba dolens, is not infre- 
quently followed by an effusion into the knee which may continue long after the 
subsidence of the primary lesion. There are other cases, however, in which, with- 
out any of the causes named, hydrarthrosis develops, and in which the etiology is 
altogether unknown. An interesting class of cases was described as hydrarthrosis 
intermittens by Seeligmi'iller in 1880. In this form of disease the effusion recurs at 
fixed intervals, usually in both knees. It reaches its height often in a few hours, 
continues unchanged for from forty-eight to seventy-two hours, and then disap- 
pears. In a case seen by the writer this condition continued during three years 
without leaving the joint permanently damaged or seriously interfering with loco- 
motion, even during the height of the effusion. In only two of the recorded cases 
was there a previous history of malaria. 
Larger joints, like the knee, the elbow, the shoulder, and the hip, 
are often the seat of hydrarthrosis, although the knee is affected more 
frequently than all of the rest of the joints together. The character of 
the effusion is ordinarily serous; occasionally it is tinged with blood, 
and contains at times shreds of fibrin, free globules of oil, and, in old- 
standing cases, fat-crystals. In its amount it varies materially. In the 
knee there may be just enough of an effusion to efface the patellar 
grooves, or, in old-standing cases, as much as a pint. With the long 
continuance of hydrarthrosis, irrespective of its cause, certain structural 
changes result. The synovial membrane in its deeper layers becomes 
very considerably thickened; the folds or reflections show marked 
induration, and can often be felt in distinct ridges. The synovial 
fringes become enlarged, cedematous, and by proliferation far more 
numerous than in the normal condition. The articular surfaces of the 
bones are ordinarily unchanged. The important ligaments do not 
usually become relaxed, so that pathological displacements are never 
seen. 
Although in long-standing cases of hydrarthrosis appreciable muscular atrophy 
ensues, contractures are very uncommon. Only so far as the presence of the fluid 
acts mechanically is the joint function restricted. When the accumulation is 
large, the bursae with which the joint is in communication ordinarily participate 
in the effusion, thereby giving to the joint surface an uneven, at times lobulated, 602 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
appearance. When, as at times occurs, the hydrarthrosis disappears spontaneously 
the bursal effusion may remain unchanged. 
The diagnosis of hydrarthrosis of the knee, the elbow, the 
wrist, or the ankle is easily made. Effusions into the shoulder and hip 
can only be recognized directly when they are quite large. The wave 
of fluctuation in extensive effusion is distinct. The articular outlines 
are effaced, and in the knee the ballottement of the patella can be easily 
demonstrated. The chronicity of the condition, its slow development, 
the absence of rise of temperature and of pain, confirm the diagnosis. 
The prognosis of hydrarthrosis is largely that of the under- 
lying condition. In the simpler forms spontaneous cures occasionally 
result. As a rule, considerable fluctuation in the quantity of the 
effusion is manifested. A partial or total absorption will often be fol- 
lowed by an increase and reaccumulation of the fluid. 
Treatment. — In comparatively recent cases of hydrarthrosis 
absorption may often be secured by the treatment advocated for acute 
synovitis with serous effusion. Friction, methodical massage, repeated 
blisters, and the continuous application of an elastic bandage will often 
effect a permanent cure. In the failure of these measures recourse may 
be had to immobilization, from which the danger of ankylosis is not so 
great as in the cases of acute disease. In the majority of old-standing 
cases, however, recourse must be had to aspiration of the joint, to be 
followed by irrigation with a 5 per cent, solution of carbolic acid, of 
which from five to ten cubic centimetres may be allowed to remain 
within the joint. To make the injections painless, a f per cent, solution 
of cocaine may be injected before introducing the carbolized water. In 
cases where even this has failed the draining of the joint may be 
resorted to. 
A few cases have recently been recorded in which free incision of the joint has 
been made, the synovial surfaces thoroughly rubbed with pledgets of gauze, pro- 
liferated and hypertrophied synovial fringes removed, and the joint closed. A 
simpler method is what the writer would call that by subcutaneous drainage. 
A strand of silkworm gut is passed by means of a trocar through the affected joint: 
the ends of the strand are then carried subcutaneously through the periarticular 
tissues to a small incision made midway between the points of entrance and exit. 
After being tied the knot is buried and the wound of incision and, if need be, 
the punctures, are closed by sutures. The drainage is thus carried into the peri- 
articular subcutaneous tissue, which does the absorbing, and through which and 
through the joint there passes a strand of silkworm gut. After a cure has been 
effected the silkworm gut, if need be, can be readily removed. 
Chronic Articular Rheumatism.—This is a condition of advanced 
life and often found in the lower social strata, Individuals who have 
always been well nourished are not often subject to this disease. It occurs 
oftener in men who have led exposed lives: the earlier decades of life 
are, as a rule, exempt. The disease may follow in the wake of an acute 
rheumatic attack; generally it is subacute or chronic from its inception. 
Like its acute prototype, it is polyarticular. The pathological changes 
of chronic articular rheumatism vary with its severity and duration. 
Joint effusions are ordinarily limited in amount, if at all present. Pri- 
marily, the synovial membrane, the capsule, and the periarticular struc- 
tures are involved. The synovial membrane becomes thickened, the 
ligaments indurated, and periarticular fasciae show a tendency to become 
fixed. INJURIES AND DISEASES OF THE JOINTS, ETC. 
603 
Consequent upon this irritative hyperplasia, the joints often become fixed and 
a fibrous ankylosis results. The cartilages and the articular ends of the bones 
remain unchanged for a long time. It is only after prolonged fixation that cell- 
proliferation in the cartilaginous covering takes place, followed by abnormal bone- 
formation. This metamorphosis of bone occurs relatively often in the small joints, 
particularly in women over thirty. 
Tile SYMPTOMS AND COURSE OF CHRONIC ARTICULAR RHEUMATISM 
correspond to the morbid conditions described. Mild or severe pain 
in one or more joints will be complained of. This is associated with 
restricted movement in the respective joints. There is usually an 
absence of redness over and about the joint, and tenderness is never 
excessive. 
Joint motion is very often associated with a distinct crepitus. With 
the continuance of the process restriction of motion and faulty position 
will often eventuate in the disability of an entire limb. It is in this 
way that, by the multiplicity of joints involved, the subject of chronic 
articular rheumatism is often permanently invalided. Acute exacerba- 
tions of the chronic disease are of frequent occurrence. 
The diagnosis is ordinarily easily made. The conditions with which 
it may be confounded are arthritis deformans and the articular affections 
consequent on diseases of the spinal cord. 
The treatment of this condition is chiefly general. During the 
acute exacerbation sodium salicylate is as serviceable as in the typical 
acute articular disease. During the intervals alkaline waters, particu- 
larly those containing lithia, have been found efficient. Sulphur and 
mud baths, when long continued, seem also to have proven serviceable. 
Methodical massage may accomplish much in overcoming joint fixation, 
hastening the absorption of effused fluids and reducing the thickened 
capsule and periarticular structures. 
Osteo-arthritis.—This is a condition of degeneration and prolifera- 
tion of the structures entering into a joint, the morbid anatomy of 
which forms a distinct entity. The causes which bring about the 
changes are far from being clearly apprehended. It is for this reason 
the disease has been variously named rheumatoid arthritis, arthritis de- 
formans, dry arthritis, trophic arthritis, according to the views enter- 
tained concerning its nature. For the most part it develops by predi- 
lection in individuals past middle life, many of whom present evidences 
of arterio-sclerosis. Occasionally it develops in young subjects, prefer- 
ably in girls after the appearance of menstruation. 
As the immediate cause of osteo-arthritis trauma plays a most im- 
portant role, particularly about the hip, rapid changes of an osteo-arthri- 
tic nature following contusions of and about the trochanter. Within 
three or four weeks most extensive changes may occur which simulate the 
conditions following a fracture. Medico-1 egally, the knowledge of a trauma 
as the exciting cause of an osteo-arthritis is of signal importance. 
In the selection of the joints affected the small joints of the hand and of the 
foot often show the process first. Among the larger joints, the hip, the knee, and 
the shoulder are most frequently involved. As a rule, this disease is monoarticular, 
although in individual instances two, three, or even more joints are involved. In 
very exceptional cases the number is very large (Fig. 237). Particularly does this 
apply to the joints of the spine, which by osteophytic growth may practically be 
rendered a solid column. 604 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
In its clinical manifestations osteo-arthritis, except in the rarest 
cases, is characterized by its chronicity and the tendency to joint fixa- 
tion, not by obliteration of the joint-cavity, but by the development of 
osteophytic processes which me- 
chanically impede motion. Pain 
is one of the chief symptoms of 
this disease. The joint, as a rule, 
shows early the deformation of 
its contour. The ligaments are 
thickened, prominent, and indu- 
rated ; often bony deposits can be 
felt within them and continued 
into the periarticular fasciae and 
tendons. In the early stages 
joint distention by fluid can occa- 
sionally be made out, although, 
as a rule, the process is one in 
which synovial fluid is rather 
reduced than increased in quan- 
tity. In accordance with this, the 
patient often experiences a dis- 
tinct creaking or grating when he 
makes an attempt at motion, and 
therefore stiffness and pain in the 
part will be complained of in the 
morning until the joint has been 
considerably used after a night’s 
rest. Acute exacerbations follow- 
ing a trauma, for example, or a 
breaking off of one of the osteo- 
phytic growths, may be followed 
by hemorrhage or serous effusion 
into the joint. This condition 
usually subsides more readily in 
cases of this character than in 
joints that are otherwise nor- 
mal. 
Morbid Anatomy. — Al- 
though all the structures entering 
into the joint are ultimately in- 
volved, the first changes are 
observed in the articular carti- 
lages. The disease begins usually 
with a proliferation of the deep 
layers and a rapid multiplication 
of the cells within the capsules. 
Where the joint surfaces must 
press upon each other the matrix 
of the cartilage becomes fibrillated, almost velvety. Where there is 
less pressure on the joint surfaces the proliferation of the cartilage-cells 
proceeds, while the matrix remains intact. In the periphery, therefore, 
Fig. 237. 
General osteo-arthritis, with multiple synostoses 
(“ossified man”) (Park). INJURIES AND DISEASES OF THE JOINTS, ETC. 
605 
the process is formative. Thus there are formed ecchond'roses, which 
are most marked along the borders of the joint surfaces, with a distinct 
tendency to outgrowths into the synovial membrane and the capsule 
where it joins the epiphyseal margin. The process of destruction pro- 
ceeds in the central portions of the joint, where, by attrition, the 
fibrillated portions of the cartilages are removed and the underlying 
bone-tissue becomes exposed. The changes in the latter tend toward a 
complete obliteration of the meshes of the uppermost lamellae, a com- 
pact layer of unusual hardness taking the place of the normal cancellous 
bone; thus the eburnated surface of one bone grates against its fellow. 
Any unevennesses which may have been present soon cut furrows into 
the yielding surface opposed to them; therefore in many cases osteo- 
arthritis is characterized by grooves and ridges alternating with each 
other on the surface of a bone involved in the disease. Their presence ex- 
plains why in joints so deformed motion is often limited to a single plane. 
The proliferation of the cartilage along the periphery of the artic- 
ular surfaces and into the margins of the joint-capsule presents marked 
tendency toward ossification. Osteophytic 
growths develop along the margins of the 
articular surface, thereby producing a dis- 
tinctly lipped appearance. Often the entire 
circumference of a joint will thus be en- 
sheathed by new bone-formation. Frequently 
these processes entirely change the outline of 
the joints, as will be seen by reference to 
illustrations, wherefore the name of arthritis 
deformans happily designates the morbid con- 
dition, as seen in advanced cases (Fig. 238). 
The capsule and ligaments often present 
osseous plates within them, the joint-fringes 
are early enlarged, often presenting infiltra- 
tions with various forms of connective tissue, 
fat, cartilage, or bone. The eating away of 
one or more of these processes is a fruitful 
source of the development of foreign bodies 
within the joint. The synovial membrane 
never becomes entirely obliterated, wherefore 
ankylosis does not occur in this disease. A 
vestige of the joint-cavity is always present. 
The joint becomes locked by proliferation of 
bone about it; a true ankylosis, however, 
rarely, if ever, takes place. By attrition, 
absorption of existing and deposition of new 
layers of bone go on synchronously. It is in 
this manner that, as the head of the femur, 
for example, in morbus coxce senilis (which is 
arthritis deformans of the hip) becomes absorbed, the acetabular rim is 
widened and made shallower by deposition of new layers of bone. In 
this process of absorption the head of the femur may almost disappear, 
the neck be reduced to a right angle or less, and the entire length of the 
femur shortened by from three to four inches. 
Fig. 238. 
Arthritis deformans, knee 
(original). 606 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
Symptoms.—The beginning of arthritis deformans, except when it 
follows a trauma, is ordinarily insidious. Pains varying in their inten- 
sity, but often severe and associated with creaking of the joints and 
moderate joint effusion, are among the earliest clinical manifestations. 
Very frequently the pains are of a neuralgic character. In the hip, for 
example, they are referred to the sciatic nerve. The joint deformity, 
however, usually manifests itself early. Irregular nodules appear, grow 
slowly, and show no tendency toward absorption. With the temporary 
joint effusion and the pain, muscular contraction often manifests itself 
early, fixing the joint in an abnormal position. 
The course of the disease is ordinarily chronic, continuing at times 
for from three to ten years or more. Exacerbations consequent on 
trauma are frequently shown ; severer injuries may produce fracture or 
dislocation. 
Treatment.—The treatment of osteo-arthritis is extremely unsatis- 
factory. In every feasible way joint movement should be maintained 
by active and passive movements. Massage may also be advantageous. 
Fixation by immobilizing dressings is to be strenuously avoided. 
Operative treatment is not often called for, although in younger individuals, 
and particularly when the disease affects only one joint, excision may be resorted 
to in cases where the pain is very severe or the limb rendered useless. In a num- 
ber of cases in which Konig made excision recurrence of the disease did not ensue 
during six years after the operation. A resected elbow-joint performed its func- 
tion well, although the arm was weak. A knee united firmly, although the patient 
was over sixty years of age. In two excisions of the hip of patients, aged respect- 
ively seventeen and twenty-eight years, the result was very satisfactory. 
Neuropathic Diseases of Joints. 
Although M. T. R. Mitchell called attention to the joint complica- 
tions of nervous diseases in 1831, it was not until their classical descrip- 
tion by Charcot in 1868 that they were given a fixed position in articular 
pathology. Whereas joint complications may follow injuries of the 
peripheral nerves or of the spinal cord, they are for the most part asso- 
ciated with the chronic diseases known as locomotor ataxia and syringo- 
myelia. Notwithstanding great variations in the mode of development 
and the rapidity of their course, neuropathic arthritis appears under two 
forms clinically, the benign and the malignant. The former begins as an 
acute or subacute swelling of the joint and the periarticular joint struc- 
tures. There is a serous effusion into the joint, which may after a short 
time be absorbed, the disease being unmarked by either fever, pain, or 
redness. The malignant type, according to Charcot, is found exclusively 
in tabetic subjects. With or without absorption of the serous effusion 
the joint-capsule remains relaxed and weakened, the ligaments show a 
tendency to undergo softening, and the articular ends of the bones are 
rapidly destroyed. 
The morbid anatomy would permit the logical division of neurog- 
enous arthropathies into the atrophic and the hypertrophic. In the latter, 
proliferative processes in the cartilages, the capsule, and the periarticular 
structures predominate, since, as in cases of arthritis deformans, extra- 
capsular stalactitic growths and exostoses are of common occurrence. 
Atypical bone-formation is also found in the contiguous tendons and 
fascia. In the atrophic arthropathies, on the other hand, the degenera- INJURIES AND DISEASES OF THE JOINTS, ETC. 
607 
tive process predominates and leads to the destruction of the bony 
components of the joint. Often the entire epiphysis is changed in its 
conformation. Where, after destruction of 
the cartilaginous covering, attrition takes 
place, absorption follows, the process being 
one of rarefying osteitis. 
Fig. 239. 
The head of the femur may be absorbed with- 
out leaving scarcely a trace (Fig. 239). In the 
knee absorption causes the disappearance of the 
condyles and of the head of the tibia. Thus a 
disproportion is established between the area of 
the joint surface as a whole and that of its com- 
ponent bony parts; thereby is produced a flail 
joint, and as characteristic of this condition the 
tendency to luxations and subluxations. The 
arthropathies of nervous origin affect chiefly the 
knee. In 56 observations by Barry the knee was 
affected in 33, the hip in 15, the shoulder in 10, 
the joints of the foot in 11, the elbow in 8, and 
the joints of the hand in 1. In 66 cases the 
arthropathy was mono-articular ; in 25 more than 
one joint was affected. As a rule, joint compli- 
cations do not supervene in tabes until the latter 
is well marked and has existed for from three to 
five years. It may develop before the tendon 
reflexes are lost, and occasionally it appears as 
the initial symptom. 
Symptoms.—The onset of the disease 
is ordinarily sudden. Without apparent 
exciting cause the joint and periarticular 
structures are swollen, and oedema may 
involve the entire extremity. The latter 
usually disappears rapidly, leaving the 
hydrarthrosis (Figs. 240 and 241). In a number of cases the joint 
effusion is preceded for a number of days by a grating sensation. The 
periarticular oedema has been ascribed by DeBove to a detachment of 
the joint-capsule from the bone, and the consequent effusion of the 
synovia into the periarticular tissues. In 23 out of 56 cases the onset 
was gradual. Most of the cases are marked from beginning to end 
by complete absence of pain and of local and general manifestations of 
inflammation. Except for the abnormal mobility of the joint and the 
consequent tendency to faulty position, the patient need not be embar- 
rassed by the presence of the arthropathy. In a few cases, spontane- 
ously or through trauma, the joint has been opened. The joint perfora- 
tion in these cases has not been followed by the disastrous consequences 
of like lesions in normal joints. Preternatural mobility is characteristic 
of this condition. The knee, when the patient is erect, is thrown back- 
ward, with the receding angle in front; in the hip external rotation can 
be carried to the point of bringing the heel forward. Except for the 
often enormous joint distention in tabetic disease of the shoulder, the 
upper extremity assumes the position of one in which excision of the 
shoulder-joint had already been made. 
The diagnosis of neuropathic arthritis is ordinarily easily made. 
Aside from the symptoms of the parent affection, the rapid course of 
Disappearance of joint end of femur 
in neuropathic atrophy (original). 608 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
the disease, the relative freedom from pain, the large joint effusions, the 
local anaesthesia, the muscular atrophy, the relaxation of the ligaments, 
and particularly the age of the patient, are sufficiently diagnostic. The 
condition with which it may most 
readily be confounded, osteo-arthritis, 
afflicts for the most part older individ- 
uals, is associated with severe pain and 
joint fixation, and is essentially slow in 
its development. It is only in the 
Fig. 240. 
Fig. 241. 
Charcot’s disease. 
Charcot’s disease of elbow. 
hypertrophic form of neurogenous joint disease that the diagnosis can 
become difficult. 
Treatment is palliative. When the effusion is extreme temporary 
benefit may be obtained, as in a case recently operated on by the writer, 
by tapping and injection of carbolic acid, as in the treatment advocated 
for hydrarthrosis. Joint fixation by proper appliances or retentive 
dressings may be of avail in locomotion. When the disease is limited 
to the knee, recourse may be had to excision with a hope of securing a 
firm limb. Rotter has thus excised the knee in 4 cases, with fair results 
in 2. 
Hysterical Joints.—As a result of slight trauma or over-exertion— 
as, for example, in dancing—and very frequently without any exciting 
cause, there develops in hysterical subjects a train of symptoms which, 
to casual observation, may closely simulate organic joint disease. From 
the time of Brodie the joints thus apparently affected have been des- 
ignated as hysterical joints. The individuals usually afflicted are girls 
and young women, sometimes pregnant, otherwise well nourished, and 
generally in the higher walks of life. They may or may not display 
other phenomena of hysteria or allied neuroses. The joints most fre- 
quently involved are the hip, the knee, and the ankle. Clinically cha- 
racteristic of an hysterical joint is the disparity between the intensity of 
pain complained of and the local manifestations. INJURIES AND DISEASES OF THE JOINTS, ETC. 
609 
Although, from hysterical paresis or voluntary'muscular contractions, the limb 
may assume an abnormal position, the joint contour is never interfered with. From 
sluggishness of the circulation the part may present a subnormal temperature, be 
given to profuse perspiration, and from disuse present slight muscular atrophy. 
Fixation of the joint, such as occurs in organic disease, is never present except 
during the waking hours. During sleep, particularly that induced by anaesthesia, 
absolute relaxation is obtained and joint movement to a normal degree readily 
elicited. 
Another clinical characteristic of the condition is the variability of 
the position assumed by the limb. The variations often follow each other 
at short intervals. A sign to which Brodie called particular attention is 
the intense hypercesthesia of the joint and of the overlying integument. 
This is more marked even than the tenderness of the joint in organic 
disease, in acute articular rheumatism, or in an acute periarticular abscess 
about to rupture. The pain of hysterical joints manifests itself only 
during the waking hours. The starting-pains complained of at night, so 
characteristic of some forms of organic disease, are seldom seen in hys- 
terical joints. In very rare instances organic diseases have been com- 
plicated by the exaggerated suffering of hysteria, but here the permanency 
of muscular contractures, joint fixation in one position, and the test by 
anaesthesia will make the diagnosis clear. 
The progress of an hysterical joint keeps pace with that of other 
manifestations of hysteria. As a rule, under proper treatment it disap- 
pears rapidly, although in exceptional instances it continues for months 
and even years. An hysterical hip known to the writer withstood all 
forms of treatment during four years, to become finally dissipated in a 
single night through the agency of the faith cure. 
The treatment of an hysterical joint should be directed toward the 
psychical condition of the patient. When once thoroughly assured that 
that there is no serious disease present, applications of electricity and 
massage will ordinarily speedily cause the symptoms to disappear. Too 
much attention should not, however, be given to local treatment, and 
retentive appliances and dressings should be strenuously avoided. 
Loose Bodies. 
In previously healthy joints or joints that have been diseased there 
are not infrequently found bodies varying in size, number, and histolog- 
ical construction, either loose and contained within the joint-cavity or 
adherent at some point by a pedicle of varying length and thickness. 
The joints oftenest the site of loose bodies are the knee and elbow. 
The former is involved in nearly 86 per cent, of all cases. In the 
remaining joints foreign bodies are only exceptionally found. In joints 
that have been free of disease these loose bodies—or floating cartilages, 
as they are often termed—are invariably the result of a trauma. 
Experimentally, it has rarely been found possible to tear away fragments of 
bone ana of cartilage, although accidents doubtless occasionally produce results 
that cannot be wilfully duplicated in the cadaver. Paget, Teale, Fuerer, and oth- 
ers have reported cases in which portions of the external condyle with the over- 
lying cartilages have either been loosened from their attachment by the trauma 
itself or soon thereafter by attrition. 
Allied to tills class of cases is that known as the internal derange- 
ment of the knee, where, in consequence of a violent wrench, one of 610 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
the semilunar cartilages, preferably the internal, has been loosened from 
its moorings to the tibia and the coronary ligament, and is deflected 
toward the joint interior. First described by Hey, the subject has been 
investigated particularly by Allingham and Bruno. Of 43 cases exam- 
ined by operation or autopsy, the internal cartilage was luxated in 27 ; 
the external in 13; not stated, 3. Primary laceration of the synovial 
fringe, or its infiltration with blood and consequent exfoliation, may 
likewise be the source of a foreign body in a hitherto normal joint. 
According to Hunter, Shattuck,. and Fisher, the organization of an 
intra-articular clot will sometimes give rise to a loose joint body. 
Finally, the penetration and encapsulation of a foreign body, like a 
needle, may, though rarely, be the nucleus of a loose body. In diseased 
joints foreign bodies may develop as a consequence of fibrinous deposits 
on the joint surfaces. By organization and long-continued attrition the 
deposits are broken up, as a rule, into large numbers of minute bodies 
varying in size from a grain of mustard to a bean. They compress each 
other into ovoid biconvex forms, and occasionally fill the joint-cavity. 
These corpora oryzoidea, or rice-bodies, have been so called from their 
shape, size, and pearly appearance. 
The development of these rice-bodies is not always so simple. In many cases, 
besides presenting the striations of superimposed fibrinous layers, they show in the 
interior more or less distinct traces of organized tissue. Particularly in the 
hydrarthrosis which accompanies tubercular disease these rice-bodies have been 
often found. Their first development, then, is in connection with the synovial 
membrane, from the surface of which they sooner or later sever their attachment 
and become floating. The condition is analogous to that seen in tuberculosis of 
tendon-sheaths and of bursse. 
The hyperplastic synovial fringes observed in many of the diseases of 
the joints form another common source of these loose bodies, many of 
them floating freely within the joint, others fixed by more or less attenu- 
ated pedicles to the joint-wall. These synovial fringes may present all 
the histological variations of the connective-tissue types found in the 
make-up of the joint; therefore, these foreign bodies may be cartilag- 
inous,, contain true bone, consist of a mass of fat, present a cyst within 
their interior, and, in very rare cases, a mass of mucoid connective tissue. 
In size these bodies vary very materially. The smaller ones, usually being ec- 
ologically of tubercular or inflammatory origin, are formed of the softer connec- 
tive tissues, the larger bodies, as a rule, being made up of firm fibrous tissue con- 
taining cartilage and very often bone. The latter often measure two to three cen- 
timetres in length by one centimetre in width and thickness. AVhen thus large 
the bodies commonly occur singly or in small numbers. In cases of osteo-arthritis, 
on the other hand, the entire joint interior may be filled with a large number of 
severed osteophi/tic processes. The condition of the joint itself shows the changes 
belonging to the disease of which the foreign body is but an incident. In the 
traumatic cases, besides the evidences of irritation produced by the foreign body, 
distinct defects have occasionally been seen on the articular surface which corre- 
spond in shape and size to the loose body, and evidently indicate a part from 
which the latter has been derived, either by the primary trauma or by the subse- 
quent process of its severance therefrom. The foreign bodies not infrequently 
resemble small lipomata both in shape and structure. In joints that have previ- 
ously been diseased they are due to the infiltration of the synovial fringe already 
alluded to. Of larger size, they can generally be referred to a trauma. They have 
only been found in the knee, where two subserous cushions of fat normally exist— 
the one underneath the patellar ligament; the other between the upper synovial 
pouch and the front of the femur. The rupture of the synovial membrane will INJURIES AND DISEASES OF THE JOINTS, ETC. 
611 
permit a hernial protrusion of a mass of fat into the joint, where, when connected 
with the parent mass by a pedicle, it may grow much as does an omental hernia 
within its sac. 
As a result of long-continued irritation from a foreign body in the knee-joint 
of young subjects the femur has been found elongated one or two centimetres. 
Symptoms.—The symptoms of loose bodies vary with their size, 
situation, mobility, and the conditions under which they were developed. 
When they are small and numerous, as in cases of hydrarthrosis, tuber- 
cular disease, and arthritis deformans, they produce few symptoms and 
rarely of themselves require attention. In the larger bodies—which, as 
we have seen, are directly or indirectly of traumatic origin—the symp- 
toms are far more pronounced. Frequently their existence does not 
make itself manifest until the immediate resnlts of the accident to the 
joint have largely disappeared. Thus, after a fall upon the knee, for 
example, a loose cartilage will occasionally be discovered a week or ten 
days after the injury and after a partial subsidence of the articular dis- 
tention with serum and blood. In other cases months and years may 
pass after an accident before the loose body is discovered. In the 
largest number of cases the symptoms manifest themselves in conse- 
quence of the locking of the foreign body between the articular surfaces 
and the consequent violent stretching of the joint ligaments. An 
individual makes a misstep or an awkward movement, and suddenly 
feels an excruciating pain which compels him to stand where he is or 
possibly to sink to the ground. The limb itself usually remains fixed 
nearly in extension in the knee; in the elbow, at an angle of 130° or 
140°. By a little manipulation the patient, or some one assisting him, 
brings the joint surfaces again into apposition, and except for some 
tenderness of the part and temporary effusion into the joint a return to 
an approximately normal condition follows. This incarceration of the 
foreign body occurs at intervals varying between a few weeks and as 
many years. Between the attacks the joint function, however, is rarely 
normal. Limitation of motion is very common. In the knee, the 
foreign body being usually in the anterior portion of the joint, or in the 
subquadricipital pouch, complete extension is not easily accomplished. 
In the elbow, the foreign body lodging more frequently in the anterior 
pouch, flexion to a right angle cannot be made. In cases of partial 
detachment of the semilunar body it can often be felt in its abnormal 
position and is but slightly movable. 
A positive diagnosis of a loose body can only be made when it is 
subject to palpation. When felt it appears as a hard round body under 
the soft parts, usually over the interarticular line or in relation with 
the external condyle of the femur. Its position can ordinarily be 
shifted, and as a rule it disappears from observation, often for long 
periods. Through long experience the patient himself is often more 
successful than the surgeon in bringing it to the surface. As to the 
nature of the foreign body, pre-operative diagnosis cannot be made. 
Treatment.—The multiple bodies which belong to the graver joint 
diseases, like tuberculosis and osteo-arthritis, very rarely require sur- 
gical intervention. In the larger bodies, which are the important 
factors in a diseased condition of the joint, the treatment is palliative or 
radical. The former consists in the wearing of an elastic bandage, 612 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
which will, in a measure, keep the foreign body from between the joint 
surfaces. The radical measure applicable to-day is extirpation. To 
transfix them by needles and bury them without the joint by subcu- 
taneous measures must not be practised to-day. The excision, as a rule, 
should be made by an ample incision directly over the foreign body, 
which is held by an assistant, or, for the time being, transfixed bv a 
needle. When, after the incision is made, the foreign body is not visi- 
ble, manipulation of the joint surfaces will either bring it to the surface 
or expose it somewhere in the interior. In the latter event it can 
readily be drawn into the wound by means of forceps or blunt hook. 
If there be a pedicle, this should be cut off as close as possible, and 
preferably without previous ligation. It is always wise as far as pos- 
sible to explore the interior of the joint for other foreign bodies, one of 
which might be readily overlooked in its more hidden recesses. 
When the foreign bodies are small and numerous a very free incision must be 
made for their dislodgement. and only in these cases is lavage of the joint requisite. 
In the pedunculated growths from the synovial fringes many may unfortunately 
escape removal, and, growing, require subsequent operation. The operation itself 
must be done with the strictest precautions as to asepticism. The fatality of the 
operation in pre-antiseptic days was nearly 40 per cent. It has been reduced to 
almost nothing. With the removal of the foreign body the irritative changes pro- 
duced by it rapidly subside, and joint function is almost completely restored. This 
applies particularly to the operative removal or fixation by suture of a ruptured 
or dislocated semilunar cartilage. 
Tubercular Arthritis. 
Through many centuries medical writers have described a disease of 
the joints marked by chronicity, swelling, and deformity, a tendency to 
the formation of abscesses, and the destruction of the joint. Among the 
many names which have been given to it may be cited : tumor albus or 
white swelling, scrofulous or strumous disease, fungous disease of the joint, 
caries, and spina ventosa. Since the important investigations of Fried- 
lander and the discoveries by Koch of the causative relation of the 
specific bacillus to tuberculosis the term properly reserved for this de- 
structive disease is tubercular arthritis. 
Although tubercular arthritis may attack individuals at any period 
of life, it is most frequently developed before the period of puberty. 
While it is not common under one year, it sometimes develops in infants 
with remarkable rapidity. 
Of 860 cases tabulated by Gibney, it developed in 84 per cent, in children 
under fourteen. In them the hip, the knee, and the ankle are the most fre- 
quently affected, in the order given. The shoulder and the wrist are not often the 
seat of the disease in children, whereas in adults they are relatively often involved. 
Particularly often is the shoulder the seat of tubercular disease in persons past the 
prime of life. In the majority of cases the disease is limited to one joint. In less 
than 5 per cent, of all cases it is polyarticular. 
As in tuberculosis elsewhere, heredity appears to be a decided predis- 
posing cause. Bollinger examined the antecedents of 250 cases of tuber- 
cular disease, and concluded therefrom that the disease occurred not so 
often in the children as in the grandchildren of phthisical subjects. In 
401 cases of disease from the Alexandra Hospital reports, 24 per cent, 
presented a family history of phthisis; 35 per cent, were ascribed to a INJURIES AND DISEASES OF TIIE JOINTS, ETC. 
613 
trauma. Over 90 per cent, of cases involve the joints of the lower 
extremity, which is subjected to traumata of slight degree infinitely 
more than the upper extremity. The relation between trauma and 
tubercular disease of the joint has been made plain since the classical 
experiments of Schuller, who demonstrated that animals which had 
been rendered tubercular by the inhalation of tubercular sputum de- 
veloped typical local tuberculosis when the joint was subjected to injury 
of even moderate severity. This corresponds to the fact that severe 
injuries are rarely followed by tubercular disease, but that compara- 
tively slight injuries to the epiphyseal ends of bone and to joints are 
often followed by local tubercular infection. 
An injury per se produces tuberculosis only through the infection of 
a hlood-clot or the formation of an infective thrombus in the epiphyseal 
end of bone. The source of the tuberculosis, particularly in children, 
is, as a rule, a latent tuberculosis of the bronchial lymph-nodes. Only in 
a small proportion of cases has the tuberculosis been found on autopsy 
in the bones alone. 
Konig reported 66 autopsies of cases of tubercular arthritis in which only 13 
failed to reveal latent tubercular foci. Landerer goes even farther in the state- 
ment that in 150 autopsies all save one or two presented disease of the lymph- 
nodes which evidently preceded the bone affection. Experimental research other 
than that of Schuller lias shown the channel of infection. Injection into the 
joints of tubercular sputum or of true cultures, and into the nutrient vessels, have 
almost invariably been followed, in the hands of many experimenters, by the 
development of typical tuberculosis of the epiphysis, and secondarily of the joint. 
These experiments of Schuller, Watson-Cheyne, Muller, and Krause conclusively 
demonstrate the importance of trauma in the etiology of tubercular disease and 
the specific influence of the Koch bacillus. 
Pathological Anatomy.—Tubercular arthritis in advanced cases 
includes in its destructive tendencies all of the joint structures. In its 
inception, however, it begins either in the epiphyseal ends of the bone, 
when it is called osteopathic, or in the synovial membrane, when it is 
known as arthropathie. 
According to the investigations by Muller of specimens obtained in Kbnig’s 
clinic, of 232 cases the primary seat of the disease was the bone in 158, the syn- 
ovial membrane in 46, the origin was doubtful in 28. Of 61 cases involving the 
hip the disease was osteopathic in 47, arthropathie in 3, and doubtful in 11 cases. 
Of 118 cases of disease of the knee the bone was first involved in 69, the synovial 
membrane in 33, the origin of the disease unknown in 16. Of 53 cases of disease 
of the elbow the bone was first involved in 42, the synovial membrane in 10, doubt- 
ful 1. 
Volkmann believed that in children the disease was almost invari- 
ably of osseous origin, whereas in adults the synovial type predominated. 
Nevertheless, according to the investigations of Muller, 76 per cent, of 
the cases occurring after the thirtieth year were probably developed in 
bone. 
(a) Osteopathic Arthritis.—This begins, as a rule, as a well-out- 
lined nodule of reddish-gray or yellowish color in the epiphysis. It 
may be situated near the epiphyseal cartilage or directly underneath 
the articular line. In very many instances it is first found near the 
periosteum or in proximity to the capsular attachment. Whereas, as a 
rule, it at first presents itself as a single nodule, there may be many. 
In the severest types of the disease the entire epiphysis is evenly occu- 614 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS 
pied by the infiltration. The bone about the nodule is distinctly hyper- 
semic, thereby accentuating the more subdued color of the tubercular 
nodule itself. In the hypersemic area the bone trabeculae are somewhat 
thickened, the cancellous spaces are devoid of fat-cells, and within them 
are often found miliary tubercles. These are often the means of the 
extension of the disease. As the central focus increases in its dimen- 
sions it becomes yellowish in spots from deficient nutrition and fat- 
necrosis. Thus there are found nodules varying in size from a pea to a 
nut, consisting of a soft cheesy material, early containing spiculae of 
bone that have resisted absorption. Older nodules are made up alto- 
gether of this cheesy debris, and can readily be washed away or 
removed as an entity with the finger. This material has often been 
called tubercular pus, although it bears only a physical resemblance to 
the latter. At this early stage the nodule is contained within a cavity 
lined with granulation-tissue, thus constituting what is sometimes called 
the tubercular epiphyseal abscess. Very frequently the tubercular 
nodule, as has been shown by experiment, is of embolic origin. As in 
infarctions of the viscera, there then results infection of a wedge-shaped 
segment of the epiphysis, the base of the wedge being directly under 
the articular cartilage, the apex toward the epiphyseal line. The result 
Fig. 242. 
Central sequestrum (original). 
of this is an epiphyseal necrosis, which, while it may be as small as a 
bean, may, on the other hand, be as large as the epiphysis itself. In very 
many cases such small epiphyseal sequestra may remain for years im- 
bedded within the epiphysis, or, being absorbed by granulation pro- 
cesses, leave a cavity filled with serous exudation, or one that even- 
tually closes by the formation of cicatricial tissue. So fortunate a 
termination, however, is the exception. As a rule, a tubercular nodule 
becomes surrounded by a layer of granulation-tissue, which in turn be- INJURIES AND DISEASES OF THE JOINTS, ETC. 
615 
conies invaded with miliary tubercle«, and it is through the growth of 
this granulation-tissue that bone absorption takes place. ( Vide Chapter 
IX.) Through the growth of the primary focus in the direction of the 
encrusting cartilage the joint itself, sooner or later, becomes involved. 
Even before a perforation of the encrusting cartilage has taken place 
there is a reactionary inflammation within the joint, as has been shown 
by Lannelongue, Yolk maim, and many others who have operated early 
for tubercular disease (Fie;. 243). 
Before perforation ensues the synovial membrane becomes thickened, the car- 
tilage over the tubercular epiphyseal focus shows signs of proliferation, and the 
vascular offshoot from the synovial mem- 
brane intervening between the articular 
surfaces in part causes adhesion between 
them with a tendency toward partial ob- 
literation of the joint-cavity. This reaction 
may prevent joint infection or limit it to a 
part thereof. This is not infrequently seen 
in the knee. Generally, however, this takes 
place through direct communication of the 
epiphyseal tubercular focus with the joint 
interior. The granulations undermine the 
articular cartilage either in limited and 
numerous areas or as an entity. In the 
former the cartilage, having lost its pearly- 
white appearance, is cloudy, yellow, and 
presents numerous erosions, the floors of 
which are made up of fungus-like granu- 
lations. In other cases the entire encrusting 
cartilage, exfoliating as a mass, can be 
stripped from the underlying granulation- 
layer like the cuticle from a bleb (Fig. 243). 
Fig. 243. 
With the penetration of the tuber- 
cular focus into the joint a panarthritis 
is speedily developed. The capsule 
becomes thickened, the synovial mem- 
brane injected; it loses its smooth 
appearance and becomes covered with 
fungous granulations, within many of 
which will be found a miliary tubercle, 
as first described by Kdster. With 
the thickening of the capsule there is 
infiltration of the periarticular struc- 
tures, which in the more superficial 
joints may extend into the subcuta- 
neous cellular tissue, binding down 
the skin, the fascia, muscles, and ten- 
dons to the joint-capsule. This infiltration is largely of a gelatinous 
nature, and but the result of the retarded circulation produced by the 
distended capsule. Within the joint there is, as a rule, found a little 
fluid, which is not pus in a strict sense, but is the product of the lique- 
faction of the cheesy substance in the depots and the cellular output of 
the fungous granulations (pyoid or archepyon). 
At this time there is a manifest enlargement of the joint, which is 
emphasized usually bv the wasting of the muscles above and below. 
Usually spindle-shaped, covered by an anaemic, often glistening, and 
Tubercular panarthritis (original). 616 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
adherent skin, underneath which a few of the larger veins will be seen, 
the joint now presents the typical appearance of tumor albus, or white 
swelling, the fungous or gelatinoid joint disease (Fig. 244). I n the majority 
of cases the capsule itself is softened at one or more places, whereby the 
granulation process becomes extra-articular. Sooner or later the skin 
Fig. 244. 
Tubercular panarthritis of elbow. 
becomes involved from underneath, and the products of the tubercular 
disease escape through what is incorrectly called a tubercular abscess. 
From the absence of acute inflammatory signs such abscesses are some- 
times designated cold abscesses. Such a periarticular abscess may 
develop without involvement of the joint. A subperiosteal nodule not 
infrequently makes its way to the surface, undergoes caseation, and 
remains extracapsular to the end. 
As in other abscesses that have discharged, contraction usually takes place 
until a fistulous opening is left. The sinus leading to the tubercular focus is very 
often tortuous, and its cutaneous aperture far removed from the site of the disease. 
In long-standing cases of tubercular arthritis many sinuses are found, often under- 
mining the periarticular tissue over large areas. With the formation of abscesses 
the process ceases to be strictly tubercular, for the infection with ordinary pus- 
formers, as a rule, takes place soon after the tubercular depbt has been discharged 
through the skin. In the prognosis of tubercular arthritis this secondary infection 
is of the greatest moment, since it is more destructive to the joint, and even to life, 
than the primary disease. 
(b) Arthropathic Arthritis.—When the synovial membrane is pri- 
marily attached the tuberculosis maybe diffusely disseminated over more 
or less of the entire area or be limited to one portion thereof, preferably 
one of its reflections or a synovial fringe. In the diffuse form there 
may be deposited a large number of miliary tubercles, without much 
change in the intervening tissue. The joint itself is not much altered. 
It is occasionally found in general miliary tuberculosis, of which it is 
only one of the many manifestations of infection. In other cases the 
diffuse tuberculosis of the synovial membrane is associated with increased 617 
INJURIES AND DISEASES OF THE JOINTS, ETC. 
vascularity, as a product of which an extensive serous or sero-fibrinous 
exudation is found within the joint. This latter, which is known as hy- 
drops tuberculosis (Fig. 245), must always be taken into consideration in 
the etiology of chronic articular effusions. The capsule itself is very often 
thickened by excessive vascularization, and as a product of this a more 
or less extensive deposit of fibrin will be found covering the synovial 
membrane and the articular cartilages. This may be extensive enough 
to completely cover the tubercular nodules. The partial organization 
of fibrinous deposit from proliferation of endothelial layers underneath 
will often give rise to the development of rice-bodies in large numbers, 
to which consideration has already been given. In the majority of cases 
the synovial membrane is very much thickened and softened, and within 
it there are disseminated tubercular depots of larger size, which also 
invade the subsynovial tissues. Commonly, there is only a slight increase 
of the synovial fluid, which soon becomes turbid and pyoid. As in the 
osteal form of tuberculosis, granulation-tissue develops from the surface 
of the synovial membrane and soon occupies the joint interior. From 
it are invaded the encrusting cartilages. Ordinarily these present a 
distinctly worm-eaten appearance, and it is from the periphery toward 
the centre that the process of invasion takes place (Fig. 243). 
Fig. 245. 
Tubercular hydrops of knee, 
In the synovial form of tuberculosis the destruction of bone usually involves 
only the superficial laminae, in marked contrast to that which is primarily of 
osseous origin. For the same reason, in the primarily synovial type of the disease 
there is a greater tendency to the involvement of both bones entering into the joint 
formation, whereas in the osseous form it is not rare to find the disease limited to 
a single epiphysis. The circumscribed type of synovial tuberculosis, as accurately 
described by Konig, is very rare. It presents itself in the form of a large granu- 
loma, the tumor being as large as a nut or even as an egg. It is firm, grayish-red 
in color, and consists of embryonic connective tissue partly the seat of caseation 618 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
and often containing miliary nodules. (Tyroma, vide Chapter IX.) Occasion- 
ally it springs from the fibrous portion of the capsule; the synovial membrane 
may then long withstand infection. If left to itself, general infection of the joint 
takes place, from which result the conditions above described. 
Repair in tubercular arthritis follows the paths by which recovery 
takes place in tuberculosis elsewhere. Its first evidences are found in 
the granulation-tissue, which loses its succulence from decreased vascu- 
larity and shows a tendency toward conversion into fibrous tissue. In 
this process small caseous depots are often left for years, and account for 
the tendency to recurrence of the disease. While it is certain that the 
bacilli do not live throughout such long periods, it is probable that their 
Fig. 246. 
Bony ankylosis of knee (original). 
spores live and develop actively after a slight trauma sustained some- 
times years after an apparent cure has been effected. (Although this 
explanation is hypothetical, it best accords with the clinical facts as 
often seen.) 
In the process of cicatrization joint surfaces are often welded together by 
fibrous bands, thereby reducing the joint-cavity in size, and particularly obliter- 
ating the subtendinous joint-pouches. It is in this way that limitation of joint 
movement remains as a permanent result. When the disease has destroyed both 
encrusting cartilages, fibrous bands firmly unite the articular ends, constituting a 
common source of fibrous ankylosis. With long continuance of this condition the 
fibrous bands undergo ossification until, where the condition has lasted for many 
years, the cancellous systems of contiguous bones are merged into each other, often 
without more than a vestige of the pre-existing interarticular cleft, thus producing 
bony ankylosis (Figs. 246 and 247). 
Symptoms.—The early stages of a tubercular arthritis are, as a rule, 
vaguely indicated by symptoms. Occasional pains, felt particularly 619 
INJURIES AND DISEASES OF THE JOINTS, ETC. 
during sleep, and in the lower extremities a passing lameness, are the 
earliest indications of the disease. With its progress the symptoms 
become more pronounced. Those to which attention is earliest directed 
are defective movement, swelling, deformity, and muscular wasting. The 
first of these is among the most valuable aids in diagnosis. There is 
early seen a limitation of movement, which is most marked in the 
Fig. 247. 
Section of bony ankylosis of hip (original). 
shoulder and in the hip, almost always present in the knee, and to a less 
extent in the wrist and ankle. Tubercular hydrops, which is oftenest 
found in the knee, may exist without limitation of joint movement. 
Swelling and deformity are early seen in all cases of tubercular arthritis 
except in the cases of the deep-seated hip and shoulder. The swelling 
depends on the pathological conditions above described. Though seem- 
ingly the deformity may be due to an enlargement of the bones, this in 
reality rarely takes place, and then only as an excessive repair. In very 
exceptional cases there is an absolute elongation of bone in consequence 
of tubercular arthritis. The deformity is very frequently enhanced by 
partial or total luxation. In the knee there is a tendency toward sub- 
luxation backward of the tibia on the femoral condyles, the latter 
becoming abnormally prominent. In the hip, what is left of the femoral 
head often leaves the deformed acetabulum, thereby producing great 
deformity with shortening. The deformity is almost always enhanced 
by vicious joint fixation. 
Reflex contractures, invariably of the stronger flexor muscles, and 
angular deformity speedily ensue. The knee is flexed upon the thigh; 
the elbow becomes fixed at an angle of 120° to 130° ; the wrist drops; 
the hip is flexed upon the abdomen ; and the foot assumes the talipes- 
equinus position by the contracture of the stronger muscles which act 
upon the joints named respectively. The contracted muscles can 620 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
always be felt early as well-defined ridges in close proximity to the 
angle in which the limb is fixed. With the contracture there is often 
associated an atrophy of the muscles as an early evidence of the disease. 
Although the degree of atrophy may not at first be measurable, the 
flabby condition of* the muscles is significant of its presence. 
Pain varies materially at different periods of the disease and in the 
various types. It is most marked in the osteopathic form of the disease. 
In the synovial type, even when associated with large effusion, it may 
be slight or altogether absent. Whereas, as a rule, the pain is experi- 
enced in the joint involved, it may be reflected, as is the case notably in 
the hip, to parts far removed. Through fixation of the limb by mus- 
cular contracture motion does not necessarily increase pain. Children 
with advanced disease of the hip or of the knee often do not suffer at 
all, even from violent exercise. By substituting the functions of other 
joints for that of the one diseased motion in the latter is involuntarily 
reduced to a minimum. 
The constitutional complications of tubercular arthritis are rarely 
marked in the early stages. Adults and children are seemingly in per- 
fect health except for the local condition. In proportion as this extends 
the general condition suffers. 
Careful observation will reveal an evening rise of temperature, although in 
the morning it returns to the normal. Particularly in the lower walks of life, 
where the disease is long neglected, the pain and the consequent loss of sleep will 
frequently give the children a haggard appearance, which, however, may be made 
to disappear with the institution of proper treatment. When the disease has pro- 
duced extensive destruction of the joint and periarticular abscesses have devel- 
oped, the temperature, as a rule, is continuously elevated, and the constitutional 
manifestations are not unlike those of visceral tuberculosis. If infection occurs 
with the ordinary pus-formers, the general health may be very rapidly undermined 
and death ensue from more or less acute suppurative toxaemia. Generally the 
suppuration is long continued, and if death from visceral changes occurs, it is only 
after many months or years of suffering. In the very great majority of cases 
proper treatment will localize the tubercular process. Nevertheless, cases are by 
no means rare in which a generalization of tubercular disease occurs, and particu- 
larly in disease of the hip. In children there is a marked tendency toward a 
tubercular meningitis. Improper treatment, and especially untimely and imper- 
fect surgical interference, is often speedily followed by generalization. 
The diagnosis of tubercular disease is, as a rule, easy. In 
fully 90 per cent, of the cases it is almost self-evident. Far more diffi- 
cult is it to distinguish the individual types of the disease. The fun- 
gous variety of the superficial joints, like the knee, elbow, wrist, and 
ankle, is very easily recognized by the swelling, the deformity, and the 
sense of false fluctuation. More difficulty attaches to the recognition 
of a deep-seated tubercular nodule within the epiphysis. The condition 
with which this is most easily confounded is the epiphyseal gumma of 
late inherited syphilis. The presence of corroborating evidences of 
syphilis, rapidity of development, and, above all, the therapeutic test, 
will, as a rule, make the diagnosis clear. 
Until all doubt is removed the case should be looked upon one of tubercular 
origin. Diagnostic difficulties are often produced by extensive hydropic joint 
effusion. Particularly in adults it will simulate chronic serous effusions from the 
presence of foreign bodies or the chronic effusion following trauma. Whereas the 
insufficiency of the treatment which is usually effective in the last-named condi- 
tions may give rise to a suspicion of the tubercular nature of the hydrops, a posi- 
tive diagnosis can often be made only after joint aspiration or incision. INJURIES AND DISEASES OF THE JOINTS, ETC. 
621 
From arthritis deformans tubercular disease is easily distinguished by 
the chronicity of the former, the enlargement of the articular ends of 
the bones, and the tendency to osteophytic growth. 
Prognosis.—The prognosis of tubercular arthritis depends very 
largely upon the treatment instituted and upon the degree of local dis- 
ease when it first comes under observation. With proper treatment the 
disease may be arrested in its incipiency, and it is possible for complete 
restitution to occur. In the great majority of cases, however, the best 
that can be hoped for is a limitation of joint function, either from the 
partial obliteration of the joint-cavity or from the development of fibrous 
adhesions. 
In the majority of cases, the cartilages having been more or less extensively 
destroyed, a complete fibrous ankylosis results and absolute restriction of motion 
exists. Occasionally, although recovery has apparently taken place, a small sinus 
will continue for months and even years, leading to a carious patch or an epiphys- 
eal sequestrum, such as have been described in the pathology of the disease. 
Treatment.—The treatment of tubercular arthritis must be based 
on the natural tendency of the disease toward recovery. With or with- 
out deformity such recovery ensues—in disease of the spine, for example, 
where operative interference cannot be resorted to early. Conservatism, 
therefore, must be the keystone of treatment, and only in the failure of 
this must resort be had to active interference. 
Since tubercular arthritis is but the local expression of an infectious 
disease, general measures are not to be overlooked. An abundance of 
fresh air, a suitable diet, and attention to cleanliness are of first import- 
ance. The internal administration of guaiacol and of creosote has been 
found to be beneficial. In the hands of very many Continental sur- 
geons the modified tuberculin treatment has also been followed by excel- 
lent results. 
The local treatment of tubercular arthritis should, in the first place, 
be directed toward securing absolute rest to the joint. A prolonged rest 
in bed will often at once relieve pain and swelling, and even if prolonged 
through many months will not interfere with the nutrition of the patient. 
Local rest is best obtained by the use of a retentive dressing of plaster 
of Paris, of starch, or of silicate of soda, applied with sufficient snug- 
ness to distinctly compress the distended joint. In the joints of the lower 
extremity, except the hip, and of the upper limb, except the shoulder, 
and in tuberculosis of the spine, such retentive dressings are often the 
most serviceable of the methods of treatment to be invoked. 
In the inception of the disease traction (extension) is also very service- 
able, particularly in overcoming the tendency toward the contracture of 
the flexor muscles. During the acute stages such traction can be best 
maintained with the patient in the recumbent posture, whereas later some 
form of traction splints can be successfully used. In tubercular arthritis 
of the upper extremity the use of extension is far less valuable. When 
the contractures are firm enough to resist traction an open division of 
the contracted parts should be made. 
In very many cases it is advisable to attack the tubercular disease 
directly by agents which distinctly destroy the bacillus or unfit its soil 
for necessary sustenance. Such agents are zinc chloride, balsam of Peru, 
and particularly iodoform. The direct injection of either of these agents 622 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
into a tubercular focus at intervals varying from four or five days to as 
many weeks will often obviate the necessity of a more or less crippling 
operation. The zinc chloride may be used in the saturated or 50 per 
cent, solution, and from four to five minims injected. The balsam of 
Peru is injected undiluted. The iodoform may be employed in 10 to 20 
per cent, solutions in sterilized glycerin or olive oil, and injected in 
quantities varying from one drachm to two ounces. To avoid iodoform 
intoxication it is best to begin with a smaller quantity. While the 
injections are being made the urine should be carefully examined, since 
the gravest result of such intoxication has been parenchymatous ne- 
phritis. The iodoform solution should always be sterilized by submer- 
sion of the iodoform during four days in a 1 :1000 solution of corrosive 
sublimate; it should then be thoroughly washed in sterilized water. 
The glycerin, and particularly the oil, should also be sterilized by 
boiling. 
The best results obtained by the iodoform-oil injections were those of DeVos 
of Leyden. Of 68 cases, 72 per cent, were discharged cured. The injection is 
made through a large trocar after preliminary incision through the skin. After 
whatever fluid maybe contained within the joint has been expressed, the iodoform 
oil or glycerin is injected, and by manipulation brought in contact with all por- 
tions of the joint. The shoulder-joint is to be punctured half an inch below and 
behind the tip of the acromion ; the elbow-joint, on the outer side of the olecranon 
and above the head of the radius; the wrist, below the styloid processes of radius 
and ulna, nearer the dorsal surface; into the hip the needle should be made to 
penetrate from behind and above the trochanter; the knee can be directly pen- 
etrated through the interarticular line on each side of the patella; and the ankle- 
joint is most easily reached through a point directly in front of the tip of the 
external malleolus. 
When many fibrinous shreds come away through the cannula it is 
advisable to freely incise the joint, with proper aseptic precautions, and 
to thoroughly irrigate it with a saturated boric solution before making 
the iodoform injection. If need be, the incision can be sufficiently 
enlarged to make the operation exploratory, the incision being closed 
immediately after the injection has been completed. For the cure of 
a tubercular arthritis from three to twenty injections may be necessary, 
and the time required to effect a cure varies from two months to one 
year. 
Hydrops tuberculosis will often disappear under rest and compression. 
In the failure of this, aspiration should be resorted to, and this be fol- 
lowed by the injection of carbolic acid or iodoform. The so-called cold 
abscesses require special attention in many cases, although when they 
are limited in size they may be allowed to take care of themselves. 
Through defective operative treatment, septic infection, which may 
rapidly be destructive to joint and life, has often been induced in the 
past. 
Here also the injection of iodoform, after the preliminary tapping and irriga- 
tion, is frequently followed by a brilliant success. The size of the abscess is no 
indication of the extent of the lesion which gave it origin. Its walls are lined by 
a quasi-pyogenic (pyophylactic) membrane which, as Volkmann has shown, is 
studded with miliary tubercles. When the iodoform injection, after repeated 
attempts, has failed of success, the abscess should be thoroughly incised, its walls 
cleared of the tubercular lining with a sharp spoon or, what is preferable, the 
operator’s finger wrapped in sterilized or iodoform gauze. This operation should 
be considered incomplete until the aperture of communication, which usually INJURIES AND DISEASES OF THE JOINTS, ETC. 
623 
though not always is present between the abscess and the joint interior, has been 
discovered, enlarged if need be, and the joint treated by injection. 
These conservative measures will frequently fail of encompassing a 
cure or even of stemming the progress of the disease. In cases from 
the lower walks of life the conditions when first seen may altogether 
preclude conservatism. Operative measures of greater or less extent 
are then called for, the object of which is the mechanical removal of the 
tubercular tissues and of carious bone, and the procuring of a surgically 
clean wound with its natural tendency to immediate union. 
Sometimes there can be detected in the head of the tibia, the femoral 
condyles, and the ulna a tuberculous nodule which can be removed 
through an incision that does not involve the joint. In the removal of 
such a nodule the chisel should be carried through sound bone, and as 
far as possible the infection of this from the tuberculous centre is to be 
avoided. 
In the great majority of cases the operative treatment cannot stop 
short of a free incision into the joint, thus making it in a measure explor- 
atory. Such free incision, technically termed arthrotomy, is, of itself, 
with proper precautions, devoid of danger. When thus thoroughly 
exposed the tubercular foci can be readily removed, and, if the pro- 
cedure has not been too long delayed, without seriously affecting the 
outlines of the joint surface. This operation, known as arthrectomy or 
joint erosion, means the removal usually of fungous masses from the 
synovial membrane, of the encrusting and interarticular cartilages, so 
far as they may be diseased, of the synovial membrane and capsule, if 
need be, and of the evacuation with the chisel or sharp spoon of tuber- 
cular foci in the epiphysis. The operation is therefore, in reality, an 
atypical resection. 
In joint erasions recourse should be had to cutting rather than to 
scraping instruments, since the danger of infecting the wound with 
tuberculosis is thereby reduced to a minimum. After the erasure has 
been completed sterilized iodoform is to be introduced into the wound, 
the articular wound closed by deep sutures, and the cutaneous wound in 
the ordinary way. 
Drainage is ordinarily not called for, although when oozing has been 
checked with difficulty a silkworm-gut strand, drawn through the 
wound and to be removed with the first dressing, will answer well for 
drainage. Many surgeons pack the wound for two or three days with 
iodoform gauze, after which the sutures introduced at the time of opera- 
tion are tightened. 
Even the heads of the humerus and of the femur have thus been successfully 
freed of tubercular nodules and of their encrusting cartilage, returned to their 
respectwe sockets, and excellent results obtained. 
A further advantage of arthrectomy is the ease with which the operation can 
be repeated if necessity arises, and the important fact that by not interfering with 
the epiphyseal cartilage the growth of the bone in length is not curtailed. 
Resection for tubercular arthritis, formerly very extensively prac- 
tised, is for good reasons less and less employed. Until the period of 
puberty has been reached a formal excision should rarely be performed, 
since the removal of the epiphysis is invariably followed by very great 
shortening of the extremity. It is only after arthrectomy, as above 624 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
described, has failed in children and in young adults that formal 
excision should be at all practised. In persons who have arrived 
beyond the age of puberty, the same objection not obtaining, excisions 
are more frequently to be made. At this period of life repair, so far as 
bone is concerned, is less easily accomplished, and the uneven surfaces 
which remain after arthrectomy might fail to unite; therefore—as in the 
knee, for example—we are sometimes compelled to make a formal 
excision in order to ensure the speediest recovery with a useful limb. 
As a rule, however, excision for tuberculosis of the larger joints should 
be reserved for the correction of deformity after the tubercular process has 
healed spontaneously or through the methods of treatment, operative 
and otherwise, above described. In tuberculosis of the wrist and of the 
foot total excision of the bones involved is to be resorted to rather than 
the excision of the tubercular focus and its evacuation by curette or 
chisel. It is particularly in these cases that operative infection of con- 
tiguous joints and of overlying tendon-sheaths is likely to occur. Even 
in the absence of such infection the shell of bone which is left after the 
evidement of the tubercular focus is filled with a clot which readily 
becomes infected, and in the contrary event is difficult of organization. 
In severer cases of tuberculosis of the bones of the wrist, and par- 
ticularly of the tarsus, amputation will often afford the patient the 
quickest and safest road to recovery. Amputation must likewise be 
resorted to at times in children in whom the tubercular and secondary 
suppurative processes have left the region of the joint riddled with 
sinuses and the bones destroyed over extensive areas. In the lower 
extremity such amputations must be made oftener than in the upper, 
but in both, with the improved surgical technique of recent years, the 
mortality following them has been reduced to a minimum. 
Ankylosis. 
This signifies, literally, a crooking of the joint. In a general sense 
it is reserved for fixation of the joint, with which there is often associated 
an angular deformity. The diseased process may be in the joint proper, 
in the periarticular tissues, the overlying muscles and tendons, or even in 
the integument. Every joint fixation has thus often been included in the 
term ankylosis. A division has likewise been made into the fibrous or 
false, and the bony or true, ankylosis. A better division is that bv which 
the term (a) contracture is used to designate joint fixation by abnormal- 
ities of the soft parts, and (b) ankylosis from fibrous or bony union of the 
articular surfaces proper. 
a. Contractures.—Acute inflammations of the joints and tubercular 
processes are, as we have seen, very often early associated with muscular 
contraction, which, from the inception, immobilizes the joint absolutely 
except to examination under anaesthesia. After the subsidence of the 
primary disease the contraction may continue and simulate the lock- 
ing of the joint. The periarticular swelling and the thickening of the 
capsule attending rheumatism will often leave a joint in a similar appar- 
ently ankylotic state. The cicatricial contraction which follows severe 
burns may likewise produce an apparent ankylosis. In the last-named 
condition the interior of the joint may remain, except for dryness, com- INJURIES AND DISEASES OF THE JOINTS, ETC. 
625 
paratively normal. The continuation of joint fixation of this nature will 
slowly, by the growth of new connective tissue from the periphery of 
the joint, eventually lead to a true ankylosis. In cases of severe spastic 
paralysis the condition of ankylosis is likewise simulated. 
b. True ankylosis has been properly divided into the fibrous and the 
osseous, although in long-standing cases a combination of both forms will 
be usually found, and only in very chronic cases does it ever come to a 
complete bony union of the articular ends with total obliteration of the 
Fig. 248. 
Bony ankylosis of hip (original): external view of specimen shown in Fig. 247, 
joint-cavity (Figs. 248 and 249). The diseases which are most produc- 
tive of the true ankylosis are—acute suppurative arthritis, to a less 
extent tubercular disease, and chronic rheumatism. In the latter anky- 
losis of many joints is often seen. Post-gonorrhoeal arthritis, the non- 
suppurative complications of puerperal septicaemia, and the acute infec- 
tious diseases are less often followed by bony ankylosis. 
In considering ankylosis it is important to differentiate between that which is 
associated with deformity and that in which the joint is fixed in the most favorable 
position for usefulness (Figs. 250 and 251). In the shoulder, through the mobility 
of the scapula, this differentiation is not important; in the elbow an ankylosis may 
be said to be favorable when it is nearly at a right angle; in the hip and knee, 
when fixation occurs in the extended position. 
The diagnosis of the conditions which fix a joint is ordinarily easily 
made. That of fixation from extra-articular causes must always be dif- 
ferentiated from that of true ankylosis. The clinical history of the case 
and the condition of joint movement under an anaesthetic would make 
the recognition simple. The differentiation between the fibrous and the 
bony ankylosis is, as a rule, also easily established. A bony ankylosis 
will absolutely prevent joint motion, whereas in the fibrous varieties the 626 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
patient himself or with a little assistance can always elicit a certain de- 
gree of motion. The knee forms an exception to this rule : notwith- 
standing an osseous ankylosis, some degree of motion can be elicited. 
Fig. 249. 
Bony ankylosis of knee (original). 
The writer has in two cases seen an osseous ankylosis of the patella to 
the anterior surface of the femoral condyle with slight joint motion. 
The operation revealed the joint interior free except where the patella 
had formed attachments. 
Treatment.—The treatment of joint fixation necessarily varies with 
the conditions which produce it. If the result of cicatrices, fascial or 
muscular contractures, attention must be directed to them rather than to 
the joint itself. The former must be remedied by plastic operation. 
Contractures of muscle and fascia can often be overcome under an anaes- 
thetic. If this fails, success must be expected from a division of the 
tendons and fascia, either by subcutaneous operation or, preferably, bv 
open division. 
In cases of true ankylosis that are known to be fibrous, operative 
measures are called for only after a milder treatment by baths, massage, 
and active and passive joint movements has been tried without effect. 
Mechanical appliances to stimulate motion may also be tried. Very fre- 
quently, indeed, by the combined use of massage and weight-extension, 
the deformity which so often accompanies ankylosis can be overcome. 
In the failure of these methods recourse may be had to forcible breaking 
up of the fibrous adhesions which fix the joint, always under an anaesthetic 
(brisement force). INJURIES AND DISEASES OF THE JOINTS, ETC. 
627 
The treatment must always be very guardedly applied, and never until the dis- 
ease producing the ankylosis has subsided. Untimely forcible disruption of adhe- 
sions will not infrequently be followed by a return of the acute disease which pro- 
duced them, and often with greater severity. Nor should it be early resorted to 
for post-tubercular ankylosis or that following gonorrhoea or acute "suppurative 
arthritis. Limbs and lives have often been sacrificed to the untimely use of forci- 
ble relief of ankylotic deformity. It is a wise precept to never completely over- 
come a great angular deformity from fibrous union at one sitting, however strong 
the temptation may be to at once give the limb its normal conformation. 
The less the number of adhesions broken up at a sitting, the less is 
the reaction ; therefore anaesthesia may be resorted to at intervals of a 
week or ten days, and thus gradually the deformity be overcome and an 
opportunity given for the little that is gained each time to be maintained. 
By this method there is avoided the 
danger of lacerating a large vascular 
or nerve-trunk running in close prox- 
imity and adherent to the joint- 
capsule. Particularly in attempt- 
Fig. 250. 
Fig. 251. 
Bony ankylosis of hip with deformity. 
Bony ankylosis of hip with deformity 
(original). 
ing to overcome long, old-standing angular ankylosis of the knee have 
ruptures of the popliteal artery, vein, or accompanying nerve-trunk been 
produced. In severing adhesions the force should always be so applied 
at first as to increase trie deformity. The angle of flexion of the knee 
and elbow should by the first movement be even more reduced. Upon 
this flexion should follow the first attempt at extension. Unfortunately, 
even with the most careful and oftenest repeated attempts to overcome 
a fibrous ankylosis, failure to restore, even approximately, normal joint 628 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
function is the rule. The fibrous bands which have been broken up 
reunite and the ankylosis is speedily re-established. If, therefore, the 
ankylosis is left in the most favorable possible position, it is all the 
patient can hope for. 
The treatment of bony ankylosis must be limited to the correction of the 
deformity. When bony ankylosis has occurred and the disease which 
produced it has disappeared, the danger of operative interference is only 
that which would follow a like operation upon a healthy bone. The 
cumbersome appliances which in former years have been resorted to for 
overcoming osseous ankyloses are no longer to be used. The osteoclast, 
which played an important role before the days of antiseptic surgery, is 
only of historic interest. If the position of the limb is a correct one, 
osseous ankylosis is not to be interfered with. In the overcoming of 
deformity the operation may be done through the joint or in close prox- 
imity to it. In ankylosis of the hip, in which there is often extensive 
new bone-formation, it is better to divide the bone below the trochanter. 
When the neck of the bone has not been destroyed by disease, its sub- 
cutaneous division with a saw, after the method of Adams, may be 
resorted to. In ankylosis of the knee recourse must usually be had to 
the excision of a wedge, with base anterior, before the deformity can be 
corrected. Bony ankylosis at the elbow is best treated by excision, 
which will leave a very serviceable although an abnormally movable 
joint. CHAPTER XXXIV. 
OPERATIONS ON JOINTS. 
Joseph Ransohoff, M. D. 
General Considerations.—Injury and disease very frequently neces- 
sitate operations on joints. In degree they may vary from the puncture 
with the trocar, or the simple incision for establishing drainage, to a 
complete removal of all the structures entering into the composition of 
the joint. Whatever the operation may be, the greatest attention must 
be paid to the rules of surgical cleanliness, for in no other department 
of surgery have the beneficent influences of modern wound-treatment 
been better displayed than in operations upon joints. 
Arthrotomy.—By this term is meant an incision into the joint, either 
for the purpose of establishing drainage or for purposes of exploration. 
It is indicated in chronic serous and purulent effusions where other 
measures have failed. For the removal of foreign bodies and loose 
cartilages, arthrotomy offers the only radical relief. Since the operation 
is always to be done under anaesthesia, the incision through the integu- 
ment and the capsule should be ample enough to freely permit thorough 
exploration of the joint interior. 
Arthrectomy.—Arthrectomy, or joint erasure, reserved almost alto- 
gether for the treatment of tubercular processes, has for its preliminary 
step an arthrotomy. The operation consists of the removal of the syno- 
vial membrane, of the encrusting cartilages, and of the superficial laminae, 
of bone so far as they may be diseased. In an arthrectomy, or joint 
erasure, nothing is sacrificed except that which is the seat of disease. 
The operation is therefore less severe than is an excision, can be per- 
formed earlier, and when successful may retain much of the joint func- 
tion for the patient. To be entirely successful the incision into the joint 
must be large enough to permit its thorough exploration, lest a hidden 
focus of disease escape detection and appropriate treatment. 
With experience an operator soon learns to discover an epiphyseal focus under 
an, as yet, intact cartilage, but one that is somewhat discolored from deficient nutri- 
tion. The advantage of arthrectomy is that it permits repeated operations, and 
in the event of its final failure still leaves to us the major procedure of excision. 
Resection or Excision.—Although these terms are used synony- 
mously, the former applies to the removal of portions of bone in their 
contiguity—the latter to the removal of the articular surfaces and soft 
parts that enter into the joint formation. Since the latter complete 
operations are not often demanded, the terms may properly be consid- 
ered synonymous. 
Joint excisions are called for in compound dislocations when reduction 
cannot be otherwise made, in gunshot injuries where there is much shat- 
629 630 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
tering of bone, and for the relief of angular ankylotic deformities. Sup- 
purative processes consequent on penetrating wounds or general septic infec- 
tion likewise demand resection. The great majority of cases in which 
joint excision is demanded belong to the class of tubercular arthritis. 
The indications for the operation in this class of cases have been consid- 
ered in the paragraphs on tubercular arthritis in the preceding chapter. 
Excisions made for injury are, like amputations, divided into the 
primary, the intermediary, and the secondary, the first of these being 
made within the first twenty-four or thirty-six hours and before wound- 
infection has occurred. Wherever possible excisions for injury should be 
primary. The intermediary excisions are made during the height of 
infective inflammation, and consequently of the general septic infection. 
It is for this reason that the mortality of these operations on the larger 
joints is enormously high. Secondary excisions are made after the de- 
cadence of the infective process, and have for their object the removal 
of dead bone and of pyogenic surfaces, and such preparation of the 
articular ends as will ensure an ankylosis in a good position. 
Arthrodesis.—Allied to the excision of a joint is the procedure 
which contemplates its destruction and the production of an ankylosis. 
The operation having this for its object is termed arthrodesis, and is 
applicable especially in cases of infantile paralysis, in consequence of 
which the usefulness, particularly of the knee and often of the ankle, 
has been lost. When in these cases orthopaedic appliances fail to give 
relief or the financial condition of the patient precludes his obtaining 
aid therefrom, joint excision often restores the usefulness of the limb. 
Bone resections are sometimes made as preliminary steps to other procedures. 
Segments of the skull, for instance, are temporarily removed with a flap, for 
intracranial operations, portions of the upper jaw are temporarily removed for 
operations upon the nasopharynx, and the patella is sometimes temporarily 
divided for operations on the knee. Such operations are called osteoplastic 
resections. 
In excisions of joints the incision should be as nearly linear as possi- 
ble ; tendons should be preserved in their attachments to the soft parts, 
and bruised as little as possible. Attention to the making of a clean 
wound is one of the essentials of healthy repair. Since the labors of 
Ollier of Lyons and the younger Langenbeck of Berlin and Larghi of 
Bologna, much attention has been given to the saving of the periosteum 
as a single layer, which, subsequently ensheathing the denuded bone sur- 
faces, is believed to further the development of new bone to take the 
place of that which has been removed. The subperiosteal method, as this 
has been designated, is feasible only in cases of disease where the thick- 
ening of the periosteum permits its being stripped away from the bone 
before it is divided. In these very cases, however, mostly of tubercular 
character, the saving of the periosteum is associated with the dangers 
of an incomplete operation and recurrence of the disease. In the trau- 
matic cases of adults the separation of an unbroken periosteal layer is 
quite impossible. Furthermore, the regenerative power of the perios- 
teum, except in children, has been overrated. The advantages of a sub- 
periosteal excision are therefore doubtful. 
Large blood-vessels are never endangered in excisions ; the use of the 
Esmarch bandage is therefore unnecessary. The bleeding is ordinarily OPERATIONS ON JOINTS. 
631 
so slight during the operation that with competent assistance it does not 
obscure the field of operation nor make the overlooking of a nidus of 
disease probable. Besides the ordinary instruments required, there are 
necessary for excisions large retractors, an assortment of straight and 
grooved chisels, a variety of saws and of bone-cutting forceps, and 
gouges. Except in the shoulder and in the hip the wound can 
ordinarily be fully closed without drainage. The post-operative ooz- 
ing can be reduced to a minimum by at once placing the limb at a 
right angle to the body and keeping it there for twenty-four hours : 
thereby the afferent circulation is rendered more difficult and the efferent 
facilitated. In order to fix the divided bones closely to each other many 
operators resort to bone-suture or the insertion of steel or ivory jpegs. 
All of these procedures are, for the most part, superfluous. After the 
operation of excision has been completed and the ordinary dressing 
applied a retentive dressing or splints are at once to be used in order 
that the limb may be retained in the desired position from the very 
beginning. After joint excisions, properly made, the first dressing need 
not be changed before the end of from two to four weeks. 
SPECIAL EXCISIONS. 
Shoulder. 
Resection of the shoulder is ordinarily partial, in that the head of the 
humerus alone is removed, the glenoid head of the scapula being usually 
left in situ. The operation can be made by a straight incision over the 
anterior surface of the joint, beginning at the acromio-clayicular junc- 
tion and passing over the anterior con- 
vexity of the joint for a distance of 
three to four inches. (Vide Fig. 252.) 
The incision may likewise be made 
from a point above the coracoid process 
obliquely across the front of the joint 
in the direction of the fibres of the del- 
toid muscle. Charles Bell and Morel 
practised a U-shaped incision with the 
concavity upward, making a flap of the 
deltoid muscle. Konig exposes the 
joint through a posterior longitudinal 
incision. 
Fig. 252. 
The U-shaped incision, while disastrous to 
the deltoid muscle, affords better than any 
other method a thorough inspection of the 
joint interior and the removal of the capsule 
wdien this is necessary for tubercular disease. The anterior straight incision leads 
directly upon the long head of the biceps, thus permitting it to be drawn to one 
side and saved. The oblique incision secures the safety of the circumflex nerve. 
Excision of the shoulder (Ollier): a,reg- 
ular incision; B, supplementary. 
Whatever the incision, the capsule is opened, the wound margins 
separated by broad retractors, and, while the assistant rotates the arm 
outward, the knife is carried over the lesser tuberosity, dividing the cap- 632 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
sular ligaments and the attachments of the subscapularis muscle. The 
arm being then rotated inward, the attachments of the supraspinatus, 
infraspinatus, and teres minor are divided. Wherever feasible in this 
step of the operation, the practice of Vogt should be followed of retaining 
the greater and lesser tuberosities with the muscular attachments. The 
head of the humerus is now forced out through the wound, seized with 
the forceps, and removed with the saw. The best functional results are 
obtained when the section is made through the anatomical neck. The 
line of section must be determined, however, by the extent of the lesion 
Avhich demands the operation. This is completed by the removal, if 
it be necessary, of the glenoid fossa Avith saw or forceps, although in 
this event the attachment of the long head of the biceps to its upper 
end should be preserved in connection with a few bony laminae with the 
periosteal covering. 
After-treatment.—When there has been much oozing a puncture through 
the posterior Avail of the joint should be made for drainage. The natural position 
of the arm by the side of the body, Avith the forearm over the chest, is the one to 
be maintained until consolidation has taken place. A splint is ordinarily not 
required. 
Results.—Excisions for gunshot Avounds, collected by Culbertson, in 855 cases 
give a mortality of 31.44 per cent.; Otis’s tabulation of 951 cases gives a mortality 
of 39 per cent. Almost all of these cases Avere tabulated in the pre-aseptic period. 
There Avere, according to Culbertson, 101 cases of excision for disease, Avith 16 
deaths, or 15.84 per cent. The improvement folloAving modern methods is shown 
by statistics, which, though not large, are conclusive. In Volkmann’s and Konig’s 
clinics 15 excisions of the shoulder Avere made—for injury in 2 cases, in 13 for 
disease—without a death. The usefulness of the arm after shoulder excision is 
ordinarily very good, although there is a tendency tOAvard preternatural mobility. 
When the excision is made as low as the surgical neck a flail joint is very likely 
to remain. The best results follow the so-called subperiosteal excisions of Langen- 
beck and Ollier or the subcapsular operation of Vogt. 
Elbow. 
Indications.—Partial or complete excision of the elbow must be 
resorted to for compound dislocations, ankylosis, suppurative arthritis, 
gunshot injuries, and chronic articular disease. It is likewise indicated 
in chronic dislocations in which milder operations, like osteotomy of the 
olecranon, fail to make reduction possible. 
In rare eases of symmetrical dislocation of the elbow, of which the writer saw 
one case from a fall, an operation should be performed on one side only to make 
the ankylosis of the two sides at different angles, thereby assuring the patient the 
greatest range of movement. Such symmetrical ankylosis has been described by 
■Continental writers as following acute infectious diseases. 
The various methods of operation have in common a long posterior 
incision, to which, according to various operators, may be added a par- 
allel lateral incision, a transverse incision, or both. In almost all cases 
the posterior longitudinal incision suffices (Figs. 253, 254, 255). It 
should be in adults at least four inches long, with its centre opposite 
the base of the olecranon. The incision should run a little to the inner 
side of the axis of the olecranon and be carried along its entire length 
down to the bone. The soft parts —and, if possible, the periosteum— 
are first elevated toward the inner condyle bv longitudinal incisions 
carried down to the bone. In this manner the ulnar nerve is pro- OPERATIONS ON JOINTS. 
633 
tected. The incision is carried around the epicondyle, carefully pre- 
serving, if possible, its muscular and ligamentous attachments. The 
dissection is next carried in the same way toward the outer condyle, 
equal attention being given to the protection of its muscular and liga- 
mentous connections. Particular attention should here be given to 
saving the anconeus muscle. Through forced flexion the lower end of 
the humerus is then dislocated into the wound and sawed through on a 
level with the base of the condyles. The radius and ulna are next 
Fig. 253, 
Fig. 254. 
Fig. 255. 
Excision of the elbow- 
joint : .4,Von Langen- 
beck; B, Ollier. 
' ’ 1 I 
Excision of the elbow- 
joint: A, Nelaton; B, 
C, Hueter. 
Osteoplastic method: A, 
by external incision ; 
B, Yon Mosetig-Moor- 
hof. 
brought into the wound, and, if need be, divided on a level with the 
base of the coronoid process of the ulna. When the dissection is 
made for bony ankylosis the bones of the forearm must be divided first, 
and with them there is brought through the wound the lower end of 
the humerus, which is divided below the epicondyle. Ollier employs 
a “bayonet” incision, which is a modification of the external late- 
ral incision advocated by Chassaignac. The incision begins on the 
external border of the arm, three inches above the articular line, 
and is placed between the supinator longus and the outer border of the 
triceps tendon. It is carried down to the level of the epicondyle, when 
it turns downward and inward to the olecranon, the posterior border of 
which it follows to its base and onward as far as need be toward the 
ulna. The incision over olecranon and ulna is at once carried to the 
bone. In the upper portion of the incision the periosteum is reached 
between the supinator longus and triceps and the capsule opened. In 
the middle portion of the incision the cleft between triceps and anconeus 
is followed, and the triceps tendon separated from the olecranon. After 
the detachment of the external lateral ligament the lower end of the 
humerus is dislocated outward and removed with a saw. Radius and 
nlna are subsequently removed in the same way. The ulnar nerve is 
not seen in this operation. 634 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
The After-treatment.—The position preferable after excision of the elbow 
is that of slight flexion, with the hand in pronation. Fixation should be achieved 
by wooden or metallic splints, or preferably with a bracketed plaster-of-Paris dress- 
ing. A right-angled position ought not be given the arm, since the resected ends 
are thus most separated from each other, and the tendency to a flail joint is thereby 
given. Passive movements of the wrist and of the fingers should be made early; 
those of the elbow likewise, particularly in young people, in whom the formation 
of a new and useful joint is probable. On the other hand, when in adults the 
extent of the excision precludes so favorable a result, and a flail joint is likely to 
result, passive movements should be for a long time refrained from. 
Results.—According to Culbertson, the mortality of partial excisions for gun- 
shot injury is 26.75 per cent.; of total excision, 25.32 per cent. For other than 
gunshot injuries partial excisions show a death-rate of 7.40 per cent.; total excis- 
ions, 21.5 per cent.; partial excisions for disease, 11.11 per cent.; total excisions 
for disease, 9.93 per cent. These statistics are nearly those of Otis obtained from 
cases in the Civil War, and of the German wars as tabulated by Gurlt. All of 
these statistics are of pre-antiseptic days. Most of the deaths have resulted from 
infection. Middledorpf tabulated 321 excisions of the elbow, of which 304 were 
for tubercular arthritis. Wound-infection produced no death: 28 (9.21 per cent.) 
died of phthisis, 14 (4.6 per cent.) of intercurrent disease—mortality, 31.81 per 
cent. The statistics of Konig’s clinic are similar. Of 83 cases, 4 died soon after 
the operation—1 of iodoform-poisoning, 1 of pulmonary phthisis, 1 of broncho- 
pneumonia, and 1 of diphtheria; 26 ultimately died of phthisis. Of 163 patients 
upon whom excisions of the elbow had been done, and which were observed on 
an average for nine and a half years, death resulted in 21.48 per cent, from tuber- 
culosis and amyloid degeneration. The functional results of excisions of the elbow 
are generally very good. Even when a flail joint results the arm can be made very 
useful by properly constructed prosthesis. In very many cases there is a quite 
extensive bone-repair, a new joint being sometimes formed, such cases having 
been described byTextor, Roux, Doutrelepont, and Billroth. Nepveu has recently 
collected 21 cases of this character. The general form of the new joint approx- 
imates that of the ankle, as a consequence of which flexion and extension are 
easily performed, and even pronation and supination may approach normal limits. 
The complexity of the wrist-joint, the number of bones entering into 
its formation, the firmness with which they are held in relation to each 
other, and the number of the overlying tendon-sheaths have made ope- 
rations on it difficult of accomplishment. Post-operative extension of 
the disease, protracted suppuration, and a result which is, as a rule, far 
from good, have made many operators question the usefulness of excis- 
ions. With improved technical resources, however, better results are 
being obtained, and particularly after partial excisions, and to a consid- 
erable extent after total excisions, a hand that is fairly useful may be 
retained. An excision should be considered complete only when at 
least the extremities of the bones of the forearm and all of the first row 
of the carpus, with the possible exception of the pisiform, are removed. 
Any operation short of this should be designated a partial excision. 
The conditions requiring excision are gunshot injuries, compound frac- 
tures of civil life, suppurative arthritis, and tuberculosis. In the com- 
plicated injuries of the wrist and hand as sustained in factories, and as 
often seen in civil life, partial and informal excisions should always be 
given preference to primary amputation, unless it is evident from the 
complicated nature of the trauma that gangrene would follow. It is 
particularly in this class of cases that conservative resection is followed 
by excellent results in cases apparently hopeless. For disease, resection 
The Wrist. OPERATIONS ON JOINTS. 
635 
is rarely called for before puberty, the cases being amenable to the 
milder measures of removal of individual bones. It is during the 
third and fourth decades of life that excision is most frequently 
demanded. 
Methods.—The operation most frequently performed by English 
and American surgeons is that described by Lister in 1865 (Fig. 256). 
The incision begins over the middle of the dorsum of the radius on a 
level with the styloid process. It 
is carried downward in the direc- 
tion of the inner edge of the joint 
of the thumb and first metacarpal 
bone, from which point it is 
deflected downward in the long 
axis of the latter to about its mid- 
dle. This, which is known as the 
radial incision, divides only the 
tendon of the short radial exten- 
sor of the wrist. The tissues upon 
the radial side of the incision are 
raised, the tendon of the long ra- 
dial extensor of the wrist is divided 
at its point of insertion, and all the 
soft parts are retracted outward, 
thereby exposing the trapezium, 
which is cut off from the rest of 
the carpus, but left in place to be 
removed later. By extending the 
hand the tendons are relaxed and 
the carpus cleared in the direction of the ulnar border of the hand. A 
free ulnar incision is then made, the knife being entered two inches above 
the styloid process of the ulna directly in front of the bone, and carried 
downward between it and the flexor carpi ulnaris in a straight line as far 
as the middle of the fifth metacarpal bone on its palmar surface. The 
dorsal lip of this incision is then raised, the tendon of the extensor carpi 
ulnaris cut at its insertion and dissected up from its groove in the ulna. 
The extensors of the fingers are then lifted up and the dorsal and inter- 
nal lateral ligaments of the wrist-joint divided. The flexor tendons are 
next separated over the front of the carpus, to accomplish which the 
unciform process of the unciform bone must be cut with the forceps. 
In this dissection the knife ought not to be carried below the bases 
of the metacarpal bones, to avoid injuring the deep palmar arch. 
The anterior radio-carpal ligament is then divided, the carpo-metacarpal 
articulations opened, and the carpus is extracted through the ulnar incis- 
ion with suitable sequestrum forceps. The ends of the radius and ulna 
can then be easily protruded through the ulnar incision, and as much as 
may be necessary can be removed with gouge, chisel, or saw. The ends 
of the metacarpal bones are sawn off or at least deprived of their artic- 
ular facets. The operation is completed with the removal of the tra- 
pezium, which, being seized with a strong pair of forceps, is readily dis- 
sected out without necessitating the division of the radio-carpal flexor 
or the radial artery. 
Fig. 256. 
Excision of the wrist: A, Lister’s radial incis- 
ion ; B, Lister’s ulnar incision; C, Ollier; 
D, Von Langenbeck. 636 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
Continental surgeons, following the lead of Maisonneuve, Boeckel, 
and the younger Langenbeck, usually resort to a single dorsal incision 
placed midway between the extensor tendons or nearer the radial ulnar 
border. Langenbeck’s operation with a single incision has given excel- 
lent results. In a large hand it should be at least 4% inches in length, 
or extend nearly 4 inches below the joint line and 14 inches above it. 
The incision is straight, and is placed in the interval between the exten- 
sor indicis and the extensor secundi internodii pollicis, closely following 
the radial border of the first of these tendons. The incision being 
carried down to the bone, the unopened sheaths of the tendons, with 
the periosteum and the overlying soft parts, are lifted from the bone 
with the elevator, first to the radial and then to the ulnar side of the 
incision. The hand being flexed, the articular surfaces of the first row 
of the carpus are exposed and the bones removed together or individ- 
ually. The lower end of the radius and ulna can now be easily pro- 
truded through the wound and treated according to the conditions 
found. The operation is completed by the removal of the second row 
of the carpus and the bases of the metacarpal bones. Vogt ensures 
free movement for the extensor tendons by chiselling away a thin 
lamina of bone with the periosteum from the dorsal side of the 
radial epiphysis. 
After-treatment.—Drainage is usually demanded after excision of the 
wrist. The hand and forearm should be maintained upon a well-padded splint in 
dorsal flexion, the fingers being slightly flexed. The splint ought not project 
beyond the palm of the hand, early movements of the fingers being essential to a 
useful hand. During the first twenty-four or forty-eight hours the entire limb 
should be kept suspended to reduce the post-operative oozing to a minimum. 
Active movements of the fingers should be instituted as soon as it can be done 
without pain. 
The results of this operation are not very satisfactory, although better than 
those of amputation. Culbertson collected 182 cases, of which 66 were done for 
gunshot injury, 16 for other injuries, 85 for disease, and in 15 the results were 
incompletely given. Of the 85 cases for disease, 51 were partial excisions, with a 
mortality of 15.69 per cent.—33 total excisions with a mortality of 6 per cent. The 
relative mortality was 15 per cent., 12 per cent., and 11.76 per cent. The cases 
were collected prior to 1874. Of 79 cases of excisions for disease, in 10 secondary 
amputation was required, in 6 the results were described as perfect, and in 36 the 
hand was useful. Of 6 cases operated upon by Billroth of which the result is 
known, only 1 case was permanently cured, and 3 died of phthisis. Of 33 cases 
treated by operation conservatively in 21, death resulted from phthisis in 10. 
Fahrenbach has recently reported on 28 excisions of the wrist for tubercu- 
losis made by Konig: 16 resulted in complete cure; 3 retained fistulae which did 
not interfere with the usefulness of the hand ; amputation had to be resorted to in 
1; in 5 the results were unknown. In only 3 of the 19 cases of recovery was the 
hand nearly useless. 
Formal excisions of the bones and joints of the hand, although 
formerly described in works on operative surgery, are rarely required. 
The operations are for the most part limited to the removal of necrotic 
sequestra or of fragments in compound wounds of the fingers and hand. 
The formal excision of the metacarpal bones, with the possible exception 
of that of the thumb, will usually leave a flail-like finger, which may be- 
come a source of inconvenience to the extent of necessitating a second- 
The Fingers, Thumb, and Metacarpus. OPERATIONS ON JOINTS. 
637 
ary amputation. Therefore, as a rule, with the exception of the thumb, 
the formal excisions of phalangeal or metacarpo-phalangeal joints of the 
hand are largely tentative. In most cases primary amputation is to be 
preferred. 
The Hip, 
Excision of the hip is almost always limited to the removal of the 
head of the femur and more or less of its neck. It has been performed 
for gunshot injuries, suppurative disease, and particularly for tubercular 
arthritis. Otis, from the statistics of the Civil War, maintains that 
primary excision is indicated in uncomplicated cases of shot fracture of 
the hip, and that secondary operations are called for where the diagnosis 
has not been made early and in secondary involvement of the joint. 
The disastrous results following excision in the Franco-German Wai- 
led Langenbeck and other German surgeons to promulgate conservatism 
in injuries of this character. The recoveries following conservatism 
were 25 per cent., the deaths 63 per cent.; primary excision was fol- 
lowed by a mortality of over 90 per cent. With improved antisepsis 
and asepsis it is probable that future wars will witness a very decided 
reduction in the mortality of operative interference after shot fractures 
of the hip. 
The operation is indicated in tubercular arthritis when, notwithstand- 
ing conservative measures, the destruction of the joint progresses and 
the vitality is undermined by long-continued and profuse suppuration. 
As will be seen from the chapter on tubercular arthritis, a formal excis- 
ion should be reserved for extreme cases, and particularly in children 
and in youths below maturity should the operation be limited to the 
removal of diseased structures, the operation being made an atypical 
resection or an arthrectomy. The excision of the entire epiphysis of 
the femur in a growing child means a shortening of from five to six 
inches when the subject has reached full development. In patients past 
the fifteenth year and in adults the same limitations do not exist, and 
formal excisions can be oftener made. Excisions are likewise called for 
in rare cases of arthritis deformans, for bony or fibrous ankylosis where 
simple osteotomy has not availed. Old-standing and painful dislocations 
of the hip and congenital dislocations may likewise call for operations 
upon the hip, although in the latter condition an osteoplastic operation 
looking to the formation of a new acetabulum should be given the pref- 
erence over the removal of the femoral epiphysis. 
Methods.—The simplicity of the hip-joint makes it approachable for 
operative interference from all sides except the inner. Many methods 
of excision have therefore been suggested and practised (Fig. 257). 
Longitudinal, curvilinear, and transverse incisions have been recom- 
mended for opening the joint, and flap operations with upper or lower 
convexity have likewise been practised. Of the various incisions, the 
longitudinal are unquestionably those best adapted for saving as much 
as possible of the ligamentous and muscular structures. The more 
complicated the incision, the greater the wounding of the soft parts and 
the less the probability of a good primary result. The longitudinal 
incision that is most often practised is that originally made by White, 638 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
but now known as the Langenbeck incision. The patient being placed 
upon the sound side, the limb, if it be not already so from disease, is 
flexed at an angle of 45°. An incision from three to six inches in 
length, according to the age of the patient, is made over the centre of 
the trochanter and in the axis of the 
femoral shaft. It should begin just 
above the trochanter, and in its upper 
two-thirds be placed in the gluteal region. 
Over the trochanter the incision passes 
at once to the bone, whereas the gluteal 
muscles are divided layer after layer. 
When the capsule is reached it is 
divided in the direction of the original 
incision from the acetabular margin to 
the femoral neck. Two transverse incis- 
ions made close to the acetabulum by cut- 
ting the cotyloid ligament and admitting 
air into the joint will open this freely for 
inspection and manipulation. The mus- 
cular attachments to the great trochanter 
are next divided close to their insertion, 
the periosteum as far as possible being 
preserved. The limb is rotated inward 
to expose and facilitate the divisions of 
the posterior muscles, and rotated out- 
ward to divide the anterior. The capsule 
being freely divided, the head of the 
femur is readily dislocated and brought into the wound. The ligamen- 
tum teres, having usually disappeared, demands no attention; when 
present it must be divided. The soft parts being thoroughly protected 
by retractors, the saw is applied at the base of the femoral neck or, if 
need be, at the base of the trochanter. A very serviceable method is 
that of dividing the femoral neck at its base with a chisel, and subse- 
quently removing the trochanter, if need be, with a saw. Wherever pos- 
sible the trochanter should be saved. The operation is completed by 
removing the foci of disease from the acetabulum with bone gouge or 
chisel. As much of the capsule as can be should be removed and all of 
the joint interior cleansed with a sharp spoon or the finger covered with 
gauze. Before closing the wound the sinuses which are present should 
be thoroughly opened up or scraped. Tubular drainage being provided 
for, the wound is closed with sutures. 
Fig. 257. 
Excision of the hip : A, Sayre ; B, Ollier. 
Operation by Anterior Incision.—Luecke and Schede, and more recently Barker, 
have employed an anterior incision. It begins below the anterior spine of the 
ilium half an inch to its inner side, and runs downward and a little inward for 
three inches. It passes to the inner side of the sartorius and rectus femoris, and 
exposes the external border of the ilio-psoas. The further steps of the operation 
are similar to those above described, although the neck of the femur may be 
divided in situ with a keyhole or chain saw. 
The incision of Barker is to be preferred. It is made near the external border 
of the limb, passes between the tensor vaginae femoris and gluteal muscles on the 
outside and the sartorius and rectus on the inside, until it reaches the neck of the 
femur. The operation is simpler than that of Luecke and Schede, and closely 
resembles the incision made by Hueter. The position of an anterior incision sim- OPERATIONS ON JOINTS. 
639 
plifies the use of a posterior splint and does not interfere with drainage. The 
advantages are such that English writers believe the method to be that which 
should always be practised unless contraindications exist. 
The curvilinear incision, or its modification the angular incision, is made over 
the trochanter with the concavity looking forward. Sayre’s and Ollier’s operations 
are the best known of this class, although Velpeau had already performed one sim- 
ilar. Sayre describes his operation as follows : “ Select a strong knife; drive it home 
to the bone at a point midway between the anterior superior spinous process of the 
ilium and the top of the trochanter, then drawing it in a curved line over the ilium 
and the top of the great trochanter, extending it, not directly over the top of the 
trochanter, but midway between the centre and its posterior border, and com- 
pleting it by carrying the knife forward and inward. Make the whole length of 
the incision from four to six inches, according to the size of the thigh.” In this 
manner a curved incision is made through all the soft parts down to the bone and 
through the periosteum. A second incision is made with a narrow, thick knife 
through the periosteum, only at right angles to the first incision on a level with 
the lesser trochanter or a little above it, and carried as far as possible around the 
bone in front and behind. Beginning at the angles of the two incisions, the 
periosteum is raised with the elevator and all muscular attachments severed before 
the saw is used. Sayre always divides the bone below the trochanter major. 
Ollier has recently advocated an osteoplastic excision in which, through a 
curved incision with downward convexity made over the top of the trochanter, 
the latter is exposed and divided with the chisel, turned upward with a flap, and 
reunited by sutures to the femoral shaft after the excision of the neck and head 
has been completed. 
The management of the trochanter in excisions of the hip should not 
be routine. Although, on the one hand, Sayre and Volkmann made it 
a rule to remove it with the femoral neck, on the other hand Langen- 
beck and Hueter have advised supratrochanteric excision wherever 
feasible. The latter operation necessarily is followed by the least degree 
of shortening. Circumscribed disease of the head and neck requires 
the removal only of these parts. Whenever it is necessary, on the 
other hand, to thoroughly expose the joint interior and the disease 
requires the removal of the synovial membrane and parts of the 
acetabulum, excision of the trochanter becomes necessary. 
After-treatment.—In an adequately equipped hospital the patient can be 
placed in a wire cuirass, the limb in extension. A very effective dressing is the 
fenestrated plaster-of-Paris breeches, with extension by means of weight and 
pulley, as after the method of Gurdon-Buck. Counter-extension is not often 
required. Particular attention must be given to overcome the tendency to adduc- 
tion, and many operators advise placing the limb from the beginning in slight 
abduction. Since in most cases fibrous or bony ankylosis is sought for, passive 
movements are not ordinarily to be employed after excisions of the hip. In the 
few cases in which, from the local conditions existing at the time of operation, 
the preservation of joint movement can be hoped for, passive movements should 
be instituted as soon as the wound is thoroughly united. 
Results.—The mortality of excision of the hip for gunshot injury has already 
been considered. That following operations for disease has been placed by Cul- 
bertson in 426 cases at 43.84 per cent, for partial excisions, and 46.10 per cent, for 
complete excisions. The mortality due to the operation itself has been very 
largely reduced in the last two decades as a result of modern wound-treatment. 
From 86 excisions made in Strasburg, 6 died of collapse, embolism, or other causes 
attributable to the operation; altogether 37, or 43 per cent., succumbed, most of 
them from local recurrence or generalization of the disease. Of 120 cases which 
were observed for a number of years after the operation, 44 ultimately died from 
causes independent of the operation, and, as a rule, from local recurrence of 
tuberculosis or its development in the viscera. 
The greatest mortality follows operations performed in the first five years of 
life. It decreases from that period on up to the full development. In operations 640 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
done in adults, and particularly in older subjects, the mortality is again very great. 
Regarding the usefulness of the limb after excision, the statistics of Baer show 
that in 8 out of 46 cases free active movement of the joint could be made; in 
23 movement was limited, in 11 cases ankylosis resulted, and in 1 a flail joint 
remained; 12 were able to stand without support upon the resected limb. 
The Knee. 
Resection of the knee may be demanded for gunshot or other injury, 
for deformity, ankylosis, for neuropathic arthritis, and particularly for 
tubercular disease. Resection for gunshot injury has in past wars 
proved so fatal that unless the dangers of death from sepsis can be 
materially decreased, choice should be made between conservatism and 
amputation. The mortality following resection for gunshot injury is 
placed by all writers at about 90 per cent. For ankylosis with angular 
deformity resection is a safe and almost uniformly successful procedure. 
In tubercular disease the easy accessibility of the joint fits it particularly 
for the more conservative operation of arthrectomy and informal or 
partial excisions. In the failure of this recourse may be had to formal 
excision. The latter is not called for in young children, and even in 
youths and in adults should rarely be resorted to as the primary opera- 
tion, except in cases of most extensive destruction by disease. 
Methods.—The anatomical relations of the joint make it approach- 
able by transverse, curvilinear, or longitudinal incisions made over the 
front and sidps of the joints (Figs. 258, 259, 260). The transverse 
incision is made directly across the centre of the 
joint down to the patella, which is divided with the 
saw. The flaps thus made are reflected upward and 
downward, and the joint interior is reached. Usu- 
ally the semilunar incision with upper concavity is 
resorted to. The knife, being entered at the pos- 
terior extremity of one condyle, is carried down- 
ward and forward below the patella across the 
patellar ligament near its insertion, and thence 
upward to the posterior end of the inner condyle. 
The incision is carried into the joint. The flap 
containing the patella, being grasped with a sharp 
retractor, is drawn upward by an assistant, the 
knee being flexed to a right angle. By transverse 
incisions the lateral ligaments are divided and the 
crucial ligaments are severed close to their tibial 
insertions. In this step of the operation, to avoid 
injury of the popliteal vessels, the point of the 
knife should be directed toward the inner condyloid 
depression. The articular ends of the femur and 
of the tibia are now sufficiently separated from each other to permit 
their free protrusion from the wound and, after periosteal decortication 
around the periphery, their removal with saw or broad chisel. When 
the saw is used the femoral epiphysis may be divided from before back- 
ward. To remove the upper end of the tibia it is advisable for the pro- 
tection of the popliteal vessels to saw from behind forward. The opera- 
tion is completed by the removal'of the patella if it be involved in the 
Fig. 258. 
Excision of the knee-joint 
A, semilunar incision 
B, Ollier’s incision. OPERATIONS ON JOINTS. 
641 
disease, and the extirpation of the subquadricipital pouch. The extir- 
pation of the capsule completes the operation. The proximity of the 
Fig. 259. 
Fig. 260. 
Sections to show the position of the epiphyseal cartilage at the knee and the points at which the 
section ought to he made in excision (Stimson). 
vessels makes the removal of the posterior wall of the capsule a 
delicate procedure. 
E. Hahn and, following him, a number of operators have reversed the semi- 
lunar incision, giving it an upper convexity and dividing the tendon of the quad- 
riceps femoris instead of the ligamentum patellae. The advantage of the procedure 
is the ease with which the subtendinous pouch of the joint is reached. Volkmann 
and others open the joint by the transverse incision and the division of the patella, 
the latter being reunited, if it is to he saved, with catgut or wire sutures after the 
completion of the resection. 
Moreau, Ferguson, Butcher, and Ollier employ an H-shaped incision, the hori- 
zontal portion of which is carried through the ligamentum patellae. It has no 
advantage over the transverse or the curvilinear incision. When a longitudinal 
incision is made it may be in the axis of the limb and through the centre of the 642 
AFFECTIONS OF THE TISSUES ANI) TISSUE-SYSTEMS. 
patella, which is then divided vertically with saw or chisel. As in transverse 
divisions of the patella, suture may be practised after the excision is completed. 
Langenbeck made an incision upon the antero-internal aspect of the joint. The 
methods by longitudinal incision have only the doubtful advantage of leaving the 
ligamentum patellae intact and serviceable in case joint function is retained. The 
division of the ligamentum patellae by the transverse operation does not militate 
against equally good results, as has been shown after many arthrectomies, since 
prompt reunion follows its division. The method of sawing the bone varies with 
different operators. To prevent a tendency toward angular deformity, Watson, 
Kocher, Billroth, Fenwick, and others give the femoral end a convex and the tibial 
end a corresponding concave surface. To the same end Albert removes the artic- 
ular ends step-fashion, leaving more of the femoral condyles behind and of the 
tibia in front. In an arthrectomy the patella should be retained. In an excision 
it should likewise be retained, since the ankylosis which it has a tendency to 
readily form with the femur distinctly prevents angular deformity. In every 
excision its cartilaginous covering should be thoroughly removed with saw or chisel, 
and if found diseased it should be removed in its entirety. 
For fixation of the bone surfaces Gurdon Buck in 1853 resorted to 
bone suture. Many operators have since resorted to catgut or wire 
suture, or to the even firmer fixation by means of steel or ivory pegs. 
As a rule, such procedures needlessly complicate the operation, since 
fixation is readily maintained by closely applied retentive dressings 
and proper splints. With careful attention to hemostasis during 
the operation drainage will be sufficiently provided by a strand of silk- 
worm gut passed through the most pendent portion of the wound. 
Ordinarily even this is superfluous. 
After-treatment.—Accurate apposition of the bone surfaces is best main- 
tained by means of a posterior concave splint, which is retained in place by 
plaster-of-Paris bandages applied above and below the line of incision. If desira- 
ble, the limb can be maintained suspended during the first twenty-four or forty- 
eight hours to reduce oozing to a minimum. When such a retentive appliance is 
used, it should be fenestrated over the wound to make the parts easy of access. 
When properly applied the first dressing need not be changed in less than from 
two to four weeks. 
Results.—Immediate results of excision of the knee for tubercular disease 
are very satisfactory. A. M. Phelps has recently collected 329 cases of excision 
of the knee with antiseptic precautions, with 31 deaths, or a total mortality of 
9.42 per cent. Of the fatal cases, 15 resulted from phthisis, 1 from ether, 2 from 
amyloid disease, 2 from nephritis; only 10 deaths, or 3.03 per cent., were due to 
the operation. Similar results were obtained in 84 cases operated on by Ashhurst. 
There were only 7 deaths, or a mortality of 8.3 per cent. Lossen tabulated 586 
excisions, of which 439, or 75 per cent., recovered, 10 per cent, were discharged 
with fistulous openings, and 8 per cent, required subsequent amputation; 38, or 
6.5 per cent., died soon after the operation. In approximately 75 per cent, of the 
cases, therefore, a permanent success is obtained from excision of the knee for 
tubercular disease. 
In children partial excision and arthrectomy have given equally good results. 
Paoli reported 14 arthrectomies with 1 death, which resulted from general tuber- 
culosis after amputation had become necessary. Miller of Copenhagen reported 
42 operations, 2 of which were fatal after generalization of the disease. In 15 
cases patients were free of disease during from six months to four years. In 26 
cases there was a recurrence of disease; in 12 of these the recurrence was slight 
and permanently relieved by curetting. In 8 of the remaining cases atypical 
resection wTas demanded, and in 2 amputation. Of the arthrectomies, 18 were 
made in children, of which 7 could be observed from one to four years after the 
operation. In these there was no shortening. In 6 cases there was a shortening 
of from one to two centimetres. In 5 cases there was an elongation of from half 
an inch to an inch. In the smallest number of cases ankylosis followed the arth- 
rectomy ; the greater number preserved joints more or less movable. Angerer 
reported upon 82 arthrectomies, of which 63 were upon children under fourteen OPERATIONS ON JOINTS. 
643 
years of age. In 10 of the cases there was a recurrence. In a very large propor- 
tion considerable joint mobility was retained. 
Excision of the ankle may be performed for gunshot injury or com- 
pound fracture, and particularly for compound dislocation. It may 
likewise be demanded in tubercular disease, although the protracted and 
doubtful recovery may in the cases of adults make amputation prefera- 
ble. In its limited application excision of the ankle means the removal 
of the lower ends of the tibia and fibula and the upper surface of the 
astragalus. The complicated anatomical relations of the bones and 
joints of the tarsus will therefore make a formal excision for disease 
a rarity. According to Ollier, in three-fourths of all cases the astraga- 
lus is primarily and most extensively involved. 
Methods.—Many methods have been devised for excision of the 
ankle, but they are mostly modifications of the original procedure of 
Moreau by reaching the joint through external and internal lateral incis- 
ions. In 1865, Langenbeck modified it for the purpose of making the 
operation subperiosteally. The external incision, about three inches in 
length, is made over the lower end of the fibula and its malleolus 
beyond its tip. The incision is carried down to the bone : by means of 
an elevator the fibula is separated from its periosteum and divided with 
a chain or keyhole saw an inch above its lower end. The lower bone 
segment, being grasped by forceps, is ’drawn out of the wound, turned 
from side to side, and with, short cuts of the knife severed from its liga- 
mentous attachments. In this step of the operation the external lateral 
ligament should be injured as little as possible. The second step of the 
operation, according to Langenbeck, is the removal with the saw of the 
upper articular surface of the astragalus. The third step is constituted 
by an incision over the internal malleolus, of equal length with the 
external, and likewise reaching down to the bone. The periosteum, 
being divided vertically, is peeled as far as possible from the inner and 
posterior surfaces of the bone. The internal lateral ligament is next 
divided and the tibia protruded through the inner incision by forcibly 
everting the foot. The articular end of the tibia is then removed with 
a saw. If need be, the whole of the astralagus can be removed from 
the external incision. 
The Ankle. 
The supposed imperfect exposure of the joint interior through lateral incisions 
has led many operators to resort to more or less transverse incisions across the 
front of the joint, either dividing the tendons and subsequently suturing them, or 
partly cutting and partly forcibly retracting them during manipulations upon the 
joint surfaces. These methods are, as a rule, to be condemned. Konig in 1885 
modified the operation by longitudinal incisions, placing them respectively over 
the anterior borders of the tibia and fibula (Fig. 261). From these two incisions 
all of the soft parts between them are raised as a flap from the anterior surface of 
the joint. This is now opened and the interior exposed. With abroad chisel the 
outer lamellae of the malleoli, together with their ligamentous attachments, are sev- 
ered. The soft parts being then retracted, the lower end of the tibia is divided with a 
broad chisel and removed with forceps. When it is the seat of disease the fibula 
is removed in the same manner. The astragalus is next cared for, its upper sur- 
face being removed with the chisel, or, if necessary, the bone is entirely taken 
away. 
A unilateral external incision recommended by Chassaignac and Erichsen 644 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
gives valuable results if, after the opening of the joint and division of the external 
lateral ligament, the foot be forcibly dislocated inward. With almost the same 
object in view Kocher resorts to a semilunar incision from the outside of the tendo 
Achilles to the outer border of the extensor tendons and passing underneath the 
Fig. 261. 
external malleolus. The joint is thus easily and widely opened, the peroneal ten- 
dons alone being divided. After the completion of the operation these are readily 
sutured. This method is particularly applicable to children. 
After-treatment.—The wound is closed after ample drainage has been pro- 
vided for. Any tendency to a talipes-equinus position should be overcome by the 
use of a well-padded leg-and-foot-splint made of perforated tin, felt, or plaster of 
Paris. During the first twenty-four hours the limb is to be retained at a right 
angle, after which it should be kept suspended. 
Results.—The mortality of excision of the ankle for gunshot wounds, accord- 
ing to Otis, is 33 per cent.—to Culbertson, 26 per cent. The results of excision 
for the injuries of civil life are only 12 per cent. Excision for disease has even a 
lower mortality. In 1885, Konig reported 32 cases, of which 11 were entirely 
cured and 5 retained small fistulse; 16 cases, or 50 per cent., retained a useful foot. 
Of the remaining cases, 7 were subsequently subjected to amputation, and 5 were 
of too recent a date to warrant any conclusion as to the end result. Two died of 
intercurrent disease, and of the remainder the result was unknown. In 1891, 
Buntz of Heidelberg reported upon 25 excisions, of which 10 recovered and were 
observed from one to four and a half years. Death did not follow as the result of 
the excision in any of these cases. Ashhurst reports 10 excisions of tubercular 
disease of the ankle without a death due to the operation ; 2 of the cases died sub- 
sequently of phthisis. In traumatic cases the operation is very satisfactory, and 
the resuits in tubercular diseases of children are also very good. In adults, par- 
ticularly in patients from walks of life where the time required for recovery is an 
important factor in determining the method of operation, amputation must often 
be resorted to as the speediest means of affording relief. 
Konig’s incision for excision of the ankle. 
O STEOPLASTIC EXCISION OF THE FOOT. 
For tuberculosis of the ankle-joint and of the bones of the tarsus 
Wladimirov and Mikulicz, in 1871 and 1880 respectively, advised a pro- OPERATIONS ON JOINTS. 
645 
cedure by which the ankle-joint and as many of the bones of the tarsus as 
may be necessary can be removed with the retention of the anterior por- 
Fig. 262. 
Osteoplastic excision of the foot (Mikulicz). 
tion of the foot, which is fixed in an extreme equinus position. The 
operation is performed with the 
patient in the prone position. 
An incision is carried from the 
tubercle of the scaphoid bone 
across the sole of the foot to an 
inch behind the base of the fifth 
metatarsal bone (Figs. 262, 263). 
From each end of this incision 
another is made longitudinally to 
the base of each malleolus, the 
ends of the lateral incisions 
being united by a cut across the 
ankle dividing the tendo Achilles. 
All incisions having been carried 
to the bone, the quadrangular 
flap is dissected from above, the 
joint opened from behind, the 
lateral ligaments divided, and the 
astragalus and calcaneum sepa- 
rated from their attachments and 
removed. The lower extremities 
of the tibia and fibula and the 
articular surfaces of the scaphoid and cuboid are next removed with 
Fig. 263. 
Results of an osteonlastio resection of the foot. 646 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
the saw. The foot is then brought back, the divided surfaces care- 
fully adjusted, and the wound closed. Wire suture or bone pins may 
be used to ensure fixation, although the procedure has been shown to be 
superfluous. Buntz has recently tabulated 34 cases of osteoplastic 
resection of the foot, in none of which death was attributable directly 
to the operation. Of 26 cases operated upon for tuberculosis, 18 were 
cured—11 with a very good and 7 with a useful foot; 2 died of tuber- 
culosis, and in 5 a secondary amputation had to be made. The result 
in 1 was unknown. Of the remaining cases, the result in regard to 
usefulness was good in 4, fair in 3, and bad in 1. CHAPTER XXXY. 
SURGICAL DISEASES OF THE OSSEOUS SYSTEM. 
Roswell Park, M. D. 
At the very outset of a study of surgical diseases of the osseous system it is 
necessary to emphasize a fact which students and young practitioners are often 
prone to forget—namely, that bone, even the densest, is a tissue, and that as such 
it is liable to infection, suppuration, gangrene, etc., just as is any other tissue; 
that all infectious processes are identical in general character, their gross mani- 
festations varying only by virtue of the peculiar characteristics of the tissue in 
which the infection occurs. Bone is always vascular, and even that exceedingly 
hard variety which is met with in the petrous portion of the temporal, or the 
ivory exostosis, has sufficient connection with the vascular system to permit of its 
proper nutrition. The firmest and hardest bone will bleed when divided or injured, 
and any tissue which will thus bleed can react injuriously to various irritants. 
Bone is covered, except at joint ends, by a dense fibrous membrane—the peri- 
osteum—whose relations with it are very intimate. Inside the cranium the dura 
mater functionates in a double capacity—as a cerebral membrane and as an internal 
periosteum. Joint ends of long bones and joint surfaces elsewhere are encrusted 
with cartilage, whose relations are equally intimate. In the neighborhood of joint 
ends there are, in the young, found areas of peculiar and unusual vascularity. 
These are the epiphyses, where cartilage is being transformed into bone in order 
to furnish the increase in length which characterizes all growing long bones. The 
increase in transverse dimensions occurs through the mechanism of the periosteum. 
The vascular supply is for the most part abundant, the intraosseous veins connect- 
ing always with the larger but deep venous trunks, usually in a quite direct man- 
ner. Hence it is that septic thrombosis occurring within the bone or beneath the 
periosteum leads so frequently to genuine pysemic disturbances. 
I have been in the habit of following Savory’s teaching, and calling attention 
to certain anatomical and clinical resemblances between lung and bone, because, 
for the most part, the infectious and other diseases of the densest tissue of the body 
find their counterpart in those of the softest, and because, to the average student, 
the latter are so much more easily and commonly appreciated. In fact, the minute 
pathology of bone diseases has been until recently regarded as unnecessarily 
obscure, simply because of the difficulty of noting post-mortem appearances in 
the bones as easily and with as little disfigurement as in the lungs. 
Bone and lung, then, react in a similar way to infections, the analogy being in 
some respects quite striking. Both are surrounded by firm investing membrane; 
both have more or less of spongy texture ; both are extremely liable to tubercular 
or pyogenic invasion; while in either case the disease manifestations are usually 
found near the extremities (apices). Both are in close relation, the bones espe- 
cially by their joint ends, with serous cavities which become secondarily involved 
in a majority of instances—in the one case as a pleuritic effusion or empyema, in 
the other case as a joint effusion or a pvarthrosis. In both structures may be seen 
beautiful pictures of miliary tuberculosis when present. Furthermore, the one is 
as subject to acute miliary invasion as is the other, while in both alike staphylo- 
coccus, streptococcus, pneumococcus, and other specific forms of infection are 
prone to occur. As in the lung one lobe or more may be involved, so in the shaft 
of a bone a single epiphyseal extremity or the shaft, or both together, may be the 
site of the disease. In both also local gangrene may result, its ravages being 
known in the one case as gangrene of the lung, in the other as acute necrosis. 
647 648 
AFFECTIONS OF THE TISSUES ANT) TISSUE-SYSTEMS. 
Calcareous infiltration of bone is, then, to be regarded as simply an incident 
necessary to its physiological function, but not in the slightest respect preventing 
it from becoming inflamed or acting in any other way as do the soft tissues. Acute 
infection of any or all of the structures which go to make up a bone is possible; 
in fact, it is almost impossible to conceive of a serious infection which shall 
involve, for instance, the periosteum alone and spare the true bone beneath. Clin- 
ically, however, there are three locations in which infectious manifestations are 
most common: (a) Beneath the periosteum; (b) in the epiphyses; (e) in the 
diaphyses. 
All bone marrow begins as red marrow, with 1 or 2 per cent, of fat, and ends 
by becoming yellow, with 60 or 70 per cent, of fat, and whether this change shall 
take place suddenly or rapidly depends upon diverse conditions. Many years ago 
it was claimed by Bourgery that bone is simply a large cavernous arrangement 
where stagnation of the blood-current favors the deposition of fat. Fatty altera- 
tion progresses from periphery to centre, and the bones of the hands and feet 
undergo fatty alterations before those of the trunk and pelvis. In other words, 
the truncal skeleton remains as “red bone” longer than the balance of the osseous 
system, and he whose sternum has become a really “ yellow bone ” must have 
reached a ripe old age. So in long bones distal extremities first become fatty. 
Individual peculiarities seem to govern these changes. Thus, the neck of the 
femur will sometimes be fatty and friable at the fortieth year, or reasonably firm 
and still red at the eightieth. This fatty condition is not to be confounded with 
true osteoporosis or rarefaction in bone, though it is often associated with it. When 
the two conditions are combined we have osteoporosis adiposa. Into this condition 
immobilized limbs pass more easily than those which are used. Their weeks have 
been equal to years of ordinary inactivity. Red bone seems to be too highly 
vascular to be a favorite site for tubercle, and distinctly yellow bone too non- 
vascular. Consequently, bone tuberculosis is less often seen at the very extremes 
of life. White bone, as those who make anatomical preparations call it, is most 
favorable for tubercular infection on account of its minimum contents both of 
blood and fat. These bones come most commonly from phthisical subjects. 
This condition was never accurately recognized until described by 
Chassaignac in 1853, and even he missed many of its distinctive 
features, although he gave to it a most descriptive name, “typhus 
of the limbs.” 
Pathology.—The disease is a distinctly infectious process, limited 
sometimes to the bone marrow and internal portion of the bone, some- 
times apparently involving every particle of the osseous structure. Its 
onset'is sudden, its manifestations most acute and serious, and its rav- 
ages, when not promptly checked, most extensive. The following more 
or less distinct varieties may be distinguished : 
A. The Staphylococcus. 
B. The Streptococcus. 
C. The Pneumococcus. 
D. The Tubercular. 
E. Miscellaneous other Infections, including the Colon Bacillus, 
the Typhoid Bacillus, etc. 
Acute Osteomyelitis. 
The staphylococcus variety is occasionally met with in its pure form. The 
streptococcus form is perhaps the more serious of the two, the tendency to general 
septic infection being perhaps even greater in this variety. The pneumococcus 
form has not been generally recognized until comparatively recently, and is no 
more necessarily connected with the development of a pneumonia than is any 
suppuration elsewhere due to this same organism. The onset and course of the 
disease are generally considered to be less acute than in osteomyelitis due to the 
organisms just above named. There seems also less tendency to subperiosteal SURGICAL DISEASES OF THE OSSEOUS SYSTEM. 
649 
collections of pus and a greater tendency to more prompt repair. The pyarthroses 
accompanying the pneumococcus form are also less dangerous than in the staphy- 
lococcus form. The acute form of tubercular osteomyelitis will be considered under 
the head of tuberculosis of bone. Ever since the time of Boerhaave osseous com- 
plications and sequels of typhoid fever have been recognized, and since 1885 their 
pathogeny accurately described. Still more recently it has been discovered that 
the colon bacillus alone is also capable of setting up these acute suppurative lesions 
within the bones. The same is undoubtedly true also of the micro-organisms of 
certain other diseases, particularly of influenza, or la grippe. 
Be the organism what it may, the mechanism of the infection and 
the lesions produced by it are essentially similar, and may all be de- 
scribed together. These consist of rapid thrombosis, coagulation-necrosis, 
and suppuration, along with the local destruction incident thereto, and 
with unlimited possibilities in the way of auto-intoxication, both from 
the local lesions and from the disturbance of the general economy and 
interference with excretion. Every severe case is accompanied by more 
or less of general septic intoxication, presumably from the ptomaines 
produced by the bacteria, while in many instances, particularly those 
where the bacteria at fault seem extremely virulent, the intoxication is 
overwhelming and the course a rapidly fatal one. Death has been 
known to follow within thirty-six hours after the first symptom of an 
acute osteomyelitis. For the average case three more or less distinct 
stages can usually be distinguished : first, a period of purulent infiltra- 
tion, with the formation of local foci in the bone marrow and speedy 
secondary involvement of the periosteum and synovial membrane; 
second, a period of sequestration or formation of a sequestrum inside of 
an abscess-cavity; third, the stage of repair. 
First Stage.—During this there occurs most violent inflammatory 
infiltration, localized areas becoming at first hypersemic, then infiltrated 
with hemorrhagic exudate, whose rapidity of production will indicate 
the intensity of the infection, since often at the same time one finds 
enlargement of the spleen and hemorrhagic exudations in distant serous 
cavities, such as the pleura and pericardium. The locally infected 
areas of bone marrow quickly break down into depots of pus, which 
spread either toward the epiphyseal line or else along the Haversian 
canals toward the periosteum, which becomes both infiltrated and loos- 
ened. The loosening is particularly marked about the shafts rather 
than the joint ends, while, as a rule, that end of the bone toward which 
the nutrient artery is directed is the one whose epiphysis is first loosened, 
Nevertheless, about the knee it would seem as though the lower end of 
the femur and upper end of the tibia are the particularly predisposed 
localities. 
In many instances obliteration of nutrient vessels and thrombosis are very 
early features of the case. The area of separation of the periosteum is usually 
an index of the extent of deep destruction. From the periosteum the infection 
may extend toward the covering soft parts, in which case we may have a parosteal 
abscess, or it may perforate toward the joint-cavity, leading quickly to pyarthro- 
sis and destruction of joint structures. It would appear in children, particularly, 
that the epiphyseal cartilage forms often a■ barrier to the advancement of the 
lesion in the direction of the joint, and thus it happens that we have acute 
necrosis of the shaft of a long bone, with perforation through the periosteum 
at both of its ends. In adults this takes place less often, the joint ends being 
often primarily involved. Softening and separation of cartilages are usually 
secondary to the other processes. It is possible even to have the primary infec- 650 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
tion in the joint end proper, and extension therefrom to the epiphysis permitting 
of epiphyseal separation and extrusion of this fragment as a sequestrum. This 
separation occurs in many instances rapidly and before the attendant is alive to 
what has really happened. 
Second Stage.—The second stage includes, coincidently with the 
occurrence of suppuration, the proliferation of considerable granula- 
tion-tissue, by which more or less protection is afforded; also, when 
time is afforded, the rapid formation of new bone, whose effect is to 
wall off the scene of conflict and death from the surrounding tissue, by 
which event prognosis, so far as the patient’s life is concerned, is very 
much improved. Intraosseous abscesses may quickly coalesce, and the 
result may be one long tubular abscess extending through the shaft. 
At other times both bone marrow and the cancellous tissue are bathed 
in pus, while if the periosteum has been totally separated the conse- 
quence will be a sequestrum whose dimensions correspond with those 
of the shaft. When periosteum is not loosened the necrosis will prob- 
ably be central and more or less circumscribed. ( Vide Plate XVIII.) 
The degree to which rigid osseous tissues are capable of yielding under these 
circumstances is astonishing, and we may have remarkable enlargements occur- 
ring within a comparatively short time, producing most striking discrepancies in 
size between healthy and diseased bones. The extent to which the periosteum 
has yielded may be in some respects estimated by the intensity of the pain, spon- 
taneous subsidence of it being an evidence of spontaneous yielding of tissues and 
relief of tension. Epiphyseal separation is one expression of such yielding. Another 
is, for instance, the purulent diastasis of the tripartite suture entering into the 
formation of the acetabulum, while the external table of the skull or of the sternum 
may give way in the same manner. 
Third Stage.—The third stage is the period of efforts at spontaneous 
repair. There is a natural effort toward elimination of the sequestrum 
by the process of softening or liquefaction in the direction of least resist- 
ance. This process may extend over months when surgical relief has 
been delayed, and may be accompanied by so much other disturbance as 
to completely ruin a bone or limb for further use. In neglected cases 
several sinuses may lead down toward the central sequestrum. On the 
other hand, once this sequestrum be eliminated an extraordinary amount 
of activity is usually displayed in the direction of repair. 
Symptoms.—In a general way the signs and symptoms of all acute 
infectious lesions in bone are strikingly similar, and are most significant 
when construed aright. Patients complain usually first of exhaustion, 
followed quickly by pain, which may speedily become agonizing. This 
is often accompanied by an introductory chill with high fever, after which 
the general character of the disease quickly assumes the typhoid aspect. 
Evening temperature may rise high and be followed by some morning 
remission. The spleen is usually enlarged, the primae via; disturbed, 
and often we have to do with a fetid diarrhoea. In the young the sen- 
sorium is early affected and children quickly become delirious. The 
pain, at first vague, quickly focuses in the particular bone or bones most 
involved, and as it increases in intensity there is a more and more signif- 
icant tenderness, which becomes exquisite. Ordinarily there is also early 
and characteristic reddening and swelling of the affected parts. With 
all these evidences goes also a characteristic muscle-spasm, by which cer- 
tain posture signs will be produced varying with the bone involved. plate XVIII. 
Acute Osteomyelitis; Showing Purulent Foci and Accompanying Dis 
turbances. (Koeher.) SURGICAL DISEASES OF THE OSSEOUS SYSTEM. 
651 
Pain is always intensified by the slightest degree of disturbance. In 
consequence, the limbs (for it is the limbs which are usually involved) 
are contracted, and every effort to overcome the contractures is followed 
bv aggravated pain. The more acute the pain the more vivid the exter- 
nal evidences of inflammation and the cedema of the parts, especially 
below and about the lesion. Thus it may happen that within forty-eight 
hours we have not merely swelling, but actual oedema of the part 
involved, which should be always regarded as pathognomonic. 
A little later, superadded to the other signs of inflammation, we find 
fluctuation if parosteal abscesses have formed, or possibly the evidences 
of epiphyseal loosening or complete separation. When the disease is pri- 
mary in an epiphysis the corresponding joint will be early involved, and 
the joint symptoms will take on rapidly the type of an acute purulent 
synovitis, only with a much more significant degree of pain. It is prob- 
able that under few, if any, circumstances is pain complained of more 
serious or aggravating than in cases of acute osteomyelitis of the fulmi- 
nating type. 
So far, only local symptoms have been described. To these there 
must be added the list of those pertaining to thrombosis and metastatic 
infection, with their septic and disastrous consequences. The disease is 
frequently so acute and rapid that even within the first day or two 
there is not only extensive thrombosis in and along the bones, with rapid 
purulent degeneration and thrombi, but that even more serious general 
condition to which these lesions so easily give rise—i. e. unmistakable 
pyaemia. 
While patients may die of septic intoxication before sufficient time has elapsed 
to permit of the formation of secondary abscesses, yet it is known that death may 
result from true pyaemia within a comparatively very short time. Moreover, other 
septic infections—as, for instance, septic pneumonia, metastatic meningitis, peri- 
carditis, nephritis, etc.—may occur in a more irregular or less classical manner. 
In fact, there are few, if any, infectious processes which can be followed by death 
from such a variety of causes, and which are so augmented by dangers if not 
promptly relieved, as acute infectious osteomyelitis. 
The general symptoms are common to the disease, no matter what 
bone be involved. Local symptoms will, of course, change in accord- 
ance with their location. While not so common, the flat bones, like the 
pelvis, cranium, and sternum, may be involved in most active manifes- 
tations of this disease. The same is true even of the vertebrae, but, as 
a rule, it is in the long bones of the extremities that its ravages are most 
frequently seen. 
In the case of the cranium, for instance, we have periosteal separation, exten- 
sive local swelling, and oedema, soon changing into fluctuation, while in the diplde 
the anatomical arrangements especially favor prompt pysemic lesions. Among the 
less usual incidents are subperiosteal hemorrhages in the vicinity of epiphyses, with 
perhaps complete detachment of that membrane. Small, localized subperiosteal col- 
lections of pus may also appear at points quite distant from the internal foci. In 
the adjoining muscles there may be characteristic alterations, for the most part 
showing themselves as white points or white lines extending through the muscle- 
tissue. These are, for the most part, minute collections of pus or linear abscesses. 
These are seen more often in the tibialis anticus and in the biceps cruris than in 
the other muscles. Such spots may even be found in the heart-muscle in fatal 
cases. Disseminated foci are also found in various viscera. From almost all 
sinuses which have formed spontaneously the issuing discharge has a most offen- 
sive and fetid odor. Occasionally during the course of these cases peculiar erup- 652 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
tions are seen upon the skin, simulating scarlet fever or other exanthemata. These 
are due to the peculiar poisons generated by the pyogenic microbes, some of which 
are known to have a peculiar vasomotor excitant action. Fat-embolism is another 
of the complications of the fulminating forms of these bone infections. Albumin- 
uria is not infrequent. 
Of the different forms above mentioned, describing the disease in detail, it is 
not always possible to distinguish before cultures are made or before autopsy. As 
a rule, those which are due to the pneumococcus are distinguished rather by pre- 
dominance of joint complications, with minor tendency to subperiosteal abscess or 
the sequestrum-formation, while clinically their course is more rapid, their symp- 
toms more acute, and, when recovery follows, their duration relatively shorter. 
The pneumococcus form is not necessarily connected with manifestations in the 
lungs of pneumonia. When the disease is due to the bacillus pyocyaneus there is 
more liability to eruption on the skin and the odor from discharges is peculiarly 
fetid. In the most fulminant cases the staphylococcus seems to figure steadily, 
whereas in the post-febrile cases—e. g. those following typhoid or scarlatina—we 
are more likely to meet with streptococci alone or in relative abundance. 
Prognosis.—The prognosis depends in large measure upon the early 
recognition of the disease and the prompt affordance of surgical relief. 
There is perhaps no disease less amenable to purely medicinal treatment, 
and, if bones are to be saved in their entirety, early and free incision is 
called for. Consequently, when the case is seen late it almost invari- 
ably entails necrosis with more or less disturbance of function, or pos- 
sibly such a serious condition as to call for amputation. The fulminant 
cases when not early recognized and promptly operated often prove fatal, 
and death has been known to follow within thirty-six hours after the 
onset of the first symptom, the fatal result being due to overwhelming 
septic infection with thrombosis, etc. Almost every case, however, if 
seen early enough, can be saved. 
Fig. 264. 
Atrophy of ulna and hypertrophy of radius, result of acute inflammation (Ollier). 
Complications.—The complications are to be divided into the con- 
stitutional and the local. The former refer rather to the spread of 
septic infection and its more or less disastrous and remote ravages. 
Metastatic infections may produce serious or fatal complications, while, 
when less acute, important functions may suffer a serious impairment. 
Among the local sequelse are to be considered mainly the results of 
destruction of bone-tissue and neighboring joint structures. When the SURGICAL DISEASES OF THE OSSEOUS SYSTEM. 
653 
disease occurs in young and rapidly-growing children partial or complete 
arrest of development in the bone involved is not infrequent. This may 
lead to inequalities in length of the femora or humeri. It may lead also 
to compensatory hypertrophy of bone, with perhaps considerable distor- 
tion during subsequent growth (Fig. 264). 
More or less persistent joint lesions frequently result, sometimes in the direc- 
tion of a?ikylosis, partial or complete; sometimes as muscular contractures, which 
lead in course of time to subluxations ; sometimes to persistent enlargements ; some- 
times to torsion and flexion of the bones themselves, largely due to muscle-pull. 
In another place1 I have divided these deformities into those which pertain to 
juxta-articular lesions and those pertaining to the shafts of the long bones, to 
which those interested are referred for more particular description. Dislocations 
may be permitted by distention of the joint as the result of outpour of inflamma- 
tory products, or by early consolidation between epiphysis and shaft, with conse- 
quent cessation of growth along this line. A third form of dislocation is due to 
overgrowth of ligaments, permitted by constant hyperaemia of the parts and 
increase of nutriment, the ligaments, thus overgrown, stretching and giving rise to 
flail-like conditions. Spontaneous epiphyseal separation is of course equivalent to 
fracture. 
An entirely distinct, much less serious, consequence of osteomyelitis 
is the condition usually known as bone-abscess, in which the acuteness 
of symptoms has long since subsided, but in which a distinct local focus 
remains. This will be considered by itself. 
Etiology.—That the disease is an infection from the very beginning 
is settled beyond a doubt. The source of the infection, however, is not 
always easy to trace. Two distinct causes seem to conspire to produce 
the majority of these bone infections—micro-organisms of more than 
ordinary virulence, and a predisposing condition of the system, due 
sometimes to constitutional weakness or inherited taint or at other times 
to the results of exposure and fatigue. The causes of suppuration in 
general have been much more elaborately discussed in Chapter III., and 
it is hardly necessary to reiterate them here. It is a fact, however, that 
the majority of cases occur in children and after a combination of 
exposure and fatigue—as, for instance, sitting upon the ice after being 
exhausted in skating—all of which, however, would be inoperative to 
produce an infection were not the germs at hand ready to assail every 
tissue whose resistance is thus temporarily lowered. 
The actual infection may occur from within or from ivithout—from within per- 
haps through the alimentary canal or the respiratory tract, most probably in most 
instances from the tonsils and the pharynx. Infection from without may occur 
through a little abrasion or scratch, the blister upon the foot made by an ill-fitting 
shoe or by a skate-strap, or something of the kind. These cases occur almost 
always in the young, more often in boys than girls, probably because in the former 
more opportunities for infection are permitted. Bone infections, however, are 
possible even in the new-horn, in which case the infection may occur through the 
pharynx or through the umbilicus, while the local resistance may have been 
lowered by the injury due to mechanical delivery, turning, etc. In elderly people 
the disease is almost unknown. 
Diagnosis.—The disease for which this is most commonly mistaken 
is acute rheumatism. There may have been some excuse for this in 
time past, because of the lack of general knowledge of bone infections; 
now there is none. The majority of cases of necrosis following osteo- 
myelitis which have come under my observation were the result of 
1 Med. Record, Nov. 2, 1895. 654 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
errors in diagnosis at the time when surgical relief might have prevented 
any local disaster. 
Rheumatism is never followed by suppuration, nor does it produce, except in the 
rarest instances, a septic type of disease; its painful lesions are rarely so painful 
as those due to osteomyelitis, and the clinical picture is almost always easily dis- 
tinguished. Lesions of rheumatism are usually multiple; those of bone infection, 
for the most part, single. The first complaint of pain in the latter is more likely 
to be along the shaft of a bone than at the joint end, while this is not true of 
rheumatism. Moreover, in acute osteomyelitis the disease assumes from the very 
outset a seriousness and gravity which is seldom if ever approximated by acute 
inflammatory rheumatism. 
Treatment.—As stated, the treatment for acute osteomyelitis is 
essentially surgical. Anodynes may be necessary for relief of pain, but 
no time should be lost, when once the diagnosis is made, in making 
incisions sufficiently long and deep to expose the bone involved, and 
then, by means of suitable instruments, opening to its interior in order 
to relieve tension and to remove septic products. The incision required 
may possibly be ten or twelve inches in length, as over the femur or 
tibia. In almost every instance the tissues as we go deeper will be 
found more and more oedematous or infiltrated, with every evidence of 
the proximity of pus; the periosteum will be thickened and infected, 
and between it and the bone we may find collections of pus, as well as 
outside of it. If seen late, the characteristic muscle appearances already 
described may be noted. The periosteum should be incised completely 
down to the bone throughout the length of the incision, and then an 
ordinary bone-drill may be used to perforate the bone for exploratory 
purposes, just as the aspirating needle is used in the soft tissues. From 
every puncture in the bone thus involved will exude purulent fluid, 
often sanious, thus indicating the condition within. It is now necessary, 
with the bone-chisel or other suitable instruments—made for the special 
purpose—if at hand, to cut a deep groove or channel, perhaps from one 
bone end to the other, completely opening into the marrow-cavity, in 
which numerous foci will be discovered or in which all distinctive struc- 
ture of bone marrow may be lost, the cavity being filled with pus. The 
entire pus-containing cavity, being thus freely opened, should be scraped 
and disinfected with hydrogen peroxide and cauterized with zinc chloride 
or its equivalent, and packed, the wound being left open. Even this 
may not always be enough, but if there be epiphyseal separation, or, 
more unfortunate yet, if there appear evidences of joint infection, the 
neighboring joints must be explored, first under aseptic precautions, 
while if pus be found within, they must then be freely opened, washed 
out, and drained. Meanwhile, if in the soft tissues exposed by the 
incision the parosteal veins be found filled with septic thrombi, they 
should be opened so far as exposed and their contents removed. 
These operations are often severe, perhaps prolonged, but nothing in 
the way of operative treatment can be so severe nor so serious as the 
disease itself when left unoperated; and the rule then is stringent and 
far-reaching that every infected tissue, and especially every infected 
bone interior, must be thus exposed without mercy and thoroughly 
cleaned out. Only in this way can lives be saved which would other- 
wise be certainly lost. Moreover, it is necessary to carry out this treat- 
ment in the fulminant cases as early as possible; and, consequently, SURGICAL DISEASES OF THE OSSEOUS SYSTEM. 
655 
errors in diagnosis by which it may be postponed until metastatic infec- 
tion or grave pulmonary and cardiac complications have set in are most 
unfortunate. So long, then, as the local indications are as above 
described surgical treatment is loudly called for, whether the systemic 
complications be pronounced or not. The immediate effect of the ope- 
ration having passed away, the relief thus afforded will often prove 
amazing—to such an extent that within twenty-four hours patients may 
be comfortable and evidently out of danger who were at the time of 
operation in the gravest danger of a speedy fatal termination. 
The later results of this operation are a wound which will discharge at first 
freely, and which, so soon as septic material is out of the way, will begin to 
granulate. Ordinarily, no attempt should be made to close such a wound, though 
much may be done to favor rapidity of granulation. While some antiseptic dress- 
ing is always employed, it will be of advantage occasionally to change the charac- 
ter of the same, and to alternate between perhaps iodoform with boric acid and 
acetanilid, the effect of any one drug being apparently lost after it has been used 
for some time. 
There are some cases where an entire diaphysis or bone-shaft will 
be found separated from one or both epiphyseal terminations, lying in a 
subperiosteal abscess-cavity, bathed in pus, and dead beyond possibility 
of repair. This is total necrosis of the shaft from an acute infectious 
process, and is to be treated by complete removal of all dead and dying 
tissue. In the case of the forearm or leg it may be that the remain- 
ing bone, when only one is involved, as is usual, will be sufficient to 
maintain the integrity of the limb until new bone can be reproduced 
within the periosteal bed occupied by the old one. More or less com- 
plete regeneration of hone is possible, particularly in the young, and in 
connection with compensatory hypertrophy of the parallel bone will 
permit the restoration of the leg to partial or complete usefulness. . On 
the other hand, should this prove later a complete failure, amputation 
and substitution of an artificial limb may be called for. 
When the disease has involved the articular side of an epiphyseal line, and 
when we have complete epiphyseal separation with consequent pyarthrosis, the 
probable consequence will be necessity for a complete or partial resection of the 
joint and the probability of subsequent ankylosis. Patients may find later that a 
modern artificial limb with its possibilities will be much preferable to such a con- 
dition, and may readily consent later to an amputation which they would at first 
refuse. 
Acute Infectious Periostitis.—This is an infection of the same 
general character and type as the osteomyelitis just described, but refers 
to those cases where the disease apparently is confined to the periosteum 
and the outermost layer of the bone. In its possibilities for harm it is 
scarcely less serious, although in its tendency to spontaneous perforation 
and escape of pus it is less likely to prove fatal. 
The causes and the general clinical manifestations are practically 
identical. The disease is perhaps a little less grave in its acute mani- 
festations, the localization of pain more exact, with ordinarily less tend- 
ency to serious joint complications. Local tenderness is exquisite, and 
particularly in those bones which lie near the surface—e. g. the tibia— 
and early recognition of fluctuating areas is easy. It may be localized 
over a small area or the entire periosteum of the shaft may be involved ; 
in which case, so soon as pus forms and the periosteum is separated from 
the bone, there is probability of acute necrosis of the shaft. Here, 656 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
again, there may be a tendency to mistake at least the first signs of the 
disease for acute rheumatism, from which it must necessarily be early 
differentiated as above. 
Treatment.—Here also there is the same necessity for immediate 
intervention, if possible before pus has formed, in order that there may 
be little or no periosteal separation and encouragement to necrosis. 
Anaesthesia is necessary, with prompt incision, the use of the sharp 
spoon, and disinfecting agents: no attempt should be made to close the 
wound, but drainage should be favored in every way. The intensity of 
the pain is promptly relieved and the whole clinical picture immediately 
changed by such a procedure. 
The ordinary bone-felon upon a terminal phalanx is practically an 
expression of this type of disease, and universal experience corroborates 
the wisdom of deep and early incision, even in the case of so small a 
bone-entity as a phalanx. 
Acute Epiphysitis.—This is a term applied rather indiscriminately 
to a form of acute osteomyelitis involving primarily and especially the 
the epiphyseal lines, or to a condition of hypersemia and neuro-vascular 
excitement at epiphyseal junctions, stopping short of suppuration, but 
giving rise to intense pain, muscle contraction, joint tenderness, etc. It 
is most often seen at the upper end of the tibia. Sympathetic disturb- 
ance may extend even to serous effusion into a joint, although this is 
not necessarily the case. The limbs are early drawn up, and every 
attempt to extend them simply aggravates the distress. So long as 
there be no evidences of suppuration, it is sufficient in these cases to 
apply a sufficient degree of traction to overcome muscular contracture 
and to completely straighten the limbs. This must probably be applied 
first under anaesthesia, and the patient be kept under anodynes for a 
few hours thereafter. So soon, however, as the muscles are tired out by 
the steady traction, pain subsides, and the intensity of the condition may 
be thus relieved within forty-eight hours or less. It would be well to 
continue physiological rest and traction so long as there remains the 
slightest tenderness. Should evidences of suppuration supervene at any 
time, incision and evacuation of pus and exudate must be practised. 
Periostitis Albuminosa.—This is a quite rare manifestation of bone 
disease, only given an identity of its own since 1868, when Ollier first 
distinguished it, and since which time it has been the subject of consid- 
erable controversy. The name refers to a condition less acute than the 
infectious periostitis just described, localized for the most part in a 
single bone, calling almost always for incision and evacuation of a fluid 
which is gelatinous or mucoid in appearance rather than purulent. It is 
because of the peculiarity of the subperiosteal collection of fluid that it 
has in time past received the name periostitis albuminosa, and it was not 
generally regarded until recently as a variety of the infectious form of 
periostitis. It is, however, now generally conceded as being a mitigated 
form of infection in which the products of exudation assume the serous 
rather than the purulent type. In certain instances it appears to be the 
tubercle bacilli which are at fault. At all events, the organisms which 
produce the disease are more or less virulent, else the clinical form of 
the disease would be less serious than it really is. Cultures made 
from these subperiosteal collections have in almost all recent instances 657 
SURGICAL DISEASES OF THE OSSEOUS SYSTEM. 
revealed the presence of some one of the numerous pyogenic organisms. 
Within the past year Dor has described a polymorphic microbe in 
instances of this kind which he has called the bacillus cereus citreus, with 
which he claims to have been able to reproduce the disease in animals. 
Chronic and Latent Osteomyelitis.—So far, I have described only 
the most acute manifestations of bone infection. As in the lungs, how- 
ever, very chronic lesions are met with, and as 
in the lungs, again, it is possible for collections 
of micro-organisms to become more or less 
encapsulated and for a long time to lie latent 
until some provoking cause excites them again 
into activity. In this way are to be explained 
the numerous instances of recurring abscesses 
within the bone necessitating repeated opera- 
tions, often at long intervals (Plate XVIII.). 
Fig. 265. 
The explanation is first an acute infection, which 
has been incompletely, if at all, attacked, and in 
which depots of pyogenic bacteria have been walled 
in by granulation-tissue which may later have ossified. 
Here there lurk quiet or latent possibilities for harm 
for months or years, a period of at least twenty years 
having been positively established in numerous in- 
stances. The occasion which may call out their de- 
structive capabilities may be either local injury, as 
fracture, bruising, or a local ischaemia from any cause, 
or, on the other hand, a lowering of vitality, such as 
may be produced by the puerperal condition, by the 
acute exanthemata, or by any of the acute infectious 
or wasting diseases. Starvation, over-exertion, or 
exposure may have the same effect. The consequence 
is a recrudescence of local symptoms and the return 
of all the previous evidences of deep suppuration, 
though probably in mitigated degree. This is one of 
the common causes of bone-abscess, and calls, prac- 
tically invariably, for operation in the shape of ex- 
posure of the area involved, removal of the overly- 
ing bone, and complete cleaning out of the deeper 
focus or foci. In many instances this repetition of 
disease occurs several times, and patients are often 
subjected to numerous operations because of failure 
to make the first or an early one complete. In cases 
of this kind nothing, however, can be done save to 
operate whenever local pain, tenderness, and swell- 
ing, with perhaps constitutional symptoms, make it 
necessary, and then with all possible thoroughness. 
Possible Consequences of Any or All 
of the Bone Infections.—Keeping ever in 
mind the fact that bone is a living tissue, calcified and stiffened by 
inorganic material simply for the purpose of giving it strength, we must 
not forget that as such it may suffer remotely from the consequences of 
local infections, as may any other tissue. Thus, it may have its nutri- 
tion impaired so as to produce atrophy on the one hand, or increased 
so as to lead on the other to hypertrophy, either regular or irregular in 
outline. Again, in its texture it may be altered to a very wide extent 
between the degree of extreme sponginess or porosity on one side (osteo- 
porosis), or to the greatest degree of density ever attained by ivory 
Compensatory hypertrophy of 
fibula, following fracture.  AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
658 
(osteosclerosis) on the other. Similar changes are also noted in cases of 
bone tuberculosis, which is to be considered by itself. The densest bone 
has sufficient vitality to permit its nutrition and life, and may assume 
dimensions much larger than that of the 
original, and a hardness which will defy the 
best steel instruments should it become 
necessary to operate upon it. The other 
extreme of osteoporosis includes a condition 
where the bone has barely sufficient inor- 
ganic material to permit it to retain its 
shape and ordinary proportions. Such bone 
is fragile in the extreme, and scarcely ser- 
viceable as a supporting tissue. The prin- 
cipal portion of its bulk is constituted by 
marrow-tissue, which make it extremely 
vascular, but far from strong. When spongy 
to this degree, it is ordinarily unserviceable 
for its proper function. Astonishing pic- 
tures of osteosclerosis and osteoporosis side 
by side are present in many instances of 
disease, the latter being often evidence of 
more or less ossification of new-formed 
granulation-tissue. This is often a happy 
combination, because the bone, which for 
the most part has been sadly weakened by 
disappearance of its calcareous material by 
liquefaction and by absorption, is reinforced 
along some of its lines by a pillar of osteo- 
sclerotic tissue, by means of which it still 
functionates as a more or less useful sup- 
port. ( Vide Fig. 266.) 
The operating surgeon has to familiarize him- 
self with the density of normal bone in various 
locations, since in many operations upon the 
deeper bones he detects healthy bone rather by 
the sense of touch and of hearing, and the resist- 
ance which it offers to his instruments, than by sense of sight. 
Fig. 266, 
Osteogenesis and osteosclerosis in 
slow infective processes (original). 
Tuberculosis of Bone. 
In Chapter IX., on Tuberculosis in general, the writer went into 
considerable detail with regard to the nature of tubercular lesions, which 
were stated to be essentially the same whether occurring in hard or soft 
tissue, the active agent being the now well-known bacillus tuberculosis, 
which, finding lodgement, for instance, in the osseous tissue, acts as a 
specific irritant, and so provokes the production, first, of a typical 
tubercle, and, later, of typical granulation-tissue, by whose ravages the 
distinctive signs of bone tuberculosis are produced. This process, then, 
is in no respect different in bones from similar lesions in other parts, 
though modified to a slight extent pathologically, to a greater extent 
clinically, by the dense environment. Nevertheless, trifling or most 
extensive destruction of bone substance is produced by this tissue, while SURGICAL DISEASES OF THE OSSEOUS SYSTEM. 
659 
by continuity or by metastasis there is more or less involvement of the 
adjoining textures, either parosteal or articular. It is by granulation- 
tissue that so-called caries is produced, and it is by the same tissue that 
distinct portions of bone are sometimes completely segregated from their 
vascular surroundings and shut off from nutrition, so that they die and 
form what are known as sequestra. Necrosis may, then, be the result 
of tubercular disease. 
So long as the process be active, this granulation-tissue tends ever to 
enlarge its boundaries, and, like pus, to spread in the direction of least 
resistance. When produced in the shaft of a long bone this may lead 
to involvement of the entire shaft, or there may be liquefaction and 
absorption of dense bone and the formation of a sinus from the marrow- 
cavity to the periosteum, beneath which the granulation-tissue will 
spread, and through which it will sooner or later perforate, to resume 
its progress toward the surface, always in the direction of least resistance. 
In this progress tendon-slieaths or bursce may be involved, or dense 
aponeuroses may turn the granulation column aside, causing it to per- 
forate toward the surface at some remote point; while, in the end, it may 
spread out more or less beneath the skin before finally causing its de- 
struction. Sooner or later, if uninterrupted by treatment, this escape 
will occur, and then we have the condition of a tubercular ulcer of the 
skin, from which leads down, by a devious path, a sinus toward the 
original focus. 
When this original focus has been juxta-epiphyseal, we see speedy 
involvement of the epiphyseal cartilage and a pathological diastasis 
which may early lead to spontaneous or pathological luxation. Or, 
again, a focus, having once originated at an epiphyseal extremity, tends 
usually to perforate quickly into a joint-cavity, after which a consider- 
able length of time is usually expended in filling up this joint-cavity 
with exuberant granulation-tissue. This is the material so often found 
in tubercular joints, and is well characterized by the name given to it 
by the Germans, fungous tissue, they calling such joint affections fungous 
joint inflammations. 
Seen thus in joints, after it has been long exposed to friction and to more or 
less pressure, it may have lost some of its original luxuriant features. It is best 
seen when it is freshest and has been exposed to least disturbance. Under these 
circumstances it is vascular, dark red in appearance, friable, and easily removed 
from the tissue upon which it has grown. Ordinarily it is infectious, and by its 
inoculation into animals is capable of reproducing the disease. 
The pathology of tuberculosis of bone may, then, be virtually 
summed up in saying that it consists of the ravages produced by the 
presence of this granulation-tissue, with the irritative hyperplasia of 
surrounding tissues which its presence always excites, even though they 
be not actively infected. This is, then, the explanation for the majority 
of cases of caries, of tumor albus, of Pott’s disease, of spina ventosa, and 
of the condition which at various times has been known under many 
other names. 
So long as this tissue be protected from access of air or from external infection, 
it usually does not suppurate, but when once infected, usually from outside sources, 
it breaks down very rapidly, and then we have the condition already described in 
Chapter IX. as cold abscess or its equivalent. Under certain circumstances it also 
caseates, and we frequently find it in old tubercular lesions, having undergone more or 660 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
less of this remarkable charge. It may involve and perforate small or large veins, 
in which case metastatic tubercular disease is easily produced. There is no bone in 
the body exempt from its ravages, and even the firm tissue of the petrous bone 
will break down in its presence. The psoas abscess of Pott’s disease is to be 
explained as first a tubercular caries of the vertebrae, with subsequent infection, 
probably now from internal, at least from indirect, causes, and then profuse sup- 
puration, the pus taking its course in accordance with the universal law, travelling 
in the direction of least resistance. When high in the vertebral column, it may 
appear in the pharynx, causing retropharyngeal abscess; from the dorsal spine it 
may produce psoas abscess; while from the lumbar spine it travels nearly always 
posteriorly, to appear as a lumbar abscess. Tuberculosis of the flat bones—e. g. 
cranium, sternum, and pelvis—is not at all uncommon, and extensive destruc- 
tion with either internal or external perforation may occur (Plate XIX.). 
While the disease may possibly be primary in the periosteum, it occurs almost 
first in the bone-tissue proper. In the young it always manifests a preference 
for joint ends of the long bones; in the middle-aged or adult it affects, for the most 
part, the diaphyses of the long bones or else the short, like those of the carpus 
and tarsus, but by continuity of tissue it may spread from one to another until 
finally several bones are involved in the diseased area. This is the affection for- 
merly known as scrofulous disease of bones—a term which ought to be expunged 
absolutely from surgical literature. This, too, is the real explanation for most of 
the cases of hip-joint disease, white swelling of the knee, Pott’s disease of the 
spine, etc., those which are not to be explained in this way being due to primary 
tuberculosis of the synovial membrane rather than of the bone. Occurring in or 
about the joint, however, it is not possible for any of the joint structures to escape, 
provided it remain long active. 
Varieties.—Acute Miliary Tuberculosis of Bone.—This corresponds 
to a similar invasion, for instance, of the lungs. It might be fittingly 
described as an acute tubercular form of osteomyelitis. It may run its 
destructive course within a short time, and cause such involvement of 
structures as to necessitate amputation of a limb, or it may appear in 
the truncal skeleton as a primary disease, spreading rapidly therefrom 
and involving the viscera or the cerebro-spinal membranes, and causing 
an early death, perhaps within a few weeks after its onset. This con- 
dition has been in time past more prevalent than generally understood, 
and has not even yet received the attention it deserves. It is perhaps 
less painful than the pyogenic forms of osteomyelitis, and may assume 
less of the septic, and more of the typhoid or meningeal, type of dis- 
ease. The pain also may be less severe, though reflex symptoms, espe- 
cially muscle-spasm, will be an early and marked feature of these cases. 
Involving a limb, the case may not be hopeless, but when involving the 
cranium, spine, or trunk it is fatal, and little, if anything, can be accom- 
plished by treatment. The operative treatment for parts which are inac- 
cessible is virtually that already given under Acute Osteomyelitis, to 
which the reader is referred. 
Chronic Tubercular Osteomyelitis.—This is the ordinary form of 
the disease, and is exceedingly common. In certain parts of the world 
it constitutes nearly one-third of the diseases calling for surgical treat- 
ment in clinics and hospitals. This is particularly so in the most thickly- 
settled portions of the European continent. In Buffalo it constitutes 
from 15 to 20 per cent, of cases found in niv wards and in my clinic. 
In fact, the proportion during certain years has been larger. 
The pathological picture of the phthisical process in the lung is not a bad 
illustration of the same disease in bone. We find here the same irregular distri- 
bution of caseous or suppurating foci or of fresher granulation-tissue, interspersed 
with cancellous tissue which has so far escaped its ravages; and we find the same PLATE XIX. 
Tubercular Disease of Hip Joint and Pelvis, involving the muscles (rare) ; o, Rarefying Ostitis, 
i.e., Osteoporosis; f, Fungous Granulation Tissue. (Rannelongue.) 661 
SURGICAL DISEASES OF THE OSSEOUS SYSTEAL 
tendency to fibroid or sclerotic changes, a bone so involved presenting, in the neigh- 
borhood of the tubercular focus, a composite picture of osteosclerosis and osteo- 
porosis in close relation, the margin of a bone-sinus perhaps being almost ebur- 
nated, while within a very short distance of it the bone-tissue will be so disintegrated 
as to yield to the finger-nail. Along with this we find thickening of the periosteum, 
sometimes to a relatively enormous extent, and serous or purulent outpour in joints 
corresponding closely to the pleuritic and em- 
pyemic complications of phthisis. As the result 
of the obstruction to the deep circulation there 
is enlargement of the more superficial veins, cor- 
responding to that often seen about the chest 
of consumptives, while oedema of parts below 
the diseased area is not infrequently noted. 
The overlying skin has usually a characteristic 
anaemic and waxy appearance, displaying to 
greater advantage the dilated veins beneath. 
Owing to the infiltration of parts in the neigh- 
borhood, especially when joint ends are in- 
volved, there is a constantly increasing degree 
of fixation, while, should granulation-tissue be 
approaching the skin, the fact can be recog- 
nized by the livid and distended appearance 
of the parts at the point where it is threaten- 
ing to perforate. Sometimes it may even be 
seen as a purplish mass just beneath the skin. 
Evident fluctuation in joint-cavities will always 
indicate the presence of pyoid material (see p. 
165), while it seldom happens that the fluid 
contained within distended joints is pure serum 
nor anything thinner than sero-pus. Erosion 
of cartilages or complete destruction and oblit- 
eration of all joint-structures is seen in ad- 
vanced and destructive cases; or, when pyo- 
genic infection lias been avoided, the reverse 
obtains, and there is such sclerosis of all the 
adjoining structures as to completely immo- 
bilize joints in a condition often spoken of as 
fibrous ankylosis. 
Fig. 267. 
Symptoms.—The essential symptoms 
of hone tuberculosis are muscle-atrophy, 
muscle-spasm, and pain, direct or referred, 
and upon the existence of these, coupled 
perhaps with local tenderness and local 
swelling, a diagnosis can almost always he 
made. Muscle-atrophy is distinct, and is 
not alone that of disuse, but is even a distinctive evidence of the tuber- 
cular process. It involves the parts above and below the lesion. 
Muscle-spasm is never lacking, but is most noticeable about the spine 
and the joints of the extremities. In Pott’s disease, for instance, the 
condition causes a stiffening of the back and an inflexibility of the spine 
which are always recognized as distinctive. About the joints it leads 
gradually to fixation, usually in the condition of more or less flexion, the 
flexor muscles being ordinarily stronger than the extensors in all parts 
of the body. Thus we see the knee and the elbow drawn up, and most 
other joints in a condition of flexion so far as it may be permitted. 
It is characteristic also that muscle-spasm is frequently exaggerated, 
usually in a reflex way, by which pain is always augmented. These 
sudden but brief contractures occur more often during sleep than during 
Tuberculous disease of hip (original). 662 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
the waking hours/and give rise to the so-called starting pains, usually 
nocturnal, which are noted in nearly every case of this kind. 
The pain is in large measure the result of contracted muscles pulling 
tender joint surfaces together, and is consequently augmented during the 
muscle-spasms just described to an extent causing the patient to cry out 
even during sleep. There is also usually a more or less deep-seated and 
constant pain or soreness, manifested in increasing degree as the lesion 
advances. These pains are also often referred, it being quite generally 
the case that lesions in the upper ends of long bones give rise to pain 
which patients refer to the lower ends. Thus, in hip-joint disease pain 
is often referred to the knee; in Pott’s disease, often to the anterior part 
of the trunk. Of all cases it may be said, in a general way, that slight 
but slowly increasing disturbance 
of function of a joint inaugurated 
by trifling muscle-spasm, with 
complaint of aching or pain, is 
most significant, and should call 
for careful examination, it being 
a mistake to anaesthetize patients 
for this purpose, since by the anaes- 
thetic the pathognomonic muscle- 
spasm is abolished and mistakes in 
diagnosis favored. 
Treatment.—The treatment 
of tuberculosis of bone is both con- 
stitutional and local. The former 
consists in the best possible hygiene 
and in those measures which are 
everywhere recognized as helpful 
in similar conditions. I believe 
in the internal use of benzosol, or 
its equivalents, in doses large 
enough to quickly impress the 
tissues with its influence. I be- 
lieve also that the treatment by 
tuberculin, or its equivalent prep- 
arations, is helpful, although by 
no means self-sufficient. In addi- 
tion to these, the very best tonics 
and evacuants should be judici- 
ously used. But it is mainly with 
local treatment that we shall here have to deal. 
The local treatment may be divided into the non-operative and the 
operative. The former consists in enforcing the general principles 
of physiological rest, which is done partly by orthopcedie apparatus 
proper and partly by the general principles of traction, and is resorted 
to mainly in a class of cases treated of in Yol. II. under Orthopaedic 
Surgery, the best methods for the purpose, apparatus, etc., being found 
under that heading. 
In a general way, by traction proper is meant sufficient pull upon a limb to 
overcome and to undo the most serious effects of muscle-contraction. The pain 
Fig. 268. 
Healed tuberculosis of spine (original). 663 
SURGICAL DISEASES OF THE OSSEOUS SYSTEM. 
complained of in and about tubercular joints is, for the most part, due to joint 
tenderness and the extra pressure made upon joint surfaces by muscles in a con- 
dition of chronic spasm. By traction we have no expectation of completely sepa- 
rating these surfaces, but do in most cases, especially when thus treated, easily 
overcome chronic and excessive muscle-pull, and so relieve pain. 
Aside from this, a hopeful method has been that recently suggested 
by Bier, consisting of making an artificial chronic congestion, it having 
been long known that tubercles do not thrive when bathed in too much 
blood. The congestion is secured by wearing an elastic bandage above 
the point involved, elastic constriction being made to a degree as 
great as may be comfortably borne. The result is venous congestion, 
possibly oedema of the parts below, which to be made effective should 
be carried nearly to the tolerable extreme. Constriction, when applied 
for this purpose, may be at first enforced for only a short time, but can 
be later borne for longer and longer periods, until a time is reached when 
the patient can wear a comfortably snug bandage nearly all of the time. 
Marked improvement follows this method in many cases. 
The operative treatment consists in ignipuncture, curettage, or formal 
extirpation. Ignipuncture is the insertion into the bone-focus, no matter 
how deep, of the glowing point of the thermo-cautery. It is best prac- 
tised under an anaesthetic, and when the bone is superficial no hesitation 
need be felt in plunging the cautery directly through the skin, making 
it burn its way into the depth of the bone. This is easy when the can- 
cellous tissue is that at fault. If the bone be deep, an incision may be 
made down to it, after which the cautery is applied as above. The 
result in almost every instance is relief from pain, frequently surprising 
in its rapidity and effectiveness. 
This effect seems to be brought about partly by relief of tension, partly by 
destruction of diseased tissue; again, in large measure, by the acute congestion 
which is the result of the most vigorous counter-irritation. It need occasion no 
fear nor difficulty, and is applicable to all accessible bones. It must not be 
expected to cure every case, but is a measure which may be confidently expected 
to relieve pain and to do good. 
The more radical form of treatment is always called for when one 
can determine in any way that the carious process is advancing or that 
pus or caseated deposits are present. This is made known in various 
ways already indicated; but when one is reasonably sure of their pres- 
ence it is best to begin the operation as an exploration, going so far as 
the findings may justify. This may include merely scraping out of a 
small focus, or it may entail removal of a large portion of a bone or 
resection of a joint, or even amputation, according to the severity of 
the deep lesion. It is best to do whatever may be necessary, and to do 
it all at once. The operator should not rest content with mere opera- 
tive attack, but should carefully disinfect the entire tract, cutting away 
or removing with the spoon all the sinus-wall and all fungous tissue, 
which he should follow wherever it may lead, disinfecting freely with 
hydrogen peroxide or caustic pyrozone, and then using some active 
caustic, like zinc chloride or the actual cautery, unless he have already 
used caustic pyrozone. In this way material may be destroyed which 
has escaped the instruments used ; and in this way, also, absorbents are 
seared or closed and protection afforded. My personal preference is for 
a packing made of iodoform gauze, soaked in a mixture of balsam of 664 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
Peru containing 10 per cent, of guaiacol, which I find more advan- 
tageous than anything I have used. One should always add to these 
measures, however, whatever may be necessary in the way of after- 
treatment, both local and constitutional, and should be prepared to ope- 
rate again should latent foci subsequently manifest themselves or should 
there be recrudescence of the active disease. 
Bone-abscess. 
Bone-abscess is a term applied to deep and circumscribed, collections 
of pus within the bone, for the most part within the shafts of long bones. 
They are due either to the acute ravages of pyogenic cocci or to the 
slower lesions produced by the tubercle bacillus. They are frequently 
evidences of return of disease of the acute type after a more or less 
long period of latency. The manifestations are usually quite local- 
ized, in this respect differing materially from those of acute osteomye- 
litis. The pain is deep-seated and boring, while there is local tender- 
ness, often with considerable enlargement of the overlying bone. The 
lesion occurs more often in the tibia than in all of the other bones put 
together—at least under those clinical conditions which entitle it to be 
called bone-abscess. The pain is frequently nocturnal or osteoscopic, 
and patients may endure it for weeks or even months before coming for 
operation or relief. 
One may always expect to find a layer of condensed, sometimes 
extremely hard, bone around these local foci, and it is due to this that 
they do not either perforate or diffuse and cause extensive trouble. 
Treatment.—Treatment is always operative; should consist in 
anaesthesia, exposure of the bone, effective exploration by means of the 
bone-drill, as one would use the hypodermic needle for exploration in 
the soft parts, and then the free use of the bone-chisel or other instru- 
ments by which the area may be widely exposed. The density and firm- 
ness of the bone under these conditions will sometimes almost defy the 
best-tempered instruments. Care should be taken to make the external 
opening as large, or nearly so, as the deep focus, in order that the surface 
may not heal too readily and before the deeper part is filled up. The 
same directions with regard to cauterization and packing the cavity 
obtain as given before. 
Syphilis op Bone. 
Syphilis of bone may assume the type of gummatous involvement 
of the periosteum or of the bone itself or of syphilitic caries and necrosis. 
The former appears usually as a distinct tumor, ordinarily tender and 
exceedingly painful, especially at night, it being characteristic of almost 
all cases of bone-syphilis that the pain, however great during the day, 
is exaggerated at night. The true syphilitic gumma, or syphiloma, of 
bone is but little, if at all, different from gumma in other tissues, which 
may become secondarily infected and then suppurate with the formation 
of sinuses, etc. Suppuration, however, is rare. Central gumma, like 
central osteosarcoma, is possible, and will probably lead to expansion of 
the surrounding bone. Syphilitic necrosis, so far as the bone lesion is 
concerned, scarcely differs from the other varieties already described or SURGICAL DISEASES OF THE OSSEOUS SYSTEM. 
665 
to be described. It is, however, almost always of the slow form, and 
involves more often the fiat than the long bones. It is especially seen 
in the cranium and the sternum. Syphilis of bone is often mistaken for 
rheumatism or pseudo-rheumatism, because of the deep-seated, somewhat 
indolent, pain. Syphilitic disease of bone permits occasional spontane- 
ous fracture, the bone affected with 
this disease being always more friable 
than natural. There is also another 
form of bone-syphilis—namely, the 
Fig. 270. 
Fig. 269. 
Syphilitic gummata of head and face (after 
Jullien). 
Syphilitic ostitis and osteosclerosis 
(original). 
hereditary—which deserves a moment’s consideration. It leads, usually 
early, either to bone enlargement or to caries and necrosis, the latter most 
usually upon the cranium, where extensive ulceration and sequestrum- 
formation may be observed, even the dura being exposed by breaking 
down of fungous tissue. 
Hereditary bone-syphilis is also characterized by osteophytic formation, by tlie 
substitution of gelatinous for spongy bone-tissue in the neighborhood of epiphyses, 
and by early and easy epiphyseal separations. It is characterized also by irregu- 
larity of ossification of cartilage and consequent deformity of bone ends, especially 
about the phalanges and the metacarpal and metatarsal bones. In almost every 
case where doubt would in other respects arise, the other evidences of congenital or 
acquired syphilis are so plain as scarcely to permit uncertainty. ( Vide Fig. 270.) 
The possible combination of syphilis and tuberculosis in the same sub- 
ject must never be forgotten, the lesions partaking of one or the other 
character according as the tubercular or syphilitic taint may predom- 
inate. 
There is urgent necessity in all cases of syphilis in bone, whether 
operated on or not, for the combination of suitable internal treatment with 
surgical interference. Only by this combination can the efforts of the 
surgeon be crowned with ultimate success. In failure to appreciate this 
fact operation often seems to be almost futile. 666 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
Caries. 
Caries is a terra applied to infiltration of and substitution in healthy 
bone by granulation-tissue, and has been in use for many centuries, from 
a time long before the pathology of the condition was understood. 
Caries never occurs except in the presence of a specific irritant, which 
for the most part is tubercular, sometimes syphilitic, in character. The 
pure type of caries is connected entirely with the formation of granula- 
tion-tissue, already repeatedly described, and the slow ravages connected 
with its presence in and substitution for the original bone. So long as 
septic infection (pyogenic) be avoided, it assumes the dry type, as it used 
to be known, called by the older writers caries sicca. When the fungous 
tissue is invaded by putrefactive or pyogenic organisms suppuration of 
course occurs, and then we have the moist forms 
of caries, the caries humida of our forefathers, 
connected always with the presence of pus. When 
closed areas of bone, small or large, being thus 
shut off from nourishment, die as the result of its 
presence, the complicated condition used to be 
known as caries necrotica. Occurring under any 
circumstances, caries is a result and not a cause, 
and is to be dealt with accordingly. 
Fig. 271. 
Peculiar alterations and markings in bone are the 
consequence of carious changes, and bones are given a 
most fantastic and peculiar appearance in consequence. 
The surface is almost always irregular, tunnels or canals 
are formed, and the bone is often honeycombed, as it 
were, by the excavations just made. Along with the 
process of osteoporosis and disappearance of bone at 
one point may be seen osteosclerosis in the adjoining 
area, and the bone, which is apparently much weakened 
by the destructive process,’ is strengthened in a compen- 
satory way by the artificial density of the tissue unde- 
stroyed. 
Caries, being but an expression of tubercular 
or syphilitic, possibly of other specific disease, has 
been thus sufficiently if briefly dealt with both from 
the pathological and the surgical standpoint. Its 
clinical evidences are those of joint and bone tuber- 
culosis or syphilis, which have been already dis- 
cussed, and its operative treatment consists always 
in surgical attack with bone-chisel and sharp spoon, 
according to the rules already laid down. The bone which is completely 
carious calls for extirpation—i. e. usually amputation. In the carpus and 
tarsus resection will often suffice, as also when the disease is limited to 
joint ends. Occurring in the pelvis, ribs, sternum, or cranium, more or 
less extensive resections of fiat bones are called for, in the latter place 
leading often to exposure of the dura (of which one need have no fear) 
when necessary. The same rules with regard to cleansing and packing 
the wound are to be carried out as given before for operation on tuber- 
cular bones. 
Caries of lower end of femur. SURGICAL DISEASES OF THE OSSEOUS SYSTEM. 
667 
Necrosis. 
Necrosis corresponds to gangrene of soft parts, and the term, 
when used by itself, is by common consent limited to death of bone-tissue. 
Necrosis by itself is never a distinct disease, but simply indicates the ter- 
mination of some preceding disease process. It may be considered as— 
(a) Traumatic. 
(b) Pathological—i. e. the result of disease ; or 
(c) Toxic, due to the presence of specific poisons in the system. 
(a) Traumatic necrosis is, for the most part, due to the shutting 
off of blood-supply by accident or by separation of the whole or a part 
of a bone in the same way. Thus in consequence of multiple fractures 
fragments occasionally die and require later removal. The same result 
has been ascribed to traumatic or non-traumatic embolism of the prin- 
cipal nutrient artery of a bone, but the possibility of this pure condition 
is very doubtful, bone being too well supplied by its surrounding perios- 
teum. Necrosis in connection with fracture is rare except in compound 
fractures, and, when a detached fragment can be seen, may and should 
be anticipated by removal of the same. 
(b) The pathological form is due almost entirely to the pre-exist- 
ence either of tuberculosis, syphilis, or an acute infection, such as osteo- 
myelitis in some of its expressions. It may also be the result of acute 
infectious periostitis, where the periosteum is completely loosened from 
the shaft of a long bone. These conditions have been already described 
at some length, and it would scarcely seem necessary to do more than 
allude to them as causes. They are connected either with the slow 
ravages produced by granulation-tissue, so often alluded to, itself being 
the result of the provocation of a specific irritant, or else to the acute 
septic processes by which infected exudates shut off large areas from 
sufficient blood-supply, or by which in consequence of septic thrombosis 
a similar result is brought about. In consequence, we may have bone 
dying in small visible particles, or the entire shaft of a long bone or 
several smaller ones may be at once involved in the destructive processes. 
The portion which dies, be it larger or smaller, is known as the 
sequestrum, which may assume most irregular and unusual shapes, 
varying entirely with the area involved. The general character and 
size of a sequestrum will depend, for the most part, upon the nature of 
the cause. In acute osteomyelitis it is usually either an entire bone- 
shaft or an entire epiphysis which thus suddenly dies. In the slower 
processes, connected really with caries, the fragments may be of almost 
any imaginable size and form—irregular with jagged ends, or long, 
extending completely through a bone, either from end to end or from 
side to side. 
(c) The toxic forms of necrosis are due mainly to two substances 
used in the arts—mercury and phosphorus—whose use seems to be 
inseparable from the manufacture of many modern industrial products. 
Mercurial necrosis may come either from the volatilization of the metal in 
factories where mirrors are made or from refineries where amalgam is distilled. 
It may also come from the internal use of the drug. Its effects are seen rather in 
the alveolar portion of the lower and upper jaw than anywhere else. It is, in fact, 
through some unknown peculiarity that the jaws are the bones commonly involved 
in both of these forms. 668 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
Phosphorus-necrosis, on the other hand, manifests itself almost entirely in the 
lower jaw, and is met with, usually among the young, in factories where matches 
are made. It is due to the vapors of phosphorus, which cause a form of nearly 
distinct maxillary necrosis—a fact which has been so widely recognized as to lead 
to state legislation preventing the employment of the young in such work. 
Phosphorus-necrosis begins as a periostitis with the production of osteophytes, 
Fig. 272. 
Phosphorus-necrosis of lower jaw (Mus6e Dupuytren). 
and is completed as a nearly total necrosis of the entire bone. That regeneration 
of bone is possible after the separation of the dead portion is shown in the speci- 
men from which the accompanying figure was made. This, however, has only 
been noted in the lower jaw, and rarely if ever in the upper. The trouble appears 
first as an odontalgia, with swelling of the gums, bleeding at the gingival mar- 
gins, later with extension of pain and swelling and pyorrhoea alveolaris; finally 
Fig. 273. 
there occurs formation of fistuhe opening either within or without the mouth, with 
evident effort to extrude the dead portion of bone. Submaxillary abscesses often 
accompany the disease, and the ingestion of their purulent products leads often 
to disturbance of the digestive organs, as well as of the lungs by a sort of aspira- 
tion pneumonia. The disease occurring in the upper jaw is much more severe 
and of much less favorable prognosis. 
Phosphorus-necrosis of lower jaw, new hone-formation (Mus6e Dupuytrcn) PLATE XX. 
Necrosis of Shaft of Femur with Sequestra, life size. SURGICAL DISEASES OF THE OSSEOUS SYSTEM. 
669 
Treatment of the Toxic Forms.—The preventive treatment must consist 
of careful supervision of the teeth, the use of alkaline mouth-washes, inhalation 
of terebinthinate vapors, which neutralize those of phosphorus, and always the 
perfect ventilation of establishments devoted to match-making. The curative 
treatment consists of buccal antisepsis, opening of abscesses, and the removal of 
diseased bone, especially of dead bone, upon the first provocation. The occur- 
rence of fistulie should always be regarded as pathognomonic of diseased bone. 
In aggravated cases, such as are rarely if ever seen to-day since legislation has 
been brought to bear upon the subject, practically complete necrosis of the lower 
jaw, either en masse or in portions, was far from unknown, and the possibilities of 
regeneration of the bone was for a long time discredited, until the late James R. 
Wood of New York exhibited a specimen, both at home and abroad, which proved 
its possibility. Since then we have learned that it is possible for bone thus to 
regenerate, the cause of the disturbance having been removed. 
Sequestrum-formation.—To the portion of bone which dies, be it 
large or small, regular or irregular, is given the name sequestrum, while 
multiple sequestra are by no means uncommon. 
The sequestrum is white and ivory-like in hard- 
ness—at least when it consists of original compact 
structure. It is rare to find a distinct sequestrum of 
Fig. 274. 
Fig. 276. 
Fig. 275. 
Central necrosis of tibia, 
long central sequestrum 
(original). 
Sequestrum inside of a core 
of new bone-tissue, ar- 
ranged much like a puz- 
zle (original). 
Necrosis of tibia, showing seques- 
tra after removal (original). 
spongy tissue, simply because this yields so readily to the presence of 
granulation-tissue and of pyogenic infection. A sequestrum may include 
an entire bone, shaft or epiphysis, or only a small fragment. A given 
portion of the bone, having lost its vitality, becomes properly a foreign 670 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
body which the surrounding tissues endeavor to extrude or to wall off 
and surround. The extrusive effort is the one which is usually seen. 
This is done by the continued presence of granulation-tissue, which 
gradually perforates the surrounding bone at places of least resistance, 
the result being the slow formation of a sinus or several sinuses, ulti- 
mately connecting with the surface, and in which in neglected cases the 
dead fragment of bone can be seen or felt, or from which it can be with- 
drawn almost without operation. While this weakening of bone is 
going on in certain portions, a corresponding strengthening process is 
also being put into effect; and the result is a quantity of new bone, 
which is often wrapped around the sequestrum or which is simply the 
effort to atone for its pathological weakness and to strengthen it, some- 
times to an amazing degree. This new osseous tissue which so often 
surrounds the sequestrum is called the involucrum, and in many 
instances it is necessary to remove more or less of the involucrum before 
the sequestrum can be lifted out of its bed or removed. 
The whole necrotic process is perfectly intelligible if simply read aright as an 
endeavor on the part of nature to get rid of dead and irritating material. When 
this effort is properly interpreted and early enough, the natural efforts can be 
seconded by the interference of the surgeon at a time when disturbance shall be 
limited to the minimum and before external sinuses have 
had any opportunity to form. On the other hand, ignorance 
and neglect may lead to the extreme condition, and most 
fantastic arrangements of sequestra and involucra are seen 
in all pathological museums, some of which seem to partake 
almost of the perplexities of Chinese puzzles. The explana- 
tion, however, is always as above afforded. 
Fig. 277. 
Diagnosis.—Diagnosis is rarely difficult, and 
in practically all cases can at least be made to 
the extent of recognizing when operation is called 
for. It is made partly by the history of the case, 
partly by the local appearances, which latter are 
in large measure those either of bone-tuberculosis, 
bone-syphilis, or bone-abscess, already described. 
Caries and necrosis alike call for operation, and, in 
view of their possible complications, it is not always 
easy to make a minute diagnosis. 
Treatment.—This is always surgical, and con- 
sists in removal of the dead portions and restoration 
of the parts to a condition favoring rapid regenera- 
tion. The treatment must always be radical, and is 
made difficult sometimes by the inaccessibility of the 
fragment or by the density of the involucrum and 
the necessity for large external openings in order to 
remove the sequestrum. 
Necrosis of lower end of 
femur (original). 
A generation ago it was held inexpedient to attempt to remove bone until a 
number of weeks had elapsed, during which nature was supposed to effect its dis- 
lodgement or its loosening. There is, however, no reason for waiting, and dead or 
dying bone should always be removed as promptly as possible. 
Large and powerful forceps and strong and well-tempered bone- 
chisels are usually necessary, while, after making the necessary opening 
for removal of the sequestrum, the sharp spoon should be used thor- SURGICAL DISEASES OF THE OSSEOUS SYSTEM. 
671 
oughly to scrape away all the lining material of cavities in which frag- 
ments have been lying or all fungous tissue which may fill sinus tracks. 
It will be well after this to thoroughly cauterize the wall of the cavity, 
after which it is to be packed. 
The packing of old bone-cavities is of importance, and operators should appre- 
ciate the reason for so treating them. The packing is essentially a foreign mate- 
rial which the tissues will naturally endeavor to extrude as they did the seques- 
trum. The method of extrusion is by filling up beneath and around it with 
granulation-tissue, which later may ossify. The packing is therefore a constant 
provocation to the formation of this tissue, which is now desirable and is used 
mainly for this purpose. It is antiseptic material, and will serve always to pre- 
vent decomposition of the pyoid material which would otherwise fill such a cavity 
as the result of waste—Nature’s effort at formative material gone to waste. A 
number of years ago Gunn suggested the use of wax for this purpose, wax being 
plastic and incapable of absorption. A piece of white wax was heated in hot 
water, moulded with the fingers to fit the cavity, where it served the purpose of a 
packing, and was reduced in size with each dressing, as was necessary to permit it 
still to remain. It is not now used as much as it deserves to be. 
In favorable cases it may be possible to so thoroughly cleanse the 
bone-cavity without the use of caustics as to justify the attempt, after 
rigid asepsis, of allowing it to fill with blood which shall coagulate and 
organize directly into connective tissue. When this effect is desired the 
wound should be covered with green silk protective, over which the other 
dressing may be snugly applied. This healing by the aseptic blood-clot 
is the ideal method when possible. 
Fig. 278. 
Junction of old and new bone, osteoblasts arranged both regularly and irregularly (Ollier). 
It has been held for a number of years to be necessary to retain the periosteum 
in these bone operations as an essential bone-forming element. Of late, however, 
we have learned that the periosteum as such has no bone-forming power, but that 
it may preserve, adherent to it, some of the osteoblastic cells removed with it from 
the underlying bone, which themselves have the power of reproducing their kind. 
Subperiosteal operations, therefore, are not as highly regarded now as a few years 
ago. Nevertheless, when the periosteum is not diseased it is always well to pre- 
serve it. When diseased, however, especially when tubercular, it should be unhes- 
itatingly removed. 672 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
The extent to which regeneration of bone is possible is often amazing, espe- 
cially in the young. Thus, after removal of the entire shaft of a tibia there may 
be in time not a complete restoration to former integrity, but, nevertheless, the 
formation of so much new osseous material as to restore a great degree of strength, 
and which shall, with the compensatorily hypertrophied fibula, make the leg as 
useful as ever. In the thigh, however, complete necrosis of the femur will almost 
always mean amputation, as it will also in the arm unless the necrotic portion be 
but a small proportion of the length of the humerus. The treatment of necrosis 
of the skull, or, in fact, of any bone in the body which is accessible, is based prac- 
tically on the principles already laid down. 
Other Parasitic Affections of Bones. 
These are mainly of two varieties—hydatid disease and actinomycosis. 
Hydatid disease of bone consists in the development of hydatid 
cysts which may be either of primary or secondary origin. Almost all 
the bones of the skeleton are liable to cyst-formation, save only the very 
short bones of the carpus, tarsus, and digits. In the very long bones 
they occur most frequently in the region of the epiphyses. The partic- 
ular vascularity of this region is the main factor in their location at this 
point. The cysts may be unilocular or multilocular, and around them 
may be a thin or a large area of infiltration. In other words, their 
boundaries may be abrupt or not. Their volume is exceedingly vari- 
able, unilocular cysts sometimes attaining considerable size and distend- 
ing the bone out of all its normal proportions. (See Chapter XXVI. 
for further reference to the pathology of hydatid cysts.) 
Hydatid cysts in bone pursue a most insidious course, and oftentimes their 
growth seems to be arrested and they remain stationary for long periods. Lesser 
has, for instance, reported a case remaining absolutely stationary for forty years. 
In the long bones indolence is characteristic, but may terminate in acute symptoms 
if the bones be fractured. On the other hand, in the flat bones there is a distinct 
new formation, circumscribed, compressible, and accompanied by a peculiar parch- 
ment crepitation which is considered pathognomonic of these cysts. Spontaneous 
openings are rare. When undisturbed these collections remain indefinitely indo- 
lent, but subject at all times to possible pyogenic infection. Spontaneous fracture 
of a bone is always a suspicious occurrence, and may lead to the detection of 
hydatid disease in the same. 
Prognosis is not usually good. Although the infection is one of 
such slow course, the disease tends to advance rather than retrogress, 
and suppuration is frequent, while important viscera like the brain and 
cord may suffer compression. 
The TREATMENT is purely operative. The contents of the cysts must 
be evacuated and its walls radically destroyed by caustic, spoon, etc. 
All sequestra must be removed; in the limbs amputation is sometimes 
necessitated by the extent of the affection. 
Actinomycosis (see Chapter VIII.).—The general character of this 
parasitic disease lias been already considered. It should be remembered 
here, however, as one of the possible, though in this country rare, affec- 
tions of the bones. 
The peculiar fungus may be found in the periosteum, in the compact outer 
layers of the bone, or within its more spongy depths. When the lesion is large 
enough to be recognizable to the naked eye it assumes, for all practical purposes, 
the appearance of caries like that due to tubercular or leprous diseases, while in 
the pus or debris discharged from the same or contained within the invaded bones 
the characteristic yellow, cheesy, or calcareous particles will always be recognized. SURGICAL DISEASES OF THE OSSEOUS SYSTEM. 
673 
In this disease there never seems to be the slightest tendency to encapsulation, nor 
to protect against further spreading by any process of repair. The diseased area 
constantly enlarges its dimensions, involving everything as it spreads, it being 
limited by no membrane nor tissue of the body. Occurring in the bones, it is for 
the most part a secondary or metastatic infection, and may be found in any part 
of the body. 
The symptoms will be those of osteoperiostitis occurring first in the 
jaws, as it nearly always does in cattle and often in man; it will be 
accompanied by loosening of the teeth and involvement of the submax- 
illary tissues in a way scarcely imitated by any other disease. The 
course of the disease is always slow, with little or no tendency toward 
spontaneous recovery. 
It requires mainly to be distinguished from tuberculosis of the bone and from 
syphilis. Occurring in deep locations, it may prove most puzzling. It is much 
easier to exclude syphilis by the history and by examination of the rest of the body 
than to exclude tuberculosis. If, however, pus or any discharge from the affected 
part can be secured, a careful examination of it will ordinarily permit a prompt 
diagnosis. It may also require to be distinguished from sarcoma of bones, which 
again may be difficult and perhaps possible only before operation, when the cha- 
racteristic granules can be discovered in the discharges. When the limbs or 
accessible parts of the body are involved, however, these cases will always call for 
operation, and diagnosis can be then made if not before. 
Leprosy.—While leprosy is not often included as a disease of the bones, it 
must not be forgotten that some of the most characteristic disfigurements of this 
peculiar disease are due to the lesions involving and subsequently destroying the 
bones, as already mentioned in Chapter IX. Leprosy is a specific infectious dis- 
ease whose existing cause is a peculiar bacillus, but whose lesions, so far as struc- 
ture is concerned, are practically those produced by granulation-tissue, which 
encroaches upon and takes the place of normal tissues, its own presence being 
provoked by the organisms at fault. 
The picture of a leprous involvement of a bone is not different from that of 
tubercular disease of the same part, although there is in the former case little or 
no tendency to secondary infection and to ulceration or necrosis. In this respect 
lies the principal difference in the two diseases. 
Trophoneurotic Diseases of the Bones. 
Under this general heading it is proposed to group a number of dis- 
eases whose clinical manifestations are distinct or classic, but whose 
underlying causes are as yet more or less obscure, in most cases more 
so, and about which we can speak with but little definiteness; neverthe- 
less, the diseased conditions are distinctive and important. 
Achondroplasia.—This is a lesion of intra-uterine life which includes 
a softening of primary cartilaginous structures and curvature or malfor- 
mation of the bones which should be formed from them. It concerns 
that period of fetal life between the third and sixth months. It has 
been sometimes spoken of as intra-uterine rickets. (In fact, the term 
rickets has been made to cover many different conditions.) Under this 
name it was first described by Muller in 1860, and since then by vari- 
ous authors under various names, most commonly as foetal rickets. It 
appears that in this disease the foetal cartilage contains mucus abnor- 
mally collected, for the most part, in minute cavities or cells just at its 
borders. The chondroblasts and osteoblasts are not regularly dispersed, 
and the development of the growing bone is thereby much interfered 
with. The periosteum appears to have nothing to do with this condi- 
tion. In consequence the cartilage does not do its proper duty. The 674 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
long bones fail to attain their proper proportionate length, but become 
thicker than normal, the periosteum being unaltered. On the other 
hand, those bones into whose 
formation cartilage enters but 
slightly, such as the clavicle and 
the ribs, retain their normal pro- 
portions : the consequence is a 
peculiar malformation and dis- 
proportion of the whole skeleton 
(Fig. 279). 
These deformities are sym- 
metrical, and pertain for the 
most part to the bones at the 
base of the skull and to the long 
bones of the limbs; therefore 
the distinctive appearance may 
Fig. 279. 
Fig. 280. 
Achondroplasia skeleton (Porak). 
Achondroplasia (Lugeol). 
be recognized even at the birth of the child. The head is dispropor- 
tionately large, the spinal column short, the lumbar curvature exag- 
gerated, all of which is rather the reverse of the ordinary rachitic 
manifestations. The disease is not common (Fig. 280). 
Prognosis is unfavorable, because it seems impossible to undo the 
faults of the intra-uterine condition. The disease, however, is not 
incompatible with a long life. 
Rachitis.—This also is a constitutional condition, and has been already 
described in Chapter XIV. So far as the manifestations in the bones 
are concerned, it is a constitutional dystrophy caused by improper depo- 
sition of calcareous material in the softened and somewhat perverted 
foetal cartilages. It is a condition, however, pertaining rather to post- SURGICAL DISEASES OF THE OSSEOUS SYSTEM. 
675 
natal life, and while inconspicuous at birth becomes more and more 
marked as the child develops. 
It is essentially a disease of malnutrition, and consequently may be 
seen in all walks of life, as well in the bottle-fed babies of the wealthy 
as in the best-nourished children of the very poor. The lesions are 
widely distributed. The disease is divided by some writers into three 
periods : (a) rarefaction of hone-tissue ; (6) softening of same ; (c) re-ossi- 
fication. 
The first stage is the intra-uterine part; the second and third stages 
are post-natal. To foetal rarefaction have been attributed intra-uterine 
fractures, even by Hippocrates. 
The general dyscrasia and visceral alterations of rachitis interest us 
here less than deformities of the various bones. The head is dispropor- 
tionately large, the vertex flattened, the frontal and parietal eminences 
pronounced; the anterior fontanelle closes very late. To the atrophic 
alterations of the head have been given the name craniotabes. The face is 
disproportionally small, the lower jaw assuming a polygonal shape. The 
palatal vault is of the Gothic type, dentition irregular and retarded. In 
the thorax the clavicular curves are exaggerated, by which the bones are 
shortened and the shoulders made narrow. The costo-chondral junctions 
are enlarged, the result being the so-called rachitic rosary. The sternum 
projects and gives the peculiar appearance known as pigeon-breast. The 
pelvis is often deformed, frequently distorted to such an extent as in late 
years to make normal delivery impossible. The spinal column may 
either be distorted very early, or is likely to undergo alterations of 
curvature due to the combined results of pressure and traction upon 
softened vertebrae. The joint ends of the long bones are enlarged or 
clubbed, this being true even of the phalanges. Joint movements are 
often accompanied by crepitation. The axes of the long bones are 
distorted, and more or less marked deviations and curvatures result, 
giving rise to such deformities as knock-knee, bow-leg, etc., all of which 
are especially treated of in Chapter XVI. Vol. II. 
It is these deformities especially which give rise to some of the most exacting 
operations within the domain of orthopaedic surgery, while upon the skull, where 
those deformities are known to occasion defective development, operations having 
for their purpose the relief of pressure or expansion of a too slow-growing cranium 
have lately been extensively practised. ( Vide Chapter I. Yol. II., Microcephaly.) 
The medical treatment for these conditions is mainly the administra- 
tion of calcium salts in solution, of which perhaps the best is the 
so-called compound syrup of the hypophosphites. When taken very 
early it is possible to accomplish much for these cases by a combination 
of proper nourishment with suitably directed gymnastic exercises and 
insistance upon such carriage of the body and such habits as shall per- 
mit a proper distribution of the body-weight. In this way much can be 
done in preventing deformity; but if it have already occurred it may 
be rectified by some one of the numerous operations elsewhere described 
within this work. 
Osteomalacia.—As rickets is essentially a disease of the very young, 
osteomalacia is practically confined to adults. The name implies a 
peculiar softening of the hones by which their resistance and rigidity 
are weakened and deformity permitted. The disease is common to man 676 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
and animals in confinement, and is frequently noted among wild 
animals dying in zoological gardens. It is perhaps most often noted in 
pregnant women, where it would appear as if the mineral elements 
needed for the growing foetus were abstracted from the mother’s bones 
rather than from the food ingested. It is brought about also by starva- 
tion, possibly by lactation, especially among those who nurse their 
children for unusual periods. 
The histological changes are slight, the condition being essentially an absorp- 
tion of the calcium salts through the fluids in which the bone-elements are bathed. 
In consequence the bones are made more elastic and flexible and marked changes 
in their shape and form permitted. This is particularly true in the pelvis, where 
deformity takes place to an extent often calling for artificial delivery or even 
Caesarean section (Fig. 281). 
Fig. 281. 
Osteomalacic pelvis (Mauclaire). 
The theories advanced to account for osteomalacia are unsatisfactory and need 
not detain us here. Just what role the trophic nerves play is not made out with 
any definiteness. The disease is insidious, and deformity is frequently preceded 
by pains, usually nocturnal, often exasperating, for the most part referred to the 
muscles. Sometimes they are only produced by pressure or movement. They are 
almost invariably described by the patient as rheumatic. They are frequently 
accompanied by muscular cramps. There is an accompanying sense of general 
debility and muscle-fatigue. The tuberosity of the ischium becomes tender, and 
patients in consequence assume a horizontal position. All these signs may be 
obscure and the condition pass actually unrecognized until deformities begin to 
occur. Should they be complained of by a pregnant woman, careful pelvic 
examination should be insisted upon, in order that such deformity, as may render 
approaching delivery difficult or impossible, may be appreciated in due time. 
In patients not pregnant the first deformity will probably be noticed in the 
vertebral column, while the pelvis will remain intact. Changes in the thorax and 
in the limbs are more easily appreciated and ordinarily earlier recognized. The 
adjoining figure (Fig. 282), taken from the Dupuytren collection, illustrates one of 
the most remarkable cases of this kind on record. SURGICAL DISEASES OF THE OSSEOUS SYSTEM. 
677 
Spontaneous fractures, especially of the long bones, are frequent. 
These may refuse to unite properly, and false joints may result. The 
urine will under these circumstances contain an excess of mineral salts, 
carbonates, phosphates, and oxalates, and when these are discovered in 
the urine of those suffering from fractures it should always be a warning 
to administer calcium salts and mineral acids internally, preferably 
phosphoric, and to carefully watch the excretions. 
Fig. 282. 
Osteomalacia: celebrated case of Moraud, 1753.—Skeleton now in Musce Dupuytren. 
The progress of the disease is slow, yet steady, and often not easily 
checked, if at all affected, by mineral acids. Occurring in pregnant 
women, it may be checked after delivery, especially if the child be not 
allowed to nurse from the mother. In some instances it occurs with 
each successive confinement in the same patient, and makes distinct 
advance with each fresli attack. 
The prognosis is therefore unfavorable, least so in puerperal cases. 
An infantile form, as well as a foetal form, has been described, but it is doubt- 
ful whether these forms really come under the same category, and whether they 
are not manifestations of rickets. A senile form has also been described which 
affects for the most part the sternum and thorax, which is characterized by excess 
of nervous excitability and by bone-pains, as well as by liability to multiple frac- 
ture upon the slightest provocation. This form, however, differs but little from 
the osteoporosis of advanced years, and scarcely deserves distinct consideration. 
Certain writers have also spoken of a symptomatic form observed in cases of cancer, 
syphilis, scurvy, etc., which, however, is entirely unnecessary, since the fractures 
occurring in cases of cancer or syphilis are due to secondary lesions of the same 
character, while those occurring during scurvy are simply an expression of star- 
vation and weakening even of the bones. Cases of cancer, for instance, where 
bones have broken without being previously weakened by secondary growths, have 
been described, but are exceedingly rare and need only to be mentioned here. 678 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
The treatment for all these conditions must be removal of the cause if dis- 
coverable, and the administration of calcium salts in accessible shape, as in cases 
of rickets. 
Osteopsathyrosis, or Fragility of Bones.—This seems to be a con- 
dition distinct from osteomalacia, just described, it being, more than the 
other, a condition due to trophic nerve disturbance. The condition seems 
to be hereditary, often extending through several generations. It is cha- 
racterized by fracture of long bones upon the slightest provocation, and 
is a disease common to all ages. While apparently congenital in origin, 
it persists often throughout life, no impression being made upon the con- 
dition by medication. It is not characterized by distinctive histological 
changes, and all theories heretofore advanced toward its explanation are 
disappointing. We are as yet in complete ignorance as to its cause. It 
is seen, at least in this country, most often in paretics and inmates of 
insane asylums. The ease with which the bones of such patients are 
broken has given rise to repeated charges of violence or homicide. From 
one case in which this charge was made I secured specimens of the ribs, 
which were so fragile that they could be easily crumbled between the 
fingers. Such patients might easily sustain serious fractures when 
undergoing necessary restraint, even of the gentlest nature. 
Fig. 283. 
Osteopsathyrosis (Blanchard’s case). 
Osteopsathyrosis of this congenital type is perhaps best illustrated hv a case 
reported by Blanchard of Chicago,1 in the case of a woman twenty-seven years of 
age at the time of his report, who up to that time had sustained over one hundred 
fractures. In her case it was sufficient to merely gently slide from the sofa to the 
1 Trans Am. Orthopcedic Assoc. SURGICAL DISEASES OF THE OSSEOUS SYSTEM. 
679 
floor to break some bone. Treatment in her case had been of no avail (Fig. 283). 
It is important to impress these facts upon the mind of readers, because allegations 
of undue violence are frequently made in these cases, which, especially in asylums, 
may be most unjust and difficult to prove or disprove. 
Senile Fragility of Bones.—This simply means weakening of the 
bones, which is incident to advanced age in either sex due to and com- 
prised under the term osteoporosis. Added to this, in certain places is a 
positive change in shape, also characterizing the senile condition—e. g. 
the neck of the femur. Under these circumstances bones will break 
with a minimum of violence and without invoking any theory of osteo- 
malacia, osteopsathyrosis, or the like. As bone disappears under these 
circumstances, fat usually takes its place, so that while the volume of 
the bone may be not particularly diminished, it weight and density are 
materially altered. (Vide also introductory remarks to this chapter.) 
Atrophic Elongation.—This is a term first applied by Ollier, and 
refers to a distinct type of alteration in long bones by which their actual 
volume is relatively diminished, although they increase in length. It is 
produced largely by lack of pressure, and is seen in many amputated 
stumps, in which it has much to do with the conicity of the same. It 
is seen in another expression in certain cases of typhoid fever or in 
forced confinement of the young to bed, where the bones appear to grow 
at a much more rapid rate than normal. It may also be due to unequal 
amounts, or defects, of nutritive supply, especially that furnished by the 
periosteum, and in certain other cases seems to be a purely reflex or 
trophoneurotic change which is always inexplicable. Frequently accom- 
panying it is muscular wasting, which is to be explained rather by reflex 
action through the cord, produced perhaps through the mechanism of 
the terminal filaments of the articular nerves. 
Ostitis deformans, or, as it is often called, Paget’s disease of the 
bones, is a condition found alike in long and flat bones, the osseous tis- 
sue being condensed in texture and increased in amount, or at other 
times the osseous tissue becoming quite porous and the spongy tissue 
rarefied without alteration in the marrow. It is due to the unknown 
causes which may be summed up in the expression trophoneurotic, a 
painful and a painless form having been described, the former the more 
frequent. It produces deformities, disfigurements, and hypertrophies 
of the long bones. It is distinguished from arthritis deformans, 
described in Chapter XXXIII., which is a distinct malady, this under 
consideration having no particular reference to joint structures. 
In the skull it is usually the face bones which are most involved, 
although the disease often commences in the cranial bones. The skull 
proper may be thickened even to three centimetres. The thorax becomes 
globular or cubic in form ; the arms are relatively too long, and there is 
usually dorsal kyphosis; the pelvis is thickened and distorted; the ribs 
are augmented in size, the femora irregularly curved; the patellae 
enlarged; the tibiae more massive and their curves exaggerated. The 
disease is essentially a symmetrical one, commencing for the most part in 
the cranium and radius. Fractures are rare, because the bones become 
stronger rather than weaker (Fig. 284). 
In many instances these changes are accompanied by severe pains, sometimes 
exaggerated by pressure. The malady is usually regarded as rheumatism, but it 680 
AFFECTIONS OF THE TISSUES ANI) TISSUE-SYSTEMS. 
must be said that, even were accurate diagnosis made early, it would scarcely avail 
in treatment, since there is none for it. It may require to be distinguished from 
hereditary syphilis, in which the tibiae have more of the sabre shape; from acro- 
Fig. 284. 
Ostitis deformans (Paget) 
megaly, soon to be described, or leontiasis, which begins in the bones of the face 
and involves the cranium only secondarily. 
Osteoarthropathie hypertrophiante pneumique.—Under this title, 
which has no exact equivalent in English, was described in 1890, by 
Marie, a peculiar affection which is usually spoken of in this country 
as Marie’s disease. This is for the most part a pulmonary affection 
accompanied by enlargement of the extremities. There is some reason 
to think that, whatever it be, there are present some micro-organisms 
giving rise to products that are absorbed into the general circulation, the 
result of whose presence is an irritative hypertrophy of certain parts, 
particularly the joints and ends of the fingers, the elbow-, shoulder-, 
and knee-joints, and often the wrist. There is also ordinarily dorso- 
lumbar kyphosis, which in acromegaly is usually cervico-dorsal. 
The cranium remains intact; the borders of the jaw are sometimes 
involved. 
Clinically, it is characterized frequently by articular pains, occasionally by 
excessive perspiration and by certain cutaneous eruptions or pigmentations. In 
the bones involved are found areas of new bone-formation, and synostosis of 
adjoining bones is possible. It is most commonly seen in males of adult age. 
From Paget’s disease and from acromegaly it is distinguished by not involving the 
head at all (Fig. 285). 
Acromegaly is so named from its tendency to increase the volume of 
the bone extremities or apices. The first case of this disease was pub- 
lished by Marie in 1885. It is characterized by progressive increase in SURGICAL DISEASES OF THE OSSEOUS SYSTEM. 
681 
weight, by enlargement of all the extremities, bones and soft tissues 
alike, but the most characteristic involvement is that of the lower jaw, 
the upper jaw being little if at all affected. The lower jaw assumes 
enormous size and projects so that its teeth are far in front of those of 
the upper. The supraorbital ridges enlarge, as do also the sternal ends 
Fig. 285. 
Fig. 286. 
Osteoarthropathy (Marie). 
Acromegaly (original). 
of the clavicles and costal cartilages. As the disease progresses the ribs 
are widened and the scapulae enlarged, the vertebrae and the interverte- 
bral cartilages thickened and fused together, causing usually cervico- 
dorsal kyphosis. The long bones of the limbs suffer later, especially at 
the lowermost joint ends—i. e. hands and feet. The viscera are rarely 
affected, but there is a peculiar and characteristic enlargement, usually 
of the thyroid and pituitary bodies. The lower cervical ganglion of the 
sympathetic is also sclerosed; the mucous membrane of the nose is 
usually hypertrophied; the uvula is enlarged, while often the larynx 
participates in the changes. Acromegaly is essentially symmetrical, and 
for each change upon one side of the body we notice a corresponding 
alteration upon the other. Particular features are observed in individual 
cases, but the above are practically common to all. 682 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
The underlying pathological condition is as yet undetermined, though most 
indications point to late alterations along the original cranio-pharyngeal trad of 
the young embryo, whose remains are best known in the pituitary body and the 
Fig. 287. 
thyroid. The greatest complaint usually is of headache, which is difficult or 
impossible of relief. The disease is steady, progressive, unaffected by treatment, 
and the prognosis bad, though its course be slow. 
Leontiasis.—A diffuse, bilateral, symmetrical hypertrophy of the 
bones of the face and later of the cranium, described first by Virchow, 
the real origin appearing to be in the superior maxillae, the result being 
a peculiar leonine appearance of the face, whence the name given to the 
disease. There is no distinct tumor-formation in the bone, but rather 
Hand and foot of natural size contrasted with acromegalic extremities. 
Fig. 288. 
Leontiasis: skull of a Chinese woman (U. S. A. Museum, No. 10,620), 
the entire structure of the bones involved is affected. As it advances— 
for this it always does—function of the parts is interfered with, masti- 
cation becomes impossible, headache and pain are constant. The special 
senses are disturbed because of involvement of their nerves, and patients SURGICAL DISEASES OF THE OSSEOUS SYSTEM. 
683 
die usually from inanition, because no longer able to chew and swallow 
food. It is distinguished from Paget’s disease, because it shows no 
tendency to involve the rest of the skeleton ; from acromegaly, in which 
the general shape of the jaw is preserved, though its dimensions are 
magnified; from tumors of the jaw or face, because of its symmetrical 
enlargement. Its pathogeny is as obscure as that of the other bone 
affections mentioned in this list, and its treatment as unsatisfactory. 
Tumors of Bone. 
As between the various hypertrophic conditions of the bones just 
above catalogued we must distinguish the true neoplasms, which answer 
• Fig. 289. 
Multiple exostoses, congenital (Fischer). 
all the requirements of the definition given in Chapter XXVI., but 
which deserve special consideration here because of their importance. 
There are few if any of the true tumors which may not be met with in 
bone, including the periosteum. 
Fibromata of even large size spring from the periosteum, especially 
about the jaws and from the base of the skull, from which latter place 
they may project into the nasopharynx and seriously interfere with the 
welfare of the patient. Some of these tumors are soft and succulent, as 
well as extremely vascular, and I have seen death occur upon the table 
in an endeavor to remove a growth of this kind, hemorrhage being 
simply uncontrollable. 
Cartilaginous tumors, as stated in Chapter XXVI., are not often 684 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
found outside of the bony skeleton. They may spring from cartilaginous 
extremities of growing bones, from epiphyseal cartilages, or from the 
interior of long and short bones, where 
their origin is probably due to inclusion 
of cartilaginous elements, as compre- 
hended in Cohnheim’s theory. In 
young children they are often multiple 
and involve various parts of the body. 
Occurring in adults, they are less often 
multiple, but may attain considerable 
size. They are found most often about 
the ribs, sternum, pelvis, and femora. 
If the entire structure of a given bom* 
be involved in a growth of this kind, 
its eradication—that is, amputation— 
will probably be called for. When 
otherwise, complete removal with care- 
ful cauterization of the base of the 
growth or surface from which it sprang 
will usually be enough. These carti- 
laginous tumors tend on the one hand 
to mucoid softening and cystic forma- 
tion, and on the other to calcification or 
ossification, by which the original carti- 
laginous character of the growth may 
be concealed. 
Osteomata are by some writers 
made to include exostoses and hyper- 
ostoses. In accordance with the system 
adhered to in this work, only those growths are considered as tumors 
which are of no physiological usefulness, and I should prefer to main- 
tain a distinction between osteomata and the exostoses (Fig. 289) or 
bone-hypertrophies, which pertain either to evolutionary relics or to 
constitutional affections. 
There is, however, a peculiar form of exostosis which becomes covered 
Fig. 290. 
Exostosis bursata (Orlow). 
Fig. 291. 
Cancellous osteomata springing from the diploe (Hustle Dupuytren) 
by an adventitious bursa, whose walls become in time quite thick, and 
which now goes everywhere under the name exostosis bursata. In the SURGICAL DISEASES OF THE OSSEOUS SYSTEM. 
685 
cavity of this bursa will be frequently found rice-grain or other fibrinous 
concretions. This lesion is common in the neighborhood of joints, 
and the new bursa frequently communicates with the joint-cavity 
(Fig. 290). 
Osteomata are of all degrees of consistence, from the softest spongy bone-tissue 
to the densest ivory growth. They partake in character of the nature of the bone 
in which they originate. They give pain only ordinarily as they cause pressure 
upon nerve-trunks. Other disturbances may also be caused by pressure. 
These tumors also may be multiple, though usually single; no part of the 
osseous skeleton is exempt. Ingrowths from the cranial bones may produce all 
the signs of brain-tumors (Fig. 291). They call always for operative interference, 
which may be simple or most dangerous in accordance with their site and size. 
Very often amputation or resection is necessitated. 
Fig. 292. 
Fig. 293. 
Sarcoma of femur (original;. 
Fungating osteosarcoma of cranium (Pemberton). 
Myxomata are rare in bone, and are seen usually only as degen- 
erated forms of cartilaginous bony or malignant growths. They lead 
to cystic degeneration. A primary growth of this kind mnst have for 
its origin the bone-marrow, such cases having been described. 
Sarcoma of bone is often spoken of as osteosarcoma, the former 
term, however, being preferable. This occurs most commonly in the 
long bones, although none are exempt; usually single, it nevertheless 686 
AFFECTIONS OF THE TISSUES ANI) TISSUE-SYSTEMS. 
may be multiple. It occurs frequently in the young, is seen even at 
birth, and in these instances is supposed to take its origin usually from 
epiphyseal structures. No period of life is, however, exempt. Tumors 
attain sometimes enormous size. Marsh has recently described such a 
tumor weighing thirty-three pounds. Microscopically, these tumors 
may assume either of the varieties, those of the most rapid growth 
being found rather of the round-celled type, while those of slow growth 
are usually myeloid or contain giant cells. 
Sarcomata frequently rise from the periosteum. Commencing in the 
interior of a bone, they are known as intraosseous, and as they develop, 
for the most part very slowly, they expand the bone more or less sym- 
Fig. 294. 
Osteosarcoma of humerus. 
metrically, in distinction to those growths of external origin which 
are in evidence on one or another aspect of the bone involved. The 
former are also sometimes spoken of as central sarcomata. 
They have to be distinguished for the most part from tubercular, more rarely 
from syphilitic, lesions. From the former they differ in that they do not produce 
the characteristic starting pains at night nor the characteristic muscle-spasm and 
muscle-atrophy. The type varies—deep circulation being, however, obstructed, 
there is often a superficial appearance strongly reminding one of tubercular lesions. 
So, too, the central form grows for the most part toward the epiphyses, tending to 
spread and involve joints in a way quite similar to tubercular affections. The 
general history and appearance of the patient must be carefully regarded in favor- 
ing one or the other diagnosis. 
Sarcomata are peculiarly prone to degenerations, particularly mucoid and myx- 
omatous, and hemorrhages; less so to calcification and ossification, and still less so to SURGICAL DISEASES OF THE OSSEOUS SYSTEM. 
687 
pyogenic infection. In many of these cases, moreover, peculiar dendritic formation 
of new bone, or that in layers, is noticeable. The pigmented form of growth is 
exceedingly rare in bone; dissemination, especially to the lungs, is much more 
common ; and the lungs are not infrequently involved in aggravated cases. This 
should often be taken into consideration before operating. 
Sarcoma not infrequently lias its origin from the callus of a delayed 
bone-union, and I have had repeatedly to amputate for this most 
unpleasant sequel of fracture. (See Fig. 297.) 
As the disease advances there is increase of pain, usually with 
increasing cachexia, while augmentation in size of such a tumor may 
make a limb not only useless, but the 
source of greatest annoyance and 
difficulty in management of the case. 
Treatment.—There is but one 
treatment in cases which will permit 
it—amputation of limbs, extirpa- 
tion of tumors from certain bones, or 
Fig. 295. 
Fig. 296. 
Sarcoma of periosteum of humerus (Pemberton). 
Cystic osteosarcoma of tibia (original). 
excision of entire bones. Thus for sarcoma of the scapula we extirpate 
the entire bone; for sarcoma of the skull we make extensive resections 
of the same, removing the underlying dura when involved; for sarcoma 688 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
of the upper or lower jaw we remove it in whole or in part. Sarcoma 
of the spine is inoperable, that of the pelvis for the most part equally 
so. In absolutely inoperable cases treatment by the toxines of erysipelas 
may be tested. In all the cases where pain is severe it is only humane 
to administer opiates, which under these circumstances are both anodyne, 
stimulant, and almost nutritive. Patients in this desperate condition 
should not be allowed to suffer, and opium in assimilable form should 
always be administered to any amount necessary. 
Endothelioma.—We are hardly yet in a position to speak very def- 
initely with regard to this growth, especially in bone, where, by the time 
it comes under observation, its original characteristics will have under- 
gone more or less alteration. There is, however, good reason to think 
that some of the growths, especially of the softer variety, described as 
the central sarcomata, belong really among the endotheliomata. At all 
events, they are essentially malignant, and are to be treated in exactly 
the same way as the growths for which they are mistaken. 
Fig. 297. 
Sarcoma developing in callus (Haberen). 
Epitheliomata and carcinomata, in general, being distinctly of 
epithelial origin, can never originate normally in bone. It is character- 
istic of these cancerous growths, however, that from surrounding struc- 
tures they may spread to and involve bone, in which case we have an 
epithelial infiltration of the latter which is distinct and characteristic. 
Under these circumstances, and these only, is it possible to have true 
cancer, of bone, save only in the rare cases in which it is of distinctly SURGICAL DISEASES OF THE OSSEOUS SYSTEM. 
689 
metastatic origin, these latter being especially cases of cancer of the breast, 
in which we occasionally have metastatic foci even in the distant bones 
of the skeleton, but especially in the sternum. 
Error in diagnosis can only here arise when the secondary disease is 
distant from the primary, but will be less frequent if the possibility of 
metastasis be borne in mind. 
For such secondary or metastatic growths there can be but one treat- 
ment, if any be possible—that is, merciless extirpation. . CHAPTER XXXVI. 
FRACTURES. 
By H. H. Mudd, M. D. 
Tiie term fracture, in surgery, is applied to a break or solution in the 
continuity of a bone or cartilage. Fractures are said to constitute one- 
seventh of all injuries. They are ten times as frequent as dislocations. 
This break may be a dent or an irregular depression, as frequently occurs 
in the flat bones. The bone may be compressed, as happens in the 
irregular bones, or the break may be a complete separation of the frag- 
ments of a bone with displacement. 
In order to give accurate meaning to the term fracture one must 
modify it by a qualifying adjective or distinguish it by some phrase or 
name that will designate its characteristics. Thus we classify fractures, 
first, as Incomplete and Complete. Incomplete fractures may be sub- 
divided as follows : (A) The separation of an apophysis, the detachment 
of a fragment by a cutting instrument, or the fracture of the malleolus, 
which, although exhibiting complete detachment of a portion of bone, is 
classed as an incomplete fracture because the body of the bone remains 
intact. (7>) The green-stick fracture, which is the bending of a long 
bone, notably of the radius and ulna. This occurs only in young sub- 
jects. (C) The fissured, fracture, which is a line of fracture extending 
partly across a flat bone, as the parietal, or a fracture in a long bone 
which does not completely sever a fragment from the body of the bone. 
In the long bones this fracture usually begins at the expanded end 
and extends into, but not through, the shaft. The line of a fissure 
may be spiral in its course. (D) A depressed fracture is a dent in the 
surface of a bone which is produced by direct violence. It may occur 
in the shaft of a long bone; is more frequent in the spongy bones, but 
it is most common in the flat bones of the skull. (E) Partial fractures. 
The green-stick fractures, the fissured and depressed fractures, are par- 
tial fractures, but there is a fracture which, although it may possibly be 
complete, conies properly under the designation of partial fracture. It 
is a fracture without mobility and without displacement. Crepitus is 
absent, but an injury to the bone is evident by impaired function, pain, 
and swelling. The swelling develops slowly as the osteoplastic deposit 
envelops the injured part. This partial fracture is frequently observed 
in the clavicle, but it occurs also in other long bones. 
It may not be recognized for several days or until repair is advanced. If the 
patient is submitted to the close inspection of the surgeon soon after the injury, 
pressure may elicit slight mobility and possibly crepitus. This fracture affects 
children and young adults more than older subjects. The pathology of such frac- 
690 FRACTURES. 
691 
tures is that of the simplest fractures. The periosteal covering may not be broken. 
If a Dend is present, it may resist immediate etfort for correction, but gradually 
under pressure or by nature’s nutritive changes it is slowly eliminated. The 
adjustment of the fractured surfaces is practically perfect and repair is rapid. 
Recovery is sometimes so rapid and seemingly perfect that it might excite a doubt 
as to the existence of a break. Such breaks, however, do occur, and grave disaster 
may follow their non-recognition and neglect. By secondary bending or displace- 
ment they occasionally force the physician to a recognition of the wisdom of treat- 
ing doubtful cases as fractures. The clinical symptoms may be limited to impaired 
function and a sensitive area over the bone. 
Complete fractures may be classified as follows: (A) A transverse 
fracture is one in which the line of fracture makes a right angle with 
the axis of the bone or where it does 
not vary from it more than ten or 
twenty degrees. The surfaces must 
be so near a right angle that they 
Fig. 298. 
Fig. 299. 
Transverse fracture, ununited. 
Oblique fracture, badly-united. 
will oppose each other, and not slip so as to overlap after adjustment. 
Irregular serrated surfaces often aid in maintaining the adjustment. 
( B) An oblique fracture is one in which the line of fracture is at an 
angle of not less than ten degrees nor more than seventy degrees with 
the axis of the bone. It is intermediate between a transverse and a 
longitudinal fracture. The surfaces are at such an angle that even if 
they are well adjusted there is a disposition to overlapping. Any force 692 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
tending to shorten the bone, whether it be pressure or muscular contrac- 
tion, produces displacement with consequent shortening. The fractured 
surfaces are disposed to slip one on the other until there is overlapping. 
(C) Longitudinal fractures approach the axis of the bone, and may 
extend from one end of the bone to the other, or, entering at one end of 
it, may pass very obliquely through the bone to emerge at some distance 
from the point of entrance on one side of the shaft. 
(D) The epiphyseal fracture is of course found only in the young sub- 
ject, not after the twenty-first year. It is the separation of the articular 
end of the bone from the shaft; the separation occurs at the cartilagi- 
nous junction of the shaft and the expanded extremity. This line is 
transverse, except as it finds irregularity in the overlapping of a portion 
of the shaft, as at the tubercle of the tibia. The cartilaginous lamina 
between the shaft and epiphysis is not suddenly obliterated at one time, 
so that where the separation occurs at a time when it is partly ossified 
portions of the shaft or epiphysis are broken off, usually as thin scales 
of bone. It requires considerable force to produce such a fracture, and 
the damage inflicted is often increased by the stripping of the periosteum 
from the shaft. 
(E) A multiple fracture occurs when there is a fracture at separate 
points of a bone or when there are several fractures in different bones 
at the same time. This term should not, however, be applied to the 
fracture of associated parallel bones, such as the radius and ulna or the 
tibia and fibula, when only one break in each is present, for they act as 
a common bone in resisting violence. A multiple fracture of a single 
bone implies that the fractured points are separate and are not close 
together. A bone may be broken into a number of fragments, but if 
the lines of fracture run one into the other and the fragments are 
comparatively small, it becomes a comminuted fracture. 
(F) An impacted fracture is where one fragment penetrates the 
other and becomes imbedded in it. This fracture may occur in any 
part of a long bone, but is most frequent in the expanded extremity, 
where a point of bone is likely to be entangled in the cancellated bone. 
The interlocking of the fragments must be firm enough to give some 
stability to the parts and to resist free movement at the line of fracture. 
This occurs not infrequently at the trochanter of the femur and the 
lower end of the radius. 
(6r) A compound fracture is one in which the broken bone has a 
more or less free communication through the muscles and fascia with a 
wound in the skin. An incomplete fracture may be compound. A 
compound fracture may be produced by direct or indirect violence. 
Direct violence bruises and lacerates the tissues. Indirect violence 
forces the bone through the skin and soft parts. It is one of the most 
important complications of fractures. A gunshot fracture is, of course, 
always compound. If a gunshot fracture occurs in the shaft of a long 
bone, it is almost always accompanied with comminution of the bone, 
thus adding another complication to the fracture. If the ball enters 
the cancellated bone, the fracture may be very limited, and, notwith- 
standing it is a compound fracture, it may heal readily and intlict but 
little damage. The splitting and splintering of the shaft of a long bone 
by a bullet is a serious injury. FRACTURES. 
693 
(77) The intra-articular fracture passes directly into the articular 
surface of a joint. 
Etiology of Fractures.—The strength of a bone is determined 
by its texture; hence the same bone in different individuals varies 
markedly in its resisting power. Compact bone substance is always 
stronger than spongy bone. 
The form of a bone may predispose it to fracture. The long bones and the flat 
bones are more liable to fracture than the irregular ones. The function of a bone 
may predispose it to the violence which results in fracture; thus the forearm and 
leg are most exposed, but the single bone, the humerus, transmitting the violence 
of many falls to the body, is often fractured. The clavicle is in the same way sub- 
ject to fracture. 
The habits of life of the individual have much to do with exposure to accidents, 
the period of greatest activity being the time of the most frequent occurrence of 
fractures—viz. from the twentieth to the thirtieth year of life. Males are most 
exposed, and, although their bones are stronger than the bones of the female, they 
suffer more fractures than females do. 
The age of the individual is a potent factor in the etiology of fractures. It is 
a well-known fact that the increased size of the medullary canal and the dimin- 
ished thickness of the cortex of the shaft of the long bones that occurs in old age 
are predisposing causes of fracture. The atrophic changes occurring in the aged 
affect alike both sexes, but with this fragile condition of the bones of the aged the 
relative weakness of the bones of females becomes more evident in the marked 
increase in the frequency of certain fractures, notably those of the neck of the 
femur and of the lower end of the radius. 
Rickets weakens very materially the bones and predisposes to fracture, though 
it so markedly limits the activity of the child that in many cases it protects from 
fracture by imposing conditions which prevent exposure to violence. The 
stumbling of rickety patients, however, inflicts many hills and consequent frac- 
tures. No doubt intra-uterine fractures are more frequent in infants where the 
foetal bones are diseased, as in congenital rickets. Various constitutional diseases, 
such as scurvy, syphilis, and struma, disturb the nutrition of the bones and 
weaken them. Trophic changes resulting from diseases of the nervous system 
may change the bone so as to predispose it to fracture. Rauber found that the 
tibia of a paralyzed extremity weighed 6.6 ounces, and of the healthy extremity 
of the same subject 9.4 ounces. 
Local inflammatory conditions of a bone, such as caries and necrosis, 
may materially weaken it. Atrophy of a bone, whether produced by 
disease, paralysis, senile changes, or disturbed circulation, enlarges the 
medullary canal, increases the size of the interspaces in the cancellated 
bone, and thus weakens the cortex of the bones, so that they have but 
little resisting power. Mollities ossium or osteomalacia is a disease of 
adult life apparently dependent upon trophic changes due to nerve 
lesions, pregnancy, or cancer. The outline of the bone is not changed. 
The medulla changes in character, so that it does not renew the dis- 
integrating bone. The cortex is largely replaced by fatty material and 
the bones readily bend or break. The bones also become fragile from a 
condition of osteoporosis which results from an inactive life or mal- 
nutrition. 
Syphilis, by the development of gummy tumors or a rarefying oste- 
itis, may predispose the bones to fracture. Thus it is manifest that 
physiological as well as pathological conditions predispose to fractures. 
The immediate cause of fracture is found in the violence of extra- 
neous force or muscular action. Fractures from external violence are 
caused either by direct or indirect force applied to the bone. Direct 
violence may produce a fracture at any point to which it is applied. 694 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
Indirect violence usually produces a fracture at some particular point of 
weakness to which it is transmitted. It is apparent that the degree of 
violence necessary to produce a fracture will vary not only with differ- 
ent bones, but with the physiological and pathological conditions of the 
bone, together with the manner of the infliction of the violence. 
Tillmanns gives the following in regard to the strength of the bone: “The 
tensile strength of the compact bone substance amounts, in the fresh condition 
and in middle life, according to Rauber and Messerer, to from 9.25 to 12.21 kg. 
(20.35 pounds to 26.86 pounds) for every square millimetre of cross-section; that 
is, it is about equal to that of brass and cast iron. Its resistance to pressure is 
still greater, being from 12.56 kg. to 16.8 kg. (27.63 pounds to 36.96 pounds) for 
every square millimetre of cross-section, being about double as much as that of 
wood, granite, or lead. The capacity to resist torsion amounts on the average to 
8 kg. (17.6 pounds) per square millimetre of cross-section. The strength of the 
spongy bone substance is much less. The resistance to pressure of the spongy 
part of the condyles of the femur, according to Messerer, amounts to only 0.96 
kg. (2.11 pounds) per square millimetre on cross-section; that of the body of the 
vertebrae to 0.84 kg. (1.84 pounds) in middle life, and in senility to only 0.22 kg. 
(0.48 pounds) per square millimetre of cross-section. 
“ Of especial practical significance in the etiology of fracture is the strength 
of the bone as a whole. The tensile strength of the humerus, for example, 
according to Messerer, amounts to 533 kg. (1192.6 pounds); of the femur, to 674 
kg. (1482.8 pounds). 
“ For strength to resist pressure Messerer found the separate bones to be in 
the following descending scale: Tibia, femur, humerus, radius, ulna, clavicle, 
fibula. 
“By pressure in the long axis there occurred a crushing fracture of the shaft 
of the tibia, for example, with maximum weight of 1650 kg. (3630 pounds); of the 
femur, in men, on the average, as a result of 756 kg. (1663 pounds); of the radius, 
in men, on the average, as a result of 334 kg. (735 pounds); and in women the 
radius broke as a result of 220 kg. (484 pounds) pressure. Frequently the break 
did not occur at the most exposed place—that is, the middle of the bone—but 
through the compression of an articular extremity. 
“A great number of fractures, as is well known, are bending breaks (Messerer; 
P. Bruns). The ability of bones to resist this kind of force varies in the different 
periods of life, attaining the maximum in middle life. A bending fracture of the 
femur in men follows a pressure of 400 kg. (880 pounds), and in women a force of 
263 kg. (578 pounds) produces a break. 
“ The torsion elasticity amounts to perhaps one-third of the bending elasticity. 
A torsion break of the femur, according to Messerer, follows generally as a result 
of 89 kg. (196 pounds) force, and the clavicle breaks on the application of 8 kg. 
(17.6 pounds). 
“ According to the experiments of Messerer, in most cases, with gradually 
increasing pressure upon the skull, the free diameters increased very little indeed. 
The diminution of the diameters in the direction of the pressure did not occur 
uniformly over the whole skull, but only the parts to which the pressure was 
applied yielded inward. In the sagittal direction the skull bore a greater burden 
than in the transverse. By transverse pressure there occurred a transverse break, 
and by longitudinal pressure a longitudinal break.” 
Direct violence may be inflicted either by the muscular action of the 
individual forcing the bone against a resisting body, or by an extra- 
neous force driving the foreign body against the bone. The calcaneum 
may be broken by the direct violence of a fall, the heel coming violently 
in contact with the ground. A wheel passing over a limb, breaking it 
at the point of contact, inflicts direct violence to the part. 
Indirect violence more frequently breaks the long bones than the 
short or irregular ones. It is evident that peculiarities in the mechan- 
ism of the violence are important factors in determining where the frac- 
ture occurs; for instance, a fall upon the hand may break the radius, FRACTURES. 
695 
the ulna, the humerus, or the elavicle; so also a fall upon the foot may 
break the fibula, tibia and fibula, or the femur. 
Weak points and curves in the bones help to determine the site of 
fracture. Certain important differences in the fractures produced by 
direct and indirect violence must exist. The damage to the soft tissues 
at the seat of fracture will be much less by indirect violence. The 
broken ends of the bones may lacerate the muscles, the skin, or the 
vessels and nerves, but the damage is not likely to be so great as in 
fractures produced by a violence which may bruise and crush all of the 
tissues surrounding the injured bone. Muscular action, unaided by 
external violence, may produce fractures. The olecranon and patella 
are the most frequent examples of this kind of fracture. The humerus 
and femur are not infrequently broken in this way. The humerus is 
thus broken in the act of throwing. It may also be broken by torsion, 
instanced by two men placing their elbows on a table with their fore- 
arms upright and interlocking hands, and each endeavoring to force the 
hand of his opponent backward toward the table. 
The femur may be broken by a twist in kicking. These fractures 
occur as a result of comparatively little force, as the bones have but 
little capacity to resist torsion. 
The compression of uterine contractions and external violence may 
produce an intra-uterine fracture. A congenital fracture is to be distin- 
guished from a fracture produced during delivery by the traction and 
manipulation of the attendant. 
The deformities produced by the displacement of the fragments of 
the long bones are designated as angular when the axis of the bone is 
bent at the break ; as lateral when the fractured ends are displaced to 
one side, so that the axis of the two fragments are not in the same line, 
though they may be almost or quite parallel; as longitudinal when the 
ends overlap; and as rotary when a segment of the bone is turned upon 
its own axis. A wide separation of the fragments may occur by mus- 
cular action, as in the olecranon process of the ulna, or in the os calcis 
when the posterior extremity is detached and pulled up, or in the wide 
separation of the fragments of the patella. 
The complications of fractures are of two kinds, immediate and 
remote. The primary local complications are numerous; for example, 
the open wound, the extreme obliquity, the involvement of a joint in a 
fracture, injury to a contained organ, as in the fractures of the skull and 
thorax, comminution of the bone, or compound fracture with the impli- 
cation of a joint. To these we may add great destruction of adjacent 
tissues, the injury of arteries, veins, and nerves, the intervention of the 
tissues between the fragments, the wide separation of the fragments, 
emphysema, and free hemorrhage. The constitutional complications of 
shock and delirium may be present. 
The secondary complications may develop in simple fractures, but are 
more likely to follow complicated ones. These secondary complications 
are deformities, delayed union, and false joint or an ankylosed joint; or 
trophic changes, together with sepsis, thrombosis, embolism, or tetanus. 
Symptoms and Diagnosis.—The diagnosis of a fracture is often 
very easy, though in some cases it is extremely difficult even after the 
careful consideration of every symptom. The symptoms are both sub- AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
jective and objective. Some of them are pathognomonic, others only- 
suggestive. In many fractures all of the symptoms are easily elicited ; 
in others nearly all of them are absent. Even where most of them are 
absent the diagnosis may be positive. Symptoms such as pain, loss of 
function, and history vary in importance with different patients, though 
the fractures may be similar. 
The points to be considered in the diagnosis of fractures are as fol- 
lows : 1. The history; 2. Loss of function; 3. Pain; 4. Crepitus; 5. 
Mobility; 6. Deformity; 7. Ecchymosis; and 8. Redisplacement. 
The history, to be complete, should include an inquiry into the exist- 
ence of predisposing causes and also that of previous injuries. The 
immediate history of the accident includes the manner and the points 
at which violence was inflicted, as well as a statement of the degree of 
violence and the recognition of an audible snap. It is generally impos- 
sible to estimate the degree of violence, and very generally the snap of a 
bone, if any is produced, is unrecognized in the excitement of the acci- 
dent. The character of the violence and the point of its reception are the 
most valuable items in the history. Loss of function almost uniformly 
accompanies fractures. Impacted fractures, as at the trochanter and 
an occasional simple fracture of the tibia or fibula and the green-stick 
fractures, may exist without total loss of functional activity. On the 
other hand, it should be remembered that temporary loss of function is 
sometimes produced by contusion, fright, and nervous disturbances. 
Localized pain and tenderness are often important symptoms of a 
fracture. Pain on muscular movements of the limb or at a point where 
no direct violence has been inflicted is a valuable aid to diagnosis. Pain 
at a point where direct violence has been inflicted may be due to con- 
tusion of the superficial soft parts or of the periosteum. If the pain is 
referred to a limited area, is elicited only on pressure, and always at the 
same point, but without apparent contusion of the parts, it is strongly 
suggestive of fracture. The pain of contused parts is more likely to be 
vaguely diffused and not so fixed in its location. 
Crepitus is the grating caused by rubbing the fractured ends together, 
and is recognized by the sense of touch as well as by being heard. It 
is pathognomonic of fracture, but is often absent, and in many cases 
should not be sought for, as the diagnosis is clearly established without 
it. The crepitus of rough bone surfaces rubbing upon each other is, in 
the neighborhood of joints, simulated by inflamed bursae and by tenosyn- 
ovitis. The crepitus of cancellated bone is softer than that of the dense 
bone of the shaft. 
Abnormal mobility in the shaft of a long bone is a positive symptom 
of fracture, but where the injury is near a joint it is sometimes extremely 
difficult to differentiate between the motion of the joint and the mobility 
of a break. This is especially true about the elbow and the hip, and it 
may be only after repeated trials or by the existence of crepitus that one 
can say surely there is abnormal mobility. Abnormal mobility is 
determined by manipulation, unless spasm of the muscles or voluntary 
movements exhibit it. It is absent in an impacted fracture and in a 
green-stick fracture, except where manipulation breaks the interlocking 
fragments apart. Roughly moving the fragments inflicts damage upon 
the contiguous tissues and pain upon the patient. FRACTURES. 
697 
Deformity is one of the most important symptoms of fracture. It 
may result from the swelling of the soft parts or be dependent upon the 
displacement of the bones. The swelling is due primarily to hemor- 
rhage, later to the infiltration with serum and lymph of the tissues sur- 
rounding the fracture. The deformity resulting from displaced bone 
may be a shortening, an angular or lateral displacement, a rotary dis- 
placement in the long bones, or an indentation of the irregular or flat 
bones. It is often pathognomonic, telling not only of the fracture, but 
suggesting more or less clearly its character. A wide separation of 
fragments may occur in certain fractures, as in those of the patella and 
the olecranon process. A careful inspection and palpation without 
movement of the injured parts, will often give the surgeon accurate 
knowledge concerning the situation of the fracture, the character of the 
violence, and the extent of the injury to the soft parts, and suggest the 
manipulation and the treatment required in a given case. 
The two sides of the body should be compared, in order to make mea- 
surements, expose symmetrical parts, and define the relative position of 
important landmarks, so that the deformity may be fully appreciated, 
for, though often most palpable, it is frequently so slight that the most 
careful investigation is necessary to reveal its presence. 
Eechymosis is sometimes distinctive of a fracture. An incomplete fracture may 
be suspected after injury if a point of pain exists where no direct violence has 
injured the soft parts, followed by the gradual development of ecchymotic areas at 
or some distance from the location of the pain. The blood follows the planes 
of the fascia, and is not evident until these lead it near the surface of the body. 
This symptom is especially valuable in the diagnosis of the fractures of the base 
of the skull, particularly of the posterior fossa. 
The existence of these symptoms may be more or less fully established without 
manipulation of the patient. It is important that all the facts in the case be 
made clear with as little handling of the parts as is compatible with security. 
It is a well-known fact that a dislocation once reduced generally 
keeps its place. This is not so with the majority of fractures, for they 
require extension and retentive apparatus to keep them in place. The 
re-establishment of a deformity after its correction is a valuable symp- 
tom and suggests the existence of a fracture. 
Treatment.—Bones so uniformly unite when properly treated that 
an exception to this rule needs explanation. The treatment of a frac- 
ture is a great responsibility, and every surgeon knows that in certain 
fractures it is difficult to get a perfect result; hence dissatisfaction 
between the patient and the surgeon is not infrequent. Every effort 
must be taken to give each case careful attention, and the treatment 
must include both local and general conditions. The local treatment 
involves two most essential points—the reduction of the displacement 
or correction of the deformity, and the retention of the fragments in 
their normal position. 
The reduction of the fracture, the “ setting ” of the bone, should be 
accomplished as early as practicable. In many cases it may be done at 
once, but in others it is better to wait until the patient is at home, 
where he can be kept quiet and where efficient treatment may be 
enforced. It is very rarely necessary to wait for the swelling or tume- 
faction to subside. This traumatic swelling subsides much more quickly 
and certainly if the adjustment of the fracture is promptly accomplished. 698 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
The perfection of the adjustment may be confirmed or established after 
the swelling has subsided, but it must, in part at least, be accomplished 
at once. Success in many fractures is best attained by prompt and 
efficient reduction. 
If the injury to the soft parts is excessive and danger of gangrene is 
imminent, it may be wise to limit the effort at reduction to simple con- 
tinuous extension with or without lateral support. The stability given 
to the injured parts by lateral supports is usually, even in these cases, 
a safeguard rather than a detriment, as its prevents excessive swelling, 
favors absorption, and diminishes the irritation produced by displaced 
fragments. Even in crushing injuries, when the extremity can be saved, 
it is extremely rare to find a case that demands a delay of several days 
in the adjustment. The effort to reduce displaced fragments or to set 
the bone should be carefully conducted. The surgeon should avoid in 
his examination undue manipulation, and above all things he must not 
add to the injury already inflicted. 
The application of heat and cold, as also the use of liniments and medicated 
washes, is of secondary importance. However soothing they may be, they cannot 
be of much use if the bones remain displaced, irritating the soft parts, exciting 
muscular spasm, and destroying tissues by pressure. Moist heat applied to stimu- 
late the circulation and aid in maintaining the vitality of the contused parts is 
perhaps the most universally advantageous. Cold compresses and ice-bags must 
be cautiously used, for, while they limit the acuteness of the reactionary pro- 
cesses, they may so depress the vitality of the injured tissues as to determine 
necrosis. 
Muscular contraction is the first obstacle to the reduction of a 
fracture. This is to be controlled by traction and counter-traction, rarely 
by anaesthesia. Anaesthesia is more frequently demanded for diagnostic 
purposes than for the adjustment of fracture. The temperament of the 
patient often determines the necessity for its use. It is demanded in 
cases of doubt. The stage of muscular excitement which so often pre- 
cedes the relaxation of full anaesthesia is at times a serious disadvantage 
in treating patients. Gentle traction, often necessarily continuous, aided 
by the knowledge of the fracture obtained through inspection and the 
history of the accident, will enable the surgeon to set the bone without 
much pain and with a minimum amount of manipulation and injury. 
If the fracture is oblique with overlapping or transverse with angling, 
extension is often all that is needed. If it is transverse with lateral dis- 
placement, it will need not only extension, but careful manipulation with 
pressure. The interposition of muscle and fascia and impaction occa- 
sionally resist proper adjustment. 
The retention of the fragments in position after they are adjusted 
may be easy, but it will often tax the ingenuity and tact of the surgeon 
to the utmost to maintain even a fair approximation. Surgeons should 
remember that slight motion at the seat of fracture does not interfere 
with repair. Absolute immobility is not necessary for good and rapid 
union. The ribs, the clavicles, the femur, and the humerus are con- 
stantly in evidence on this point. Extension and counter-extension 
without lateral supports may be all that is necessary. Rest and an easy 
position secured by lateral supports and slight pressure are efficient in 
many fractures of the forearm and leg. A fractured bone may usually be 
kept in good position without being subjected to undue lateral pressure. FRACTURES. 
699 
The union will not be good unless the fragments when at rest are 
properly adjusted; hence the retaining apparatus must so utilize the 
principles of extension and lateral support as to accomplish this purpose. 
Repair of Fractures. 
Tlie repair of a fractured bone is by the formation of new bone-tissue. This 
new bone is ultimately perfect in its character. It is rare that union fails or that 
untoward morbid processes are engendered by a fracture. 
The amount of new bone formed about a fracture is greater in the shaft of a 
long bone than in its epiphysis or in the flat or irregular bones. It is increased 
when the adjustment is imperfect and when the fragments move so as to increase 
the amount of irritation. 
The histological changes and clinical phenomena which accompany 
the healing process are uniform. The character of the bone fractured 
and the complications encountered may alter the orderly process, but not 
the method, of repair. A fracture is uniformly accompanied by more 
or less hemorrhage from the bone and soft parts, the amount being de- 
pendent upon the location and character of the fracture and the extent 
of laceration of the contiguous tissues. This blood-clot plays a part 
in the generation of bone that is to follow only in that it gradually dis- 
appears, and is replaced by a soft vascular mass, the so-called germinal 
tissue, which envelops the bone at the seat of fracture. The cells in 
the vicinity of the fracture begin to multiply and new tissue is generated 
(see Fig. 300). This tissue is rapidly vas- 
cularized if the fracture is in cancellated 
bone, as in the flat and irregular bones and 
in the expanded ends of the long bones. 
Medullary tissue is found not only in the 
central cavity of a bone, but also distributed 
throughout the cancelli of bone, and under its 
influence and that of the periosteum a small 
amount of new material is converted rapidly 
into bone-tissue. It does not, necessarily, 
become first cartilage and then bone. The 
bone-cells, or osteoblasts, are found in small 
irregular cavities. Lime salts are deposited 
in the fibrous matrix of the new bone. The 
bone-tissue first formed is soft and coarse, 
taking a long time to become firm, hard 
bone of normal vascularity and density. 
The fibrous mass which develops about 
a fracture in the shaft of the long bones is 
quite abundant and forms a large plastic 
mass, which lifts the periosteum from the 
bone and envelops it both on its superficial 
and deeper surfaces. It forms a film be- 
tween the firm broken edges of the cortex 
which connects this external envelope with 
the plastic osteoid substance which fills the 
medulla. The part of this plastic mass 
which immediately surrounds the break is generally converted into 
cartilage before calcareous or ossific matter is to be found in it. 
Fig. 300. 
Fracture three weeks old; periosteal 
and medullary callus partly ossi- 
fied, partly cartilaginous : P, peri- 
osteum ; K, bone; M, medulla (Till- 
manns). 700 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
This fibrous mass or callus envelops the bone, extends in a thin 
lamina between the ends of the bone, and occupies the medullary canal 
for some distance above and below the site of the fracture. The portion 
within the medullary cavity is called the internal callus, while that 
between the ends of the bones is the intermediate callus. 
The periosteum is buried in the new deposit. That portion of the 
periosteum near the periphery of the callus is the part which is vascu- 
larized first. Here the circulation is most perfect, and the osteoblasts 
are first found. The vascular supply from the periosteum is most free, 
and the blood-vessels extend from it into the callus. The blood-vessels 
from the bone emerging from the Haversian canals also permeate it. 
The periosteum is the most active osteogenetic agent, but the medulla is also 
very active. The thicker portions of the callus immediately surrounding the break 
where the blood-supply is slowest in being perfected becomes cartilaginous. The 
blood-vessels must permeate this cartilage before it is converted into bone. Osteo- 
blasts are not found in cartilage except under the direct influence of and in contact 
with blood-vessels. A zone of osteoblasts penetrates the cartilage about the blood- 
vessels, and then the osseous tissue is formed around them, so that, though neither 
cartilage nor blood-vessels alone are capable of forming bone, the two, together 
with the aid of the osteoblasts, accomplish this end. 
The ossification of this callus occupies from four to eight weeks. 
During this time the broken ends of the bone still present a hard, rough 
line and have undergone but little change. The Haversian canals with 
their blood-vessels are, however, growing larger and the bone more 
porous. The spaces become large and irregular in outline and are filled 
with osteoclasts or giant cells. These large cells are destructive and not 
conservative. The bone-tissue is riddled with holes. A rarefying 
osteitis is established which continues until the ends of the bone are 
more like cancellated bone. 
Fig. 301 
Lacunar bone-absorption by osteoclasts (Tillmanns). 
As blood-vessels permeate the thin cartilaginous or osseous lamina between the 
ends of the bone, this lamina and the hone ends become highly vascularized. The 
rarefying osteitis thus established precedes the reparation of the break by new 
bone-tissue now to be formed between the broken ends. The new porous bone 
already enveloping the fractured surfaces and the bone occupying the medulla are 
becoming more dense. The spongy bone which now forms the ends of the frac- 
tured surfaces becomes less vascular. Osteoblasts replace the giant cells which 
have absorbed the dense cortical bone, and it again becomes more compact. The 
two surfaces are joined by bone, open and porous at first, but becoming denser as 
the active nutrient changes subside and the osteoclasts disappear, which were so 
necessary in preparing the bone for the vascularization essential to the formation 
of the bone required to unite the fractured surfaces. FRACTURES. 
701 
Pathologists differ concerning the origin of osteoclasts. “ Kdlliker states that 
they are derived from the osteoblasts; Wegner, that they are formed out of adven- 
titia cells; Von Recklinghausen, that they come from the white blood-cells; but, 
according to Pommer, the osteoclasts do not arise alone from the osteoblasts, but 
from the adventitia cells of the blood-vessels, from the perivascular endothelium 
of the lymph-spaces, and from the Haversian blood-vessels. In short, the proto- 
plasm of all the cells which lie in the 
vicinity of the bone can under certain 
conditions take on the functions of osteo- 
clasts. The origin of the osteoclasts is 
varied, so also is their final disposition. 
“The action of the osteoclasts is 
altogether local. The bone disappears 
under their effect, forming small exca- 
vations which are enlargements of How- 
ship’s lacunae (Fig. 301). The osteo- 
clasts probably generate carbonic acid 
by which the lime salts are dissolved. 
The remaining ground structure is 
assimilated, and taken up by the osteo- 
clasts or resorbed by the blood- or 
lymph-stream.”1 
Osteoblasts are seen next to the bony trabeculae which form the walls of the 
granulation-spaces (see Fig. 302). Laminae of bone are deposited, and a condens- 
ing osteitis takes place, so that after many weeks the bone surfaces are reunited 
by dense, firm bone. 
Fig. 302. 
Periosteal bone-formation by agency of osteo- 
blasts : c, old bone (Tillmanns). 
The osseous tissue that still occupies the medulla and forms the mass 
which envelops the bone, and produces the thickening at the seat of the 
fracture, is now to be absorbed and removed. This is slowly accom- 
plished, the medullary cavity is re-established, the external callus is 
absorbed, rough points are rounded off, and the evidences of injury 
slowly disappear. 
If the fracture cannot be made immobile or is imperfectly adjusted, the orderly 
process described is interrupted. The amount of new material necessary to unite a 
fracture under these conditions is much greater and the time required is increased. 
The healing process is delayed or completely interrupted, just as it is in the soft 
tissues when they are pulled apart or disturbed by motion or imperfect adaptation. 
There is also more scar and the deformity is increased. The callus is thick and 
abundant when union occurs under such conditions. 
Osteophytes may develop during the healing of a fracture. They 
are most apt to spring from points of tendinous insertion or from mis- 
placed pieces of periosteal tissue. 
It must not be understood that the fractured surfaces are unchanged 
until the provisional callus which constitutes the primary union is fully 
organized. The rarefying osteitis which precedes the solid union of the 
cortex of the long bones begins soon after the injury, but the vascular 
canals are plugged with blood-clots and the process of vascularization 
is slow. The collateral circulation which is to be developed in the bone 
requires time. It is so slow that the bone is united by the surrounding 
callus, and is firm enough to resume its function before ossific matter 
has transformed the intermediate callus into bone of normal structure 
to complete the repair. 
The repair of intra-articular structures is modified by the synovia 
and the cartilaginous lamina over the surface. Cartilage is not 
developed to repair the break in its surface. The line of fracture 
1 Tillmanns, vol. i. p. 499. 702 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
remains either as a sulcus with the bone at the bottom of it, or it has a 
thin fibrous band at the depth of the sulcus bridging the line of fracture. 
I ntra-articular fractures are said to be more liable to non-union ; this, 
however, is not well established, for union generally occurs. 
The union of epiphyseal fractures takes place rapidly. The line 
of fracture follows generally the epiphyseal line, but frequently varies 
slightly from it, for scales of bone are found adherent to the cartilagi- 
nous line. If the irritation and inflammation are excessive, the cartilage 
may be destroyed or converted into bone. Hence the growth of the 
bone in length may be arrested. This seems to be the exception, how- 
ever, and not the usual result. 
The treatment of compound fractures is of the greatest 
importance. Antiseptic and aseptic surgery lias completely revolution- 
ized the practice of surgeons in caring for such wounds. The first 
essential in the treatment of such an injury is that the surgeon shall 
approach it with perfectly clean hands. The area about the wound 
should be rendered aseptic by the use of the razor, soap and water, and 
antiseptic washes. The wound should not be hermetically sealed when 
the injury is severe and complicated by comminution and contusions. 
Let the wound serve as an avenue for drainage. Gauze dressings may 
materially aid in making drainage free and safe. 
In a large percentage of cases produced by direct violence, where 
extraneous matter has been forced into the wound, it is better to anaes- 
thetize the patient. The wound can then be more thoroughly cleansed 
and inspected. This inspection means that the opening should be 
enlarged or that other openings be made that will permit of a thorough 
recognition of blood-extravasation, of the laceration of the soft tissues, 
and of the degree of comminution of bone. Loose fragments of bone 
should be removed and lacerated tissues, if their vitality be much 
impaired, should be trimmed off. Large blood-clots should be evacu- 
ated, and especially is this true if they are in the subcutaneous tissue. 
The fractured ends of the bone are to be adjusted. The wounds are 
then to be partly closed, an angle usually being left for drainage. It is 
not often necessary to use drainage-tubes, and rarely for more than two 
days, if primary union is to be attempted. 
Even if the wound is clean, small, and the injury to the soft parts 
slight, it is safer to dress it as an open wound with an abundant pad of 
gauze over it. The dressing, no matter what material is used, should 
not expose a moist surface to the air, for this favors contamination and 
infection. Absorbent dressings should be abundant, for it is not wise 
to disturb unnecessarily the fractured bones if possible to avoid it, but 
cleanliness must be maintained. 
It is very rarely necessary to wire fractured bones together in order 
to maintain apposition in compound comminuted fractures. It may be 
necessary to remove fragments and cut off sharp ends of bone, so as to 
facilitate adjustment, but the fracture can usually be retained in position 
without sutures. There are many compound fractures of the extremities, 
especially when produced by indirect violence, which after cleansing, 
Compound Fractures. FRACTURES. 
703 
removing fragments of bone and blood-clots, can be safely closed, and 
union will occur promptly. However, in the hands of the average sur- 
geon drainage is a safeguard. 
It requires more time for compound fractures to unite than for the union of 
simple fractures, but the nutritive changes are essentially the same. The for- 
mative material consists first of soft tissue rich in cells, which gradually, through 
the ossifying activity of the periosteum and medulla, is converted into bone. It 
should be the rule to inspect such fractures at proper intervals until they become 
fixed in position. Any one who is competent to make a first dressing for a com- 
pound fracture is able to inspect it without special danger, and he can be more 
certain of good adjustment and perfect position if it is inspected a week after the 
first dressing. The external wounds can often be benefited by a renewal of dress- 
ings. The progress of the wound toward recovery will of course determine the 
frequency of the dressings and inspection. 
Amputation is only justified in the gravest of compound fractures. There must 
be not only severe injury of the bone, but extensive laceration of the soft parts or 
grave interference with circulation before it is justified. Generally, the function of 
the limb must be fully compromised to justify it. Aseptic surgery makes it possi- 
ble to save almost all cases even where joints are invaded. If joints are freely 
drained and kept aseptic, they bear severe injuries well. The adjustment should be 
made as perfect as possible. The joint being opened does not in itself 
justify amputation. 
Delayed Union and Non-union. 
The formative power of bone is very great and repair is usually most 
perfect. Nutrition of bone, its normal waste and repair, as also its 
regeneration after injury, are influenced by the general condition of the 
patient. Pregnancy, lactation, general debility, and acute diseases may 
interfere, just as an exhausting hemorrhage or a great physical drain 
may interrupt the process. There are certain local conditions which 
delay or prevent union—viz. marked displacement, the intervention of 
muscles and fascia, or a foreign body. Suppuration may destroy repara- 
tive material. Defective nutrition, either through innervation or 
deficient blood-supply or disease of the bone, may arrest the reparative 
process. 
Certain bones and definite parts of a given bone are more liable to 
such interruption than others. The humerus, the bones of the leg, the 
femur, and the bones of the forearm are, in the order given, most liable 
to non-union. 
A careful distinction must be made between delayed union and non- 
union. Union may be so delayed that at the end of the first, second, or 
third month the plastic deposit is deficient in amount and very soft. Stim- 
ulation of the nutritive process by rubbing the bones roughly together, 
or by puncturing the fibrous material as well as the ends of the bones 
with a drill, may arouse renewed action and secure solid union. The 
establishment of more perfect circulation or the improvement in the 
general health effected by getting the patient out of doors and by renew- 
ing his activity may start anew a halting reparative process. 
In non-union the ends of the bone are rounded off, the medullary 
cavity is closed, the blood-supply to the seat of injury is diminished, 
and the ends of the bone at times may be widely separated by the 
absorption of bone. Non-union occurs very rarely—according to Ham- 
ilton, not more than once in five hundred fractures. It must be ap- 
parent to surgeons of large practice who have studied the clinical his- 704 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
tory of fractures that the treatment of the fracture has much to do with 
the failure to unite. Undue pressure, too light bandaging, over-anxiety 
about the process of union making the surgeon over-zealous in inspec- 
tion of the parts, imperfect adjustment, and undue mobility, are all ele- 
ments which should be considered. The surgeon should carefully con- 
sider every detail of his management of the case, as well as the local 
conditions pertaining to the fracture and the general condition and sur- 
roundings of the patient, before accepting the non-union as being pre- 
determined by conditions beyond his control. 
Age cannot be said to interfere with union of bones, for the general fact that 
fractures unite readily in the aged is daily verified by results. It must also be 
firmly impressed upon the mind of every surgeon that cases exist in which the 
nutritive conditions cannot be controlled by the most skilful management. These 
cases may come from chronic disturbances in health, from acute diseases and 
infections which may find in the fracture a seat for suppurative action. Compli- 
cations may arise in which it is impossible to maintain local conditions which 
favor reparative changes. 
Again, without visible reason absorption or atrophic changes may be excited in 
the bone instead of new deposits for regeneration and union. Even after the 
bone has been apparently well united the absorption process which removes 
redundant tissue may take place too rapidly and the bone bend, or fibrous mate- 
rial replace bone-tissue until a false joint is established. The diagnosis is not 
difficult: mobility, loss of function, wasting of the limb from non-use, and the 
pain are the symptoms. 
The purpose of treatment for delayed union or false joint is to re- 
excite the activity of the nutritive processes. The procedures adopted 
for this purpose are varied. If the mobility is slight, as is often the 
ease in fractures of the leg and the thigh, lateral supports may be 
adjusted and the patient allowed to use the limb. The continued irri- 
tation of the intermittent pressure exerted in walking renews and main- 
tains active nutritive efforts until union is finally accomplished. 
Where there is much atrophy of the soft parts massage exerts a good 
influence. The Brainerd method—viz. boring the ends of the bone—is 
a safe procedure if performed as an aseptic operation. 
If these simple methods fail, then the false joint may be exposed by 
a free incision, the tissues,'whatever they may be, that intervene between 
the ends of the bone cut away, and the medullary cavity opened by 
resecting the bones in such a way as to give good broad surfaces for 
approximation and easy retention. It is important in the operation to 
so arrange the local conditions as to give full approximation and easy 
retention. This approximation may be secured by nails, wire sutures, 
ivory pegs, chromicized catgut or kangaroo tendon, or simply by a splint. 
The individual case must determine the necessity of the use of the suture. 
It is not always necessary. It usually requires a much longer time to 
secure union in such cases than it does in primary fractures. The peri- 
osteum from the portions of the bones excised must be saved. 
SPECIAL FRACTURES. 
Fractures of the Nose. 
The nasal bones increase rapidly in strength and resisting power as 
they approach the os frontis. The nasal spine of the frontal bone rein- FRACTURES. 
705 
forces them at this junction. Fractures of the base of the nose are 
infrequent, but quite dangerous. The cribriform plate of the ethmoid is 
very apt to be implicated in this fracture, the fragments of which very 
easily penetrate the brain. Inflammation and sepsis are apt to follow, 
for the spicuke of the cribriform plate are sharp and the communication 
with the nasal fossae offers a good opportunity for septic infection. The 
fracture may include the nasal process of the superior maxilla and the 
vomer. A broken nose is not dangerous to life, except when it is broken 
at the base and complicated with fracture of the cribriform plate. The 
break in the lower segment is most frequent, the injury being to the nasal 
bones only, though the perpendicular plate of the ethmoid may be bent 
or broken. The fracture is always by direct violence, is frequently 
comminuted, and often compound both by wound of the skin and the 
mucous membrane. 
The cartilages of the nose are frequently separated from their attach- 
ment to the nasal bones. This accident is of the same clinical import- 
ance as a fracture of the nasal bones in their lower segment. Hemor- 
rhage is occasionally severe, recurrent, and prolonged. 
Deformity by deviation to one side or a flattening of the nose, crep- 
itus under pressure, mobility, obstruction to the nasal passages by blood- 
clots, swelling of the mucous membrane, and the history of the accident 
are the common symptoms of these fractures. 
Emphysema of the eyelids or cheeks also indicates fracture of the 
nose, and, although it may conceal the real deformity of the displaced 
bones, it is not a serious condition and rapidly subsides. It is produced 
by the escape of air from the nose in the act of sneezing or blowing. 
Bleeding into the subcutaneous tissue and the swelling from the contu- 
sion of the soft parts may also conceal the exact nature of the injury. 
The deformity produced by an irregularity in the outline of the nose 
makes these fractures of extreme importance, and an accurate adjust- 
ment of the comminuted bone is necessary to the symmetry of the part. 
Any irregularity in the outline is most obvious and changes the whole 
expression of the face. If the displacement is marked, the adjustment 
can be accomplished best by force applied from within the nostril, a firm 
knitting-needle or a small grooved director serving very well for accom- 
plishing this purpose. It is well to wrap it with iodoform gauze or plain 
sterilized gauze, which should be firmly applied to the bar, and the whole 
should not be more than three-sixteenths of an inch thick. This is to be 
carried upward and backward along the septum until it passes beyond 
the break, and then carried firmly and strongly forward until the bones 
are pushed and moulded into position. In order to accomplish this it 
should be carried forward along the septum parallel with the nasal bones 
until it rests in the groove between the plate of the ethmoid and the 
nasal bones. The wrapping of gauze should be held in position by the 
porte-meche, the fingers, or the forceps while the smooth rod upon which 
it has been carried into place is withdrawn. 
If the comminution and displacement have been marked, a small cylinder of 
gauze should be put into each nostril. This plug, if well placed, certainly helps 
to maintain the fragments in good position and does not interfere with respiration. 
It helps to prevent contamination of the wound by the secretions of the nose, and 
it is a most efficient treatment for the free hemorrhage which occasionally occurs. 
The plugs of gauze should be allowed to remain undisturbed three or four days, 706 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
and then maybe renewed if deemed necessary. As the adjustment of the displaced 
fragments is painful, anaesthesia may be necessary, and should be used rather than 
accept an imperfect adjustment as final. If the fracture is at the cartilaginous 
junction, the plug of gauze must be made large enough and firm enough to give 
distinct support to the misplaced cartilage or the deformity is almost sure to recur. 
It has been recommended that the nose be transfixed with a needle and the 
ends of the needle supported by pads. This might give efficient support under some 
circumstances, but it is rarely necessary. External supports are of little avail, and 
the strips of plaster used for this purpose are of little use except to protect the 
external wound and to conceal deformity. Cotton steeped in comp, tinct. of ben- 
zoin and coated with collodion makes an efficient protective dressing. The bones 
are vascular, well nourished, and consolidate rapidly, being fairly firm in ten days 
or two weeks. Rubbing the nose, blowing, or sneezing, however, may displace the 
fractured bones during the first ten days. 
Lachrymal Bone. 
The lachrymal bone is broken in fractures of the base of the nose. 
It accompanies fractures of the nasal process of the superior maxilla and 
the lateral plate of the ethmoid. Emphysema is frequently present. 
The lachrymal duct may be obstructed. 
The treatment of fractures of the lachrymal bone is the treatment 
of the more serious injuries of which it is the accompaniment. The 
lachrymal duct must, however, be kept free by the passage of a full- 
sized probe. 
Superior Maxilla. 
The nasal and alveolar processes are frequently broken. The nasal 
process suffers fracture in the crushed injury of a broken nose. The 
alveolar arch is broken by blows which loosen the teeth or break away 
the entire arch or a segment of it. Fractures of the body of the bone 
are the result of great violence. The blow may be transmitted through 
the malar bone. The injury inflicted in this way is to the wall of the 
antrum. Breaks in the body of the bone may separate the alveolar arch 
and the palate process from the upper segment of the bone. 
This complete and extensive fracture is usually accompanied by a fracture of 
the palate bone, and may involve the pterygoid process of the sphenoid bone. The 
separation may be complete and the movements of the detached lower segment 
quite free. Comminution of the bones of the face results from violence inflicted 
by a blow from a club, a kick of a horse, or, as in one case that came under per- 
sonal observation, by the hoof of an ox which was planted on the face of a pros- 
trate man. Undue mobility, irregularities in the outline of the face, hemorrhages 
from the nose, the mouth, the pharynx, or the orbit, as also emphysema, crepitus, 
and the history, indicate the character of the injury. Stimson states that Guerin 
has found mobility and crepitus of the pterygoid process characteristic of the hor- 
izontal fractures of the bone where the symptoms were obscure. 
Patients bear these injuries wonderfully well. Repair is rapid and 
union by bone almost certain, though the deformity may be great. It 
is earnestly recommended that all fragments shall be left in place, as 
no portion of the bone, unless it be completely detached, should be 
removed. All the fragments should be saved and moulded into the best 
possible shape, and then given such support as it is possible to secure 
to keep them in place. Loose teeth should not be removed, for they 
will become fixed in position again. Notwithstanding the extreme 
vascularity of the parts, hemorrhage is not apt to be excessive. The FRACTURES. 
707 
cavities of the nose, the pharynx, and the mouth, as also wounds of the 
skin, are open avenues to infection. Phlebitis, lymphangitis, septicaemia, 
erysipelas, and necrosis are possible complications which make the injury 
a serious one. Suppurative inflammation of the antrum is also a trouble- 
some sequel which may develop. 
Partial fractures of the alveolar arch must be held in place, if 
mobility or displacement be present, by wiring the teeth in the fragment 
to the adjacent teeth in the uninjured portions of the arch. The frag- 
ment of the arch, either with or without the teeth, may be secured by 
an interdental splint of wire, gutta-percha, or other suitable material. 
The skill of the dentist is often required. Displacements of portions of 
the body of the bone are often difficult to treat. The displacement is 
generally downward and backward. The Angers in the mouth and a 
blunt hook to catch behind the palate or to hook over the orbital margin, 
or to pass from a wound or incision in the cheek about some point of 
the displaced bone, even when vigorously used, cannot always accom- 
plish perfect adjustment. This is especially true in fracture of the 
maxilla with depression of the malar bone. 
Consolidation is rapid, repair being complete in a few weeks. Suppuration 
and necrosis may delay repair and make the union of the fragments tedious. 
Fortunately, the violence usually forces the fragment downward; hence it is only 
where the base of the nose is injured that we are liable to direct injury to the base 
of the skull and brain as a complication in the fracture of the superior maxilla. 
Malar Bone and Zygomatic Arch. 
The body of the malar bone is very rarely broken, for it is thick and 
strong and articulates with a bone which gives way and allows displace- 
ment inward before sufficient force has been applied to cause fracture. 
The wrall of the antrum caves in or the bone is displaced toward the 
orbit. The zygomatic arch breaks under direct violence or as a compli- 
cation in the displacement of the malar bone. The break most fre- 
quently occurs in the temporal portion of the arch. 
Deformity, pain, and interference with the motion of the lower jaw 
are the symptoms most frequently present. The depression at the seat 
of the fracture is not so difficult to correct as it is where the malar bone 
is displaced and the fracture of the arch occurs as a complication of 
fracture of the maxilla. 
The zygomatic arch may be elevated and the malar bone occasionally brought 
into position by passing a hook under the zygomatic process of the malar bone 
and pulling and lifting it into place. The incision through which the hook is 
passed need not make the fracture a compound one, and is not a dangerous pro- 
ceeding if made with aseptic precautions. If the injury is confined to the arch, 
the normal outline can usually be restored, but if the malar bone is fractured and 
displaced, even great force will not always correct the deformity. 
Inferior Maxilla. 
The position and prominence of the inferior maxilla greatly expose 
it to fracture. It is a dense, strong bony arch, compactly formed, some- 
what elastic, capable of free lateral movements, and well calculated to 
resist violence and maintain its integrity. It is, however, more fre- 
quently broken than any of the bones of the face. Fractures occur 708 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
most frequently in the body of the bone. Compression at the angles or 
blows upon the angle may break it near the centre of the arch, but the 
symphysis and the anterior portion of the body are the parts most 
exposed to direct violence, and are thus frequently broken. The ramus 
and the coronoid processes, though protected from violence, are generally 
broken by the direct injury of blows or by penetrating wounds. The 
condyle—or, more correctly, the neck—is broken by indirect violence 
transmitted through the body of the bone from the chin. The site of 
the most frequent fractures is at or forward of the mental foramen, often 
at the symphysis. 
The fracture is most frequently slightly oblique, extending downward and 
backward, and it is bevelled so that the anterior fragment is longer on its internal 
surface (Fig. 303). Fractures may occur at every part of the body of the bone.. 
Fig. 303. 
Fracture of the lower jaw. 
When they occur at the angle the obliquity is apt to be more marked. The bone is 
not infrequently, perhaps in one-fourth of the cases, broken at two separate points. 
The multiple associated fractures are situated, usually, one in the anterior portion 
of the bone, and the other at or near the angle of the opposite side, but the seat 
of the multiple fractures may vary from the condyle to the symphysis. Nearly all 
of the fractures are compound by communication with the oral cavity. This is 
especially apt to be the case where a tooth has been displaced. 
Diagnosis.—The diagnosis is easily made except when the fracture 
is in the coronoid process or in the ramus of the jaw. It is sometimes 
extremely difficult to determine the presence of a fracture when it is 
distinctly above the angle of the ramus. 
The general symptoms of a fracture of the jaw are pain, deformity, 
mobility, and crepitus. The pain is provoked by the movement of eat- 
ing and talking, and is often very great. The patient endeavors to miti- 
gate its severity by supporting the jaw. It should be remembered that 
the inferior dental nerve passes through the body of the bone. This 
nerve may be torn, but if not torn its encasement in a broken bony 
canal no doubt adds to the severity of the pain on any motion of the 
fragments. Fractures anterior to the mental foramen should not be so 
painful as those situated farther back in the body of the bone. The 
deformity is best recognized by observing irregularities in the teeth. 
The fracture rarely occurs in the body back of the molar teeth. The 
anterior fragment is apt to be displaced downward and inward. Where FRACTURES. 
709 
the fracture is well back toward the angle or in the ramus or neck, the 
deformity can sometimes be best detected by observing the symphysis. 
If this be displaced to one side of the central line of the upper incisors, 
and there be tenderness and pain in the region of the ramus on the same 
side, it is suggestive of fracture, and careful search should be made for 
it. Mobility may be very free, but slight mobility is most common. 
Mobility, when the fracture is in the neck or condyle, may be appreci- 
ated best during movements of the jaw. Crepitus is usually plain and 
easily detected, except in fractures of the coronoid process. 
One or more teeth are loosened in fractures through the alveolar arch. Some- 
times a section of the alveolar arch with several teeth is broken from the body of 
the bone. The vascular supply is, however, good, and with the union of the frag- 
ments the teeth become firm again. Loose teeth should not be removed until it 
is evident that they will not become fixed in position. Necrosis of small fragments 
is frequent after these fractures. It is not, however, serious, except as it provokes 
suppuration and delays union. 
The treatment required in the great majority of cases is simple. 
It is not easy to secure immobility, but the slight movement between 
the fragments does not appear to interfere with union. Many of these 
fractures recover with practically very little help from treatment. To 
secure as much stability as possible the body of the jaw should be sup- 
ported by a splint or bandage and held against the upper jaw, which 
Fig. 304. 
Application of four-tailed bandage. 
serves as a splint. A moulded pasteboard, felt, or gutta-percha cup 
makes a good splint. This should be fitted to the chin and the body of 
the jaw, and serve as a cup in which the jaw rests, a padding of com- 
mon non-absorbent cotton being placed next to the skin. This splint is 
held in position by a four-tailed bandage. The sling or four-tailed 
bandage may be used without the splint (Fig. 304). 
Putting a wire or silk ligature about the teeth in many of the fractures is a 
simple and an efficient treatment if used in conjunction with an immobilizing cup. 
The wire loop should include at least two teeth on each side of the break, as con- 
stant tension on the teeth will soon loosen them. The wire should be silver, of 
medium size, and not too tightly drawn. If only the teeth next to the break are 
surrounded by the wire loop, their loosening is very apt to increase the irritation 710 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
about the fracture. If the break is markedly oblique, the difficulty in adjusting 
the fracture is often very great, and the retention in good position by a supporting 
splint is unsatisfactory. In these cases the tension on the wire loop is too great 
for the teeth to bear, and the tendency to displacement is so great that it will fre- 
quently break a wire if it is passed through drill holes in the bone. Interdental 
splints of heavy wire fitted to the teeth, formed from a plaster mould, are at times 
very valuable. The fastening together of the lower and upper jaw by wire loops 
about the teeth may offer material help during the short time it is necessary to 
immobilize the fracture. 
Ivory pegs driven through drill holes made in the bone near the break are usu- 
ally efficient and satisfactory. Generally a drill hole in one end may be so placed 
that the peg can be passed through it and forced into the cancellated tissue of the 
other end in a way to immobilize the fracture. If the bone be kept quiet for a 
week or ten days, it is not difficult to maintain reduction during the time neces- 
sary for consolidation. The ivory peg or the wire loosens in the bone by the rather 
rapid absorption, and the support given becomes lax. The ingenuity of the sur- 
geon will often be taxed to the utmost to devise methods to immobilize some of 
the fractures of the jaw. 
Union is rapid when necrosis does not occur. The bone is fairly firm 
in three weeks, though mastication of solid food should be longer delayed. 
Non-union is very rare. Fractures through the ramus of the jaw do 
not show much displacement. Immobilization of the jaw is all that is 
required in the way of treatment. 
The Hyoid Bone. 
The hyoid bone is broken by compression, either by direct force or 
by bending the head forcibly backward. Hemorrhage or marked inflam- 
mation, with collateral oedema, may render the injury serious. The 
swelling may impede respiration. The fracture ordinarily unites readily 
and without much inflammation, the union being either cartilaginous or 
bony. The result is usually satisfactory, as the displacement is generally 
slight. Dyspnoea, difficult deglutition, and pain on talking may be 
present as symptoms. 
The treatment is symptomatic. If the displacement is great, or if 
the cornua has penetrated the pharynx or been turned so as to be caught 
in the tissues, an attempt should be made to replace the fragment, and 
if this should be impossible it may be removed. The oedema of the 
glottis may demand tracheotomy, and the difficulty in swallowing might 
necessitate feeding by an oesophageal tube. 
Fractures of the ribs are frequent, but authorities differ as to the 
most common seat of these fractures. They are broken generally in the 
lateral wall of the chest (Fig. 305) at or between the angle and the 
anterior third of the rib. It is a very rare accident in the child, fre- 
quent in the adult and aged. It occurs from direct or indirect violence. 
It may result from a compressing force, one or more of the ribs being 
broken. 
The Ribs. 
The displacement is slight when only one rib is broken, but may be very con- 
siderable where several are broken. Direct violence produces fracture by pushing 
the arch of the rib inward, while indirect violence increases the outward curve 
until the bone breaks. The ribs most frequently broken are from the fourth to 
the eighth inclusive. The first, second, and third are well protected from violence 
by the clavicle, by the pectoral muscles, and by the shoulder. The lower ribs are FRACTURES. 
711 
not fixed and elude violence, so that they are rarely broken. The fracture is not 
often compound, except in those cases produced by direct violence. Penetrating 
wounds producing fracture may also add to this complication a wound of the pleura, 
the lung, the diaphragm, or the pericardium. Hemorrhage into the pleural cavity 
is at times a dangerous complication. 
Symptoms.—Collapse or profound depression may follow the violence 
inflicted. A weak and rapid pulse with dyspnoea and local pain are 
present in the graver injuries. Pain which is made worse by pressure 
at the point of fracture, or by pressure which will increase the arch of 
the rib, is an important symptom. Diaphragmatic or abdominal respi- 
ration is present. Emphysema beginning at the seat of the fracture may 
extend over the body. Hemorrhage from the wound, if the fracture is 
Fig. 305. 
Fracture of ribs; synostosis. 
compound, may be either external or into the thorax. Hcemoptysis from 
the wounded lung may occur. Crepitus may be distinct, but is often 
absent. The displacement is rarely enough to require attention except 
when several ribs are broken. It may then be necessary to correct the 
deformity by adjusting the fractures and securing them in position by 
fastening the ends together. 
Treatment is directed to the relief of pain, to limiting the motion 
of the chest-wall in breathing, to the arrest of the hemorrhage, and to 
the control of the irritation of the injured parts. Pain is relieved or 
controlled by a firm bandage or plaster strip applied so as to encircle the 
thorax and limit the movement of the chest-wall in respiratory efforts. 
This firm bandage helps to immobilize the fragments. Anodynes are 
also most useful, and in many cases must be resorted to. Relief from 
pain favors reaction and shortens the depression following the injury. 
Hemorrhage from an external wound may be controlled by direct 
ligature or by pressure. A pouch of gauze may be carried through the 
bleeding wound into the cavity of the thorax and stuffed with small 
strips of gauze, so that a knob of gauze can be firmly pulled against the 
inner thoracic wall. This prevents hemorrhage into the thorax, and by 
its pressure arrests it in the intercostal space. Haemoptysis is not often 
very free. Hemorrhage must always be carefully considered and con- 
trolled. 
The Sternum. 
The sternum is an open cancellated bone composed of several pieces 
which unite at different periods of life. It may be broken or separated 712 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
at the junction of the manubrium and the body, or the break may occur 
at the cartilaginous junction of the separate pieces of the body of the 
bone. According to Hoffa, statistics show that the sternum is broken less 
often than any of the bones, making only about 1 per cent, of fractures. 
The sternum is fractured most frequently by forcible flexion of the 
spine. A fracture induced in this way is most apt to occur in the upper 
section of the bone. Muscular action must also be recognized as a 
source of fracture. The great muscular effort used in lifting heavy 
weights has produced this fracture. Blows upon the sternum by a pole 
or club may induce fracture by direct violence. By far the larger num- 
ber of fractures result from the forcible bending of the body, either 
from a fall upon the head or the buttock, or by being caught while in a 
sitting posture between a moving wagon or car and a beam overhead, 
and thus forcibly bending the spine. 
The displacement at the seat of fracture may be marked. It is most fre- 
quently a forward displacement of the lower fragment, though it may be the 
reverse. This can be reduced usually by throwing the shoulders and head back- 
ward and taking a deep inspiration, though direct pressure upon the overriding 
end may aid in reduction. It is not always easy to maintain reduction. A pad 
over the fracture with a circular bandage pinned snugly around the chest may 
assist materially, however, in maintaining it. The union of the fragments is usu- 
ally rapid, and even if the displacement is not corrected, the function of the bone 
is restored. If the displacement is a source of great discomfort and danger to the 
patient, it should be corrected, even if an incision is necessary, and ivory pegs or 
steel nails may be utilized to secure the reduction. 
The xiphoid cartilage may be luxated or broken. This is sometimes 
a painful and dangerous accident, as it may induce spasm or irregular 
action of the diaphragm and violent vomiting. If its symptoms should 
be violent and serious, it can be exposed and fastened into place or 
removed. 
The Clavicle 
The clavicle is exposed to both direct and indirect violence. It is a 
curved slender bone, and to it or through it is transmitted the force of 
falls upon the hand, the elbow, and the shoulder. Direct blows upon 
the upper surface of the shoulder or upon the anterior surface of the 
base of the neck are also received by the clavicle. It is a very com- 
mon break, constituting 15-16 per cent, of all fractures. It occurs 
most frequently in children under five years of age. It is compara- 
tively rare in the aged, but frequent in middle life. The common seat 
of fracture is in the body of the bone just outside the middle, near the 
junction of the external with the middle third. The fracture at this 
site is generally the result of indirect violence. It is produced by a 
blow or a fall upon the shoulder or by violence transmitted through the 
arm. Any portion of the bone may be fractured by direct violence, 
though the external end is rarely the seat of fracture. It is rarely a 
compound fracture, although the bone is superficial, being covered only 
by the skin and subcutaneous tissue. Complications in the way of dam- 
age to adjacent important structures are also rare, the subclavian vessels, 
the plexus of nerves, and the pleura almost uniformly escaping injury. 
The displacement in fracture of the clavicle is very uniform—viz. the internal 
fragment is pulled upward by the sterno-mastoid, and the external one depressed FRACTURES. 
713 
and carried inward by the weight of the shoulder and hy muscular action. Dis- 
placement of the fractured ends is less marked if the seat of fracture be near either 
end. 
The SIGNS AND SYMPTOMS OF A FRACTURED CLAVICLE vary with 
the seat of fracture. The deformity and disability are less marked 
when the break is in the outer third. If it be in the body of the bone, 
the shoulder drops downward, and if the displacement be marked, it 
comes forward and inward. The head is turned toward the affected side 
and the patient seeks to support his forearm and elbow. The irregu- 
larity at the seat of fracture is easily discerned. The pain on motion 
is acute and the loss of power in the arm is complete. These signs are 
nearly all well marked in the adult, but in children a break in the 
clavicle often occurs with little displacement. The periosteum may 
remain untorn and the ends of the bone remain in good position. This 
modifies the deformity and lessens the pain, and the loss of function is 
not so complete, so that it is not an infrequent thing to have the injury 
overlooked by the mother for several days. 
Treatment.—Cases of the character last mentioned need but little 
treatment. A well-adjusted sling, giving support to the forearm and 
the elbow and confining the hand and arm of the child, will often 
answer all the indications. Strenuous but injudicious efforts to immo- 
Fig. 306. 
Moore’s dressing for fracture of the clavicle. 
bilize the shoulder in these simple cases may provoke further displace- 
ment and add to the deformity and pain. The multiplicity of the plans 
suggested for the treatment of fractures of the clavicle testifies to the 
inadequacy of the methods in vogue. The results of treatment in cases 
in which the deformity is marked are usually not perfect. There is gen- 
erally a little shortening and a well-marked callus. A comfortable and 
fairly-efficient method of treatment is the “ double figure of 8 ” sug- 714 
AFFECTIONS OF TIIE TISSUES AND TISSUE-SYSTEMS. 
gested by Dr. E. M. Moore of Rochester, New York (Fig. 306). The 
illustration shows the bandage applied. It is as follows: A strip of 
muslin a little over two yards in length and wide enough to be folded 
four times upon itself until it is a strip eight inches wide is held on the 
surgeon’s hand; the hand is placed under the elbow of the injured side ; 
the folded strip with ends of unequal length crosses the under surface 
of the flexed forearm at the elbow. The longer end, which is to the 
inner side, is passed upward inside and in front of the arm and is car- 
ried over the shoulder across the back and through the opposite axilla. 
It is brought over in front of the sound shoulder and meets in the back 
the short end, which is carried first up over the outside of the forearm 
and backward across the spine. 
These ends are secured to each other in the back and about the 
sound shoulder. The hand is supported in a sling which is attached to 
the bandage as it passes over the injured shoulder. The efficiency of 
Moore’s dressing depends on a recognition of the position of the fibres of 
the pectoralis major. Those arising highest are inserted lowest on the 
humerus, the tendon making a half turn as it descends to its insertion. 
Hence the farther back the elbow is held, the more are the clavicular 
fibres pulled upon—i. e. the fragments held in place. 
The figure of 8 crossing over the spine with a loop around each shoulder is fre- 
quently used. The loop placed about the injured shoulder should fit rather snugly, 
so that it will not slip too far inward from the point of the shoulder. If the loop 
is too large, it makes a downward pressure on the outer fragment, and tends in 
that way to increase the deformity. The most efficient treatment is attained by 
placing the patient in the recumbent position on his back, with a firm support 
under the spine. This should be so adjusted that the injured shoulder is allowed 
to hang free, its weight carrying it upward and backward. This treatment enforced 
for three weeks gives very good results. It is simple and effective, but irksome, 
and very few patients will submit to the position and the long restraint. 
The Scapula. 
The acromial process of the scapula is usually broken bv direct 
violence. The break is most often near the end of the process. The 
mobility of the fragment is easily detected, so that the diagnosis is not 
difficult. The outline of the spine can be followed, for it is subcutane- 
ous throughout the entire length. The pain and contusion confirm the 
diagnosis. The union is usually ligamentous, rarely bony. 
The treatment consists in holding the head of the humerus well 
up in the glenoid fossa and immobilizing the arm. This is most com- 
fortably accomplished by a broad strip of folded domestic, which is so 
placed that its central portion passes under the elbow. The ends of the 
strip are carried upward to the shoulder and crossed over it, and carried 
across the chest in front and behind to the opposite axilla, and secured 
to each other as they meet. The hand should be secured in a sling fas- 
tened to this bandage at the crossing above the shoulder. A pad of cot- 
ton or wool should be put in the axilla, thick enough to keep the arm 
from the body, so that the humerus may be nearly vertical. 
The next most common fracture of the scapula is of the surgical 
neck. In this fracture the break passes from a point below the 
glenoid fossa upward to the suprascapular notch, including the coracoid 
process. FRACTURES. 
715 
The symptoms are lengthening of the arm, flattening of the shoulder, 
an unoccupied space below the acromion, loss of function of the arm, 
crepitus, and an easy reduction, with immediate recurrence of the de- 
formity as soon as the support under the elbow is removed. There is 
unusual passive mobility of the arm in this fracture. The union is 
usually bony and occurs promptly with restoration of the function of 
the arm. 
The treatment enforced should support the arm firmly, so that the 
head of the humerus is pushed up against the acromion process. The 
head of the bone and the neck of the scapula should be held out from 
the body by a pad. This may be accomplished by the support given to 
the elbow by a broad strip of adhesive plaster (moleskin), which should 
pass about the body and up over the top of the sound shoulder. It 
should be firmly applied. The arm is thus immobilized after carrying 
the elbow forward on the chest. 
The angles of the scapula, and also the spine and the body of the 
bone, are broken by severe direct violence. There is not much displace- 
ment except where the fracture involves the inferior angle, which may 
be carried forward and upward. The fragments can generally be mo ved, 
so that crepitus is evident. The bone is well protected with muscles, 
and it is not easy to detect irregularities of outline. 
The treatment consists in padding the scapular region and binding 
it firmly to the chest-wall. The arm must be immobilized by fixing it 
in a sling. 
The Humerus. 
The humerus is not broken as often as the clavicle or the bones of the 
forearm. The fractures of this bone are to be considered in groups—first, 
of the upper end ; second, of the shaft; and 
third, of the lower end. Fractures of the 
anatomical neck, fractures through the 
head or through the tuberosities and the 
head, may well constitute one class of the 
first group, as the clinical history is much 
the same. A fracture of the anatomical neck 
is very rare. The line of the break gen- 
erally follows the groove between the tuber- 
osities and the smooth cartilaginous head. 
Fractures through the head rarely occur, 
except as a complication of the more ex- 
tensive fractures through the tuberosities 
and the surgical neck. Fracture through 
the tuberosities does not occur frequently. 
These breaks are generally produced by di- 
rect violence, rarely from uncomplicated 
indirect violence. 
The symptoms accompanying these frac- 
tures are not so distinctive as to permit a 
differential diagnosis. The shoulder is swollen and generally flattened 
over the joint. Crepitus is present and the function is lost, while pain 
is quite marked, especially on motion. 
Fig. 307. 
Fracture of the anatomical neck of 
the humerus (Hoffa). 716 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
The tearing or breaking off of the greater tuberosity occasionally occurs as a 
complication of subcoracoid dislocation of the humerus. The line of fracture 
usually involves the bicipital groove, the shaft and head of the bone remaining 
intact. The loss of power of external rotation is evidence of this fracture. It 
appears to me very probable that this fracture—viz. the one which separates the 
greater tuberosity from the head by running along the anatomical neck and thence 
into the bicipital groove—may continue inward under the lesser tubercle and sep- 
arate the head and the lesser tubercle from the shaft. Such a fracture has been 
described by ltobert Smith. 
Fracture of the surgical neck is the most frequent and the most 
important of this group of injuries. The line of fracture is below the 
tuberosities and above the insertion of the pectoralis major and the 
Fig. 308. 
Fracture of the surgical neck of humerus (Hoffa). 
latissimus dorsi (Fig. 308). It results from either direct or indirect 
violence. 
This fracture usually presents a well-defined group of symptoms. 
The head of the bone can be felt in its proper place. The axis of the 
shaft points inward toward the coracoid ; the upper end is almost always 
pulled inward by the pectoral muscle and by the latissimus dorsi. It 
makes a slight angle with the head; crepitus is distinct, and can be 
elicited by traction and rotation ; the arm is shortened and hangs power- 
less at the side; and mobility is marked. The head of the bone is in 
the proper position, but does not rotate with the shaft; voluntary move- 
ments are lost, while passive movements are free. Fractures at the 
upper extremity of the bone may be impacted, and are then rendered 
still more obscure. The violence producing this fracture is well cal- 
culated to produce separation of the epiphysis in young subjects. The 
displacement is, however, different, FRACTURES. 
717 
The deformity resulting from epiphyseal separation has its angle outward 
and forward instead of inward and backward. The lower fragment is prominent 
and stands forward. The axis of the humerus is directed upward and forward. 
The break following the cartilaginous line leaves an abrupt right-angled surface 
which marks the anterior margin of the shaft and can be outlined, as it pushes 
forward the skin. This displacement is the usual one, and is best reduced by 
carrying the elbow upward and forward while making traction upon it. The 
motion of the head is arrested when the inferior posterior portion of the capsule is 
put upon the stretch, and by pressure and manipulation the displacement, though 
difficult to reduce, can usually be overcome. This epiphyseal separation cannot, 
of course, occur after union of the shaft and the epiphysis in or about the twentieth 
vear. 
After the reduction of the displacement present in this group of 
injuries the treatment which is adapted to the most common frac- 
ture—viz. that of the surgical neck—answers the indications that should 
be met in the others. The deformity present in the fracture of the sur- 
gical neck may be corrected by traction downward, outward, and for- 
ward until the shaft comes into line with the head. Direct pressure of 
the hand aids the movement of coaptation. If the patient is able to sit 
up, the dressing is more easily applied. The elbow should be held just 
away from the body and the forearm flexed at right angles. The splint 
most universally applicable for these fractures is the plaster-of-Paris 
folded compress or a plaster roller. It should extend from the lower 
part of the forearm to the top of the shoulder, enveloping both the 
elbow- and the shoulder-joint. The entire arm should be first wrapped 
in cotton. During the application of the plaster splint extension from 
the elbow is continued. 
A piece of pasteboard, not too heavy, may be carried into the axilla, outside 
of and overlapped above by the cotton which is next to the skin. The arm must 
be held in about the position it is desired to retain while the plaster cup is being 
adjusted to the shoulder, for if it is held in a position of too great abduction, the 
cup will not fit the shoulder when the arm hangs at the side. Pasteboard splints 
or starch bandages may be used instead of the plaster-of-Paris bandage, but care 
must be taken to see that the supporting splint is not too tight. The splint to 
secure immobility must envelop the elbow-joint, the forearm, and the shoulder. 
The weight of the arm and the splint are the chief agents in maintaining a proper 
adjustment, it being impossible to fix the upper fragment by any direct pressure. 
The forearm must be supported by a sling which is placed about the wrist. The 
sling must not give support to the elbow. It does not appear to me to be good 
practice to bind the arm to the body in any of the fractures of the humerus, for the 
movement of the body in flexion or lateral motion must disturb the arm. 
If these fractures be complicated by dislocation of the head of the 
humerus, they are of much more serious import. Reduction of the dis- 
location must at once be attempted by manipulation. If this fails, then 
either at the first dressing or at some time within a week or ten days, 
as indications may suggest, the reduction must again be attempted by 
cutting down upon the fracture and attempting reduction by McBurney’s 
method—that is, with a hook passed into a hole drilled into the upper 
fragment. Traction and rotation through the medium of the hook, 
together with a more direct manipulation of the parts, should succeed 
in effecting a reduction of the dislocation. Reduction may possibly be 
accomplished by direct manipulation of the head without the hook. 
After the reduction of the dislocation the treatment is to be directed to 
the cure of the fracture. If the local condition be such as not to per- 
mit the application of a splint, the patient should be placed upon his 718 
AFFECTIONS OF THE TISSUES ANI) TISSUE-SYSTEMS 
bed, and, while the arm is placed in a comfortable position on pillows, 
traction should be made by means of adhesive strips and weights and 
pulleys or by elastic bands until the swelling subsides. 
Two points must be clear to the surgeon in treating injuries of the 
upper end of the humerus. These are usually easily determined, as 
they present distinctive diagnostic symptoms. The most important 
point is to know that the head is not dislocated ; second, that the injury 
is not confounded with fracture of the neck of the scapula. 
The shaft of the bone is frequently broken by direct and indirect 
violence, but muscular action is not an infrequent source of fracture. 
Displacements in the broken shaft may be lateral, angular, rotary, or 
overlapping. Mobility is marked ; crepitus is easily obtained ; shorten- 
ing is not usually very marked ; swelling and pain are present. Injury 
to the musculo-spiral nerve is one of the complications of this fracture, 
as is also injury of the brachial artery. The nerves may be injured by 
the violence of the accident or by involvement in the callus. Injury to 
the artery may be detected by a disturbance of the circulation and 
absence of the radial pulse. Motor and sensory disturbances indicate the 
extent of the nerve-injury. Plate XXI. 
Delayed union and non-union are said to be more frequent than in any 
other bone, but the fracture is easily managed and is almost uniformly 
satisfactory in result. If the circulation is free, the nutrition should be 
good and union fairly certain. This bone has, however, been known to 
disappear by absorption after fracture. Untoward results of this kind 
cannot be guarded against, so that, though it is an injury which usually 
results in union, it may be accompanied by grave complications. These 
fractures should be treated as are those of the upper end of the bone. 
The splint should immobilize the shoulder and the elbow, while it gives 
some lateral support to the break. A plaster-of-Paris or starch bandage 
or pasteboard splint should be used. 
Fractures of the lower end of the humerus are frequent, and are 
of the greatest importance, for imperfect adjustment is likely to result 
in permanent deformity and impairment of function. It is always desira- 
ble to make an accurate and exact diagnosis, though it is sometimes 
difficult or impossible to do so. 
The epicondyles are subject to fracture by direct violence. The 
line of fracture does not usually enter the joint. The internal epicon- 
dyle is the much more prominent and is most frequently broken. The 
fracture does not involve the joint, and the displacement is not usually 
great. The intermuscular fascia helps to retain these fragments in 
position, though they are occasionally torn loose from their muscular 
attachment. When this occurs they may be distinctly separated from 
their normal situation. If detached and in bad position, it is well to 
remove the fragments. 
The treatment is rest with the forearm fixed in a flexed position. 
Supracondyloid fracture and separation of the epiphysis are 
similar in some of their symptoms, their correction, and their treatment. 
They both ordinarily result from indirect violence. The epiphyseal sep- 
aration follows the line of the cartilage, and is nearer the articulation 
than the supracondyloid fracture. The position of the arm in each of 
these injuries is much the same, the arm being slightly flexed, with PLATE XXI. 
Supra-Condyloid Fracture, child of nine years; union with deformity, fragment so joined to lower 
end of shaft of humerus at an angle that when forearm is completely flexed upon this fragment, it yet 
is only at right-angle with arm. Operation indicated. (X-Ray picture.) FRACTURES. 
719 
marked fulness in front of the elbow, and the olecranon more prominent 
posteriorly. The deformity is increased by putting the arm in an ex- 
tended position, and is diminished by flexion. Mobility is increased, 
the crepitus is soft in epiphyseal separation, and is easily elicited in 
supracondyloid fractures. The projection in front of the elbow-joint is 
sharp and more easily outlined in the fracture than it is in the epiphyseal 
separation. Here, as in all injuries about the elbow-joint, it is import- 
ant to determine the relation of the olecranon to the external and the 
internal epicondyles. They maintain their normal position in both of 
these injuries. If the arm be flexed, a line drawn from one epicondyle 
to the other in a vertical plane crosses the top of the olecranon. If the 
arm be extended, a line so drawn in a horizontal plane also touches the 
top of the olecranon. In a dislocation of both bones of the forearm 
backward, which simulates these injuries, this relation is altered. 
Either condyle may be broken from its fellow and from the shaft 
of the bone. A transverse supracondyloid fracture may be complicated 
by a fracture extending from the transverse line of fracture to the joint 
(Fig. 309). These fractures implicate the joint. 
They may result from direct or indirect vio- 
lence. The fracture may be comminuted and 
compound, and the contusion and the lacera- 
tion are often extensive. The T-fracture above 
described is the intercondyloid fracture and is 
usually produced by direct violence. The sep- 
aration of either condyle is more frequent than 
the intercondyloid fracture. The lines of sep- 
aration in these injuries vary considerably, but 
the treatment is much the same. 
In fracture of the external condyle the 
fragment is more apt to be displaced forward. 
Fracture of the internal may be associated with 
a backward displacement of the bones of the 
forearm and with widening of the joint. In 
these fractures swelling, ecchymosis, marked mobility, and crepitus are 
present. The deformity may be marked in any of these injuries, but it 
is always great in the intercondyloid. 
The surgeon must bear in mind that a good movable joint is to be 
sought in these fractures, and it is usually attained if the treatment is 
directed by tact and good judgment. It must not be conceded that frac- 
ture into the joint necessarily implies a bad result. The extent of the 
injury, the comminution of the bone, and the violence of the separative 
action, may result in a stifl* and deformed joint, but this is not the usual 
result. Accurate adjustment is the essential to successful treatment. 
Maintenance in perfect position is not always possible, but may be 
attained in the majority of cases. An anaesthetic is here not infre- 
quently demanded in order to make an accurate diagnosis and to secure 
good adjustment. The surgeon must bear in mind the fact that the axis 
of the forearm and the arm are not the same when in a position of 
extension. They make an obtuse angle, the forearm diverging outward, 
so that when hanging at the side, in a position of supination, the hand 
is carried away from the body. It is also extremely important, both on 
Fig. 309. 
T-fracture of humerus 
(Helferich). 720 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
account of symmetry and usefulness, to retain this outward deviation, 
which gives to the arm its carrying power. How may accurate adjust- 
ment and maintenance be best attained? The fragments can be most 
accurately moulded into position when the arm is extended or when 
only slightly flexed. The extended position is often necessary to per- 
fect adjustment. If a splint is to be adjusted to the arm, and it is not 
thought best to flex it to a right angle, it should not be placed in full 
extension, but slightly flexed. The support may be a posterior splint 
or an immovable cast. Elastic extension or traction by pulley and weight 
is occasionally necessary if the swelling be too intense to permit the 
immediate application of a retaining splint. 
It has been a habit with me to treat these cases in a right-angled 
splint. Good results have been the rule, but in the condyloid fractures 
the position of very slight flexion is the best for accurate adjustment, 
and the arm may be secured in this position. It is, in my opinion, 
important that the recumbent position be assumed for a time in the cases 
dressed in full extension. I have in a number of cases, after using this 
position for a week, flexed the arm to a right angle and then continued 
treatment in a rectangular splint. Passive motion in order to retain 
mobility of the joint is out of place and dangerous. It is to be con- 
demned as pernicious. The joint is to be put at rest until the bone is 
consolidated; then the patient will gradually recover motion if the 
adjustment has been good. 
The splints most useful in these fractures are those which can be 
moulded to the outline of the parts. Plaster of Paris, pasteboard, and 
starch are the most useful. If it be desired to inspect the arm, a section 
of the cast may be cut away. The cast can then be replaced and held 
in position by a roller bandage. It requires five or six weeks to secure 
good union in fractures of the humerus. There is but little danger of 
permanent loss of motion in the joint if the adjustment has been perfect, 
though every surgeon will meet cases in which even with the greatest 
care a deformity will occur that impairs the symmetry of the arm or the 
function of the joint. 
Fractures of the Forearm.—The Ulna. 
Fractures here, excepting Colics’ fracture, most frequently involve 
both bones, but either bone may be broken without implicating the other. 
Muscular action sometimes produces fracture of the olecranon pro- 
cess, the fragment so detached being usually a thin portion, often only 
a scale from the tip. The process is more frequently broken by direct 
violence, which usually occurs in a fall with the elbow bent and strik- 
ing against a hard substance. The process is thus broken off near its 
junction with the shaft. In these cases the muscular contraction of 
the triceps materially aids the violence in producing the fracture. The 
joint is opened, and, the bone being so superficial, the fracture is 
easily rendered compound by the violence producing it. The contusion 
inflicted and the involvement of the joint result in rapid swelling. The 
tumefaction of the parts obscures the injury somewhat, but the diagnosis 
is not usually difficult, for the posterior surface of the process is subcu- 
taneous and the line of fracture can be felt on the sharp ridge which is FRACTURES. 
721 
continuous with the shaft of the bone. If the laceration is extensive, 
the detached fragment may be pulled well up by the triceps. In these 
fractures the tip of the process does not hold its proper relation with 
the epiconclyles, and this relation is especially destroyed when the arm 
is Hexed at a right angle. 
It is not always feasible to put the part in good position at the first 
dressing. It is well to put a splint on the arm while it is in a position 
of slight flexion, though later in many cases the arm may be safely 
flexed to a right angle. A plaster-of-Paris case makes a good splint for 
immobilizing the arm. After it hardens a large fenestrum can be cut in 
it, so as to expose the posterior surface of the joint. Then a compress 
can be placed above the olecranon process, and be made to pull it down- 
ward toward the ulna by a strip of adhesive plaster or an elastic band 
Fig. 310. 
Fracture of olecranon with fibrous union (Park). 
that should be secured to the anterior surface of the plaster splint some 
distance below the bend of the elbow. After a week or ten days the 
splint can be changed to a right-angled plaster cast and the same method 
of pressure continued. It is well to have firm pressure made over the 
subcutaneous surface of the process at the time of the bending to avoid 
a tilting or angling of the fragments. The result is usually good, a close 
fibrous or bony union being attained. Passive motion is to be avoided 
until the fragment has firmly united. 
The coronoid process is rarely broken, except in the backward dis- 
location of both bones by the combined force of the muscular action of 
the brachialis anticus and the pressure of the coronoid against the 
trochlear surface of the humerus. It must be a rare injury even under 
these circumstances, for a backward dislocation occurs most frequently 
from hyperextension of the arm. It should be treated by putting the 
arm at rest in the right-angled position. 
The shaft of the bone is broken singly almost always by direct vio- 
lence. Breaks are more common in the lower half of the shaft than in 
the upper part. 
The diagnosis is easy: crepitus, irregularity in outline, generally 
due to the violence producing the fracture, pain at the seat of fracture, 
swelling, and loss of power, with the history of the accident, make the 
evidence of fracture conclusive. 
Treatment.—The arm should be placed in a semi-prone position, 
and an anterior or palmar splint extending from the internal epicondyle 
to the fingers, and a posterior dorsal splint that should extend from the 
metacarpus to the head of the radius, should be used. These light 
wooden splints should be padded with cotton and should be a little wider 
than the forearm. A pad should also be placed against the ulna at the 722 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
fractured point, if this be in the middle third of the bone, so as to keep 
it from sagging or angling. The splints are secured in position by a 
roller bandage. There is not much danger of loss of rotation by angling 
of the bone outward toward the radius in simple fracture of the ulna. 
The pronator quadratus, however, tends to pull the lowrer fragment out- 
ward toward the radius if the break be just above its attachment to the 
ulna. 
The Radius. 
This bone is more subject to fracture than any other except the 
clavicle. The head or the neck of the bone may be broken either by 
direct or indirect violence, though indirect violence is the most frequent 
source of the injury. Falls upon the pronated hand drive the radius 
against the capitellum, thus producing these fractures. Injury to the 
neck of the radius is frequent in children. The shaft of the radius is 
broken by direct or indirect violence. Fractures of the shaft of this 
bone are usually complicated with a break of the ulna. The biceps, the 
supinator brevis, and the pronator radii teres are to be considered in 
treating all fractures of the shaft of the bone. If the break is above 
the insertion of the pronator radii teres, the upper fragment is rotated 
into a position of supination, while the lower fragment is in a position 
of pronation. The fracture is best managed if the arm is kept supine. 
The usual symptoms of fracture are present. 
It is not easy to make the diagnosis when the fracture is in the 
upper part of the shaft, for it is deeply buried under the muscles. The 
failure of the head to rotate with the shaft of the bone in fractures of 
Fig. 311. 
Colles’ fracture (Anger). 
the neck and shaft is an important sign of fracture. It must, however, 
be remembered that when the fractured surfaces are interlocked the 
head may rotate with the shaft even if a fracture has occurred. 
Fractures of the shaft are treated, if in the lower half, bv the same 
method used in treatment of injuries to the shaft of the ulna. If the 
fracture be above the pronator radii teres, it should be treated with the 
forearm supinated and Hexed at a right angle. A posterior rectangular 
splint is best. It should immobilize the elbow and secure the arm and 
the forearm. 
The most common fracture of the radius is at the lower end, and is 
known as Colies’ fracture, though the usual seat of the fracture is 
below the point indicated by Colles in his description. It results from 
a fall upon the palm of the hand, and occurs in childhood and extreme FRACTURES. 
723 
old age, but is most frequent in elderly females. The break is rather 
uniform in its symptoms, position, and line of fracture. It is situated 
in the expanded end of the radius at front one-fourth of an inch to one 
inch from the articular surface (Fig. 311). 
The line of fracture may be transverse or oblique, though it is difficult to 
determine from the many descriptions and cuts presented to the profession just 
what is the most common break. It appears reasonable, however, to assume from 
the manner of the infliction of the injury, from the plane of the articular surface, 
and from the uniformity of the displacement that the line of fracture is from 
below upward, beginning on the palmar surface and extending to the dorsum. 
This common fracture was for centuries regarded by surgeons as a dislocation. 
The deformity resulting from the fracture is very uniform. The 
lower fragment is displaced backward on the dorsum of the bone, the 
articular end is tilted backward, and the styloid process is carried up 
the forearm and backward, so that, instead of being well forward and 
below the level of the styloid process of the ulna, it is displaced upward 
and the hand is drawn toward the radial side. Crepitus is not easily 
elicited. The deformity, the history of the accident, and the mobility 
of the fragments are the symptoms. Impaction of the fragments is, I 
believe, not very common. If there should be impaction, and it be firm 
enough to resist the proper adjustment, it can be released by forcibly 
and strongly extending the hand until the fragments separate, and 
then the adjustment can be accomplished in the usual manner. 
The reduction of the fracture can usually be accomplished by the following 
method: An assistant holds the elbow by grasping the lower end of the humerus; 
a second assistant grasps the hand as if to shake hands, and makes firm extension 
while the hand is prone. The surgeon then places the fingers of both hands on 
the palmar surface of the end of the upper fragment and presses downward and 
forward upon the dorsal surface of the distal fragment with his thumbs. Firm 
pressure will almost certainly carry it well forward into position. It is rare to 
have much difficulty in keeping it in good position. If the fracture is not com- 
minuted, but transverse, there is little tendency to redisplacement. 
Fracture of the styloid process of the ulna may also occur. The obliquity of 
the line of fracture and the occasional comminution of the distal fragments have 
much to do with the difficulty in keeping the fracture in good position. Among 
the complications attending this fracture is a rupture of the radio-ulnar ligaments. 
This complication makes the prominence of the ulna more marked than the slight 
shortening of the radius alone could account for. The injury is, moreover, often 
complicated by compound dislocation of the styloid process, with penetration of the 
internal lateral ligament. 
Fractures in this situation are safer and more comfortable if a splint 
be applied that will give rest and support to the hand and the forearm. 
These splints are of great variety, but the simpler ones answer every 
purpose. It is, I think, hard to devise one which will fulfil more of 
the indications than a plain straight wooden splint, properly padded, 
that will extend from the end of the fingers to the epicondyle. This 
splint should be fitted to the palmar surface, and should be so padded 
as to put the fingers in a position of slight flexion. Some loose cotton 
may be placed under the radius to support the lower end of the upper 
fragment. A bandage is then applied to secure the hand and forearm 
to the splint while it is in a semi-prone position. It is a good plan to 
place a compress of cotton on the dorsum of the distal fragment. At 
the end of a week the splint should be shortened and the fingers made 724 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
free, so that they can be flexed and extended. This is of extreme 
importance in patients above forty years of age. This plan of treat- 
ment secures comfortable quiet for the arm until the union is firm, and 
it provides for free movements of flexion and extension of the fingers 
after the first week. The fracture almost uniformly unites in five weeks. 
The sling to support the forearm should be a narrow strip, and it should 
exert its pressure on the forearm and not on the hand. An excellent 
splint is also made of lint soaked in plaster of Paris applied to the 
palmar surface while the parts are held in exact position. 
The results should be good so far as restoration of function is con- 
cerned, and the contour is very nearly perfect, except in cases where the 
comminution is marked and the retention of the fragments is difficult 
or impossible. A slight shortening may take place in these comminuted 
fractures of the end of the radius. 
The pistol-shaped splint and Levis’s perforated moulded splint are frequently 
used. The deviation of the hand toward the ulnar side is not an efficient agent 
in maintaining the fragments in position, and should never be enforced to the dis- 
comfort of the patient. In the more common and simpler cases, where the line of 
Fig. 312. 
Fig. 313. 
Moore’s dressing for Colles’ fracture of radius. 
fracture is transverse or slightly oblique and not comminuted, a wide strip of adhe- 
sive plaster encircling the wrist gives sufficient support, or a firm compress made of 
a soft roller bandage may be fastened to the palmar side of the radius by the plaster 
strip to give more definite support. This treatment, devised by Dr. Moore of 
Rochester, is applicable to many cases and gives excellent results (Figs. 312, 313). 
Fracture of both bones of the forearm is frequent, but it rarely 
occurs in the upper third. It may follow direct violence, though it is FRACTURES. 
725 
more frequently the result of indirect violence. The displacement may 
be great and in any direction. Accurate adjustment is most important 
for overlapping; rotary or lateral displacement or any angling of either 
of the bones outward or inward is likely to interrupt the rotary function 
of the forearm (Figs. 314, 315, 316). This function is best preserved if 
the forearm be kept in a position of supination or in a semi-prone posi- 
tion, for the bones are then widely separated. In cases where there is a 
marked tendency to a recurrence of the displacement it is perhaps safer 
to keep the forearm in full supination until 
union is at least fairly firm, for accurate 
maintenance and good adjustment is best 
attained in this position. In a week or ten 
days the forearm may be put into a semi- 
prone position, as it is much more comfort- 
able for the patient. The semi-prone posi- 
tion is the one usually preferred in these 
Fig. 316. 
Fig. 314. 
Fig. 315. 
Displacement in fracture of forearm. 
Results attending angular frac- 
ture of the radius. 
cases. The splints adapted to the treatment of fractures of the shaft of 
one or both of the bones in the semi-prone position are two straight 
boards of the width of the upper part of the forearm. The palmar 
splint should extend from the epicondyle to the ends of the fingers, and 
the dorsal from the head of the radius to the wrist. They should be 
properly padded, but interosseous pads are not necessary. A simple 
roller bandage answers all the purposes for holding the splints in posi- 
tion. The hand is fastened to the palmar splint, and the roller then 
envelops both palmar and dorsal splints and is continued to the elbow. 
The forearm is then placed in a sling and kept at rest, care being taken 726 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
to give its upper part good support. The sling should not exert traction 
on the hand and arm below the seat of fracture. 
Green-stick fractures of the bones of the forearm are frequent. They occur in 
children. It is generally best to straighten the bones at the first sitting, though it 
is not always necessary to do so, and indeed a complete fracture may be avoided in 
some cases by not insisting too strongly upon a perfect straightening of the bones 
at once. This form of fracture usually unites rapidly. Delayed or non-union of 
fractures of the forearm is not uncommon. The causes which prevent primary 
union may render operations unavoidable. The treatment of non-union is to be 
guided by the general conditions which govern such cases. Injury of the blood- 
vessels and interference with the circulation may result in gangrene. 
The Wrist and Hand. 
Fractures of the carpal bones are rare, except when the wrist is 
crushed. 
The diagnosis is difficult and replacement uncertain. 
The treatment consists in rest and in controlling the engorgement 
likely to follow such injuries. 
Fractures of the metacarpal bones are more frequent, and may 
occur as a result of direct or indirect violence. The distal half of the 
bone is most frequently the seat of fracture. The fracture that follows 
indirect violence is usually situated within an inch of the articular sur- 
face of the head. The displacement is uniformly forward, with the head 
of the bone bent toward the palm of the hand. 
The diagnosis is best made with the fingers closed, so that the first 
row of phalanges are at a right angle to the metacarpal bones. If the 
symmetry of the row of knuckles is broken by one or more of them 
being less prominent than they should be, it is strongly suggestive of 
fracture. If there be also a sensitive point on the dorsum of the short- 
ened metacarpal, with slight irregularity at the point of tenderness, then 
the diagnosis is fairly certain. This may be confirmed by restoring the 
symmetry by traction on the finger and pushing the head of the bone 
toward the back of the hand. 
The treatment should be by traction on the extended finger with a 
firm pad or support under the head of the bone. The hand should be 
placed upon a long palmar splint securely bound to the forearm by 
a bandage or by plaster strips, or both. The extension should be by 
adhesive plaster about the finger, attached to an elastic band fastened to 
the end of the splint. The splint should extend several inches beyond 
the fingers. Union always occurs, generally within three weeks. 
The phalanges are almost always broken by direct violence, so that 
the distal phalanx, being most exposed, is most often fractured. The 
violence causing the fracture frequently complicates it by an external 
wound. Suppurating fractures of the first and second phalanges expose 
the patient to the dangers of purulent infiltration along the sheaths of 
the tendons in the palm and the forearm. Extension of suppurative 
inflammation is especially apt to follow the tendinous sheath of the little 
finger, for the sheath of this tendon is continuous with the sheaths of 
the forearm. Prolonged suppuration is apt to destroy the bone, and it 
almost certainly entails impairment of function from adhesive or destruc- 
tive inflammation. These compound fractures often heal kindly and FRACTURES. 
727 
quickly, and the wound may be made to pursue an aseptic course if due 
care is taken. The soft tissues are often pulpefied by the crushing 
violence which causes the break. 
The diagnosis is usually easy. Mobility, crepitus, and the history 
of the accident are the cardinal indications. 
Adjustment of the fracture is not difficult, and maintenance is gen- 
erally effected by placing the hand on a padded splint with the fingers 
well supported in a position of partial flexion. The contiguous fingers 
are valuable supports in the proximal row of phalanges. Extension, as 
described in the treatment of the metacarpal bones, is sometimes essen- 
tial, and union is rapid and satisfactory except in suppurating fractures. 
It is a good rule not to amputate injured fingers unless they are hope- 
lessly destroyed, but the danger of long-continued inflammation in the 
arm must not be overlooked in the desire to save them. 
The Pelvis. 
Fractures of the pelvis are properly divided into two classes—those 
which implicate the ring of the pelvis and those which involve only some 
of the more exposed prominences of the ilium, the ischium, or the sacrum 
and coccyx. Fractures of the pelvic ring are always serious. They are 
produced by a crushing violence applied to the pelvis and sacrum, by 
lateral compression, or through violence transmitted through the femur 
or trochanter. 
A double fracture frequently follows a crushing injury, one line of fracture 
being through the pubic bone, and one through the ilium behind the acetabulum. 
It is also possible that both the pubic and sacro-iliac joints may be separated 
by violence transmitted through the leg. A break at the symphysis may also 
occur from internal violence, as in childbirth. Associated with other fractures 
Fig. 317. 
Fracture of pelvis. 
of the pelvic ring, and as a result of great violence, the sacrum is sometimes trav- 
ersed by a vertical fracture. One of the greatest dangers attending these injuries 
is found in the involvement of the viscera situated in the pelvis: in this way the 
urethra, the bladder, the blood-vessels, or the intestines may receive serious injury. 
The contusion of the soft parts by the breaking of these important bones, the 
laceration of the viscera, and the shock accompanying such violence render these 
fractures of the pelvic ring most serious accidents. 728 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
The most common of the fractures of the pelvic ring are of the pubic 
bone. This may be a separation at the symphysis, but is more frequently 
a break that involves the horizontal ramus of the pubis and the ascend- 
ing ramus of the ischium (Fig. 317). The urethra and the bladder 
frequently suffer injury in this fracture. Urinary infiltration is especially 
dangerous, and if it occur should be promptly provided with free exit 
and drainage. Fractures of the true pelvis are determined by the history 
of the violence and by the disability they entail. The patient cannot 
walk, contusion is apparent, mobility is present, and the shock is marked. 
The viscera give special symptoms. Mobility, and occasionally crepitus, 
can be determined by pressure upon the anterior portion of the crest of 
the ilium. When the fracture is in the pubic portion, mobility and 
crepitus can be detected by direct manipulation. 
Fracture produced by violence transmitted through the femur may 
occur by the head of the bone being forced through the acetabulum, or a 
line of fracture posteriorly may begin with the 
sciatic notch and extend through the ilium, and 
another involve the ramus of the pubis and 
ischium anteriorly, thus separating a section of 
the bone, including the acetabulum from the 
ring of the pelvis. These lines of fracture may 
extend through the sacro-iliac junction and the 
symphysis pubis. 
The treatment of either of the fractures 
last named must include extension applied to 
the leg. The treatment necessary in most of 
the fractures of the pelvic ring is rest in bed, 
with the support of a circular bandage about the 
hips. Visceral complications will require such 
attention as is needed to meet the particular 
indications. 
Fractures of the false pelvis or of the ilium 
are more frequent, and are not very serious 
injuries. It seems to me that a portion of the 
crest may be detached by muscular action in the 
young adult. The anterior spine may also be 
detached. A break in the ilium usually involves 
the anterior or the posterior portion of the crest, 
the line of fracture beginning near the middle 
and extending in a curved line either forward 
or backward, the concavity of the curve being 
upward. 
Quiet without pressure is the treatment. 
Recovery is the rule, but it may occur with deformity. 
Transverse fractures of the lower portions of the sacrum and of the 
coccyx may occur. The pain is great; the displacement is forward, 
making an angle which presents posteriorly. Replacement can be 
accomplished by introducing the finger into the rectum and making 
backward pressure, but maintenance in a good position is difficult. It 
has been attained by stuffing the rectum with gauze or with a hollow 
tube wrapped with gauze. The rim of the acetabulum is sometimes 
Fig. 318. 
Great deformity after multiple 
fracture of femur, with synos- 
tosis (Park). FRACTURES. 
729 
broken, generally as a complication in dislocation of the femur. This 
is a rare injury. The violence producing it is probably applied directly 
to the trochanter while the leg is flexed and either rotated strongly 
outward or inward, the head of the bone being thus driven against the 
rim. The segment detached is a part of the posterior margin of the 
ring. 
The diagnosis is not easily made. The dislocation of the femur 
must be reduced and maintained in position by quiet and extension. 
A fracture of the tuberosity of the ischium is a rare accident, and 
is caused by direct violence which produces a severe contusion of the 
soft parts. 
The Thigh. 
Fractures ot the lower extremity are one-half as frequent as those 
of the upper. About one-fourth of such injuries of the lower extremity 
are of the femur. Fractures of the lower end of the femur are infre- 
quent, those of the upper end are more common, but the middle third 
is more frequently broken than any other part. The fractures of the 
upper end include those of the neck, epiphyseal separation, and those 
breaks which pass through the trochanters. The epiphyseal separation 
must be very rare as a result of violence. It occurs more frequently 
however, as a pathological condition. 
Fractures of the neck are such as are styled intracapsular and 
extracapsular or mixed. The intracapsular fractures are those involv- 
ing the narrow portion of the neck. These fractures occur most fre- 
quently in the aged. The increased amount of medullary substance 
and the diminished amount of cortical and trabecular bone-tissue in the 
aged weaken very markedly the neck of the femur. This fracture is 
by indirect violence transmitted through the 
shaft of the femur or through the trochanters 
and the neck, or it is produced by a twist or 
strain upon the leg in the endeavor to avoid 
a fall. The capsule of the joint is not neces- 
sarily torn and the immediate displacement 
is not great. The fracture may precede 
the fall that accompanies it, the fall being 
consequent upon the fracture, though the 
reverse is most commonly true. Great vio- 
lence is not required to produce such a frac- 
ture. The loss of function is not necessarily 
absolute and immediate, patients having been 
known to walk with such an injury. The 
mixed or extracapsular fracture (Fig. 319) 
occurs in the same manner as the intracapsu- 
lar fracture, though it may require a little 
more violence and the line of fracture is not so uniform. It extends 
through the broader portions of the neck at the base of the trochanter, 
and is partly within and partly without the capsule of the joint. It 
may involve one or both trochanters. The line of fracture here, as in 
the narrow portion (or intracapsular), is more likely to be oblique when 
the violence is transmitted through the shaft of the femur to the tro- 
Fig. 319. 
Extraeapsular fracture of thigh 
(original). 730 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
chanter and neck. This fracture is also most frequent in the aged. 
The most common break of this class is along the line of junction of the 
neck with the trochanter. These fractures are frequently impacted, 
though not necessarily very firmly so. 
The deformity in fracture of the neck sometimes shows an anterior 
angle in the neck of the bone, the posterior portion of the neck being 
shortened and interlocked, while the anterior surface is separated or not 
so firmly impacted. This puts the femur in a position of outward 
Fig. 320. 
Fig. 321. 
Impacted fracture of neck of femur (Park) 
rotation. The deformity accompanying this fracture is more immediate 
and marked than in intracapsular fracture. In extracapsular fracture 
we may have the lesser trochanter attached to the neck. 
The diagnosis and the prognosis of fractures of the neck of the 
femur will be here considered, but the treatment is best considered 
in connection with the treatment of other fractures of this bone. 
The differential diagnosis between these two varieties is not clear, 
although now and then the diagnosis of an extracapsular fracture is 
plain and definite. The symptoms of a fracture of the neck, besides the 
history, are disturbed function, pain, crepitus, eversion, shortening, relax- 
ation of the fascia lata, the abnormal relation of the anterior superior 
spine of the ilium to the trochanter major, the rotation of the trochanter 
on a shortened radius, and a fulness of Scarpa’s triangle. The diagnosis 
should be made with as little manipulation as possible; hence the age 
of the patient and the history of the accident, together with the position, 
the shortening, the fulness of Scarpa’s triangle, and the relations of the 
trochanter, should be grouped and considered before manipulating the 
patient. The age is usually above fifty and the history often one of 
slight violence. The position of the limb is suggestive : it looks help- 
less, and lies usually in an everted position on the bed, with the muscles 
and fascia relaxed. The lessened tension of the fascia is noticeable 
above the trochanter. The function of the limb is impaired or com- 
pletely lost. The patient is sometimes able to flex the thigh and lift the 
foot from the bed without much pain. The individual can in excep- 
tional cases walk for a short distance after the injury has been received. FRACTURES. 
731 
The pain of this fracture is generally very severe. Any motion or mus- 
cular spasm causes sharp exacerbations, and there is a dull aching pain 
even when the limb is quiet. Crepitus is not uniformly present, but can 
generally be elicited if care be taken to bring the broken surfaces in 
apposition. It is not, however, necessarily essential to a diagnosis. 
Eversion of the limb is almost uniformly present, and is in many cases 
quite marked, for the foot often rests on its outer aspect. This ever- 
sion is produced partly by the violence inflicting the injury, partly by 
the muscles attached to the trochanter major, as well as by the psoas 
and iliacus. The natural disposition of the leg is to external rotation 
when in the dorsal decubitus. 
Inversion is sometimes present, due probably to tbe peculiar relation of the 
fragments induced by the violence fracturing the neck. The character and extent 
of the rotary movements are important in making the diagnosis. Rotation of the 
injured leg causes pain, often develops crepitus, and the trochanter moves in an 
arc with a shortened radius. This makes a diagnosis of a fracture of the neck of 
the femur clear. The radius of the arc may in isolated cases be increased, but it 
is rarely normal if a fracture exist. Where the femur rotates upon its own axis it 
is pathognomonic of fracture of the neck. This symptom can be easily recognized 
if the surgeon will follow the trochanter in its movements with the finger. Short- 
ening of the leg is produced by a change in the angle of the shaft with the neck 
or by a displacement upward of the trochanter and the portion of the neck 
attached to it. This shortening of the leg can usually be determined to be in the 
altered neck by verifying the length of the leg from the trochanter to the external 
malleolus. The extent of the shortening will vary from a fraction of an inch to 
three inches. The exact amount of shortening in a given case is not easily 
determined. 
For purposes of examination the patient should be either on a fairly 
firm bed or a table, and the legs must be symmetrically placed with ref- 
erence to the pelvis. The adduction or abduction, as well as the degree 
of flexion, must be the same in each extremity. A cord should be 
stretched between the two anterior superior iliac spines. This should 
be bisected at right angles by a line passing downward over the sym- 
physis, and the shortening will be determined by the relations of the 
malleoli with this downward line. It may also be determined by 
Bryant’s method, which is as follows : The legs are symmetrically placed ; 
a vertical line is dropped from the anterior superior spine of the ilium 
on each side, and a line is carried upward from the trochanter to this 
vertical line, intersecting it at right angles. The difference in the dis- 
tance from the trochanter to this vertical line gives the amount of short- 
ening of the leg. Fulness in Scarpa’s triangle and a widening or a 
thickening of the trochanter are also worthy of notice as symptoms of 
a fracture of the neck of the femur. 
The diagnosis of fracture of the neck is often easy and positive, 
but there are cases where it becomes extremely difficult to determine 
certainly the existence of a fracture. The differential diagnosis between 
the intracapsular and the mixed or extracapsular fracture is often 
impossible. Extreme age, moderate violence, a slight shortening with- 
out complete loss of function, suggest the intracapsular fracture. Com- 
minution or a thickening, either primary or secondary, of the trochanter, 
with marked shortening, indicates extracapsular fracture. Many eases 
will remain doubtful. 
The prognosis of an intracapsular fracture of the neck is not so 732 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
favorable as that of a mixed or extracapsular fracture. It was for a 
long time a mooted question whether bony union ever occurred in this 
break, or whether it was always fibrous. It is now known, however, 
that bony union does occur. The mixed or extracapsular fracture is 
much more likely to give a good result, for bony union is the rule if the 
treatment is good. Most authors recommend a guarded prognosis, and 
admit the possibility of an imperfect result. The prognosis must in 
many cases be guarded, for it is extremely difficult, and often impossi- 
ble, to determine certainly whether it is an intracapsular or an extra- 
capsular fracture. Fractures of the neck, occurring as they do in per- 
sons of limited vitality, who are old in tissue if not in years, demand 
extreme care in treatment. The first consideration is, of course, the life 
of the patient, and, as confinement in a fixed position is not only irk- 
some, but is dangerous to the life of the aged, the prognosis will involve 
not only the usefulness of the limb, but a consideration of the danger to 
life. It is wise to treat these cases as if we expected a good result by 
solid union, for it can generally be attained. 
The treatment must be so ordered as to save life even at the 
expense of an imperfect leg. (See Treatment below.) 
Fractures of the upper and middle thirds of the femur occur 
generally as the result of indirect violence. They are usually oblique, 
Fig. 322. 
Fig. 323. 
Fig. 324. 
Fracture of upper third of femur. 
Overlapping fracture of 
femur. 
the line of fracture being downward, forward, and inward or slightly 
outward. Fracture in the middle third of the femur by muscular action FRACTURES. 
733 
is not very infrequent. The violence of the injury may help to deter- 
mine deformity, but the line of fracture, the contraction of the tibio-pelvic 
and the ilio-trochanteric muscles, as well as the external rotators, are active 
agents in the formation of the external anterior angle (Figs. 322, 323). 
The natural eversion of the leg when the patient is in the recumbent pos- 
ture is also a factor in producing this deformity in the thigh. The thigh 
is also shortened. This is partially due to the angling, but an overriding 
or an overlapping (Fig. 324) of the fragments is also present. Spasm 
of the long muscles of the thigh is a very constant symptom, exciting 
pain and increasing the deformity and irritation of the soft parts. The 
mobility is easily determined, and crepitus is sharp and decided. 
The diagnosis can often be determined by inspection simply, with- 
out manipulation. The thigh is slightly flexed, everted, broadened, and 
shortened, with a distinct prominence on the anterior outer surface of 
the thigh, which exhibits a marked increase in the anterior curvature at 
the site of the fracture. 
Fractures of the lower end of the femur may be by indirect vio- 
lence, though they are most frequently due to direct violence. These 
fractures are classified as are those at the end of the humerus. A 
supracondyloid fracture is of the shaft within four inches of the con- 
dyles. It has generally a slight obliquity 
downward and forward, with the lower 
end of the upper fragment displaced 
anteriorly and the lower fragment pulled 
backward. This backward displacement 
of the upper end of the lower fragment 
may injure the blood-vessels, as the 
artery runs close to the bone here. The 
gastrocnemius, soleus, and plantaris help 
to increase the deformity. The rectus 
and the hamstring muscles pull the lower 
fragment upward, thus increasing the 
deformity and the danger to the popliteal 
vessels. The deformity is peculiar in 
this, that the patella is made prominent 
by the flexion of the joint produced by 
the backward displacement of the lower 
fragment. There is a depression above 
the partially flexed joint. This supra- 
condyloid fracture is occasionally com- 
plicated by a vertical fracture into the 
joint, separating the condyles. This 
intercondyloid fracture is a serious 
injury, for it complicates a bad fracture with a lesion of a large articula- 
tion, and makes the fracture intra-articular. There is present in this 
fracture, in addition to the deformity noticed in a supracondyloid frac- 
ture, a widening of the joint, and the condyles are pushed apart by the 
fractured end of the shaft. The capsule of the joint is distended with 
blood and serum and the mobility is great. Fracture of either condyle 
may result from a fall upon the flexed knee, the violence expending itself 
on the condyle detached. It may also result from the violence of a 
Fig. 325. 
Fracture of lower end of femur, with great 
displacement of condyles (Park). 734 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
twist transmitted through the lateral ligaments of the joint, thus tearing 
off the condyle. The violence may also be transmitted through the head 
of the tibia to the condyle which suffers the fracture. 
The diagnosis of this fracture is not difficult. The undue freedom 
of the lateral movements in the extended limb is easily determined and 
crepitus can be detected. The detached condyle may be displaced for- 
ward and backward, but, as the shaft of the femur remains intact, there 
is no shortening of the leg. An epiphyseal separation of the lower 
extremity of the femur is a most serious injury, and not infrequently 
demands amputation. 
"Treatment of the Various Fractures of the Femur.—The 
principles guiding us in the treatment of fractures of the different por- 
tions of the femur have been the subject of wide discussion and very 
diversified views. This has resulted in many methods of treatment and 
in a multiplication of apparatus designed to meet the supposed indica- 
tions. Dr. Allis has called attention to the difficulty in obtaining an 
accurate adjustment in fractures of the upper third of the femur, and 
also to the difficulty in maintaining the adjustment. It appears to me, 
however, that he has exaggerated the latter and underestimated the 
efficiency of proper extension in accomplishing the purpose. Permanent 
deformity often occurs in fractures at this site, but I believe that continu- 
ous extension will generally control the deformity. Imperfect extension 
will not do it. Dr. Allis suggests that we cut down upon the fractures of 
the upper third, adjust the fragments, and keep them in position by fas- 
tening the ends together with ivory pegs, steel pins, or wire. 
Oblique fractures in any part of the shaft may gradually find a per- 
fect adjustment under the influence of continuous traction, but the trans- 
verse fracture with lateral displacement and overlapping requires more 
than a complete extension to secure this end: it must also have direct 
lateral pressure to force the fragments into position. Failing in this way 
to accomplish the purpose, success may be obtained by increasing the 
angular deformity until the ends can be put in apposition, and then with 
extension and gradual straightening of the leg, while maintaining firm 
lateral support at the fractured point, the fragments may be set or prop- 
erly adjusted. It is not easy to determine that adjustment is good, for 
the bone is enveloped in a mass of muscles and so placed that it cannot 
be distinctly outlined. The intercondyloid fractures require not only 
extension, but lateral pressure on the condyles, in order to secure good 
apposition in the vertical line of fracture. 
Every form of splint devised for the treatment of fractures of the femur is 
designed to meet the acknowledged need for extension, and in addition to this 
some of them utilize lateral support. All surgeons admit the value of traction, 
although many deny the wisdom of relying solely upon its efficiency for the result 
desired. It is quite difficult to obtain good lateral support for its fractured ends 
through the great mass of muscles which envelop this bone. The soft mass of 
muscles prevents the lateral pressure from accomplishing the purpose for which it 
is intended. The muscles rapidly atrophy under the influence of rest and pressure, 
and the lateral support becomes inefficient unless it is reapplied. The problem in 
treatment is to secure the best extension, with such lateral support as is needed, 
with the least discomfort and the greatest freedom to the patient. 
The double inclined plane has been discarded. 
Buck's extension by weight and pulley with the leg and thigh in the extended 
position is adopted by many surgeons. It is also used in conjunction with some FRACTURES. 
735 
form of a long side-splint by surgeons who are not willing to rely solely upon 
extension. Lateral support is also given by sand-bags placed alongside the thigh. 
Buck’s extension is applied in the following wray: A strip of moleskin plaster four 
inches wide, and long enough to have the free ends extend above the knee when 
the centre of the strip passes loosely across the sole of the foot, is to be used as a 
Fig. 326. 
Extension-band and foot-piece. 
medium for making extension. A flat piece of wood, three by four inches, with a 
hole in its centre, is placed in the middle of the long strip. A cord passes through 
this wooden piece and also through the moleskin plaster. The adhesive strip is 
placed in contact with the skin along the sides of the knee, and is held firmly in 
Fig. 327. 
Same, folded and ready for use. 
position by a roller bandage which should envelop the leg as high as the plaster 
extends. The cord that passes through the foot-piece is carried over a pulley at 
the foot of the bed, and continuous extension is made by a weight, the leg and 
thigh resting on the bed or on cushions (Figs. 326-328). Hamilton uses, in addi- 
Fig. 328. 
Mode of applying adhesive plaster. (When the dressings are completed the limb is to rest on the 
bed.) 
tion to the extension, a long side-splint extending almost to the axilla, which is 
designed not only to give lateral support to the fractured bone, but also to prevent 
rotation and secure a good relative position of the body and leg. Lister’s long 
splint is still used. The plaster-of-Paris splint has also many advocates, the latest 
being Dr. Nicholas Senn, who uses it for fractures of neck of the bone. His splint 736 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
envelops the foot, leg, thigh, hips, loins, and abdomen, and is applied under ames- 
thesia while firm extension is made. He also thinks it absolutely necessary to 
envelop the thigh of the other side in the dressing, and includes in the dressing 
for the injured bone an apparatus for applying pressure directly on the trochanter 
major by a set-screw. The plaster-of-Paris splint is used for the shaft of the bone. 
The plaster-of-Paris dressing is an inefficient agent for extension, and as applied 
by Dr. Senn for fracture of the neck of the bone implies such rigid confinement 
that it appears to me it cannot be borne by many aged patients. 
Simple and continuous extension was, I think, first obtained in oblique 
suspension by Nathan R. Smith when he introduced his anterior splint, 
of which the Hodgen suspension splint is a modification. The advan- 
tages of the Hodgen splint are—(1) The most equable perfect and com- 
Fig. 329. 
The Hodgen suspension splint. 
fortable extension yet devised. (2) Easy adjustment. (3) It leaves the 
thigh exposed for inspection. (4) The muslin supports on which the leg 
and thigh rest can be separately adjusted, so that the tension on any one 
ot them can be easily changed and the normal anterior curvature can be 
Fig. 330. 
maintained, notwithstanding the rapid atrophy of the soft tissues. The 
fractures in the shaft and in the lower end of the femur can be very 
perfectly immobilized in this splint. Clinical results and theory confirm 
me in the belief that it conies nearer adjusting and immobilizing the 
fractured ends of a break in the neck than any other method of treat- FRACTURES. 
737 
ment devised. If the ends are in apposition, the movement should be 
easier at the head than in the fracture. The head of the femur should 
move with the neck if adjustment is good; the swing of the leg does 
not imply that the movement is at the break. 
Moderate extension approximates and sets the fractures of the neck. The 
impacted fractures at the base are not disturbed by moderate equable extension. 
Displacement by rotation can be avoided in this splint. If pressure upon the 
trochanter is desired, it can be secured by a flannel bandage about the hips. The 
freedom of the motion allowed the patient does not interfere with the union of 
the broken shaft, as the splint and the leg are free to move with the body of the 
patient. The only motion is at the hip-joint, and there is no possibility of angling 
at the fractured point by the dragging of the leg on the bed as the patient moves 
from one side to the other. The patient can sit upright in bed or use the bed-pan 
without disturbing the fracture. 
This Hodgen splint1 is composed of a single piece of No. 2 wire, bent as 
shown in Fig. 331. The sliding hooks, D D' and E E/, are used for attaching the 
suspending cord to the splint. The use of the arch O is to maintain the proper 
width of the upper end—viz. eight to ten inches. This arch is loose and is easily 
slipped into position over the ends of the wire which forms the splint before the 
latter is applied to the leg. The width of the splint at the foot is about five inches, 
and is determined by the bend in the wire which forms the body of the splint. 
The wire hooks, E E' and D D/, present at one end a free loop for the attachment 
of the supporting cords, while the other side is coiled somewhat snugly around the 
lateral bars of the splint at D Dr and E EL The lateral bars extend upward on 
each side of the leg, so that the two ends of the wire reach, the inner one to a 
point above the pubes, and the outside one nearly to the crest of the ilium. The 
bend of the splint at the knee permits slight flexion of the leg. The suspending 
apparatus is composed of—first, the pulley A (Fig. 330), which is fixed in a high 
framework at least ten feet above the level of the bed, or preferably in the ceiling; 
secondly, of the perforated sliding block B and the cord ABC; thirdly, of the 
two cords D C E and D' C Er (Fig. 329) of equal length, with a loop at each 
end for attachment to the wire hooks at D' W and D E. These cords are passed 
through a loop in the cord B A C at its end C. The suspension of the leg and 
splint is readily accomplished by sliding the block B downward on the cord 
B A C (Fig. 330). The amount of extension is determined by the degree of obliq- 
uity of the cord B A C. It is transmitted from the splint to the leg through the 
adhesive strip H (Fig. 329), which, extending from the lower part of the thigh 
down the leg across the board N at the sole of the foot, is fastened by a cord to 
the crossbar at F, and thus securely holds the leg in the splint. 
In Fig. 331 an adjustable splint,2 easily fitted to any leg, long or short, is 
shown. It is composed of hollow tubes and sliding bars, as described below: 
Fig. 331. 
the lateral bars B C are square tubes furnished with thumb-screws at their 
extremities, B and C. These tubes are of sufficient size to admit the terminal 
ends of the lateral bars, and by pushing in or pulling out the extremities of the 
lateral arms the length of the splint may be varied. Its width can also be 
The adjustable splint. 
1 It can be made by any blacksmith. 
2 Sold by Aloe & Co., St. Louis, Mo. 738 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
changed by sliding the lateral arms into the hollow tube A A, which is furnished 
with thumb-screws at A and A. The hooks D D' and E E' for suspending the 
splint slide on the lateral bars B C, but should be kept near the end of the 
hollow tubes B C. 
The application of the Hodgen splint is simple and in skilful hands 
is painless. Suppose the leg with its fractured femur to be resting 
upon the bed. The adhesive strip with its foot-piece and cord is placed 
in position: an assistant grasps the foot with one hand, and with the 
other hand under the knee lifts the leg from the bed, while at the same 
time he makes steady extension of the femur. The surgeon then 
applies the roller as high as the plaster extends, binding it to the limb. 
The leg is again allowed to rest upon the bed: the assistant maintains 
moderate traction on the foot so that the extending force applied to the 
fractured bone may be continuous. The splint is then put into position. 
The lateral arms of the splint are held apart by a metal arch; one arm 
of the splint is placed upon either side of the leg, and the crossbar is 
brought close to the sole of the foot. The cord secures block B (Fig. 
330) to the foot of the splint. Strips of muslin are passed under the leg 
—one at the ankle, one at the knee, and perhaps two under the thigh. 
These are secured by pins to the lateral arms of the splint, while it is 
held so that the inner arm extends above the pubes and its outer arm 
reaches nearly to the crest of the ilium, the lower end of the splint 
being on a level with the malleoli. The inner wire may be shortened or 
bent upward so as to give the patient opportunity to sit upright, but it 
should always extend to a point in front of the pubic bone. The leg 
can now be suspended by attaching the cords D C E and D' C' E' (Fig. 
329), and adjusting the slide B so as to lift the splint and leg from the 
bed. The cradle, of cloth strips, upon which the leg is to rest is now 
made complete by,adding strips of muslin and adjusting them to the out- 
line of the leg as indicated in the cut. 
No special or violent attempt to adjust the fractured bone is made except where 
there is lateral displacement of a transverse fracture. The free swing of the leg 
and the efficiency of the extending force secure adjustment of the ordinary oblique 
fracture in a few hours. The flexion of the leg on the thigh should be very slight, 
not more than an angle of 170° or 180°; for if the bend approaches a right angle, the 
elevation of the knee is necessarily great, and most of the extending force applied 
to the thigh would be through the muslin strips on which the upper part of the leg 
rests (those just at and below the bend of the knee). The angle of flexion at the knee 
may be varied from that of the splint by lengthening or shortening the strips 
which support the thigh. The foot may be elevated or lowered, and the support 
rendered by the muslin strips under the thigh varied by sliding the loop at C 
downward toward the foot or upward toward the groin. The flexion of the knee 
is only sufficient to put the leg in a comfortable position, slightly relaxing the 
tension of the hamstring and gastrocnemius muscles. The slight flexion of the 
thigh on the pelvis with extension puts at rest the psoas and iliacus and the 
rectus extensor of the thigh. External rotation, if it occurs, can be obviated by 
securing the foot to a foot-piece or by a muslin strip passed around the outer 
border of the ball of the foot and fastened to the inner arm of the splint. A foot- 
piece can be easily adjusted to the splint if it is thought desirable to steady the 
foot in a fixed position. 
The degree of extension necessary to accomplish the result desired may be 
determined in part by the sensations of the patients. It is never necessary, when 
using this splint in the adult, to apply (as recommended by Hamilton when 
speaking of other methods of making extension) twenty pounds as an extending 
weight. An extension of twenty pounds, applied through an adhesive strip to 
the leg and pulling upon the knee-joint and femur, is a serious trial to the FRACTURES. 
739 
patient’s endurance, and it taxes the surgeon’s ingenuity to steadily maintain such 
a force. The amount of extension required in this suspension splint is much less, 
being from three to ten pounds. There is no friction to overcome, and so long 
as the patient remains in bed there is no appreciable variation in the extending 
force, provided the point of support is ten feet or more above the plane of the 
bed. It is a quiet, persistent, non-irritating, effective pull. There is no perineal 
band to fret and worry the patient. The extending force is determined by two 
factors, and these are entirely within the control of the surgeon—viz. the obliquity 
of the extending cord and the weight suspended. The first can be varied by the 
relative position of the bed and the suspending pulley, and the latter can be 
increased, if desired, by placing sand-bags across the lateral bars of the splint. 
It seems difficult for some surgeons to understand how extension 
can be applied to a fractured thigh by direct traction upon the leg 
without counter-extension through the perineal band. They fail to 
recognize the efficiency of the weight of the leg as an extending force 
and the stability of the body as a counter-extending force. The amount 
of the extension in a particular case where the patient weighed one 
hundred and fifty pounds was calculated mathematically and estimated 
at 6.1 pounds. The suspending cord in this case formed an angle of 
15° with the perpendicular, and the weight of the leg was estimated as 
being twenty-one pounds. The suspended limb should not be raised 
much above the bed, the heel remaining within two inches of the bed. 
If the pulley from which the splint is suspended is fixed in a ceiling 
that is nine feet to twelve feet high, a perpendicular line dropped from 
the pulley should fall beyond the foot of the adult patient. In the case 
of a child, where the weight of the leg is less, the obliquity of the cord 
should be greater. The obliquity of the cord should be sufficient to 
make an angle of from 15° to 35° with the perpendicular. The point 
of fixation for the pulley for suspension should not be nearer the plane 
of the bed than ten feet. This gives the patient the full liberty of the 
bed without changing materially the extending force. The inclination 
of the patient to slide toward the foot of the bed may be obviated by 
raising the foot of the bed by means of blocks. In the case of a child 
it may be well to pass a cord loosely about the body under the arms and 
fasten it to the head of the bed, to serve as a check to any great change 
in the position of the patient. 
The nutrition is undisturbed, for the circulation is not interfered with by the 
pressure of retentive apparatus, and it is as perfect as it can be during enforced 
quiet. The leg can be kept cool or warm as desired. The patient may sit up or 
lie down as comfort suggests. The bed-pan can be used without disturbing the 
fracture, and the best possible result can generally be obtained—viz. early union 
with no appreciable shortening. This is obtained without bed-sores or any of the 
constitutional complications which are liable to follow confinement in a fixed 
position. 
The splint is well adapted to the treatment of all fractures of the 
femur, whether they are intra- or extracapsular, through the trochanters, 
the shaft, or the condyles. The results of the treatment of fractures of 
the neck of the thigh with this splint are very satisfactory in the major- 
ity of cases. Most of the unsatisfactory results obtained are probably 
due to imperfect adjustment of the fractured ends, or are found in the 
fractures that occur in the neck very near the head. The feeble, aged 
persons who are most liable to this injury derive comfort from the use 
of the Hogden splint, for the freedom of motion it gives is greater than 740 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
they can obtain with any other apparatus, or than pain will permit if 
the injured member is allowed to go without treatment. The spasmodic 
or violent contraction of the muscles of the thigh when the fracture is 
in the shaft is sometimes so great in nervous children that Buck’s exten- 
sion with the leg resting upon the bed, and the lateral support of sand- 
bags about it, is best for a few days. After this irritability subsides the 
leg is more comfortable and more efficiently treated in the suspension 
splint. This spasm subsides after a few days, but provokes by irritation 
an increased exudative deposit about the break. I find that a sand- 
bag partly full, placed on the thigh while it is in the suspension splint, 
materially mitigates the spasmodic action. Clonic contraction will, in 
isolated cases, occur with any splint and under any plan of treatment, 
for no lateral support nor compression can prevent the contraction which 
accompanies a muscular spasm. Sulphonal or, if necessary, opiates, 
will help to control this clonic spasm, and may be given to nervous 
children with advantage for a few days after such an injury. This 
method of applying extension affords a most perfect means of neutraliz- 
ing the tonic contraction of the muscles. The oblique suspension gives 
equable and continuous extension of an amount sufficient to accomplish 
a perfect result without the waste of any force, and it ensures the 
patient the most perfect liberty attainable by any known means compati- 
ble with comfort and safety. 
The Patella. 
Fracture of the patella is the most frequent during the period of 
greatest muscular activity—that is, between the ages of twenty and 
forty years. The patella maybe fractured by direct or indirect violence. 
Indirect violence is inflicted by muscular action. The fracture inflicted 
by muscular force is in the majority of cases transverse, and occurs in 
the lower half of the bone. The violence may be purely muscular, or, 
as often happens, may through a fall be combined with some degree of 
direct injury. The fracture is usually complete, and it 
is evident from the swelling, loss of extending power 
of the leg, and by the mobility and more or less marked 
separation of the fragments. The power of extension 
may not be completely lost, but it is always enfeebled. 
The fascia extending laterally from the patella over the 
joint may not be extensively torn, and through the 
influence of the vasti some degree of power of exten- 
sion may still remain. The swelling is not only in the 
tissues about the knee-cap, but the capsule of the joint 
is distended by the hemorrhage resulting from the fracture and by a 
serous effusion into the irritated joint. This swelling may materially 
influence the degree of separation of the fragments. 
The transverse fracture may be compound from the violence of a 
direct blow. Fractures by direct violence are more uncertain and 
irregular than when caused bv muscular action. The separation of the 
fragments in a fracture produced by a direct blow upon the patella is 
not apt to be so great as where the line of fracture is transverse and 
largely the result of muscular action. The lines of the fracture may be 
Fig. 332. 
Comminuted fracture, FRACTURES. 
741 
stellate or vertical, and the displacement very slight, for the tissnes on 
the superficial surface of the bone may not be completely separated. A 
compound fracture of the patella is not very infrequent, and, as the 
knee-joint is in these cases exposed to the dangers of infection, it is a 
much more serious injury than a simple one. In such cases the utmost 
care is demanded to preserve aseptic conditions and avoid suppuration. 
The treatment of the fractured patella is generally conservative 
and efficient. Extensive effusion of blood and serum, with consequent 
distention of the capsule of the joint and marked infiltration of the sur- 
rounding tissues, sometimes delays the adjustment of the fracture, though 
immediate adjustment is generally possible. The preliminary treatment 
for the first three or four days should be such as to limit and control the 
reparative action. Equable and slight compression applied by a well- 
adjusted bandage and the use of cold applications should be resorted to 
at once. The treatment is most efficiently carried out by some firm or 
fixed dressing which shall keep the limb in an extended position, give 
complete rest to the joint, and limit the movements of the muscles of the 
thigh. Hence the splint should include the whole length of the thigh 
as well as the leg. Moderate compression of the muscles of the thigh 
lessens the contraction of the 
quadriceps extensor. The best 
splint to subserve this purpose 
is the plaster-of-Paris splint, 
which should steady the foot 
and extend to the groin and 
gluteal fold. It should be sup- 
ported and strengthened by tin 
strips incorporated in the sides 
of the splint. This splint 
should have a large oval fenes- 
trum cut in its anterior lateral 
surface, in order that the region 
about the patella may be thor- 
oughly exjDosed to the surgeon’s 
view. 
The separated fragments of 
a transverse fracture may then 
be drawn together by strips of 
plaster passing over a compress 
placed above the patella. The 
two ends of the strips are car- 
ried obliquely downward toward 
the calf of the leg and secured 
to the splint. Traction is thus 
made upon the upper fragment, drawing it downward. Another strip 
may be carried across the ligament below the knee-cap and upward 
toward the posterior surface of the thigh, and likewise fastened to the 
splint. The traction upon these strips of plaster may cause some tilting 
of the fragments at the line of fracture. This can be controlled by a 
compress placed over the surface of the patella and held in place by a 
bandage about the splint. It is a great source of comfort and security 
Fig. 333. 
Fracture of the patella, illustrating impossibility of 
securing bony union because of intervention of 
ligamentous and soft tissues (Park). 742 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
to the patient to have this plaster splint suspended, so that the leg can 
move with the patient. The Hodgen splint should be used for this 
purpose. 
Many devices have been used for the approximation of the fragments. Mal- 
gaigne’s hooks have been used for this purpose, as also subcutaneous ligature and 
the wiring of the fragments. The dangers attending operative measures have 
rather discouraged their general adoption. The results obtained by a conservative 
method are so good that the operative treatment is certainly not generally advisa- 
ble, though in proper hands many cases will justify operation. It is particularly 
applicable in refractures of the patella and in those fractures which have united 
badly, leaving the function of the limb much impaired. There is no question but 
what bony union occasionally results from conservative treatment, but close fibrous 
union is the usual result. A short ligamentous union gives the leg good functional 
activity. Good strength and good functional use of the leg may result even where 
the fragments are separated for an inch or more, if the ligament is firm. 
The leg should be kept at rest with the patient in bed for five weeks. He 
should then continue the use of crutches for six weeks longer. A limited use 
of the leg, aided by a cane, should be continued still longer. This carries the 
patient over a period of three or four months. Rubbing and moderate flexion of 
the knee in order to secure perfect function will have to be continued for a longer 
time. 
A compound fracture with suppuration requires free drainage and 
tlie best antiseptic precautions to limit the suppurative process. Com- 
pound fractures should be approximated by fastening the fragments 
together by wire or ligature. The wiring of the patella to secure union 
for a transverse fracture with wide separation may be used in simple 
fractures where every antiseptic precaution can be enforced. The union 
is more rapid and more certain than where treated in a conservative 
way. A patient who does well under operative measures may return to 
work in two or three months. The wire loops used on the fragments 
of the patella should not be passed into the joint, but should penetrate 
the fragment of the bone and emerge at the superficial surface, where 
they can be twisted together and flattened upon the bone. Strong kan- 
garoo tendon may be used for this purpose. 
The tibia and fibula should be separately considered in the study of 
fractures of the leg. 
Fractures of the tibia are classified as of the upper and lower ends 
and of the shaft. 
Fractures of the head of the tibia are usually by direct violence. 
The fibula may be broken with it or may be torn from its tibial attach- 
ment. The displacement is apt to be more marked if the ligaments 
uniting it to the tibia are broken. 
A transverse fracture below the tubercle (Fig. 334) is not infrequent. 
Fractures of the upper end of the tibia, implicating the joint, are 
slow in uniting. Fractures in the lower end and of the shaft of the 
tibia usually unite in five or six weeks, but in the upper end, even 
where the joint is not involved, they are slower and may require three 
or four months. Violence transmitted through the shaft of the tibia 
may detach a condyle. Swelling about the site of fracture is supple- 
mented by swelling of the distended sac of the joint when the fracture 
enters the joint. 
The Leg. FRACTURES. 
743 
The knee-joint must be put at rest, hence the splint must include 
both the thigh and the leg. Some lateral support should also be given 
to the tibia at the site of fracture. The plaster-of-Paris splint is well 
adapted to the treatment of these fractures. If adjustment is good, 
even if the injury be compound, suppuration may be avoided by careful 
attention to antiseptic details. If suppuration occur in the joint, free 
drainage by incisions properly made must be obtained. The Hodgen 
suspension splint with oblique extension is admirably suited to the treat- 
ment of these cases. Extension is often essential to the most perfect 
results. The lateral support secured by a roller bandage or by a many- 
tailed bandage maybe useful in conjunction with the Hodgen suspension 
splint. 
Fractures of the tibia may occur at any portion of the shaft, but are 
most frequent in the lower half of the bone. Fracture by indirect 
Fig. 334. 
Fig. 335. 
Fig. 336. 
Fracture of upper end of 
tibia. 
Transverse fracture, with 
anterior displacement. 
Line of fracture, at junction 
of lower third and middle 
third of tibia. 
violence is frequent at the junction of the lower and middle third. It 
is said that torsion plays a considerable part in determining this fracture. 
The line of fracture in this part of the bone is downward and forward 
(Fig. 335), so that the end of the upper fragment has a sharp point ante- 744 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
riorly. The displacement is almost always of the anterior fragment 
forward and outward. The shortening is determined either by the 
violence inflicting the injury or by the contraction of the gastrocnemius 
and soleus muscles. The anterior projection of the upper fragment may 
be in part due to the action of the quadriceps extensor of the thigh. 
Fractures of the shaft are very generally accompanied by a fracture 
of the fibula at a point a little above the line of fracture of the tibia. 
(See Fig. 336.) The lower fragment of the tibia is frequently broken 
or split into more than one piece. The split bone sometimes enters the 
ankle-joint. Fractures of the tibia, whether by direct or indirect vio- 
lence, are apt to be compound. 
The symptoms are loss of function, pain, mobility, and deformity due 
to the anterior projection of the upper fragment. Injury to the great 
vessels in fractures of the tibia, whether of the upper end or the shaft, 
are not infrequent. 
Reduction of displacement in the shaft of the tibia can usually be 
accomplished by traction upon the foot. The reduction is not always 
easily maintained where the obliquity is marked and the displacement 
great. 
The contusion and swelling which usually accompany these fractures often 
make it unsafe to put the leg into a plaster-of-Paris dressing at once. While these 
Fig. 337. 
Fracture-box suspended. 
conditions exist and prevent the use of the plaster splint, the bivalve cushion or 
pillow makes a most admirable support for the fracture. A feather or moss pillow 
makes good padding for this purpose. The pillow should be placed about the leg, FRACTURES. 
745 
and the lateral support given by a fracture-box composed of three loose boards. 
The wooden strip on the posterior surface of the leg should extend from a point 
below the sole of the foot to the fold of the joint behind the knee. This board 
should not be wider than the leg at the calf. The two lateral boards should be 
wider, being about five inches in width, and should extend from below the sole of 
the foot to a distance of four or five inches above the knee-joint. The leg is placed 
in the middle of the pillow, and the sides of the pillow are brought up on its lat- 
eral surfaces. The lateral boards are now pressed against and give support to the 
leg and foot, the amount of pressure being determined by the tension put on the 
bandage strips which pass about and envelop the splint, the pillow, and the leg. 
If the upper fragment is disposed to push forward, it may be somewhat steadied 
in position by a firm compress placed over it and secured by a strip passing about 
the fracture-box at the site of injury. This splint may be replaced in a week or 
ten days by a plaster-of Paris splint. This fracture-box is very well adapted to 
the treatment of these fractures, for it fulfils the conditions to be met in compound 
fractures. The leg can be inspected without disturbing it, and it can be kept clean. 
Good support is given by lateral pressure. Stability of position is almost essential 
to kindly healing of compound fractures. Hence the removal of a portion of the 
end of a bone, in order to relieve tension and to give easy adjustment, is justifiable 
in these compound fractures if the fractured surfaces cannot be held accurately in 
position by the fracture-box or by nails or pegs passed through the fractured sur- 
faces. This fracture-box may be suspended, and the patient can move without 
disturbing the fracture. 
If the injury to the soft parts be not too great, and the fracture be 
easily retained in position, a plaster-of-Paris splint may be at once 
adjusted. The danger of making the plaster splint too tight may be 
obviated by enveloping the leg in a thick layer of cotton batting: the 
common non-absorbent cotton is the best. A plaster-of-Paris roller is 
then applied. A stirrup made from strips of old sheeting into which 
the plaster-of-Paris is rubbed makes a good splint. This plaster stirrup 
should be about three inches wide and composed of six or eight thick- 
nesses of cloth. It should be placed outside the cotton and extend 
from a little above the knee downward across the sole of the foot and 
up on the other side of the leg to a position opposite the point of begin- 
ning. This is secured to the leg by a simple roller bandage. The band- 
age can be cut in front and the leg inspected at any time without disturb- 
ing the plaster stirrup. 
In the obstinate cases of anterior displacement of the upper frag- 
ment the tension exerted through the Achilles tendon may be relieved 
by subcutaneous division. 
Fractures of the lower end of the tibia may be either by direct crush- 
ing or indirect violence. Most frequently these fractures are produced 
by the transmission of violence through the foot. This fracture may 
involve both bones above the joint or make a comminuted fracture of 
the lower end of the tibia. The fracture, if above the joint, is to be 
treated much as a fracture of the shaft of the tibia. 
Fractures of the lower end involving the joint are inflicted either by 
eversion and outward rotation of the foot, producing a Pott’s fracture, 
or by inversion with inward rotation, producing fracture of the fibula 
about an inch and a half above its lower extremity, as well as fracture 
of the tip of the internal malleolus. This fracture does not usually 
produce serious deformity. The displacement is easily corrected, and 
the result of treatment is generally good. 
Pott’s fracture, the one produced by eversion and outward rotation 
of the foot, has three separate lines of fracture : one of the tip of the 746 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
internal malleolus, another of the fibula two and a half inches above the 
lower end; the third, not always present, is through the outer margin 
of the articular surface of 
the tibia. When the outer 
portion of the articular sur- 
face of the tibia is broken 
from the shaft, it may be 
pushed upward between the 
tibia and fibula. This frac- 
Fig. 338. 
Fig. 339. 
Pott’s fracture (Hoffa). 
Exaggerated deformity in Pott’s fracture. 
ture, if complicated by tlie displacement of this wedge-shaped fragment, 
is a serious injury. 
The SYMPTOMS of such a fracture are the outward eversion of the 
foot, the prominence of the internal malleolus, and tenderness at the 
site of fracture of the fibula, together with a widening of the articulation 
(Fig. 339). 
The adjustment can usually be accomplished by traction upon the 
foot with pressure upon the external malleolus. In these fractures the 
foot is often displaced backward, so that the anterior margin of the tibia 
presents forward on the astragalus. The treatment of these fractures is 
usually best accomplished by the application of a plaster-of-Paris splint. 
It will often be necessary to delay the application of the plaster splint 
until the swelling of the parts has subsided, but the adjustment of the 
displaced bones must be at once perfected. They can be retained in 
position by the fracture-box with lateral compression, as described above 
for use of fractures in the shaft, and by a plaster-of-Paris splint. 
Fractures of the upper half of the shaft of the fibula without a break 
of the tibia are by direct violence. Fractures of the lower half result 
most frequently from indirect violence. The upper end of the fibula FRACTURES. 
747 
may be broken by the action of the biceps muscle or by a twist or turn 
of the leg. Fractures in the lower end of the fibula frequently result 
from forcible eversion or inversion of the foot. The displacement of 
the fragments in fracture of the fibula is not usually very marked. It 
is more evident when the injury is of the lower third than when in the 
shaft or upper end. The attachments of the muscles and interosseous 
membrane prevent a very wide separation. 
Fig. 340. 
Union with backward displacement of foot in Pott’s fracture. 
The treatment of fracture of the shaft and lower end is by immo- 
bilization of the ankle and foot with a plaster-of-Paris splint. This 
treatment should also be followed in fractures of the upper end. 
Union is usually rapid and satisfactory. In fractures of the upper 
half of the fibula the splint may be removed in three or four weeks, 
but when the lower half is broken the splint should remain longer. 
Fractures of the leg and thigh are now not infrequently treated by 
the so-called ambulatory method. This means something more than 
permitting the patient to move around with crutches with some fixed 
dressing applied to the break. The object is to so arrange the dressing 
as to enable the patient to use the leg in locomotion. The various forms 
of hip-splints used for immobilizing and securing extension for hip dis- 
ease may be used in this way. The splint with a body band, a perineal 
band, or an inside steel bar, with ischiatic crutch and a cross-bar below 
the sole of the foot, on which the weight of the body falls in walking, 
is most useful. The fracture is to be enveloped by lateral supports, 
Ambulatory Method op Treatment. 748 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
which should fit snugly and give some pressure to the soft parts. 
Extension is to be secured by fastening the foot to the cross-bar. The 
lateral support may be secured by a snug-fitting plaster cast. 
It is claimed by advocates of this plan of treatment that a simple 
plaster-of-Paris splint so adjusted as to have the thick sole of the splint 
separated from the foot by a layer of cotton (one inch or more), and 
made to encircle snugly the tuberosities of the tibia, will afford a good 
medium of locomotion and firm support for the break. 
The ambulatory treatment is valuable in exceptional instances, and 
should be used ; but in many cases an enforced rest for the body and the 
leg will be most advantageous to the patient. The advantages claimed 
for this method are, first, a more rapid and less uncertain union of the 
break; second, a more satisfactory and perfect restoration of function, 
since there is less atrophy of muscle anti a diminished stiffening of the 
joints; and, third, the value of the time secured to the patient by the 
short confinement to the bed or house. 
The Foot. 
The bones of the foot suffer fracture by direct and indirect violence. 
The astragalus may be crushed by a force transmitted through the 
tibia. There is no uniformity in the line of fracture through the 
astragalus, and the diagnosis is difficult, and is occasionally impossible 
unless the fragments are displaced. The displacement of one of the 
fragments, usually of the neck, is not infrequent. If it cannot be put 
into good position, it should be removed. If the fracture be compound 
and the bone be comminuted, or if the displaced fragments suppurate, it 
is best to remove them. 
The results of treatment of fractures of the astragalus when the dis- 
placement is not marked are good. The result, even when it is neces- 
sary to remove a part of the bone, is also good. Immobilization of the 
ankle in a position at right angles to the axis of the leg is the treatment 
to be pursued. This is best secured in a plaster-of-Paris splint. 
The calcaneum may be broken by a fall upon the foot or by the 
violence conveyed through the tendo Achillis in contraction of the gas- 
trocnemius and soleus muscles. Where the fracture is the result of a 
fall upon the foot the bone may be comminuted. 
Flattening of the sole of the foot, absence of the prominence of the 
heel, with pain and disability, constitute the symptoms attending such 
a fracture. The parts are to be moulded into as good a position as pos- 
sible and treated by immobilization. If the injury be compound and 
the fragments small and detached, they should be removed. Where the 
fracture results from muscular contraction the position maintained should 
be that of extension of the foot. 
The metatarsal bones are broken by direct violence. The first and 
fifth metatarsal bones, being the most exposed, are the ones which are 
usually broken. Contusion of the parts about the site of fracture is 
very common, and the fracture is frequently compound. The displace- 
ment is not apt to be very marked. 
The symptoms are pain, mobility, crepitus, and tenderness at the site 
of fracture. FRACTURES. 
749 
The tkeatment is immobilization of the foot. 
Fractures of the phalanges result from direct violence. The bones 
are often crushed by the violence producing it. Extension applied to 
the fractured bone may be necessary in isolated cases, but usually the 
support given by the contiguous toes and by a bandage which covers the 
foot and toes, putting the foot at rest, gives sufficient stability to the 
fracture after it is adjusted. CHAPTER XXXVII. 
DISLOCATIONS. 
H. H. Mudd, M. D. 
The bones of the skeleton are joined by ligaments or by fibro-carti- 
lage. The union in some cases is so firm that separation cannot occur 
without fracture, and the resulting injury is to be regarded rather as a 
fracture than a dislocation. The separation of the smooth articular sur- 
faces of a joint that has a capsule, even if accompanied by a fracture of 
bony prominences, is a dislocation. The displacement need not be so com- 
plete as to entirely remove one articular surface from its opposing bone 
to constitute a dislocation, so that in the surgery of the joints a dislo- 
cation is the complete or partied separation of the articular surface of the 
one bone from that of another. The partial luxation which accompanies 
a sprain is momentary, the displaced bone returning at once to its place. 
If the displacement by muscular action or the tension of the ligaments 
remains unreduced, even if the articular surfaces are not entirely sepa- 
rated, it constitutes a dislocation. Dislocations are less frequent than 
fractures, being in the proportion of one to eight or ten. 
Dislocations are traumatic, pathological, and congenital, occurring in 
frequency in the order named. Traumatic dislocations result from 
direct and indirect violence and from muscular action. We are chiefly 
concerned with this class. In the pathological dislocation the ele- 
ments determining the accident are slow changes in the ligaments and 
tissues of the joint, muscular action being the active agent in produ- 
cing the ultimate displacement. 
The congenital dislocations are those which occur in the child from 
errors in the development of the joint, and not such as are produced by 
the violence inflicted during the delivery of the infant. 
The distal bone forming a joint is the one spoken of as being dis- 
located; rarely, as of the acromial end of the clavicle, is the proximal 
bone the one displaced. 
If there be a wound of the skin which communicates with the dis- 
located joint, it is characterized as a compound dislocation. Special indi- 
cations for treatment may arise from other important complications, such 
as laceration of nerves and vessels or fractures. 
Dislocation of symmetrical bones are bilateral or double. When both ends of 
a bone are displaced it is said to be double or total. If two or more bones are 
simultaneously dislocated, the displacements are said to be multiple. 
The particular point to which the distal bone of the joint mentioned is dis- 
placed often gives name to the special dislocation, as subcoracoid dislocation of the 
humerus. 
750 DISLOCATIONS. 
751 
If the dislocated bone remains at the point where it first comes to rest, it is 
primary, but if after a time, under the influence of muscular activity or patho- 
logical changes, it shifts to another point, it is a consecutive or secondary dislo- 
cation. ' 
Etiology and Mechanism. 
The anatomy of a joint and its exposure to violence determine its predisposi- 
tion to dislocation. The ball-and-socket joints have the greatest range of move- 
ment, and are on that account most liable to this accident. The shoulder is the 
ball-and-socket joint having the freest motion, and it suffers more than half of all 
dislocations. Dislocations of the shoulder are rare under the twentieth year, but 
dislocation of the elbow is frequent. The relative frequency of the dislocation of 
these joints is reversed after this age, and the frequency of the shoulder displace- 
ments is much increased during middle life. The infirmities of extreme old age 
prevent exposure to the accidents likely to result in dislocation. Dislocations are 
not as frequent in females as in males. 
Dislocations are rare in children and in the aged, separation of an epiphysis 
and fracture being respectively more apt to occur in these periods of life. People 
with loose joints and lax ligaments are peculiarly liable to dislocation. The 
determining cause of a traumatic dislocation is external force applied either 
directly to the joint or, as is most often the case, indirectly through the bones 
constituting the articulation or by muscular action. Dislocations by indirect vio- 
lence are very much more frequent than by direct violence. Muscular action alone 
rarely produces a dislocation, but it frequently produces secondary displacement in 
existing dislocations. 
Pathology of Recent Dislocations.—The laceration of liga- 
ments is determined by the mechanism of the joint and by the cha- 
racter of the ligaments. In the arthrodial joints the injury to the cap- 
sule may only be on one side, but in the hinge joints the ligaments are 
likely to be ruptured upon both sides of the articulation. The liga- 
ments may be stretched in some joints, so as to give complete displace- 
ment without laceration, notably in the dislocation of the lower jaw. 
The muscles are occasionally ruptured and the vessels and nerves com- 
pressed or lacerated, though the blood-vessels are rarely seriously 
injured. Bony prominences may be detached, as in the coronoid pro- 
cess of the ulna. The margins of the articular surfaces may be broken 
off, as the rim of the acetabulum. The tearing away of an apophysis 
may occur as a complication of a dislocation. These fractures of the 
bone are not apt to be extensive enough in dislocations to make special 
complications, though occasionally a complete break occurs. The disloca- 
tion may be compound—that is, the injury to the soft parts may expose 
the joint. 
The special pathology of unreduced dislocations is found in the change 
in the relations of the parts about the articular surfaces and in the changes 
which follow the pressure of the bone upon the contiguous tissues. The 
displaced bone becomes attached to the adjacent tissues. A new socket 
is formed of the soft parts, against which it presses or at its point of 
bony contact. If the capsule of the joint be stretched over the joint 
surface, it may become adherent to it and practically limit the formative 
processes and changes about the joint. The muscles and nerves may 
become adherent to the displaced bones and undergo atrophy or degen- 
eration. The viscera are rarely injured by dislocations, except in those 
that involve the vertebrae. Injury of the pelvic viscera is possible in 
dislocations of the femur where it penetrates the acetabulum and 752 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
enters the pelvis. The displaced clavicle also may injure the vessels of 
the neck. 
If the reduction of the dislocation is promptly made, it is generally followed 
by repair and the function of the joint is restored, though limitation of free 
movement may exist and is especially apt to accompany undue inflammatory reac- 
tion. A good recovery follows even the compound dislocation if suppuration is 
avoided. The imperfect repair of the capsule of the joint or of the ligaments 
may lead to a condition which admits of a ready displacement of the bone. Fre- 
quent recurrence constitutes what is called recurrent or habitual dislocation. 
Injuries of nerves by laceration are frequent. An injury to the nerves may express 
itself by a loss of power in the muscles or by loss of sensation. Involvement of 
the nerves may occur from a neuritis, and be dependent rather upon contusion of 
the small nerves than upon direct injury to the nerve-trunk itself. 
Symptoms of a Dislocation. 
The symptoms of a dislocation are clear and well defined, but the 
possibility of the existence of a fracture, and the swelling that occurs 
about a deeply situated joint, not infrequently make the diagnosis diffi- 
cult. The general symptoms are—(1) Deformity, evident in contour 
and in the fixed position of the distal bone. (2) Pain about the joint, 
usually quite severe : as nerve-trunks are frequently subjected to pres- 
sure, this pain may extend to the points of distribution of nerve-fibres. 
(3) Voluntary movements are very much limited, and there is a rigidity of 
the injured parts which resists passive movements, except when lacera- 
tion of the ligaments and capsule is extensive. (4) The normal outline 
of the region about the joint is changed, and bony landmarks indicate the 
altered relation of the bone. (5) The dislocated bone can often be out- 
lined in its new position, and the injured extremity may be lengthened. 
(6) The direction of the axis of the dislocated bone is altered. 
The DIFFERENTIAL DIAGNOSIS BETWEEN FRACTURE AND DISLOCA- 
TION is determined by the elastic fixation of a dislocation, the absence 
of crepitus, and the fact that there is but little tendency to redisplace- 
ment in a dislocation. Each one of these symptoms may, however, be 
reversed. Mobility and redisplacement may characterize a dislocation 
where extensive injury to the soft parts is inflicted. Crepitus may be 
present when an apophysis is detached or when a prominence of bone 
on the margin of the articular surface is broken. 
Treatment. 
The anatomy of the joint determines the nature of the efforts to be made for 
the reduction of the dislocation. Anatomical knowledge in manipulation must be 
relied upon in accomplishing the reduction rather than the application of sheer 
force to the dislocated bone. The reduction by special manipulation is to be 
effected often through the integrity of special ligaments, which, if destroyed, make 
systematic movements useless in securing the adjustment. Reduction by the force 
of extension and counter-extension overcomes muscular resistance and pulls the 
displaced bone over bony points of resistance, but it may lacerate the capsule and 
contiguous tissue and injure nerves and blood-vessels. The capsule heals, liga- 
ments reunite, and the injury to the soft parts is soon repaired in simple disloca- 
tions if reduction is promptly made. The synovitis, usually slight, soon subsides, 
and the repair is fairly complete in a few weeks. If undue inflammatory action 
should occur, it is apt to result in some loss of function by reason of agglutination 
of the parts. DISLOCATIONS. 
753 
Laceration of nerve-trunks may result in permanent injury, and 
muscles that are torn may be so imperfectly restored that weakness of 
the joint continues. Compound dislocations with fracture may result 
in acute suppurative inflammation, leading to loss of function. 
Rest is essential to perfect restoration of the joint, and even if the 
primary disturbances have subsided, the joint should not be subjected 
to excessive motion in any direction until the parts have become 
thoroughly restored. The injured joint should be kept at rest from 
three weeks to three months. The acute inflammatory process is to be 
controlled by heat or cold and rest. 
Dislocations remain unreduced by reason of ignorance, inattention, 
the interposition of muscles or tendons, a small opening in the capsule, 
or because a fracture of some of the bony prominences permits the bone 
to escape easily after reduction. Unreduced dislocations become irredu- 
cible after a period of time that varies with the anatomy of the joint 
and the degree of reaction that attended the injury. Adhesions form 
which make violent efforts at reduction dangerous. The limit of time 
when it is injudicious to make efforts at reduction cannot be said to be 
fixed. This is especially true since arthrotomy has become a com- 
paratively safe operation in the reduction of these ancient dislocations. 
The nearthrosis, or new joint formed by the displaced bone, may often 
become so perfect as to make it undesirable to attempt reduction by 
operative means. Reduction with good restoration of function is often 
possible after the lapse of a long time. The time at which this is pos- 
sible and advisable is greater in the ball-and-socket joints than in the 
hinge joints. 
Compound Dislocations.—This complication is infrequent, for the 
violence necessary to produce protrusion of the articular surfaces is 
necessarily great. The consequent injury to the surrounding tissues, 
including vessels and nerves, is serious and is apt to result in suppura- 
tion. The gravity of the condition varies, however, very greatly in 
different joints, the difference being found rather in the amount of 
injury to the contiguous tissues from the violence necessary to make it 
compound than to the special characteristics of the joint. It is an 
especially grave complication in the hip. The opening in the compound 
dislocation of the shoulder is usually in the axilla, and constitutes a 
serious lesion. Fortunately, it is a rare injury in these joints. It is 
much more frequent in the ankle, the elbow, the knee, and in the dislo- 
cation of the phalanges or the metacarpal bone of the thumb. Special 
effort must be made to attain a perfect aseptic condition. Good drain- 
age must be secured in selected cases by gauze packing. 
Special Dislocations. 
Simple dislocations of the lower jaw present only two forms—the 
unilateral and the bilateral with forward displacement. The double or 
bilateral is the most frequent. This injury is more frequent in women 
than in men. It is rare in children and in the aged. A dislocation 
backward and outward may occur, but it is as a complication of a frac- 
ture of the glenoid fossa or of the jaw, and is the lesser of the two 
injuries. The mechanism of the anterior dislocation, whether of one or both sides, is the 
same. It occurs when the mouth is widely open by the condyle slipping forward 
over the eminentia articularis. It is aided in this escape from the glenoid fossa by 
the external pterygoid muscles. The 
temporal muscle is made tense and firm, 
and helps to retain the bone in the 
abnormal position. The capsule is not 
necessarily torn. The interarticular 
fibro-cartilage is carried forward with 
the condyle (Fig. 341), 
754 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
Fig. 341. 
The SYMPTOMS are the rigidity 
of the jaw with inability to close 
the mouth, a projection of the chin, 
and the presence of the condyle 
forward of its normal position. A 
deviation of the jaw toward the 
uninjured side is present in the 
unilateral dislocation. 
Treatment.—Reduction is ef- 
fected by depressing the angle of 
the jaw, the symphyses being at the same time supported, the object of 
the movement being to pull the condyle downward until it can be car- 
ried backward over the articular eminence and forced into the glenoid 
fossa. The joint should be put at rest for two weeks at least. 
The Sternum.—The dislocation of the body of the sternum from the 
manubrium and the xyphoid appendix from the body are the usual dis- 
placements. The dislocation of the body from the manubrium is pro- 
duced by muscular action, by strong flexion of the head and body, by 
direct violence applied to the body, or by forced dorsal flexion. In 
displacement produced by flexion or muscular action the displacement 
of the body is usually forward. It may be displaced backward by 
direct violence. 
The pathology and treatment are the same as in fractures. 
Bony union occurs between the different pieces of the sternum at about 
the thirty-fourth year. (For dislocation of the ensiform cartilage, 
which is rare, see Fractures.) 
Dislocations of the Ribs.—Clinical records prove the possibility of a 
dislocation of a rib from the vertebrae. The dislocation is forward. This 
injury appears to involve the eleventh and twelfth ribs more often than 
the others. The chondral cartilage may be displaced from the ribs and 
from the sternum. These injuries are rare, and are to be treated as 
fractures. 
The Clavicle.—Both ends of the clavicle may be displaced simulta- 
neously, but more frequently only one end is dislocated. The sternal 
end is dislocated forward, backward, and upward. The forward dis- 
location is produced by forcibly carrying the shoulder backward and 
downward. The sternal end is lifted from its articulation, and when 
the shoulder is freed from its restraint the end of the clavicle is carried 
forward on to the sternum. The dislocated head is easily recognized 
by palpation, local pain is present, the shoulder is depressed, and the 
function of the arm is impaired. Dislocation backward is produced by 
direct violence forcing the bone into its new position, or by indirect vio- 
Double forward dislocation of the inferior 
maxilla. DISLOCATIONS. 
755 
lence, when the shoulder is forced forward and inward. The bone can 
be felt in its new position, and the direction of the axis of the bone 
shows that it is displaced backward. The upward dislocation occurs 
when the shoulder is forcibly depressed. The end of the bone is then 
found above the sternum. The backward and the upward dislocations 
may disturb respiration, and the backward displacement may also inter- 
fere with deglutition. 
These dislocations are reduced by carrying the shoulder upward, out- 
ward, and backward, and by direct manipulation of the displaced end. 
The great difficulty is found in maintaining reduction, for it is difficult 
to hold the shoulder in a fixed and proper position. Direct pressure 
on the end of the clavicle may aid in keeping it in position. The bone 
should be frequently inspected, for the inclination of the articular sur- 
faces favors redisplacement, and treatment must be continued for several 
weeks. The arm should be used with caution for two months. 
The acromial end is rarely displaced except in an upward direction. 
This supra-acromial displacement is caused by a blow upon the shoulder 
or by a fall. It does not often overlap the acromion. 
The symptoms are impaired function of the arm, prominence of the 
end of the clavicle, and easy reduction and recurrence of the dislocation. 
Stimson’s plan of treatment is very good. A broad strip of plaster 
is used. The middle of the band is placed under the elbow; the ends 
are carried up the arm and over the shoulder so that they cross over the 
displaced end. A firm pad may be placed between the plaster strip and 
the end of the clavicle. Moore’s dressing for fractured clavicle (q. v.) 
is also an excellent dressing. 
Total dislocation of this bone occurs from extreme violence, which 
pushes the shoulder inward, displacing the sternal end forward and the 
scapular end upward. 
Treatment is directed to keeping the bone in position by carrying 
the shoulder outward and backward and by direct pressure upon the 
bone. The result in dislocation of either end of the clavicle is usually 
good, and, though perfect retention of the displaced extremity is not 
feasible except by operative measures, its function is generally not 
impaired by the remaining deformity. 
Dislocation of the Shoulder-joint.—The bony part of the shoulder- 
joint consists of the glenoid cavity and the head of the humerus. The 
articular surface of the glenoid cavity is oval in shape, with the small 
end pointing upward and forward, and is quite small in comparison with 
the head of the humerus. It serves merely as a point of support for the 
humerus in its movements. The head of the humerus is hemispherical 
in shape, is placed obliquely on the shaft so as to form an angle of about 
140° to its axis, has a diameter of about two inches, and an articular 
surface three or four times as great as that of the glenoid cavity, although 
the articular surface of the cavity and the support it gives to the humerus 
in its movements are increased by a fibro-cartilaginous ring which is 
attached to its margin. The capsular ligament completely encircles the 
articulation, is attached beyond the glenoid cavity, and is remarkably 
loose, being much longer and larger than is necessary to keep the bones 
in position. The looseness of the capsule permits the bones to be sepa- 
rated from each other for an inch or more, and secures to the joint a 756 
affections of the tissues and tissue-systems. 
gliding as well as a rolling motion. The capsule is also remarkably 
thin, so that the articular surfaces are readily displaced on the applica- 
tion of moderate violence. 
The prominence of the shoulder, the many functions of the arm, and 
its freedom of motion, the comparatively small size of the glenoid cavity, 
and the laxity of the capsular ligament so expose the shoulder-joint to 
dislocation that more than half of all dislocations are of this joint. It 
is worthy of note that these dislocations almost never occur in children, 
are rare in the aged, and are three or four times more frequent in men 
than in women. The humerus is held firmly in position when at rest by 
atmospheric pressure ; when it is in motion the action and counter-action 
of the various muscles attached about and passing over the joint strengthen 
the capsule greatly and prevent dislocations resulting from normal 
movements. 
The shoulder-joint being without bony protection in the greater 
part of its circumference, admits of a number of different dislocations. 
Keeping the glenoid cavity as a central point from which to designate 
these displacements, they may be spoken of in the order of their fre- 
quency as anterior, downward, posterior, and upward. 
Indirect violence is the most frequent cause of the dislocation: this maybe by 
leverage, the head of the bone being lifted out of the socket by strong rotation, by 
abduction or adduction; or the head of 
the bone may be pushed through the cap- 
sule by a fall upon the hand or elbow. 
The position of the arm and direction of 
the force determine the particular form 
of dislocation that occurs. The humerus 
may also be dislocated by muscular action 
and by direct violence. 
It is said that in some cases a disloca- 
tion of the humerus occurs without lace- 
ration of the capsular ligament, but these 
cases must be very rare indeed, the rule 
being that the capsule is torn and the 
head protrudes through the opening. The 
capsule is not only thicker above than 
below, but it is reinforced from above by 
the coraco-liumeral ligament, so that the 
rent occurs generally in the lower part of 
its circumference, either anteriorly or pos- 
teriorly, depending upon the direction of 
the displacement: unless the displacement 
is considerable, the muscles are not torn 
from their insertions to any great extent, 
though there is some laceration of them 
in all primary complete dislocations. The 
axillary nerves and vessels may be pressed 
upon or lacerated by the displaced bone, 
but generally they escape serious injury. 
In the anterior or subcoracoid dis- 
locations the head of the bone escapes 
through a rupture in the anterior and lower part of the capsule, and 
pushes forward before it the subscapular muscle or ruptures its fibres. 
The margin of the head or the anatomical neck rests against the margin 
of the glenoid cavity, and the head is under the coracoid process. If the 
bone is carried farther forward by the violence, more of the capsule is 
Fig. 342. 
An old unreduced subcoracoid dislocation. DISLOCATIONS. 
757 
torn, the greater tuberosity may be torn from the bone, and the head 
finally rests to the inside of the coracoid process, and it becomes a sub- 
clavicular dislocation. The posterior portion of the capsule is stretched 
tightly over the glenoid cavity or is lacerated. The tendon of the biceps 
is sometimes torn from its groove. The downward or subglenoid dislo- 
cation occurs when the rupture in the capsule is at a lower point, and 
is apt to follow in cases where the elevation of the arm was very great 
when the violence was inflicted. The head of the bone escapes below the 
subscapular muscle, and rests against the border of the scapula rather on 
its ventral surface. The axillary vessels and nerves are more likely to 
be disturbed by pressure in this variety. The external rotators are 
more certainly ruptured or the tuberosity detached when the head is 
thus displaced. 
The posterior, subspinous, dislocation is more rare. It occurs when 
the arm is adducted and the elbow raised somewhat. The head of the 
bone passes backward under the spine or is arrested under the anterior 
extremity of the acromion process. 
The signs and symptoms of a dislocation of the shoulder are— 
pain in the region, flattening of the shoulder, prominence of the acromion 
(Fig. 343), with a depression at the glenoid cavity and lengthening of the 
Fig. 343. 
Exhibits a subcoracoid dislocation and the position of the patient in his endeavor to find relief 
from pain. 
arm in the forward, downward, and backward displacements. A short- 
ening of the arm occurs in the upward displacement. 
A change in the direction of the axis of the humerus, inability to bring 
the elbow to the side, loss of voluntary motion, with an elastic resistance to 
passive motion, and the presence of the head of the humerus in the new 
position, aid in the diagnosis. The elbow is not easily carried inward 
or forward on the chest, and the hand cannot be placed on the opposite 
shoulder while the elbow touches the thorax (Dugas). 
The differential diagnosis between a fracture and a dislocation at the shoulder 
depends upon the character of the deformity, the increased ease with which pas- 
sive motion can be made in a fracture, the resistance met with in a dislocation, 
and the ease with which extension and counter-extension reduce a fracture, unless 
it be an epiphyseal separation, while the dislocation requires certain well-regulated 
systematic movements to accomplish its reduction. The great readiness with 758 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
which the deformity in a fracture recurs, and the presence of bone-crepitus in the 
fracture, which is not present in a dislocation unless there be also a fracture about 
the point. The fracture which most closely simulates a dislocation of the shoulder 
is that of the neck of the scapula, but the mobility of the part, the ease with 
which the deformity can be reduced, and the immediate recurrence of the deform- 
ity in the fracture should not make the diagnosis very difficult. The diagnosis of 
the particular form of dislocation is determined by the position and direction of 
the shaft and the location of the head of the humerus. The lengthening of the 
arm is greatest in the downward, less in the subcoracoid, and least in the backward 
dislocation. It is short in the upward dislocation. The elbow is carried farther 
from the side in the downward displacement. The elbow is carried outward and 
backward in the anterior and subglenoid dislocation, but it is forward in the sub- 
spinous. Outward rotation is generally present in the subcoracoid and the sub- 
glenoid dislocations, while inward rotation is found in the subspinous. 
The treatment of a dislocation at the shoulder should be the early 
reduction of the deformity and the adjustment of the joint surfaces. 
An attempt should be made to do this without an anaesthetic. If this 
effort be ineffectual, then an anaesthetic must be given in order to over- 
come the muscular resistance incident to the new position and the irri- 
tation of the injury. Opposition to reduction may also be found in the 
difficulty experienced in freeing the head of the bone from the border 
of the glenoid cavity, in the small opening in the capsule, in the inter- 
vention of portions of the freely torn capsule, and in the peculiar rela- 
tions of the subscapular muscle and the biceps tendon. 
It is easier to reduce a dislocation immediately after the injury than it is at a 
later date. After a time, varying from a few days to a year or more, it becomes 
impossible to accomplish the reduction by manipulation, an operation then being 
necessary. When the replacement occurs the bones can be felt in their normal 
relations, and the resistance to active and passive motion disappears; sometimes 
an audible snap is produced by the joint surfaces coming quickly in contact with 
each other. 
In attempting to reduce the dislocation the arm should be first car- 
ried in those directions in which it meets with least resistance. When 
force is to be used, we must be 
guided in the application of it by 
our knowledge of the anatomy and 
physiology of the parts. The 
mechanism of the force necessary 
to be applied in order to reduce a 
dislocated humerus varies in the 
different dislocations and depends 
upon the form and extent of 
the displacement. Extension and 
counter-extension are, however, con- 
stant factors in all of them. In 
addition to the extending force, the 
desire is to use rotation and lever- 
age in such a way as to limit the 
power necessary to be expended. 
The anterior dislocations are by 
far the most frequent, and of these 
the subcoracoid makes a very large 
proportion, so that the manipulation necessary to reduce this form of 
dislocation has received the most attention at the hands of surgeons. 
Fig. 344. 
First position in Kocher’s rotation method. DISLOCATIONS. 
759 
Quite a number of methods have been described, but the most efficient 
of them perhaps is the one known as Kocher’s rotation method, which is 
used in the following way : The elbow is carried firmly to the side, with 
the forearm at a right angle to the arm, and the arm is then forcibly 
rotated outward till the forearm points away from the body (Fig. 344). 
When this has been done the arm is carried up from the body till it is 
Fig. 345. 
Arm is being carried forward and upward toward second position. 
in the horizontal plane running through the glenoid cavity. The scapula 
is fixed and firm extension is made during these movements (Figs. 345, 
346). When the arm comes to the level of the shoulder, it is gradually 
rotated inward, and is again brought 
to the side with the forearm across 
the body. The head slips into place 
with the inward rotation and at the 
beginning of the downward move- 
ment. This method requires care 
in its use, especially in the aged, in 
order to avoid fracturing the bone in 
the effort to replace it, for the bone 
is under the strain of torsion. 
Fig. 346. 
Although use is made of leverage in 
all of the methods of reduction, there is 
a manipulation which is called the lever 
method, which was preferred by Sir 
Astley Cooper. It is as follows • With 
the patient sitting on a chair, the sur- 
geon stands behind him and lifts the 
arm of the injured shoulder from the 
body till he can get his knee in the 
axilla, resting his foot on the chair on 
which the patient sits. He now fixes 
the acromion with one hand and grasps 
the arm above the elbow with the other, 
using the humerus as a lever, and the 
knee in the axilla as a fulcrum. When the head is brought near to a point of 
reduction, the knee is elevated by raising the foot on the toes, the head of the 
humerus being thus raised still higher. Extension is kept up during the whole 
Completion of third movement in Kocher s 
method. 760 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
of the procedure, and by moving the humerus with the hand and knee alternately 
the head is gradually brought into position. 
The method by perpendicular extension, first used by Mothe in 1812, was for a 
time very generally used. It is applied in the following way: With the patient 
sitting upon a low chair or on the floor, a folded towel is put over the shoulder 
and is firmly held by an assistant in order to fix the scapula. Another assistant 
sits on the well side and pulls firmly on a second towel which passes under the 
injured shoulder. The surgeon now stands on a chair or table and grasps the arm 
at the elbow, and makes firm perpendicular extension upon it till the head is 
brought into position. The arm is then brought cautiously to the side and held in 
a sling. 
Various devices employing pulleys in making horizontal extension have been 
used and highly recommended, but they are rarely used except in the attempt to 
reduce long-standing dislocations. Since aseptic surgery has made the operation 
of arthrotomy practicable they are becoming less and less applicable. 
The impulsion method of Avicenna possesses at least the negative merit of 
not offering the possibility of doing further injury to the parts, and, although it is 
not generally successful, it should be practised, for it is the only manipulative 
method we can apply in those dislocations in which there is also a fracture of the 
neck of the humerus, and it is sometimes successful in the complicated subcoracoid 
and axillary dislocations. It is as follows: The patient sits on a chair and the 
surgeon stands behind and a little to the injured side of him. The surgeon now 
fixes the acromion with the hand next his patient, and with his other forearm 
supports the arm of the patient at such an angle as may suit the stage of the 
manipulation, while pressing with the same hand the head of the humerus toward 
the glenoid fossa. 
In the axillary dislocation abduction, extension, outward rotation, 
and finally adduction, accomplish the reduction. Upward traction is 
here a valuable aid. 
The subspinous dislocation is replaced by raising the arm to a level 
with the shoulder, making extension in a forward direction, rotating the 
arm outward, and then bringing it to the side while direct pressure is 
made upon the head from behind. The upward dislocation is reduced 
by downward and outward extension. 
On analyzing the different methods which we have given, it is evident 
that they depend upon extension and counter-extension, rotation and 
leverage. In view of this fact, and inasmuch as that method which 
utilizes these forces in the simplest and most effective way and adapts 
itself to the greatest variety of cases is of the greatest value, it seems 
to me that the following method is good : The patient lies on ljis back 
on the floor or on a table. The operator, removing his shoe, puts his 
heel in the axilla or the foot against the ribs or the top of the shoulder, 
and, grasping the forearm and elbow with his hands, makes use of 
extension, counter-extension, rotation, and leverage in such a way as the 
character of the injury and the stage of the manipulation may suggest. 
Strong extension by an assistant can be made during manipulation by 
putting a clove hitch about the arm with a towel or sheet. This may 
also enable the surgeon, by looping the sheet about his loins, to make 
extension upward, outward, or downward. Downward traction with the 
heel in the axilla is to be made in the subcoracoid dislocations. Out- 
ward traction with the foot against the ribs is used to advantage in the 
subclavicular dislocations. 
Upward traction in the subglenoid dislocation with the foot on the 
acromion to steady the scapula is generally successful, but is more dan- 
gerous than the downward pull with direct pressure on the head with 
the heel or hands. The movement, under traction, of the arm downward DISLOCATIONS. 
761 
and forward to the chest, with inward rotation, terminates the effort. 
In the subspinous dislocation forward traction with rotation usually 
determines reduction. This combines extension and counter-extension 
with the rotation method and the lever method of Sir Astley Cooper. 
It is a very efficient method, and is to be recommended on this account, 
as well as on account of its simplicity and versatility. 
A sling which should embrace the forearm and give support to the 
elbow should be adjusted after the dislocation has been reduced. This 
gives sufficient immobility to the joint, which should be kept at rest for 
three weeks. Moderate use may then be made of the joints, but extreme 
movements should not be permitted. Special complications involving 
excessive reaction may require topical applications. The complicated 
cases are to be treated in accordance with general surgical principles. 
When a fracture and a dislocation exist together, an attempt is made to reduce 
the dislocation by the Avicenna impulsion method. If this fails, the parts should 
be cut down upon and the head replaced, and the fragments secured in position, 
if necessary, by sutures. The displaced fragment, if unreduced and if it be only 
the head and surgical neck, may be removed, or a nearthrosis may be permitted 
to form between the fragment and the shaft by separating them from each other 
by extension. The old rule, of first permitting the fracture to unite and then 
attempting to reduce the dislocation, has lost its favor since aseptic conditions 
make operations so promising. The injuries to nerves and vessels must be treated 
according to general surgical rules. 
The prognosis in a simple primary dislocation when reduced soon 
after the injury is good. The longer the dislocation has existed, the 
more unfavorable the prognosis. In the cases which are compound or 
accompanied by fracture or injury to the nerves or vessels the prognosis 
is unfavorable in proportion to the amount of injury done and the degree 
of inflammation following it. After a dislocation has occurred the 
resistance to the force tending to produce it again is less than it was 
originally. In some cases this leads to frequent repetitions of the dis- 
location, and these are called cases of habitual dislocation. These cases 
of habitual dislocation may be operated upon by excising a part of the 
capsule if it be excessive, or by suturing the rent if that be the source 
of trouble. The most frequent cause of the habitual dislocations at the 
shoulder is the tearing loose of the supra- and infraspinatus muscles 
from their attachment to the greater tuberosity, or the detachment of a 
fragment of the tuberosity from the head of the bone. In some of these 
cases bandaging the shonlder so as to prevent extreme movements of the 
arm may be tried before operative measures are resorted to. 
The exact period of time after which it is impossible to reduce a dis- 
location of the humerus by manipulation cannot be given, for it depends 
upon the extent of the injury to the soft parts, the degree of fixation of 
the bone in the new position, the extent of the displacement from the 
normal position, and the degree of change in the size of the glenoid 
cavity. In old cases, up to an age of a year or more, one should, under 
an anaesthetic, attempt to break up the adhesions, and by any of the 
methods of manipulation above described endeavor to replace the bone. 
If this effort prove fruitless and the function of the arm be greatly im- 
paired by its position or from pressure on nerves or vessels, a resection 
should be made, unless the glenoid cavity is but little altered and the 
head can be brought (Figs. 347, 348) into position by a simple arthrotomy. 762 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
The relative results obtained by resection and arthrotomy are not clearly 
defined. Franz Smith has reported 32 cases of resection in old disloca- 
tion from Wolfner’s clinic. In 20 cases (62 per cent.) a good result 
was obtained, while with arthrotomy only a moderately good result was 
Fig. 347. 
Fig. 348. 
Old subcoracoid dislocation. 
Reduced by posterior arthrotomy. 
obtained in 33 per cent, of the cases. From this lie concludes that 
resection is a better operation than arthrotomy in these cases. 
Dislocations of the Elbow.—The elbow-joint, though its bony out- 
line is so arranged that the articular surfaces are snugly and firmly 
opposed, is frequently dislocated. It is especially the dislocation of 
childhood. Both bones may be dislocated in any direction, and the end of 
either bone may be separately displaced, so that there are many forms of 
injury to this joint. The normal outline of the joint is distinct and the 
bony landmarks are clear and well defined, yet when swelling and tume- 
faction are present it is often difficult to diagnosticate the definite injury 
to the joint. 
The most common dislocation of this joint is of both bones backward. 
It results from a fall upon the outstretched arm, the violence being 
transmitted from the palm of the hand through the forearm, which 
determines a hyperextension with rupture of the anterior ligament. If 
the bones are arrested at a point where the coronoid rests against the 
articular surface of the humerus, it is regarded as an incomplete disloca- 
tion, but if the coronoid be carried backward until it rests in the olec- 
ranon fossa, it is complete. Torsion of the forearm when in a position 
of semiflexion is also given as a method of producing this dislocation. 
The lateral ligaments are torn or detached from the bone. 
Symptoms.—The elbow is partly flexed and the outlines are ob- 
scured by swelling. The olecranon has lost its proper relation to the 
external and internal epicondyles; the head of the radius may be iden- 
tified, especially if the bones are also displaced outward, by rotating the 
forearm. The deformity upon the posterior aspect of the joint is more 
marked during flexion than in extension. The trochlear surface of the 
humerus can often be clearly outlined at the elbow in the extended arm. 
Treatment.—Reduction is, as a rule, easily accomplished without DISLOCATIONS. 
763 
anaesthesia. Traction upon the extended or hyperextended arm should 
be made, and the forearm must then be moved to the right-angled posi- 
tion during the continuance of traction, with downward pressure on the 
forearm. This pressure may be secured by the hand of the surgeon or 
by the knee placed in the fold of the joint. 
The arm should be carried in a sling for three weeks or placed in a fixed dress- 
ing. Passive motion should not be used until repair is fairly complete. In old 
dislocations it is necessary to break up adhesions by forced flexion and extension 
or by lateral movements before the displaced bones can be forced into position. 
Anaesthesia is essential in these cases. 
Lateral displacements of both bones may be either outward or inward, 
and generally constitutes an incomplete dislocation. The lateral dislo- 
cations result from falls upon the extended arm. In outward disloca- 
tions the ulna rests against the articular surface of the humerus, and in 
inward displacements the head of the radius is in contact with the 
trochlear surface. Complete outward or inward dislocations are rare. 
Symptoms.—The width of the joint is markedly increased. The 
lateral projections of the humerus and those of the ulna or the radius 
are distinct. The motions of flexion and extension are painful; the 
forearm is slightly flexed, and the axis of the forearm is displaced to 
one side of its normal position or deviates from it so as to make an 
unnatural lateral angle. If these dislocations are complete, the symp- 
toms are exaggerated. 
Dislocations of the Ulna.—The only uncomplicated dislocation of the 
ulna alone is backward. It is very rare and is probably incomplete. 
The forearm is slightly flexed and adducted. The orbicular ligament 
is torn and the ulna and radius at the upper end are forcibly separated. 
The olecranon presents posteriorly, the head of the radius rotates in its 
normal position, and the forearm is inclined inward. 
The treatment of these lateral dislocations and that of the ulna 
are much the same. The reduction is accomplished by traction in the 
extended or semiflexed position, with lateral angling at the joint, while 
direct pressure pushes the parts into position. It may be necessary to 
force the ulna downward and backward away from the articular surface 
of the humerus before it can be forced into position. 
Dislocation of both bones forward is exceedingly rare, and may be 
complicated by fracture of the olecranon. It occurs by a fall upon the 
elbow when the arm is in extreme flexion. It is complete wflien the 
olecranon is fully displaced in front of the humerus. The forearm is 
lengthened and fixed. The posterior surface of the humerus presses 
against the skin, the condyles are more prominent, and the olecranon 
fossa is empty. 
Reduction is accomplished by extreme flexion and by pushing the 
forearm back into position. 
Dislocation of the Radius.—The head of the bone may be displaced 
forward, backward, or outward. The first form is not infrequent, the 
latter very rare. The anterior and posterior dislocation may be pro- 
duced by direct violence forcing the bone into its new position. The 
forward dislocation may be produced by hyperextension in a fall upon 
the pronated hand. The head of the bone slips forward in front of the 
capitellum. The orbicular ligament is torn or encircles the neck, the 764 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
head being above or beyond it. The arm is slightly abducted, partly 
flexed, and pronated. The swelling is in front of the elbow; the head 
can be felt in its new position, and there is a depression at its normal 
situation ; movements are painful. In some cases the entire bone shows 
a displacement upward. 
Reduction is accomplished by traction in the extended position with 
the forearm in forced supination. Direct pressure upon the head of the 
radius helps to force the bone into its natural position. In some cases 
there is a marked tendency to redisplacement; hence the treatment 
should be such as to keep the arm flexed and in supination until the 
rent in the capsule and the torn ligaments are reunited and firm. This 
may be done by a plaster splint or by a right-angled posterior splint. 
The backward dislocation has much the same pathology. The rent 
in the capsule is behind. The orbicular ligament is torn. The head of 
the bone can be more distinctly felt and outlined in its new position. 
The position of the arm is much the same as in forward dislocation. 
The violence may be direct or by a fall upon the supinated and partially 
extended arm. 
Reduction is by traction in an extended position with direct pressure 
on the head. The arm should be flexed at right angles and carried in 
a sling after reduction. 
The outward dislocation is rare. It is difficult to retain it in position 
after reduction. The dislocations forward and backward, if they are 
also outward, are more difficult to maintain in proper position than if 
displaced directly in front or behind. 
Dislocation of the Head of the Radius in Children.—A displacement 
of the head of the radius in children under five years of age is a recog- 
nized injury. Unquestionably, a peculiar injury at this part is found 
in children. It is produced by a firm pull upon the wrist or forearm, as 
in lifting or jerking the child by the arm. Pronation is thought to be 
present when the injury is inflicted. It is probable that the head of the 
bone is pulled out of the orbicular ligament and is displaced forward. 
The forearm is very slightly flexed ; movements of the elbow are fairly 
free, except that supination of the forearm meets with resistance. 
The displacement is rectified by forced supination, with extension and 
traction. An epiphyseal separation of the head may simulate this 
injury. This demands a few days’ rest in a splint, with the arm flexed 
and strongly supinated, though a good recovery often occurs without 
any definite restraint. 
The Wrist. 
Dislocations of the wrist-joint are rare. The backward dislocation is 
more frequent than the anterior. It is produced by a fall upon the palm 
of the hand, and the deformity simulates that produced by a Colies 
fracture. The deformity is, however, greater, and the abrupt line of the 
carpus can be somewhat distinctly outlined at the projection on the dor- 
sal surface. The sharp outline of the radius and ulna, anteriorly, is 
obscured by the mass of flexor tendons. The normal relations of the 
styloid process of the radius and ulna are, however, preserved and con- 
stitute a very important diagnostic sign. DISLOCATIONS. 
765 
The forward dislocation must be extremely rare. It usually results 
from a fall upon the palm of the hand with the hand in full dorsal 
flexion, but it also follows a fall upon the back of the hand. 
The symptoms are the reverse of those that indicate a backward dis- 
placement. The projection in front presents its sharp angle at its upper 
border, and the articular extremity of the radius and ulna can be clearly 
outlined on the dorsum. 
Reduction in these cases is accomplished by extension with firm pres- 
sure on the displaced carpus. The hand should be retained on a splint 
for two or three weeks. The joint should be kept at rest until repair is 
complete. The fingers should be free from restraint after a few days, 
for it is important to avoid adhesion of the tendons to their sheaths. 
Dislocation at the Lower Radio-ulnar Joint.—The ulna is dislocated 
forward or backward in its relation to the radius. The backward dis- 
location is produced by exaggerated pronation of the wrist. This may 
be produced either by muscular action or by forced pronation. The 
forward dislocation is usually by direct violence. 
The reduction of these dislocations is not difficult. The hand and arm 
should be retained on a splint for several weeks, and only a moderate 
use of the joint permitted until the parts have regained full strength. 
The Carpus.—The os magnum is the only one of the carpal bones 
likely to be displaced. This bone is occasionally displaced backward, so 
that it is prominent on the dorsum. The bones of the carpus are closely 
bound together and are not often displaced, though a few cases of dislo- 
cation of the second row from the first are reported. This injury is 
usually an accompaniment of a crushing injury which breaks the bones 
and lacerates the soft tissues. 
Carpo-metacarpal Dislocations.—The thumb is most frequently 
displaced. It is- usually a backward displacement, and results from 
extreme flexion or direct palmar pressure. Reduction is not difficult, 
and is accomplished by traction and direct pressure. 
Dislocation of the bone forward is usually by direct violence. The 
axis of the metacarpal bone in the forward dislocation is inclined 
inward and forward, but in the backward dislocation it is outward and 
backward. The base of the metacarpal bone is prominent in its new 
position. After reduction the hand should be kept at rest on a splint 
for three weeks. Dislocation of the other metacarpal bones is produced 
by a degree of violence which inflicts other important injuries. 
Metacarpo-phalangeal Dislocations.—This joint in the thumb is 
not infrequently dislocated backward, less frequently forward. It is 
displaced backward by a fall upon the thumb bending it backward and 
pressing the base of the proximal phalanx on the dorsum of the meta- 
carpal bone. The proximal phalanx is bent backward at a right angle 
and the distal phalanx is flexed. The capsule is ruptured and the 
lateral ligaments are probably torn. Very great difficulty is sometimes 
experienced in reducing this dislocation. It is sometimes easily reduced, 
but the obstruction to reduction is very marked when the tendons of 
the short flexor of the thumb surround the head of the metacarpal 
bone. The lateral ligaments of the long flexor and the sesamoid bone 
may interfere with an easy and ready reduction. The surgeon may con- 
vert a comparatively simple dislocation into a complex one by flexing 766 
AFFECTIONS OF TIIE TISSUES AND TISSUE-SYSTEMS. 
or extending the phalanx before the base has been brought well forward 
on the head'of the metacarpal by forced dorsal flexion. This compli- 
cation is produced by the backward displacement of the sesamoid bone 
on to the head or dorsum of the metacarpal, and to the slipping of the 
Fig. 349. 
anterior portion of the capsule between the base of the phalanx and 
the head of the metacarpal (Figs. 349, 350). 
Treatment.—The reduction is to be accomplished by forced dorsal 
flexion and pressure on the base of the phalanx. This movement is 
Metacarpo-phalangeal dislocation. 
Fig. 350. 
Metacarpo-phalangeal dislocation. 
best executed when the metacarpal bone is flexed and when the phalanx 
is grasped in a pair of forceps or in Levis’s instrument (Figs. 351, 
352, 353). It should be clearly and distinctly understood that exten- 
sion in a line parallel to the metacarpal bone is not admissible in the 
reduction of this dislocation. 
An incomplete form of this dislocation can be voluntarily produced in many 
young people and loose-jointed individuals. The forward dislocation of this bone 
is produced by forced palmar flexion and pressure. The head of the metacarpal 
is prominent on the dorsum and the base of the phalanx can be felt in the lower 
part of the thenar eminence. It is easily reduced by forced palmar flexion and 
pressure upon the displaced bone. Backward dislocation of the proximal pha- 
langes of the fingers is produced by forced dorsal flexion. They are more easily 
reduced and are not complicated by the divided short flexor tendons and the 
presence of sesamoid bones. DISLOCATIONS. 
767 
Dislocation of one or more of the second row of phalanges may occur. 
The injury is easily recognized, and can be reduced by traction and by 
direct pressure. 
Fig. 351. 
Farabceuf’s instrument for reduction of dislocation of the thumb. 
All of these injuries of the carpo- and metacarpo-phalangeal articu- 
lations need a rest of ten days or three weeks on a splint to secure a 
Fig. 352. 
Levis's instrument for making traction in reduction of dislocations of the phalanges. 
Fig. 353. 
Levis’s instrument, faulty method of use. 
good result. If reduction is impossible, then arthrotomy is demanded. 
This is rarely necessary even in the dislocation backward of the pha- 
lanx of the thumb. 768 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
The Hip. 
Dislocations of the hip are much less frequent than those of the 
shoulder. They constitute about 5 per cent, of all dislocations. They 
are more frequent in men than in women, and are most frequent between 
the twentieth and fiftieth years, though the femur may be dislocated at 
any age. The normal limits of motion are more restricted than in the 
shoulder. This ball-and-socket joint is well guarded against dislocation 
by the deep acetabulum which embraces a large segment of the sphere 
of the head of the femur, supplemented as it is by the cartilaginous ring 
which acts in the retention of the head in the socket by increasing the 
suction traction. The strong ligaments, the muscles which surround it, 
and the protection obtained by the mass of tissue that envelops the joint 
guard it against injury. 
The head escapes from the socket through a rent in the lower segment of the 
capsule, and may come to a rest at any point in the periphery of the acetabulum. 
The posterior dislocations occur during flexion, adduction, and inward rotation 
of the thigh. They are the most common of the dislocations. The anterior dislo- 
cations occur during abduction, often combined with outward rotation and exten- 
sion. The head of the bone, emerging through the lower segment of the capsule, 
does not necessarily remain on the margin of the acetabulum at the point it first 
reaches, but it passes in the backward dislocation to a point of rest in the sciatic 
notch, or on to the dorsum of the ilium, or even upward to the anterior inferior 
spine of the ilium. If an anterior dislocation of the head of the bone exists, it 
may pass from the thyroid foramen downward to the perineum, or upward to 
become a pubic or an intrapelvic dislocation. 
Each dislocation should in clinical work be classified as an anterior 
or posterior dislocation. The line of demarkation between these classes 
is drawn between the anterior superior spine of the ilium to the tuber- 
osity of the ischium and crosses the acetabulum. The symptoms and the 
treatment of the anterior are much alike and contrast strongly with the 
posterior dislocations. These two comprehensive divisions are also 
known as inward and outward dislocations. The head escapes at some 
part of the lower two-thirds of the segment of the acetabulum, and is 
carried inward if the displacement occurs when the thigh is abducted, 
and outward if it is in a position of adduction. 
According to prevalent classifications, we should include in the ante- 
rior or inward dislocation those on the tuberosity of the ischium, the 
perineal, the obturator, the suprapubic, the ilio-pectineal, and the sub- 
spinous. In the posterior or outward dislocations we should group the 
ischiatic, the iliac, the everted dorsal, and the supracotyloid. The classi- 
fication made by Allis in his recent monograph is suggestive, simple, 
and comprehensive. He recognizes the fact that all forms of dislocations 
primarily escape from the lower segment, and when inward are first 
thyroid and then are shifted upward or downward. If the primary 
dislocation is outward, it is dorsal, and is then shifted upward or down- 
ward. Allis’s classification is into— 
(1) Lower thyroid. 
(2) Middle “ 
(3) High 
All present the general characteristics of 
abduction and rotation outward. 
(1) Low dorsal. 
(2) Middle “ ' 
(3) High “ 
All present the general characteristics of 
adduction and rotation inward. DISLOCATIONS. 
769 
The integrity of the inverted Y-ligament (Fig. 354) is recognized 
as an important aid in guiding the dislocated head into a position of 
rest. The position in which the head is found gives a name to the dis- 
location. 
The symptoms vary markedly with the different varieties of the 
inward and outward dislocations, as they also do in the outward or 
backward forms. There is, however, sufficient uniformity in the anat- 
omy, the pathology, and the clinical symptoms of each of these two 
groups to justify us in making it a broad basis of classification. 
The capsule of the joint is torn by the head of the bone as it escapes. 
If the rent in the capsule is made by simple abduction, it is apt to be 
less extensive than where rotation is the chief 
factor. In the latter instance the continued 
extreme rotation may increase the tear even after 
the head is already displaced. The inverted 
Y-ligament is, however, never torn entirely from 
its attachment to the femur. The posterior arm 
of this Y is occasionally lacerated. This ligament 
serves not only as a fulcrum for the leverage 
used in posterior dislocations, but it is the ana- 
tomical structure that limits the wandering of 
the head after the dislocation occurs. This ilio- 
femoral ligament passes from the upper margin 
of the acetabulum to the anterior surface of the 
base of the neck. It does not envelop the head 
in any of the dislocations. It steadies the tro- 
chanter, and the more tense it is made, either by 
muscular contraction or by the rotation move- 
ments of the surgeon, the more strongly it keeps 
the head away from the socket; for when tense it 
holds the base of the neck against the margin of the acetabulum. This 
ligament must be considered in efforts at reduction. The torn portion of 
the capsule may overlap the socket and constitute an obstacle to reduc- 
tion and a complication in healing. This is especially apt to be the case 
if the capsule is torn near its attachment to the femur. 
Abduction and outward rotation are very constantly present in the 
anterior dislocations. Abduction may be very slight in the intrapelvic 
variety, and outward rotation may be very slight in the thyroid disloca- 
tion. The thyroid dislocation is the most frequent of the anterior dis- 
locations. The limb is flexed and appears to be elongated, while the 
trochanteric region is flattened and the trochanter lowered and displaced 
inward. The adductors are usually tense, and the head can be felt in 
its new position. The impossibility of adducting the limb and forcing 
it to complete extension aids in the diagnosis. These symptoms are 
modified if the dislocation is above or below the thyroid foramen. If 
it passes high up in front toward the spine of the ilium, then an excep- 
tion may occur and the symptoms be reversed and the leg be extended, 
everted, and slightly abducted. 
Adduction and inward rotation are the cardinal signs of the backward 
or outward dislocations. When the head rests in the sciatic notch or on 
the dorsum of the ilium the limb is flexed. The trochanter is elevated 
Fig. 354. 
Inverted Y-Iigament 770 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
above Nelaton’s line, and there is marked resistance to outward rotation, 
extension, or abduction. 
These symptoms are distinctly modified if the head passes upward 
and inward until it is above the inferior anterior spine. Here the leg 
may be abducted, everted, and extended. 
The differential diagnosis between the anterior and the back- 
ward dislocation is clear except in the subspinous (anterior) and the 
everted dorsal. In both the head is above the acetabulum. It is very 
essential to determine to which elms the dislocation belongs before under- 
taking reduction. The symptoms in these two special dislocations may 
be much the same. Dr. Allis contends, with reason, that the trochanter 
cannot be to the inner side of the line drawn from the spine of the ilium 
to the tuberosity of the ischium in the dorsal dislocations. 
Fig. 355. 
Fig. 356. 
Anterior dislocation of head of femur. 
Posterior dislocation of head of femur. 
Manipulation for Reduction.—It is a recognized fact that in 
every dislocation the head should retrace the path along which it passed 
during displacement. It should be remembered that in the dorsal dis- 
location the head escapes from the capsule in the lower posterior third of 
the margin of the acetabulum, and in the anterior dislocations it escapes 
from the lower anterior third. The head of the bone is to be brought 
to these points as a first step in reduction. It was plainly stated in the 
pathology of dislocations that strong rotation effected greater laceration 
during the escape of the head than when the head was lifted by leverage DISLOCATIONS. 
771 
through the capsule; so now strong rotation is a dangerous element in 
reduction. It must be carefully used when employed. 
Reduction of Dorsad Dislocations.—Kocher’s Method.—The 
patient should lie on a folded blanket or mattress placed on the floor or 
on a table. The luxated thigh is rotated inward and flexed to a right 
angle. This brings the head to the acetabulum, and it is then lifted 
upward, the thigh rotated outward, and straightened as it is brought 
downward parallel with the other thigh. There is a purpose in each 
of these movements—viz. the inward rotation relaxes the capsule and 
ilio-femoral ligament, lifts the head from the posterior surface of the 
pelvis, and makes it movable. The subsequent flexion of the thigh to 
a right angle carries the head downward below the uninjured part and 
brings it opposite to the tear in the capsule. This is done without the 
application of force. One must be cautious in the forcible flexion, 
otherwise it may happen that the head will slip around the under mar- 
gin of the socket and produce a forward dislocation into the obturator 
foramen. With the upward pull the ilio-femoral ligament and the cap- 
sule, chiefly at its upper posterior circumference, are put on the stretch 
as the head is lifted up to the border of the acetabulum, while with out- 
ward rotation, through the tension of the ilio-femoral ligament, the tro- 
chanter is fixed and the head is forced into the acetabulum by the parallel 
extension of the leg. 
Middeldorpf's method of reducing posterior dislocations is the following: 
Strong flexion, abduction, and outward rotation of the extremity. The strong 
flexion lifts the head from the pelvis and brings it opposite to the tear in the 
capsule; abduction puts the ilio-femoral ligament on tension and brings the head 
to the margin of the acetabulum; and the outward rotation lifts the head into 
position. The leg is now extended parallel to the other. 
The ease with which passive movements in all directions can be made and the 
snap of the joint surfaces coming in contact with each other in both methods 
prove that reduction has taken place. The inexperienced operator must be careful 
not to mistake an obturator luxation which he has produced by his manipulations 
for an anterior displacement or a reposition of the bone. 
Allis’s Method.—The patient lying supine, the surgeon kneels by his side, and 
if the right femur is dislocated he seizes the ankle with his right hand and places 
the bent elbow of his left arm beneath the popliteal space: (f) he now turns the 
bent leg outward (inward rotation) by means of the ankle and lifts upward (sky- 
ward) ; (2) then turns the bent leg inward (outward rotation) and brings the femur 
down in extension. 
The following is Kocher’s method of reducing forward suprapubic 
dislocations : The patient is placed on a table. Hyperextension is then 
made, and followed by flexion with simultaneous pressure upon the 
head of the thigh, and finally inward rotation. 
The hyperextension, and perhaps with it some increased outward 
rotation and abduction of the leg, lifts the head from the pubis. In this 
movement we use the femur as a lever, the long arm of which is the 
shaft, the short arm the neck, and the greater trochanter the fulcrum. 
When the head is freed from the margin of the pubis, it is pressed with 
the hand downward and outward toward the acetabulum, so that during 
the relaxation of the ilio-femoral ligament and the necessary flexion it 
will not slip again to the pubis. The flexion is carried to the extent of 
a right angle, by which movement the capsule is made tense, and inward 
rotation now brings the head into the acetabulum. 772 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
Middeldorpf’s method of reducing this dislocation is by hyperextension, strong 
flexion, adduction, and inward rotation. The hyperextension is done for the same 
purpose as in the previous method. The leg is flexed much more than in the pre- 
vious method, amounting to an acute angle. By the flexion the head is moved 
down to the slanting surface of the margin of the acetabulum, and the movement 
of adduction which follows brings the head nearer into position, so that the inward 
rotation can complete the reposition. In both methods the patient lies on the 
margin of a table, so that there is no hindrance to the hyperextension. 
The forward infrapubic dislocation of the thigh is reduced by Kocher 
bv making flexion to a right angle, extension on the leg in this position, 
and strong outward rotation. The flexion of the thigh is necessary to 
relax the ilio-femoral ligament. Where the thigh is thus flexed to a 
right angle no part of it is on tension. We now want to use the capsule 
in the rotation, and we make a strong pull on the leg, so that it will be 
put on tension. The thigh is now turned outward as far as possible, 
extension being made on it during the rotation. The result is that the 
ilio-femoral ligament draws the head into position. 
One reduces a perineal dislocation by Middeldorpf’s method by flex- 
ing the thigh to a right angle, following this by adduction and inward 
rotation. The flexion in the given position of the leg relaxes the ilio- 
femoral ligament and makes the head free in its position. In order to 
prevent the following adduction from carrying the head around the 
acetabulum and producing an ischiatic dislocation, a folded towel is 
passed around the thigh at its upper extremity, and a strong pull up- 
ward is made upon it. The adduction brings the head to the margin of 
the acetabulum, and the inward rotation brings it into position. 
The downward or infracotyloid dislocation is reduced by extension in 
the given position of the leg—that is, in a flexed and an abducted posi- 
tion and then rotating the leg outward. 
The upward or supracotyloid dislocation is best reduced by a folded 
towel, and finally inward rotation completes the reduction. 
Dr. Allis directs for replacement of the head in the anterior or inward dislo- 
cations— 
1, Flex and abduct the femur; 2, make traction outward; 3, fix the head by 
digital pressure and adduct. 
Dr. Allis strongly cautions the operator not to adduct until after he has made 
traction outward. He directs for reduction by means of external rotation— 
First step, flex the thigh, but not to a perpendicular ; second step, adduct, 
carrying the knee obliquely inward and downward; third step, rotate outward. 
Reduction by Means of Rotation Inward.—Bigelow puts this manoeuvre 
at the head of his ten rules. His directions are—“ Flex the limb toward 
the perpendicular, and abduct a little to disengage it from the bone ; 
then rotate the thigh strongly inward, adducting it and carrying the 
knee to the floor. The trochanter is then fixed by the Y-ligament and 
the obturator muscle, which serve as a fulcrum. While these are wound 
up and shortened by rotation the descending knee pries the head upward 
and outward to the socket,” 
Rule.—First step, flex the thigh, but not to a perpendicular; second 
step, rotate strongly inward ; third step, adduct and carry knee to the 
floor. 
All dislocations of the hip should be treated after reduction by 
rest and quiet. This is especially important in young subjects. The DISLOCATIONS. 
773 
Hodgen suspension splint for a few weeks is most comfortable and 
efficient. 
The Patella. 
A dislocation outward results occasionally from a violent muscular 
contraction of the quadriceps extensor muscle. The patella is then 
slipped over the articular surface of the external condyle. It may also 
be dislocated outward by a blow upon the inner border of the patella. 
These dislocations occur when the leg is extended. If complete, the 
internal border is directed forward and the articular surface is directed 
toward the middle line of the leg, and the margin of the patella is against 
the side of the condyle; but in the incomplete dislocation the rotation is 
reversed, and the outer border is inclined forward, while a part of the 
articular surface is still in contact with the articular surface of the exter- 
nal condyle. 
Dislocations inward are very rare, and are always produced by direct 
violence. These dislocations are most likely to occur when the capsule 
is relaxed. Laceration of the capsule is generally present. 
Reduction is effected by flexing the thigh strongly on the body, and 
by pressing firmly on the sharp projecting edge of the patella so as to 
rotate its articular surface toward that of the femur. The edge against 
the condyle is freed and the muscle pulls it into place. 
Vertical rotation of the patella occurs from a blow when the leg is 
partly flexed. The rotation is usually outward, so that the articular 
facet looks inward. 
Manipulation while the leg is fully extended may reduce the disloca- 
tion. It may also be reduced by sudden and forcible flexion. This 
manoeuvre may increase the damage to the joint. The close investment 
of the displaced patella by a rent in the capsule may render incision 
necessary to effect its release and reduction. 
These dislocations are painful and the disability is complete. Recovery 
is, however, prompt and good after moderate rest. 
Traumatic anterior dislocations of the tibia are more frequent than 
the posterior dislocations. The posterior dislocation frequently results 
from pathological changes in the joint-tissues. The ligaments soften 
and muscular action determines the gradual pathological displacement. 
The anterior dislocation is produced by hyperextension or by a blow upon 
the anterior surface of the thigh or the posterior surface of the leg. It 
is more frequently incomplete than complete. The capsule and the lat- 
eral ligaments are ruptured in the complete form. The pressure of the 
condyles of the femur on the vessels in the popliteal space is a serious 
and frequent complication in this injury. 
The leg is generally extended ; slight rotary displacement of the tibia 
is present. In the complete form shortening is evident. The projec- 
tion of the tibia in front of the condyle gives contour to this deformity. 
Reduction is easily effected by traction and coaptation. Flexion may 
also be used in effecting reduction, but hyperextension is dangerous. 
Compound dislocations of the knee-joint should meet with conservative 
aseptic treatment unless the popliteal vessels are completely destroyed. 
The Knee. 774 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
Dislocations backward, are less frequent, and are produced by direct 
violence and also by indirect violence, as in cases where the leg; is caught 
and held in a fixed position and the body pushed forward until the femur 
is carried forward by rupture of the capsule and partial or complete rup- 
ture of the lateral ligaments of the joint. Hyperextension is usually 
present. The contour of the condyle of the femur in front and of the 
tibia behind, with shortening in the complete form, indicates the diag- 
nosis. The vessels are not so likely to be injured in this form as in the 
forward dislocation. 
Traction with coaptation, and possibly flexion, will accomplish reduc- 
tion. 
Lateral dislocation of the knee may occur by forced lateral flexion. 
Torsion also enters as a factor in producing these dislocations. They are 
most frequently incomplete. The outward dislocation is most common. 
The symptoms are found in the changed outline of the joint. The 
injury to the joint-tissues depends upon the extent of the displacement 
and the manner of production. Reduction is easy. 
All of these dislocations at the knee require a prolonged rest of six 
weeks to four months. A plaster-of-Paris splint is best suited to these 
cases. Immediately after the injury it may be necessary to use local 
treatment to control the inflammatory process. A posterior splint or 
the Hodgen suspension splint should be temporarily used to keep the 
injured joint at rest. 
The Semilunar Cartilages.—Dislocations of portions of the semi- 
lunar cartilages may occur. A fragment of the cartilage is displaced 
either toward the intercondyloid notch or it is displaced toward the 
periphery, so that it projects as a ridge at the border of the tibia. The 
explanations of its pathology are not full and complete. 
The symptoms simulate those of a loose cartilage in the joint. It is 
produced by torsion and flexion of the joint. The most serious disability 
is exhibited when the cartilage is displaced into the joint. The loose sec- 
tion is not infrequently pulled into the joint during flexion, but is apt to 
appear again at the margin when the leg is straightened. If it is entan- 
gled in the joint, the disability is complete until it is again freed from 
its abnormal position. This can usually be acomplished by rotation, 
sudden flexion, and extension. 
The symptoms vary. The cartilage may be outlined as a ridge along 
the border of the tibia, especially along the inner anterior border. A 
patient may be walking or kneeling and the luxated cartilage may be 
pulled into the joint. A sudden loss of function, with sharp pain and 
perhaps swelling of the joint, discloses the condition. 
The only treatment available is to put a limitation on the flexion 
of the joint or an operative procedure to fasten the cartilage to the 
head of the tibia. The result of the operation is said to be satisfactory. 
The Fibula. 
The upper end of the fibula has been displaced forward by forcible 
inward rotation of the foot while in full extension. The extensor mus- 
cles are supposed to have pulled it forward out of place. It is also dis- 
located backward by the forcible contraction of the biceps. DISLOCATIONS. 
775 
An upward, dislocation may occur as a complication of fracture of 
the tibia or by an upward displacement at both ends. The displace- 
ments are easily reduced by pressure on the head of the bone with the 
foot at a right angle with the axis of the leg. It can be retained by 
pads and supports. The backward dislocation is more uncertain in sta- 
bility of position after reduction. Rest in a fixed position should be 
enforced. The lower end is rarely dislocated or detached, except as a 
complication of fracture. 
The Foot. 
The dislocation may be backward, forward, or inward. The outward 
dislocations are associated with a Pott’s fracture. The backward dislo- 
cation is produced by extreme plantar flexion. The lateral ligaments 
are torn and the capsule more or less fully lacerated, and a fracture of 
the external malleolus is often present. The foot appears shortened in 
front, the heel is lengthened. An incomplete backward dislocation is a 
frequent accompaniment of Pott’s fracture. A forward dislocation is 
produced by extreme dorsal flexion with forward pressure on the heel. 
The astragalus can be outlined in front of the tibia. The inward dislo- 
cation of the foot is most frequently produced by supination and adduc- 
tion of the foot. The astragalus has its external border displaced down- 
ward, and rests below and in front of the external malleolus. The 
external lateral ligament is torn, and the inner border of the astragalus 
is inclined upward against the tibia. The dislocation of the ankle is 
easily reduced by traction, pressure, and by dorsal or plantar flexion and 
by eversion of the foot. Rest in a plaster cast for a few weeks restores 
the foot and gives good functional activity. 
The foot is sometimes dislocated from the astragulus. The displace- 
ment is backward and inward or backward and outward. It is exceed- 
ingly rare to have an anterior displacement. The backward dislocations 
are incomplete, for the articular surface of the astragalus remains in 
contact with some portion of the surface of the calcaneum. The head 
of the astragalus is on the dorsum of the scaphoid, or, if the backward 
displacement is very great, it may project forward so as to rest on the 
cuneiform bone. It shifts to the outer margin or on to the cuboid or 
inward along the margin of the scaphoid, with the character of the 
lateral displacement of the foot: these dislocations result from torsion 
of or wrenches of the foot. The foot is shortened anteriorly; the head 
of the astragalus is prominent. If the foot is displaced outward, it is 
also everted, and the internal malleolus is prominent; but if the foot is 
to the inside, it is inverted and the external malleolus is prominent. 
It is said that sometimes the tibial tendons grasp the head of the 
astragalus in such a way as to make reduction difficult, or the posterior 
margin of the astragalus may be caught in the groove of the calcaneum 
and be difficult to dislodge. The leg should be flexed on the thigh, and 
extension and manipulation of the foot resorted to in the effort at 
reduction. 
The astragalus may be dislocated from the tibio-fibular articulation, 
as also from the calcaneo-scaphoid attachment. It occurs as a result of 
falls upon the foot or of twists or wrenches of the foot. The forward 776 
AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 
and outward displacement is most frequent. The foot is in full plantar 
flexion when it occurs. The head of the bone is prominent, the foot is 
inverted or everted, making prominent one malleolus or the other. 
Backward dislocation is very rare, and is produced when the foot is in 
extreme dorsal flexion. Outward and inward dislocation is very rare, 
as is also the dislocation of the astragalus about its own axis. In this 
displacement the version may be complete, the upper surface looking 
downward and the lower upward. 
Reduction of the dislocation of the astragalus is not always possible. 
If it can be perfectly accomplished, the functional result may be good, 
but if it is not possible, primary resection is the safest procedure. 
Amputation may become necessary. 
Dislocation of the tarsal bones may occur. 
The diagnosis is not usually very difficult. If they can be pushed 
into place, they may recover their function, but if the injury is com- 
pound or if it suppurates, then the bone should be removed. 
The metatarsal bones may be dislocated. The first and second alone 
are in conjunction with the others. The third, fourth, and fifth are not 
separately dislocated, but may be associated in a dislocation. They can 
be forced into position, and if extensive injury does not complicate the 
case, the recovery is usually with a good foot. INDEX. 
Abdomen, gunshot wounds of, 345 
surgical diagnosis and examination of, 
308 
Abscess, atheromatous, 554 
bone, 664 
treatment, 664 
classification of, 80 
acute, 80 
cold, 80 
gravitation, 80 
subacute, 80 
cold, infection of, 659 
collar-button, 507 
definition of, 79 
difference between, purulent infiltra- 
tion, 79 
fluctuation in, 82 
lumbar, 660 
manner of fprmation, 79 
palmar, 508 
psoas, 660 
retropharyngeal, 660 
shirt-stud, 507 
signs of, 82, 85 
subperiosteal in finger, 506 
symptoms of, 82, 85 
A. C. E. mixture, 292 
Accidents from anaesthetics, 298 
Acetanilid, germicidal effect of, 378 
Achondroplasia, 673 
Acne, 444 
treatment of, 445, 446 
Acromegaly, 680 
Acromial process, fracture of, 714 
Actinomycosis, 156 
of bone, 672 
definition of, 156 
organism of, 157 
diagnosis of, 159 
in man, 158 
prognosis, 159 
pus in, 158, 159 
of skin, 476 
treatment of, 159 
Acupressure, 260 
Acute intoxications, 251 
Adenitis following gonorrhoeal infection, 
220 
Adenoma, 429 
Ainhum, 104, 105 
Air, germs in, 362 
embolism, 38 
Allantoic cysts, 392 
Allen surgical pump, 262, 263 
Allis’s inhaler, 295 
method of reducing posterior dislocations 
of hip, 771 
Ambulatory treatment of fracture of leg 
and thigh, 747 
Ammonisemia, 122 
Amoeba coli in bone, 240 
in pus, 77 
Ampullitis, 219 
treatment of, 224 
Anaesthesia and anaesthetics, 285 
A. C. E. mixture, 292 
accidents from, 298 
arrested respiration, 298 
treatment, 298, 299 
Howard’s method, 274, 299 
Kelly’s method, 301 
Sylvester’s method, 273, 299 
cardiac failure, 301 
treatment, 301 
electricity, 302 
administration, inhalers, 295, 296 
with oxygen, 296 
chloroform, 290 
accidents during administration, 291 
death from, 291 
physiological action of, 290, 291 
choice of an anaesthetic, 293 
contraindications for chloroform, 293, 
294 
for ether, 293, 294 
death-rate from, 287 
discovery of, 285 
ether, 287 
accidents from, 289 
action of, 287, 288 
sequelae from administration, 289 
ethyl bromide, 292 
manner of administration, 292 
examination of patient before administra- 
tion, 286 
local anaesthesia, 302 
chemicals used for, 302 
Schleich method, 303 
nitrous-oxide gas, 292 
administration of, 293 
contraindications for use, 293 
relative safety of, 286 
Anel’s method in treating aneurism, 571 
Aneurism by anastomosis, 556 
aorta, abdominal, 581 
of arm, forearm, and hand, 579 
arterio-venous, 566 
axillary, 578 
bruit in, 568 
cirsoid, 418, 566, 583 
classification, 556, 560 
clinical phenomena of, 557 
of common carotid, 579 
diagnosis of, 567 
777 778 
INDEX. 
Aneurism, diffused, 563 
dissecting, 564 
etiology of, 559 
external, 557 
of external carotid, 579 
false, 563 
of foot, 582 
of gastro-epiploic artery, 581 
of hepatic artery, 581 
hernial, 563 
inguinal, 581 
innominate, 577 
treatment, 578 
internal, 557 
of internal carotid, 579 
of internal iliac artery, 582 
intracranial, 580 
intraorbital, 580 
of leg, 582 
of mesenteric artery, 581 
of popliteal artery, 582 
pressure effects of, 569 
on artery, 568 
of profunda femoris artery, 582 
pulsation in, 568 
recurrentpulsationfollowingoperation,572 
results of, 557 
rupture of, 569 
sac, suppuration of, 573 
saccular, 561 
sac in, 562 
special, 576 
spontaneous cure of, 557 
of superficial femoral artery, 582 
symptomatology in, 567 
traumatic, 322, 564 
circumscribed, 565 
diffuse, 565 
treatment by acupuncture, 576 
compression, 573 
digital, 574 
instrumental, 573 
rapid, 574 
by flexion, 575 
galvano-puncture, 575 
injections, 575 
by introduction of foreign bodies, 576 
operative, Anel’s, 572 
Antyllus’s method, 572 
Brasdor’s operation, 573 
extirpation, 572 
Hunter’s method, 573 
ligation, 571, 572 
Wardrop’s operation, 573 
manipulation, 575 
medical, 570 
thoracic, 576 
symptoms, 576 
treatment, 577 
tubular, 563 
varieties of, 556, 560 
varix, 566 
of vertebral artery, 581 
Angeioma, 418, 567 
cavernosum, 454 
Aniline preparations in treatment of cancer, 
443, 466 
Ankle, 
excision of, 643 
Ankylosis, 624 
contracture or false, 624 
diagnosis, 625 
true or bony, 625 
treatment, 626 
operative, 628 
Anthrax, 151 
definition of, 152 
etiology of, 152 
infection in, 152 
organism, 152 
incubation of, 153 
post-mortem appearances in, 153 
prognosis, 154 
symptoms of, 153 
treatment, 154 
Antisepsis in accidental operative wounds 
of pleura, pericardium, or peri- 
toneum, 369 
of bladder, 369 
of cerebral membranes, 369 
of intestines and rectum, 368 
of liver, gall-bladder, and ducts, 369 
of mouth, 367 
of stomach, 369 
of vagina, 368 
Antisepsis, definition of, 364 
in compound fractures, 702 
Antiseptic surgery, 370 
drainage in, 370, 371 
indications for drainage, 371 
manner of obtaining it, 370 
materials used for drainage, 371 
object of, 370 
Antiseptics, toxaemia from use of, 253 
Antitoxin of tetanus, 144 
method of preparation of, 144 
Antrum of Highmore, tooth in, 279 
Antyllian method for treatment of aneur- 
isms, 571 
Aorta, abdominal, aneurism of, 581 
aneurism of, 576 
symptoms, 576 
treatment, 577 
Archepyon, absence of fever in, 117 
in tuberculosis, 615 
Arm, aneui’isms of, 579 
Arrow-wounds, poisoned, 249 
Arterial varix, 566 
Arterio-sclerosis (atheroma), 554 
Arteries, aneurism of, 556 
atheroma of, 554 
diffused, 554 
localized, 554 
atrophy of, 548 
calcification of, 553 
emboli in, 560 
fatty degeneration of, 553 
inflammation of, 551 
acute, 552 
purulent, 553 
syphilitic, 552 
tuberculous, 553 
injury to, 321 
malformations and malpositions of, 548 INDEX. 
779 
Arteries, structure, 547 
surgical injuries and diseases of, 547 
thrombi in, 549 
changes in, 550 
obstructive, 550 
parietal, 549 
thrombosis of, 549 
Arteriotomy, 26l 
Arteritis, 551 
Arthrectomy, 629 
for tuberculosis, 623 
Arthritis, acute suppurative, 595 
arthropathic, 616 
deformans, 603 
following burns, 481 
tubercular, 612 
Arthrodesis, 630 
Arthropathic arthritis, 616 
Artlirotomy for tuberculosis, 623 
Artificial respiration, 273 
methods, 273, 274 
Asepsis, definition of, 364 
sterilization, 364 
by chemicals, 365 
of field of operation, 367 
of head, 367 
by heat, 364 
mechanical, 366 
Aseptic blood-clot in treatment of disease 
of bone, 671 
fever in wounds, 320, 381 
solutions, 377 
surgery, 364 
wound fever, 118 
Aspiration, 263 
Astragalus, dislocation of, 775 
Atheroma, 554 
causes, 554, 555 
cyst, 446 
treatment, 556 
Atheromatous abscess, 554 
ulcer, 554 
Atrophic elongation of bones, 679 
Atrophy, classification of, 30 
definition of, 30 
following acute infectious processes in 
bone, 657 
and hypertrophy, difference between, 27 
pathological, 31 
as a result of continuous pressure, 31 
trophoneurotic, 31 
treatment, 31 
physiological, 30 
Auto-infection, 109 
Auto-intoxication, 109, 111 
causes of 109, 111 
ferments in, 110 
intestinal putrefaction, 111 
treatment by purgatives, 113 
general, 114 
bv urea, 112 
by venesection, 111, 112 
urea in, 110 
value of venesection in, 111, 112 
Avicenna’s method of reducing dislocations 
of shoulder, 760, 761 
Axillary artery, aneurism of, 578 
Bacillus Anthracis, 75 
of bubonic plague, 76 
coli communis, 73 
in bone diseases, 649 
diphtherise, 74 
of glanders, 149 
of influenza, 76 
leprse, 75 
of malignant oedema, 75, 155 
mallei, 75 
cedematis maligni, 75,155 
pneumoniae Friedliinder, 75 
proteus, 74 
pyocyaneus, 74 
antagonizing anthrax poison, 154 
of Rauschbrand, 76 
of rhinoscleroma, 76 
septicaemia; hsemorrhagicae, 76 
tetanus, 75, 139 
tuberculosis, 75, 160 
in bone, 658, et seq. 
as a pyogenic organism, 76 
typhi abdominalis, 74 
Bacteria of pus-formation, 70 
classification of, 70 
facultative pyogenic, 70, 74 
obligate pyogenic, 71 
bacillus coli communis, 73 
pyocyaneus, 74 
colon bacillus, 73 
diplococcus pneumoniae, 72 
gonococcus, 73 
micrococcus lanceolatus, 72 
tetragonus, 73 
staphylococcus pyogenes albus, 71 
pyogenes aureus, 71 
pyogenes citreus, 71 
streptococcus erysipelatis, 71 
pyogenes, 71 
their elimination, 68 
Bacterial determination as an indication in 
treatment, 77 
Balanitis, 218 
treatment of, 223 
Bandages, 283 
Bandaging, 281 
materials used, 282 
kinds, 283 
Barbados leg, 527 
Barton’s bandage, 284 
Behring’s diphtheria serum, 115 
Beriberi, 234 
Bier’s treatment of joint tuberculosis, 177 
Bigelow’s rule for reduction of anterior or 
inward dislocations of hip, 772 
Bile, action of, as cause of auto-intoxication, 
113 
in blood, 111 
Billroth’s angio-neurotic gangrene, 106 
chain-stitch, 269 
Bites, from snakes, 247 
insect, 248 
reptiles, 248 
treatment. 248, 249 
Black leg, 156 
quarter, 156 
Bladder, gunshot wounds of, 348 780 
INDEX. 
Bladder, tuberculosis of, 174 
wounds of, following fracture of pelvis, 727 
Blisters, rules for application, 265 
Blood, abstraction of, by arteriotomy, 261 
cupping, 261 
leeches, 262 
scarification, 261 
venesection, 260 
changes in, in Hodgkin’s disease, 534 
corpuscles, red, 46 
corpuscular elements of, 43 
classification of, 44 
eosinophile leucocytes, 44 
estimation of number of corpuscles, 47, 48 
examination of, 47 
hsemocytometer, 47 
leucocytosis, 43 
leucocytosis as aid in diagnosis, 45 
lymphocytes, 43 
oligocvthsemia, 46 
poikilocytosis, 46 
surgical pathology of, 32 
thrombosis, 32 
causes of, 32 
classification of, 33 
thrombi, 34 
causes of, 32 
foreign bodies, 33 
micro-organisms, 33 
classification of, 33 
as to cause, 34 
as to seat, 33 
transfusion of, 270 
Blood-clot, organization of, 354 
Blood-vessels, regeneration of, 358 
Blue pus, 81 
Bone, abscess, 664 
treatment, 664 
acromegaly, 680 
atrophic elongation of, 679 
callus in, 361 
caries of, 666 
causes of, 666 
treatment, 666 
consequences of infection, 657 
contusion of, 326 
epiphysitis, acute, 656 
fragility of, 678, 679 
healing by second intention, 361 
leprosy of, 673 
lesion of, following typhoid, 242 
diphtheria, 243 
scarlatina, 241 
Marie’s disease of, 680 
marrow, 648 
necrosis, 667 
pathological, 667 
toxic, 667 
treatment of, 669 
traumatic, 667 
osteoarthropathie hypertrophiante pneu- 
mique, 680 
osteomyelitis, acute, 648 
complications, 652 
diagnosis of, 653 
etiology of, 653 
organisms at fault in, 648 
Bone, osteomyelitis, pathology, 648 
prognosis, 652 
symptoms of, 650 
treatment of, 654 
osteomyelitis, chronic or latent, 657 
causes of, 657 
osteoporosis of, 657 
osteopsathyrosis, or fragility of, 678 
ostitis deformans, 679 
Paget’s disease of, 679 
parasitic affections of, 672 
actinomycosis of, 672 
hydatid disease, 672 
pegs and sutures, 631, 642, 646 
periostitis, acute infectious, 655 
albuminosa, 656 
causes of, 655 
treatment of, 656 
regeneration of, 359-361 
following osteomyelitis, 655 
resemblance as to structure and diseases 
of, to lung, 647 
senile fragility of, 679 
sequestrum formation, 669 
diagnosis, 670 
treatment, 670 
strength of, 694 
suturing for delayed union, 704 
syphilis of, 664 
treatment of, 665 
trophoneurotic diseases of, 673 
achondroplasia, 673 
osteomalacia, 675 
causes of, 676 
treatment of, 677 
rachitis, 674 
deformities in, 675 
treatment of, 675 
tuberculosis of, 658 
acute miliary, 660 
chronic tubercular osteomyelitis, 660 
cold abscess in, 659 
destruction of bone in, 659 
pathological luxations in, 659 
pathology of, 659, 660 
symptoms of, 661 
treatment of, 662 
extirpation, 663 
ignipuncture, 664 
non-operative, 682 
operative, 663 
varieties of, 660 
tumors of, 683 
carcinoma, 688 
cartilaginous, 683 
endothelioma, 688 
epithelioma, 688 
fibroma, 683 
myxomata, 685 
osteomata, 684 
sarcoma, 685 
seats of, 686 
treatment of, 687 
Bones, lesions of, following exanthemata, 
239 
dysentery, 240 
pneumonia, 240 INDEX. 
781 
Bones, surgical diseases of, 647 
Boric acid, toxic effects of, 254 
Bouchard’s researches on auto-intoxication, 
109, 110 
Bougard’s paste, 465 
Bovinine as surgical dressing, 98 
Brainerd’s method of treating delayed 
union, 704 
Brasdor’s operation for treatment of aneur- 
isms, 572 
Breast, carcinoma, 434 
Paget’s disease of, 466 
surgical diagnosis and examination of, 
308 
Brigg’s sterilizer, 372 
Bronchocele, 430 
Bruit in aneurism, 568 
Brunner’s method of sterilizing catgut, 377 
Bryant’s line, 731 
Buck’s extension, 734 
Bunions, 275, 396, 513 
causes of, 275 
treatment, 276 
Burns, 479 
cicatrices following, 482 
classification, 479 
complications in, 481 
from lightning, 484 
general considerations in, 480 
prognosis, 482 
symptoms, 480 
theories to explain lethal action of, 480 
treatment, 483 
Bursae, 396 
adventitious, forming bunions, 275 
affections of, 510 
inflammation of, 511, 513 
mucosae, 510 
of new formation, 513 
simple, enlarged, 512 
synovial, 396, 510 
tuberculosis of, 173 
Bursitis, acute, 511 
chronic, 511 
fracture of, 748 
\J Callosities, 451 
Callus, formation of, 699 
ossification of, 700 
Cancer en cuirasse, 433 
Cancer-houses, 389 
Cancrum oris, 104 
Carbolic acid, toxic effect of, 254 
Carbuncle, 82, 449 
diagnosis from anthrax carbuncle, 450 
Carcinoma, 433 
of bone, 688 
cutis, 467 
differential diagnosis from sarcoma, 441 
lenticular, 467 
tuberosum, 467 
Caries, 666 
treatment, 666 
dental, 245 
Carotid artery, common, ligation of, for 
aneurism, 579 
external, aneurism of, 579 
Carotid artery, internal, aneurism of, 579 
Carpo-metacarpal dislocation, 765 
Carpopedal cramp, 145 
Carpus, dislocation of, 765 
Carron oil, 484 
! Carrying power, preservation of, in frac- 
tures of humerus, 719, 720 
Cartilage, repair of, 356 
semilunar, dislocation of, 774 
Catgut, chromicized, 377 
sterilization of, 376 
Catheter, 271 
cleansing of, 272 
Catheterization, 271 
catheters used in, 271 
normal obstacles to, 272 
technique of, 271 
untoward effects of, 272 
constitutional, 273 
local, 272 
Cautery, Paquelin’s thermo-, 266 
Cellulitis, 137 
relation to erysipelas, 137 
treatment of, 137 
Cerebro-spinal meningitis, secondary infec- 
tion in, 244 
Chancre, 187 
diagnosis of, 191 
differential diagnosis of, 191 
varieties of, 188 
Characteristic pus from different agencies, 
77 
Charbon, 151 
Charcot’s disease of joints, 606 
Chemotaxis, 50, 57 
Chest, surgical examination and diagnosis 
of, 307 
Chloride-of-ethyl spray, 302 
Chloroform, 290 
Cholera, secondary infection in, 240 
Chondroma, 412 
of bone, 683 
Chordee, 218 
Chvostek’s sign, 145 
Chylocele, 523 
Chyluria, 528 
Cirsoid aneurism, 418, 566, 583 
Clap threads, 223 
in urine, 229 
Clavus, 275, 451 
Clavicle, dislocation of, 754 
fracture, 712 
symptoms, 713 
Coagulation-necrosis as a result of bacterial 
activity, 78 
Cocaine for local anaesthesia, 303 
Coccidia in tumors, 389 
Coccyx, fracture of, 728 
I Cohnheim’s embryonal hypothesis as cause 
of tumors, 388 
views on inflammation, 55 
Coley’s method of inoculation in inoperable 
malignant growths, 442 
Collapse, 230 
Collar-button abscess, 507 
Colles’ fracture, 722 
law in syphilis, 208 782 
INDEX. 
Colon bacillus as cause of intestinal toxaemia, 
113 
Comedo, 444 
Complications of fractures, 695 
Compound dislocations, 753 
Condyloma, 206 
Congenital dislocations, 750 
hsematoma of sterno-inastoid, 490 
lymphangeiectases, 457 
muscular deformities, 487 
naevi, 453, 454 
syndactylism, 487 
webbed knee, 489 
webbed toes, 489 
Contusions, 319 
Copraemia, 113 
Cornea, repair of, 356 
Corns, 275 
treatment of, 275 
varieties of, 275 
Coronoid process, fracture of, 721 
Cornu cutaneum, 451 
Corpora orvzoidea, 173, 610 
Corrosive sublimate, toxic effect of, 254 
Coude catheter, 271 
Cough, diagnostic significance of, 315 
Counter-irritation, 264 
value of, 264 
by actual cautery, 266 
by rubefacients, 264 
by seton, 266 
by vesicants. 265 
Cowperitis, 219 
Craniotabes, 675 
Cranium, gunshot wounds of, 339 
Crepitus in fractures, 696 
Crutch paralysis, 500 
Cupping, 261 
Cyst, dermoid, 398 
sebaceous, 446 
diagnosis, 447 
treatment, 447 
Cystic degenerations, 397 
Cysticercus cellulosus cutis, 476 
in muscles, 514 
Cystitis, due to gonorrhoeal infection, 220 
Cysts, 392 
classification, 392 
definition of, 392 
glandular, 395 
of pancreas, 395 
hydroceles, 393 
of neck, 394 
of canal of Nuck, 394 
pseudo-, 395 
hydatid, 397 
neural, 397 
synovial, 396 
retention, 392 
sebaceous, 430 
tubulo-, 392 
allantoic, 392 
of remains of Wolffian body, 392, 
393 
of vitello-intestinal duct, 392 
and tumors, 385 
Czerny suture, 270 
Dactylitis syphilitica, 209 
Daland’s haematokrit, 47 
! Deformities in fractures, 695, 697 
! Delayed union, 703 
in bone, 361 
causes, 703 
treatment, 704 
Delirium tremens, 251 
causes of, 251 
symptoms, 251 
treatment, 252 
Dentition in rickets, 237 
Dermatolysis, 412 
Dermoids, 398 
Desault’s bandage, 283 
Destruction of bacteria, 68 
Diagnosis, differential, between benign and 
malignant growths, 440 
epithelioma and tuberculosis, 441 
sarcoma and carcinoma, 441 
surgical, 304 
Diagnostic features of malignant growths, 
440 
Diphtheria, secondary infection in, 243 
Disinfecting agents, 364, 365 
Dislocation, compound, of joints, treatment, 
590 
of humerus, complicating fracture of 
surgical neck, 717 
Dislocations, 750 
classification of, 750 
complications of, 751 
compound, 750, 753 
congenital, 750 
definition, 750 
differential diagnosis between it and 
fracture, 752 
etiology and mechanism of, 751 
nearthrosis in, 753 
pathology of recent dislocations, 751 
repair in, 752 
symptoms, 752 
traumatic, 750 
treatment of, 752 
unreduced, special, pathology of, 751 
Dislocations, special, 753 
astragalus, 775 
carpo-metacarpal, 765 
carpus, 756 
clavicle, 754 
treatment, 755 
elbow, 762 
both bones backward, 762 
both bones forward, 763 
fibula, 774 
foot, 775 
from astragalus, 775 
hip, 768 
classification of, 768 
differential diagnosis, 770 
dorsal reduction by Kocher’s method, 
771 
infracotyloid or downward, 772 
infrapubic, 772 
manipulation for reduction, 770 
supracotyloid or upward, 772 
suprapubic reduction, 771 INDEX. 
783 
Dislocations, hip, symptoms, 759 
jaw, 753 
knee, 773 
anterior, 773 
backward, 774 
lateral, 774 
semilunar cartilages in, 774 
metacarpo-phalangeal, 765 
treatment, 766 
radio-ulnar joint, 765 
radius, 763 
ribs, 754 
shoulder, prognosis in, 761 
old, 761 
shoulder-joint, 755 
classification of, 756 
symptoms of, 757 
treatment, 758 
sternum, 754 
Dissection wounds, treatment of, 136 
Diverticula, 395 
intestinal, 395 
pharyngeal, 396 
vesical, 395 
Drainage, 370, 371 
in compound fractures, 702 
of joints, 590 
Dressings, 375 
indication for change of, 381 
sterilization of, 375 
Duchenne’s disease, 499 
Dugas’ test for dislocation of shoulder, 757 
Dupuytren’s classification of burns, 479 
contraction, 500 
etiology of, 500 
treatment, 501 
Dysentery, 240 
followed by pyogenic infection, 240 
Echinococcus in muscles, 514 
Ecthyma-form syphilide, 199 
Elbow, dislocation of, 762 
excision of, 632 
synovitis of, 596 
Electrolysis in nsevi, 546 
Elephantiasis, 420, 457, 459, 525 
chief seats, 460 
etiology, 460 
of genitals, 527 
treatment, 528 
grsecorum, 179 
symptoms, 525 
treatment, 526 
Elimination of bacteria, 68 
Emboli in arteries, 550 
Embolism, 37 
causes of, 38 
definition of, 37 
fat, 40 
result of, 39 
Embryonal hypothesis of Cohnheim as a 
cause for tumors, 388 
Emphysema following fractures, 705, 711 
Emprosthotonos, 141 
Empyema, 86 
difference between abscess, 86 
Encephaloid, 403 
Endarteritis, 552-554 
Endocarditis, secondary infection in, 244 
Endoscope, 226 
Endothelioma, 438 
of bone, 688 
Entero-sepsis, 113 
Epicondyles, fracture of, 718 
Epidermis, regeneration of, 356 
Epiderinization, 355 
Epididymis, tuberculosis of, 174 
Epididymitis, 220 
treatment of, 224 
Epiphyseal fractures, 702 
Epiphysis, separation of lower end of hu- 
merus, 718 
Epiphysitis, acute, 656 
Epithelioma, 426 
of bone, 688 
deep-seated, 463 
diagnosis, 464 
differential diagnosis of, 464 
from tuberculosis, 441 
microscopically, 464 
papillary, 463 
of scars, 482 
superficial, 462 
treatment, 465 
Equinia, 149 
Eruptions due to drugs, 118 
of erysipelas, 132, 134 
erythema, 119 
in fever, 118 
hemorrhagic, 119 
in pyaemia, 128 
Erysipelas, 130 
constitutional, 132 
definition of, 130 
diagnosis of, 134 
epidemic form, 130 
etiology of, 130 
infectiousness of, 131 
local, 133 
of mucous membranes, 133 
of new-born, 131 
organism, relation to streptococcus, 130 
pathology of, 131 
phlegmonous, 130 
post-mortem appearances, 134 
precautions in, 135 
local treatment, 136 
prognosis in, 134 
relation to cellulitis, 137 
source of infection, 131 
symptoms, 132 
synonyms of, 130 
of synovial membranes, 134 
toxines in inoperable malignant growths, 
130, 134, 442 
traumatic, 130, 132 
treatment of, 135 
wandering, 132 
Erysipeloid, 137 
Erythema induratum, 475 
multiforme, 119 
Ervthromelalgia, 20 
in gangrene, 103 
Esmarch’s inhaler, 295 784 
INDEX. 
Esmarch’s tourniquet, 258 
Ether, 287 
Ethyl bromide, 292 
Excisions, indications for, 629 
instruments required, 631 
intermediary, 630 
of joints, 629 
primary, 630 
secondary, 630 
special, 631 
ankle, 643 
after-treatment of, 644 
methods, 643 
results of, 644 
elbow, 632 
after-treatment, 634 
indications for, 632 
methods of, 632 
results of, 634 
fingers, thumb, and metacarpus. 636 
foot, 644 
osteoplastic, 644 
results of, 646 
hip, 637 
after-treatment of, 639 
indications for, 637 
methods, 637 
results in, 639 
knee, 640 
after-treatment of, 642 
fixation of bone surfaces in, 642 
methods, 640 
results, 642 
shoulder, 631 
after-treatment, 632 
results of, 632 
subperiosteal method, 630 
wrist, 634 
after-treatment, 636 
indications fox-, 634 
methods, 635 
results of, 636 
Exostoses, 415, 684 
Extracapsular fracture of neck of femur, 
729 
Exudates, 24 
classification of, 24 
difference between inflammatory and 
hypersemic, 25 
fibrinous, 24 
purulent, 25 
serous, 24 
FACE, gunshot wounds of, 341 
False passages, 272 
Fai-aboeuf’s instrument for reducing dislo- 
cation of thumb, 767 
Farcy, 149 
Fascia, contraction of (Dupuytren’s), etiol- 
ogy, 500 
regeneration of, 356 
Fat-embolism, 40 
causes of, 41 
diagnosis from shock, 231 
prognosis in, 42 
symptoms, 42 
treatment, 42 
Fehleisen’s coccus, 130 
Fell’s apparatus for forced respiration, 274 
Felon, 506 
bone, 656 
Femoral artery, aneurism of, 582 
Femur, fracture of, 729 
intercondyloid, 733 
treatment, 734 
supracondyloid, 733 
of lower end, 733 
of neck, 729 
symptoms, 730 
treatment, 734 
of shaft, 732 
Fever, causes of, 117 
definition of, 117 
ferments in, 117 
hyperpyrexia in, 117 
resembling malaria, due to filaria san- 
guinis hominis, 525 
stages of, 117 
urethral, 273 
Fibroblasts, 351 
Fibroma, 411 
of bone, 683 
of skin, 461 
Fibrous union in bone, 361 
Fibula, dislocation of, 774 
fracture of, 746 
Pott’s fracture of, symptoms, 746 
treatment, 746 
Figure-of-8 bandage, 281 
dressing for fracture of clavicle, 714 
Filaria Bancrofti, 524 
Medinensis, 476 
sanguinis hominis, 460, 524 
life-history, 524 
manner of invasion of organism, 524 
results of invasion, 524 
Filariasis, 523 
Finger, excision of, 636 
Fingers, fracture of, 726 
webbed, 487 
Fistula, 86 
causes of, 87 
definition of, 86 
difference between sinus, 86 
treatment, 87 
Fleischl’s hsemometer, 49 
Foetal rickets, 673 
Folliculitis, 218 
treatment of, 223 
Foot, dislocation of, 775, 776 
fracture of, 748 
osteoplastic excision of, 644 
Forced respiration, 274, 275 
Forceps, haemostatic, 258 
Forearm, fracture of, 720 
both bones, 724 
Foreign bodies in wounds, 380 
Four-tailed bandage for fracture of inferior 
maxilla, 709 
Fracture-box, 744, 745 
Fracture of acromial process, 714 
ambulatory method of treatment of, 747 
calcaneum, 748 
classification of, 690 INDEX. 
785 
Fracture, classification of, compound, 692 
epiphyseal, 692 
impacted, 692 
intra-articular, 693 
longitudinal, 692 
multiple, 692 
oblique, 691 
transverse, 691 
clavicle, 712 
coccyx, 728 
Colles’ fracture, 722 
complete, 690, 691 
complications of, 695 
compound, treatment of, 702 
crepitus in, 696 
definition, 690 
deformities in, 695, 697 
delayed union in, 703 
causes of, 703 
treatment, 703, 704 
depressed, 690 
diagnosis of, 695 
etiology of, 693 
of femur, 729 
of fibula, 746 
fissured, 690 
foot, 748 
forearm, 720, 724 
green-stick, 690 
hand, 726 
history in, 696 
humerus, 715 
lower end, 718 
shaft, 718 
upper extremity, 715, 716 
hyoid bone, 710 
immediate causes of, 693 
incomplete, 690 
inferior maxilla, 707 
lachrymal bone, 706 
malar, 707 
mobility in, 696 
treatment, 697 
non-union in, 703 
nose, 704 
obstacles to reduction, 698 
muscular contraction, 698 
olecranon, 720 
pain in, 696 
partial, 690 
patella, 740 
treatment, 741 
of pelvis, 727 
complications of, 727, 728 
treatment, 728 
of false pelvis, 728 
of true pelvis, 727 
Pott’s fracture, 745 
radius, 722 
repair of, 699 
epiphyseal fractures, 702 
intra-articular fractures, 701 
ossification of callus in, 700 
retention of fragments in position, 698 
ribs, 710 
sacrum, 728 
scapula, 714 
Vol. I.—50 
Fracture, separation of an apophysis, 690 
special, 704 
sternum, 711 
superior maxilla, 706 
symptoms, 605 
thigh, 729 
lower third, 733 
treatment, 734 
middle third, 732 
treatment, 734 
upper third, 729, 732 
diagnosis, 729 
symptoms, 729 
treatment, 734 
tibia, 742 
of lower end, 745 
of shaft, 743 
of upper end, 742 
ulna, 720 
wiring of fragments, 734 
wrist, 726 
zygomatic arch, 707 
Fragility of bones, 678, 679 
Friedlander’s bacillus, 75 
Frost-bites, 485 
classification, 485 
symptoms, 485 
treatment, 486 
Fungi, 77 
in pus, 77 
actinomycosis, 77 
aspergillus, 77 
leptothrix, 77 
Madura foot, 77 
Furuncle, 82, 447 
organism in, 448 
treatment, 448 
Furunculosis, 447 
Ganglion, 509 
Gangrene, angioneurotic, 106 
causes of, 102 
constitutional, 103 
diabetic, 103 
infectious, 104 
local, 102 
carbolic dressings, 103 
ergot, 103 
traumatic, 102 
definition of, 102 
dry, 107 
symptoms of, 107 
following frost-bite, 486 
foudroyante, 104, 154 
hospital, 104 
moist, 106 
line of demarkation in, 106 
symptoms of, 106 
noma, 104 
phagedenic, 107 
amputation in, 108 
senile, 107 
signs of, 107 
symmetrical, 103 
symptoms of, 107 
synonyms, 102 
treatment, 107 786 
INDEX. 
Gangrenous emphysema, 154 
septicaemia, 154 
stomatitis, 104 
Gartner’s duct, cyst of, 393 
Gaspard’s putrid fever, 111 
Gas phlegmons, 154 
Genito-urinary tract, surgical diagnosis and 
examination of, 310 
Germicidal agents, 364, 365 
action of metals, 380 
Girdner’s telephone probe, 332 
Glanders, 149 
definition of, 149 
diagnosis, 151 
etiology, 149 
incubation of, 150 
infectious nature of discharge, 150 
organism, description of, 150 
prognosis in, 151 
symptoms, 150 
synonyms of, 149 
treatment, 151 
specific, by mallein, 151 
Gleet, 225 
Glioma, 409 
Gold-foil in skin-grafting, 277 
Gonococcus, 73, 214 
in discharges, 215 
in joints, 598 
Gonorrhoea, 214 
chronic, 225 
diagnosis of, 225 
exploration of urethra in, 225 
length of contagiousness in, 229 
treatment, 227 
constitutionally, 229 
injections, 228 
locally, 229 
sounds, 227 
chordee, 218, 223 
clinical history of, 217 
conditions favoring infection, 217 
diagnosis by specific organism, 215 
etiology, 214 
extensions of, 218 
adenitis, 220 
am pul litis, 219 
•treatment of, 224 
balanitis, 218 
Cowperitis, 219 
cystitis, 220 
deep urethritis, 219 
treatment of, 224 
epididymitis, 220 
treatment of, 224 
folliculitis, 218 
treatment of, 223 
lymphangitis, 220 
nephritis, 220 
orchitis, 220 
treatment of, 224 
peri-urethral inflammation, 218 
treatment of, 224 
post-gonorrhoeal arthritis, 220 
treatment of, 225 
prepuce, oedema of, 220 
prostatitis, 219 
I Gonorrhoea, extensions of, pyelitis, 220 
pyaemia, 221 
ureteritis, 220 
vesiculitis, treatment of, 224 
in the female, 215 
morbid anatomy of, 214 
of mucous membranes, 214 
paraphimosis, treatment of, 223 
phimosis, treatment of, 223 
pyaemia due to gonococcus, 214, 221 
rheumatism, 220 
sources of infection, 216 
thecitis, 503 
treatment of, 221 
abortive, 223 
local, 222 
Gouty synovitis, 598 
Granulation-tissue, 93 
Green-stick fracture, 690, 726 
Gunshot wounds, 329 
of bone, 335 
treatment, 336 
of head,' 338 
treatment, 338 
of joints, 338, 587, 590 
diagnosis, 338 
prognosis, 338 
treatment, 338 
of testes, 349 
Guinea-worm, 476 
Gumma, 202 
of bone, 664 
histology, 204 
surgical importance of, 203 
Gussenbauer’s condition of amrnoniaemia, 122 
HHEMATOCELE, cystic degeneration of, 
397 
Haematokrit, 47 
Haematoma of bursae, 511 
due to filaria sanguinis hominis, 525 
Hsemocytometer, 47 
Haemoglobin, 51 
estimation of, 49 
in shock, 231 
surgical importance of, 51, 52 
Htemoglobinometer, 49 
Hall’s (Marshall) method of artificial respi- 
ration, 274 
method of treatment of telangeiectases, 
456 
Hamilton’s method of skin-grafting, 277 
j Hand, fracture of. 726 
Hands, sterilization of, 366 
Hansen’s bacillus of leprosy, 179 
Head-and-neck bandage, 282 
Head, gunshot wounds of, 338 
Heart, gunshot wounds, 345 
Hemorrhage in bullet wounds, 332 
from catheterization, 272 
control of, by, 257, 258 
acupressure,260 
cold, 260 
digital compression, 257 
elevation, 260 
forced flexion, 259 
I forceps, 258 INDEX. 
787 
Hemorrhage, control of, heat, 260 
ligation, 258 
ligature en masse, 259 
pressure, 259 
styptics, 259 
torsion, 259 
tourniquets, 259 
from fractured rib, 711 
Hereditary syphilis, 207 
Heredity as a cause for tumors, 387 
Hernia of muscles, 325 
Hip, dislocation of, 768 
anterior, 772 
reduction of, 772 
classification of, 768 
dorsal reduction of, 771 
Allis’s method, 771 
Middeldorpf’s method, 771 
infracotyloid reduction of, 772 
after-treatment of, 773 
reduction of, 770 
suprapubic, 771 
reduction of, 771 
symptoms, 769 
excision of, 637 
synovitis of, 596 
Hodgen’s splint, 736 
application of, 738 
description of, 737 
uses of, 739 
Hodgkin’s disease, 532 
diagnosis, 534 
symptoms, 533 
synonyms, 532 
treatment, 535 
Housemaid’s knee, 512 
Howard’s method of artificial respiration, 
274, 300 
Hueter’s incision for excision of elbow, 
633 
Humerus, epiphyseal separation of, 716, 
717 
fracture of, 715 
lower end, 718 
symptoms, 718, 719 
treatment, 718, 719 
shaft, 718 
symptoms, 718 
treatment, 718 
upper extremity, 715 
complications of, 717 
symptoms, 716 
treatment, 717 
Hunter’s method of treatment for aneur- 
isms, 572 
Hutchinson’s teeth, 209 
Hydatid disease of bone, 672 
of Morgagni, 393 
Hydrarthrosis, 601 
diagnosis, 602 
prognosis, 602 
treatment, 602 
Hydrocephalus in rickets, 237 
Hydrophobia, 146 
Babe’s views as to virus, 146 
definition, 146 
diagnosis, 148 
Hydrophobia, dumb, 146 
furious form, 146 
incubation in, 147 
method of Pasteur treatment, 148 
Pasteur’s views as to virus, 146 
paralytic type of, 147 
post-mortem changes in, 147 
symptoms of, 147 
treatment, 148 
virus of, 146 
Hydrops, tuberculosis, 617 
treatment of, 622 
Hygroma, 173, 504, 511 
Hyoid bone, fracture of, 710 
Hypersemia, 17 
active, 18 
causes of, 18 
due to filaria sanguinis hominis, 524 
oedema, 19 
experimental study of, 19 
passive, 21 
results of, 21 
acute swelling, 22 
chronic swelling, 22 
gangrene, 23 
hypertrophy, 22 
resolution, 21 
symptoms of, 25 
treatment of, 26 
general, 27 
local, 26 
Hyperesthesia, in pyaemia, 128 
| Hyperostoses, 684 
Hyperplasia from occlusion of lymph- 
channels, 521 
Hypertrophy and atrophy, difference be- 
tween, 27 
classification of, 28 
following acute infectious processes in 
bones, 657 
pathological, 29 
physiological, 28 
Hypodermic medication, 279 
accidents from, 280 
care of syringe, 280 
method of administration, 280 
points of election, 280 
treatment of syphilis, 212 
Hysterical joints, 608 
diagnosis, 609 
TCHORRvEMIA, 125 
x Idiopathic muscular spasm, 145 
Ignipuncture, 267 
in bone tuberculosis, 663 
Iliac artery, aneurism of, 582 
Immersion, continuous, in hot water in py- 
asmia, 129 
in septicaemia, 124 
in shock, 232 
Immunity, 60, 68 
classification of, 60 
conditions which favor, 68 
Impacted fracture, 692 
Impaction, in Colies’ fracture, 723 
Implantation dermoids, 400 
Incisions in palmar abscess, 509 788 
INDEX. 
Indican in relation to intestinal putrefac- 
tion, 116 
urine, 116 
Indicanuria, 116 
as an index to coprastasis, 116 
manner of estimation of, 116 
relation to gastric acidity, 116 
relation to surgical conditions, 116 
Infection, auto-, 109 
circumstances which favor, 59 
association of organisms, 60 
foetal infection, 63 
habits and environment, 63 
hereditary influences, 60 
local predisposition, 61 
pre-existing disease, 62 
virulence of organism, 60 
classification of, 69 
mixed, 70 
primary, 69 
secondary, 69 
tertiary, 70 
sources, 64 
alimentary canal, 66 
from flies, 68 
from within system, 67 
from without, 67 
genito-urinary tract, 66 
milk in lacteals, 67 
respiratory tract, 65 
skin and hair as a source, 64 
tonsil, 65 
surgical sequelae of, 239 
Infections of bone, consequences of, 657 
Inflammation, 53 
as a cause for tumors, 388 
definition of, 53 
leucocytic increase in, 56 
phenomena of, 54 
diapedesis of leucocytes in, 53 
microscopical appearance of, 53 
specific irritants in, 58 
Inflation of lungs, 274 
Influenza, secondary infection in, 241 
Infusion, 270 
subcutaneous, 271 
Injury and repair, 320 
subcutaneous injuries, contusions, lacera- 
tions, 319 
degree of, 319 
suppuration in, 320 
symptoms of, 320 
treatment, 320 
Innominate artery, aneurism of, 577 
treatment of, 578 
Inoculation of cancer, 389 
Instillation of deep urethra, 228 
Instruments, sterilization of, 372 
Intercondyloid fracture of femur, 733 
Intestinal antiseptics in septicaemia, 125 
intoxication, 113 
synonyms of, 113 
toxaemia due to colon bacillus, 113 
relation to surgical fevers, 113 
Intoxication, auto-, 109 
Intoxications, acute, 251 
Intracapsular fracture of neck of femur, 729 
Inunction, mercurial, in syphilis, 212 
Involucrurn, 670 
Iodine, toxic effect of, 254 
Iodoform causing mania, 253 
injection of, in tubercular joints, 621, 622 
injections in tuberculosis, 166 
poisoning, 378 
Irritation as a cause for tumors, 387 
Ischium, fracture of, 729 
JACKET CANCER, 433 
tl Jaw, dislocation of, 753 
fracture of, 707 
Joint, abscess, 589 
complications following acute exanthem- 
ata, 597, 598 
Joints, aspiration of, 263 
excision of shoulder, 631 
elbow, 632 
fingers, thumb, and metacarpus, 636 
foot, 644 
hip, 637 
knee, 640 
shoulder, 631 
wrist, 634 
fractures into, repair of, 701 
hysterical, 608 
implication of, in dysentery, 240 
loose bodies in, 609 
causes, 609, 610 
diagnosis, 611 
symptoms of, 611 
treatment, 612 
operations on, 629 
arthrectomy, 629 
arthrodesis, 630 
arthrotomy, 629 
excision, 629 
general considerations, 629 
resection, 629 
Joints and joint diseases of, 593 
acute suppurative arthritis, 595 
etiology of, 597 
symptoms of, 595 
treatment of, 599 
ankylosis of, 624 
arthropathic arthritis, 616 
classification, 593, 613 
chronic, 601 
dry synovitis, 594 
symptoms of, 594 
gouty synovitis, 593 
hydrarthrosis, 601 
neuropathic, 606 
osteo-arthritis, 603 
osteopathic arthritis, 613 
post-gonorrhoeal synovitis, 598 
diagnosis of, 599 
purulent synovitis, 593 
rheumatism, chronic, 602 
simple synovitis, 593 
deformity in, 600 
general considerations of, 584 
gunshot injuries of, 590 
amputation in, 592 
diagnosis of, 591 
excision in, 592 IXDL'X. 
789 
Joints, gunshot injuries of, symptoms of, 
591 
treatment of, 592 
injuries of, 584 
contusion in, 584 
penetrating wounds of, 587 
clinical course of, 588 
symptoms of, 588 
treatment of, 589 
sprain in, 585 
clinical history of, 585 
symptoms of, 586 
treatment of, 586 
restoration of function in, 600 
tuberculosis of, 612 
complications of, 620 
diagnosis of, 620, 625 
etiology of, 612, 613 
pathological anatomy of, 613-615 
prognosis of, 621 
repairs in, 618 
synonyms of, 612 
treatment of, 599, 621, 626 
mechanical, 621 
operative, 621-623 
urethral synovitis in, 598 
Junker inhaler, 296 
KARYOKINESIS, 55 
Keloid, 412, 458 
Kelly’s bandage, 283 
cumol method for sterilization of catgut, 
377 
method of artificial respiration, 301 
Kidney, tuberculosis of, 174 
Knee, dislocation of, 773 
semilunar cartilages in, 774 
excision of, 640 
synovitis of, 596 
Knots, 268 
clove hitch, 269 
granny, 269 
reef, 268 
Staffordshire, 269 
surgeon’s, 268 
Kobelt’s tubules, cyst of, 393 
Kocher’s method of reducing dislocations 
of shoulder, 759 
dorsal dislocations of hip, 771 
forward dislocations of hip, 771 
Koch’s bacillus, 160 
tuberculin, 115 
preparation of, 115 
Konig’s incision for excision of ankle, 644 
for shoulder, 631 
Krohne and Seseman’s inhaler, 296 
Kyphosis due to rickets, 237 
LABORDE’S method rhythmical traction 
of tongue, 302 
Lacerations, 319 
Lachrymal bone, fracture of, 706 
Landerer’s method of treatment for varicose 
veins, 543 
Langenbeck’s incision for excision of elbow, 
633 
wrist, 635 
Lannelongue’s sclerogenic treatment in tu- 
berculosis, 177 
Lawrie’s inhaler, 295 
rules for administration of chloroform, 
297 
Leeches, 261 
Lembert suture, 270 
Leontiasis, 682 
Lepra, 179 
Leprosy, 179 
bacillus of, 179 
of bone, 673 
prognosis in, 180 
symptoms of, 179 
treatment of, 181 
types of, 179 
Leucocytes in repair, 350 
in Hodgkin’s disease, 534 
properties of, 49 
physical, 49 
Leucomaine, 115 
Leukokeratosis, 206, 207 
Lever method of Sir Astley Cooper of re- 
ducing dislocations of shoulder, 
759 
Levis’s instrument for reducing dislocation 
of thumb, 767 
I Ligament, -Y, 769 
Ligation for hemorrhage, 258 
I Ligature en masse, 259 
Ligatures, sterilization of, 376 
Lipoma, 410 
of skin, 461 
: Lister’s line of incisions for excision of 
wrist, 635 
Listerism, 362 
Lock finger, 502 
Lockjaw, 138 
Lues Venerea, 182 
Lumbar abscess, 660 
Lumpy-jaw, 156, 158 
Lung, resemblance as to structure and dis- 
eases of. to bone, 647 
J Lungs, direct inflation of, 274 
Lupus, 168, 470 
j vulgaris, 471 
| Luschka’s tonsil, 397, 400 
gland, 397, 400 
Lustgarten’s bacillus, 184 
| Lymphadenitis, 529 
treatment for, 529, 531 
| Lymphangeiectases, 457 
Lymphangeioma, 419 
cavernous, 521 
circumscription, 456 
hsemato-, 521 
of skin, 456 
varix, 521 
Lymphangitis due to filaria sanguinis hom- 
inis, 545 
due to gonorrhoeal infection, 220 
in septicaemia, 122 
reticular, 520 
treatment, 520 
tubular, 519 
Lymphatic vessels, anatomical arrangement 
of, 518 790 
INDEX. 
Lymphatic vessels, cyst of, 523 
elephantiasis, 525 
inflammation of, 519 
injuries and diseases of, 518 
lymph angeioina, 521 
lymphoedema, 522 
macromelia, 522 
obstruction of, by parasites, 523 
occlusion of, 520, 522, 523 
tumor of, 521 
wounds of, 518 
Lymphatics, injury to, 323 
Lymph-nodes, tuberculosis of, 169 
acute lymphadenitis, 529 
chronic lymphadenitis, 530 
in Hodgkin’s disease, 533 
inflammation of, 529 
injuries and diseases of, 518 
sarcoma of, 535 
in septicaemia, 122 
Lymphoedema, 522 
Lymphorrhagia, 522 
Lymphorrhoea, 522 
Lympho-sarcoma, 532 
Lymph-scrotum, 528 
due to filaria sanguinis hominis, 525 
varix, 521 
Lyssa, 146 
Lyssophobia, 148 
McBURNEY’S method of treatment for 
fracture of shaft of humerus with 
dislocation of its head, 717 
Macrocheilia, 420, 522 
Macrodactylia, 522 
Macroglossia, 420, 522 
Macromelia, 522 
Macropodia, 522 
Malar bone, fracture of, 707 
Malgaigne’s hooks, 742 
Malignant degeneration of scar, 97 
growths, differential diagnosis from be- 
nign, 440 
lymphoma, 532 
oedema, 154 
definition of, 154 
organism of, 155 
post-mortem appearance of, 155 
prognosis in, 156 
treatment of, 156 
symptoms of, 155 
pustule, 151 
Mallein, 151 
Malleus, 149 
Mammary gland, tuberculosis of, 175 
Mania due to drugs, 253, 254 
post-operative, 252 
puerperal, 252 
traumatic, 252 
Marie’s disease, 680 
Marshall’s method Qf treating nsevi by elec- 
tricity, 546 
Maxilla, inferior, fracture of, 707 
symptoms, 708 
treatment, 709 
superior, fracture of, 706 
alveolar arch, 707 
Maxilla, superior, fracture of, complications, 
706 
Measles, secondary infection in, 241 
Medication, hypodermic, 279 
Melanoma, 406 
Mercurial necrosis, 667 
Mercury in syphilis, 210 
toxic effect of, 255 
Mesarteritis, 552 
Metacarpal bones, fracture of, 726 
Metacarpo-phalangeal dislocations, 765 
treatment, 766 
Metacarpus, excision of, 636 
Metastasis, 126 
Metastatic abscesses, 126 
Metatarsal bones, fracture of, 748 
Metschnikoff ’s theory of inflammation, 50 
Micrococcus lanceolatus, 72 
tetragonus, 73 
Micro-organisms in bone affections, 648 
in dental caries, 245 
in wounds, manner of access, 320 
sources in wound infection, 362 
Middeldorpf’s method of reducing forward 
dislocation of hip, 771 
posterior dislocations of hip, 771 
Miliary tubercle, 161 
absorption of, 162 
degenerations in, 162 
Milium, 444 
Milzbrand, 151 
i Minor surgery, 268 
Mixed infection complicating exanthemata, 
239 et seq. 
Moles, 453 
Molluscum fibrosum, 412, 462 
Moore’s dressing, for Colies’ fracture, 724 
for dislocation of shoulder, 755 
for fracture of clavicle, 713, 714 
Morbus coxae senilis, 605 
Morve, 149 
Mucous membranes, syphilis of, 206 
Mumps, secondary infection in. 243 
Muscle, atrophy of, in tuberculosis of bone,661 
spasm, in tuberculosis of bone, 661 
Muscles, 487 
calcification of, 495 
degenerations of, 495 
diseases of, 493 
functional disorders, 493 
hernia of, 325 
symptoms, diagnosis, and treatment, 
325, 326 
injuries of, 325 
symptoms, 325 
treatment, 325 
malformations of, 487 
myalgia, 493 
myositis or inflammation of, 494 
classification, 494 
treatment, 494 
parasitic cysts of, 514 
syphilis of, 496 
transplantation of, 516 
tuberculosis of, 497 
tumors of, 514 
and aponeuroses, 489 INDEX. 
791 
Muscles and aponeuroses, contusions of, 
490 
haematoma of sterno-mastoid, 490 
hernia of, 489 
strain of, 490 
subcutaneous rupture of, 491 
treatment, 492 
surgical diseases of, 489 
and tendons, dislocations of, 492 
regeneration of, 493 
wounds and sections of, 492 
Muscular atrophy, 498 
contractures, 497 
hypertrophy, 499 
paralysis, traumatic, 500 
progressive atrophy, 498 
pseudo-muscular hypertrophy, 499 
pull in fractures, 698 
Mustard, germicidal effect of, 365, 366 
Myoma, 417 
of skin, 461 
Myositis, 494 
syphiliticus, 496 
Myotomy, 514 
Myxoma, 416 
of bone, 685 
‘VT.EVUS, 418 
i\ pigmentosus, 453 
telangeiectasis, 454 
vascularis, 454 
venous, 544 
Napthalin, toxic effect of, 254 
Nearthrosis, 753 
Neck, cysts of, 393 
gunshot wounds of, 342 
Necrosis, 102, 667 
pathological, 667 
sequestrum in, 669 
syphilitic, 664 
total, 655 
toxic, 667 
treatment, 669 
traumatic, 667 
Neisser’s gonococcus, 214 
Nelaton’s bullet probe, 331 
incision for excision of elbow, 633 
line in dislocation of hip, 770 
Nephritis, following burns, 481 
suppurative, due to gonorrhoeal infection, 
220 
Nerve, influence upon tumor-formation, 387 
Nerves, injuries of, 323 
prognosis, 324 
regeneration of, 359 
symptoms, 323 
treatment, 324 
Neuroma, 421 
of skin, 462 
Neuropathic diseases of joints, 606 
causes, 606 
morbid anatomy, 606 
symptoms, 607 
Nipple, Paget’s disease of, 466 
Nitrous-oxide gas, 292 
Noma, 104 
Non-union, 703 
Nose, fracture of, 704 
symptoms, 705 
treatment, 705 
Nostalgia in scurvy, 234 
Nuhn’s gland, cyst of, 395 
Odontoma, 415 
(Edema, lymph, 522 
of prepuce, 220 
Ointments, antiseptic, 377 
Olecranon process, fracture of, 720 
Ollier’s incision for excision of elbow, 633 
of hip, 637 
of knee, 640 
of shoulder-joint, 631 
of wrist, 635 
Onychia, 477 
syphilitic, 477 
Operations on joints, 629 
Opisthotonos, 141 
Orchitis, 220 
treatment of, 224 
Organization of blood-clot, 354 
Osseous system, surgical diseases of, 647 
Ossified man, 604 
Osteo-arthritis, 603 
morbid anatomy, 604 
treatment, 606 
Osteo-arthropathie hypertrophiante pneu- 
mique, 680 
Osteochondritis syphiliticus, 209 
Osteoclasts, 361 
Osteoma, 414 
of bone, 684 
Osteomalacia, 675 
causes, 676 
Osteomyelitis, 648 
acute, 648 
diagnosis of, 653 
etiology of, 653 
pathology, 648 
stages of, 649 
symptoms of, 650 
treatment, 654 
chronic, 657 
metastatic in pyaemia, 128 
Osteoplastic method of excision of elbow, 
633 
Osteoporosis, 658, 679 
adiposa, 648 
Osteopsathyrosis, 678 
Osteosarcoma, 685 
Osteosclerosis, 658 
Ostitis deformans, 679 
Otis’s urethrotome, 227 
urethrometer, 226 
Ovary, tuberculosis of, 174 
PACHYDERMATOCELE, 412 
Paget’s disease, 466 
of bones, 679 
Pain, 312 
in bone tuberculosis, 662, 664 
in cancer, 435 
cause of, 312 
character of, 313 
diagnostic significance of, 312 792 
INDEX. 
Popliteal artery, aneurism of, 582 
Port-wine mark, 454 
Post-gonorrhoeal arthritis, 220 
rheumatism, treatment of, 225 
synovitis, 598 
Potain’s aspirator, 263 
Pott’s fracture, 745 
Pox,182 
Prepuce, oedema of, 220 
Process of repair, 350 
Profeta’s law, 207 
Progressive muscular atrophy, 498 
Properties of leucocytes, 49 
Prostate, milking in gleet, 227, 228 
Prostatitis, 219 
Protozoa, 77 
Psammomata, 425 
Pseudo-hypertrophic muscular paralysis, 
499 
Pseudo-leukaemia, 532 
Pseudo-muscular hypertrophy, 499 
Psoas abscess, 660 
Psorosperms in tumors, 389 
Ptomaine, 115 
classification of, 115 
composition of, 115 
source of, 115 
Puerperal mania, 252 
Puruloid material, 362 
distinction from pus, 93 
Pus, 78, 80 
absorption of, 81, 85 
alterations, 86 
burrowing of, 82 
characteristics of, 80 
corpuscles, 80 
ichorous, 81 
odor of, 80 
sanious, 81 
clinical characteristics of. from different 
agencies, 77 
diagnosis of, in doubtful cases. 82 
encapsulation of, 86 
resorption of, 81 
subfascial collections of, 81 
subperiosteal collections of, 81 
Pyaemia, 125 
chronic, 128 
complications of, 127, 128 
definition of, 125 
due to gonococcus, 221 
following catheterization, 273 
following pneumonia, 240 
from osteomyelitis, 651 
incubation in, 127 
post-mortem appearances in, 129 
prognosis in, 128 
symptoms of, 127 
treatment of, 129 
urine in, 128 
wound in, 128 
Pyelitis due to gonorrhoeal infection, 
220 
Pyoid material, source of, 93 
Pyoktannin in treatment of cancer, 443 
Pyophylactic membrane, 88, 164 
treatment of, 622 
Pain, duration, 313 
how studied, 313 
location of, 314 
manner of expression, 312 
mode of onset, 313 
modification of, 314 
time of occurrence, 313 
Palmar abscess, 508 
incisions in, 509 
Panarthritis, 615 
Papilloma, 423 
Papular svphilide, 198 
Paracentesis, 263 
by aspiration, 263 
by incision, 264 
by tapping, 264 
Paraphimosis, due to gonorrhoea, treatment 
of, 223 
Parasitic theory of tumor-formation, 389 
Park’s method of sterilization of hands, 
366 
mixture for hemorrhage, 259 
Paronychia, 478, 505 
syphilitica, 505 
Paroophoron, cysts of, 393 
Parovarian cysts, 393 
Pasteur’s treatment for hydrophobia, 148 
Patella, dislocation of, 773 
fracture of, 740 
treatment, 741 
wiring of, 742 
Pelvis, fracture of, 727 
complications of, 727, 728 
treatment, 728 
in rickets, 237 
Pemphigus syphiliticus, 208 
Penis, gunshot wounds of, 348 
Perforating ulcer, 477 
Periarteritis, 551, 552 
Periostitis, acute infectious, 655 
albuminosa, 656 
Peritoneum, tuberculosis of, 175 
Peritonitis, following burns, 481 
Peri-urethral inflammation, 218 
treatment of, 224 
Phagocyte, 50 
Phagocytosis, 50, 51, 57 
Phimosis, due to gonorrhoea, treatment of, 
223 
Phlebitis, 537 
mycotic, 125 
treatment, 538 
Phlebotomy, 260 
Phlegmon, 79 
Phosphorus-necrosis, 668 
Physical properties of leucocytes, 49 
of phagocytes, 50 
chemotaxis, 50 
“ Pig-skin,” in cancer of breast, 435 
Pituitary, body in acromegaly, 682 
Pleurisy following burns, 481 
Pleurosthotonos, 141 
Pneumococcus in osteomyelitis, 648 
Pneumonia, surgical sequelie of, 240 
Poisoning, 249, 250 
by animals and plants, 247 
Poisonous snakes in America, 247 INDEX. 
793 
Rabies, 146 
Rachitis, 235, 674 
deformities in, 675 
Radius, 722 
dislocation of, 763 
of head, in children, 764 
fracture of, 722 
Colles’, 722 
impaction in, 723 
treatment of, 723 
Ranula, 395 
Rathke’s pouch, 396 
Rausch brand, 156 
Ray fungus, 157 
Rectum, gonorrhoea of, 217 
Red blood-corpuscles, destruction of, in 
burns, 480 
Regeneration of tissue, 356 
blood-vessels, 358 
bone, 359, 360 
epidermis, 356 
fascia, tendinous sheaths, and tendons, 
356 
muscles, 357 
nerves, 359 
skin, 357 
Repair, 350 
embryonal cells in, 94 
epithelioid in, 94 
first intention, 350 
formative cells in, 94 
granulation-tissue in, 94 
methods of, 350 
microscopical appearance of, 94, 350 
epithelial formation, 95 
scar formation, 96 
contractures, 96 
treatment for, 96 
giant cells in, 94 
exuberant granulations, 95 
treatment of, 95 
karvokenetic activity in, 94 
process of, 93 
second intention, 354, 355 
third intention, 355 
Report of surgical case, 316 
manner of procedure, 316, 317 
rules to be observed by recording sur- 
geon, 317 
Resection of joints, 629 
for tuberculosis, 623 
Reverdin’s method of skin-grafting, 277 
Reynaud’s disease, 103 
Rheumatism, chronic articular, 602 
symptoms, 603 
treatment, 603 
Rheumatoid arthritis, 603 
Rhigolene, 302 
Rhinoscleroma, 475 
Rhus toxicodendron, poisoning by, 249 
Ribs, dislocation of, 754 
fracture of, 710 
symptoms, 711 
treatment, 711 
Rice bodies, 504 
Rickets, 235 
cause of, 235 
Rickets, cerebral conditions in, 237 
congenital, 236 
deformities of bone in, 237 
foetal, 236 
pathology of, 236 
symptoms of, 237 
treatment of, 238 
Rider’s bone, 494 
Rodent ulcer, 463, 478 
Roller bandage, 283 
Roseola syphilitica, 198 
Rotz, 149 
Rubefacients, 264 
Rupial syphilide, 199 
SACRUM, fracture of, 728 
Salt solution, 271 
Saprsemia, 119 
cause of, 120 
definition of, 121 
relation to septicaemia, 121 
symptoms of, 120, 121 
treatment of, 121 
Sarcoma of bone, 685 
seats, 686 
treatment, 687 
cutis, 468 
differential diagnosis from carcinoma, 441 
melanotic, 468 
Sarcomata, 403 
Sayre’s incision for excision of hip, 639 
Scab, healing under, 355 
Scalds, 479 
Scapula, fracture of, 714 
treatment, 714, 715 
Scar, hypertrophied, 458, 459 
Scarlatina following operations, 119 
secondary infection in, 241 
Scars, degenerations in, following burns, 482 
Schede’s treatment for varicose veins, 543 
Schimmelbusch-Bergmann method of steril- 
izing catgut, 377 
Schimmelbusch’s box for sterile dressings, 
375 
instrument-boiler, 373 
Schleich’s infiltration method for anaes- 
thesia, 303 
Scrofuloderma, 472 
Scurvy, 234 
in United States, 234 
pathology of, 234 
symptoms, 234 
treatment of, 235 
diet in, 235 
Secondary infection in syphilis, 184 
syphilis, 194 
Semilunar cartilages, dislocation of, 610, 
774 
Senile fragility of bones, 679 
Senn’s plaster-of-Paris splint for fractures 
of cervix femoris, 735 
Sepsis, 537 
following burns, 481 
Septicaemia, 122 
ammoniaemia in, 122 
cause of, 122 
complications of, 123 794 
INDEX. 
Septicaemia, complications of, general treat- 
ment, 124 
intestinal antiseptics in, 125 
post-mortem evidences in, 123 
treatment for, 124 
definition of, 122 
eruptions in, 123 
following puerperal state, 246 
leucocytosis in, 123 
symptoms, 122 
Septic enteritis, 113 
infection, 85 
suppository as a cause of sapremia, 120 
Sequestrum formation, 669 
diagnosis, 670 
treatment, 670, 671 
Serum-therapy in cancer, 443 
in snake-bite, 248 
Seton, 266 
Shirt-stud abscess, 507 
Shock, 230 
in bullet wounds, 332 
definition, 230 
diagnosis of, 231 
relation of, to concussion of brain, 230 
symptoms of, 230 
treatment, 231, 232, 233 
types of, 230, 231 
Shock and collapse, 230 
Shoulder, arthrotomy of, for old disloca- 
tions, 761 
excision of, 631 
resection of, for old dislocations, 761 
-joint, dislocation of, 755 
anterior or subcoracoid, 756 
causes of, 756 
diagnosis in, 757 
downward or subglenoid, 757 
forward or subclavicular, 757 
old, treatment of, 761 
posterior or subspinous, 757 
prognosis in, 761 
symptoms, 757 
treatment, 758 
Kocher’s method, 759 
lever method, 759 
Sinew, weeping, 509 
Sinus, 86 
causes of, 87 
definition of, 86 
treatment, 87 
Skin diseases, surgical, 444 
inoculation through unbroken skin, 518 
regeneration of, 356 
syphilis of, 196, et seq. 
tuberculosis of, 470 
Skin-grafting, 277 
methods, 277 
Snake-bite, 247 
symptoms, 247 
treatment, 248 
Sources of infection, 64 
Sphacelus, 102 
Spica bandage, 281, 282 
Spinal column, gunshot wounds of, 343 
Spine, surgical diagnosis and examination 
of, 310 
I Splenic fever, 151 
i Sponges, sterilization of, 376 
Spontaneous fractures, due to osteomalacia, 
677 
Sporozoa in tumors, 389 
Staffordshire knot, 269 
Staphylococcus pyogenes albus, 71 
aureus, 71 
citreus, 71 
epidermidis albus (Welch), 64, 185, 366 
Steatoma, 446 
Stercorsemia, 113 
Sterilization, 364 
of accessory apparatus and instruments, 
374 
of catheters, 373 
by chemical germicides, 377 
of dressings, 375 
by geianicidal solutions, 377, 378 
corrosive sublimate, 377 
Thiersch’s solution, 378 
of instruments, 372 
of ligature and suture material, 376 
of sponges, 376 
Sterno-mastoid, hsematoma of, 490 
I Sternum, dislocation of, 754 
fracture of, 711 
i Stimson’s treatment for dislocation of clavi- 
cle, 755 
| Stitch abscesses, bacteria of, 64 
' Strength of bone, 694 
Streptococcus erysipelatis, 71 
infection of joints, 589' * 
pyogenes, 71 
Styptics, 259 
Subcutaneous injuries, 319 
Suppuration, 78 
in abdomen, treatment, 83, 84 
cause of, 78 
phagocytes in, 78, 79 
temperature in, 85 
Supracondyloid fracture of humerus, 718 
of femur, 733 
Surgical case, how to report it, 316 
diagnosis, 304 
external examination, 304 
abdomen, 308 
breast, 308 
chest, 307 
elbow-joint, 307 
eye, 305 
genito-urinary tract, 310 
kidney, 310 
penis, 311 
scrotum, 311 
testicles, 311 
groin, 312 
head and face, 305 
inguinal region, 310 
lower extremity, 312 
neck, 305 
perineum, 311 
spine, 310 
upper extremity, 306 
diseases of skin, 444 
fevers, the, 117 
cause of, 118 795 
IS I) EX. 
Surgical fevers, differentiated from poison- 
ing by drugs, 118 
symptoms of, 118 
synonyms of, 118 
terminations of, 118 
treatment of, 119 
methods, 257 
pathology of the blood, 32 
sequelae of diseases, 239 
of cerebro-spinal meningitis, 244 
cholera, 240 
dental caries, 245 
diphtheria, 243 
dysentery, 240 
endocarditis, 244 
gonorrhoea, 245 
influenza, 241 
measles, 241 
mumps, 243 
pneumonia, 240 
the puerperal state, 245 
scarlatina, 241 
syphilis, 245 
typhoid, 242 
variola, 244 
Sutures, classification of, 380 
methods of application, 269 
continuous, 269 
Czerny, 270 
interrupted, 270 
Lembert, 270 
quill or plate, 270 
secondary, 270 
removal of, 270 
sterilization of, 376 
Sylvester’s method of artificial respiration, 
273 
Symptomatic charbon, 156 
Syndactylism, 487 
treatment, 488 
Synovial tuberculosis, 616 
Synovitis, 593 
chronic, 601 
dry, 594 
gouty, 598 
post-gonorrhoeal, 598 
purulent, 594 
simple, 593 
treatment, 599 
urethral, 598 
Syphilis, 182 
anaemia in, 185 
blood-vessels in, 183, 204 
of bone, 664 
treatment of, 665 
congenital, 208 
prognosis, 208 
symptoms, 208 
treatment of, 213 
chancre, 187 
complications of, 190 
differential diagnosis of, 191 
diagnosis of, 191 
extragenital, 190 
Hunterian, 189 
incubation, 187 
induration of, 188, 190 
I Syphilis, chancre, pathological anatomy of, 
192 
prognosis of, 193 
phagedenic ulceration of, 189, 193 
treatment, 193 
varieties, 188 
constitutional, 194 
diagnosis of, 194 
effect on wounds, 196 
fever in, 195 
incubation of, 194 
pain in, 195 
definition of, 182 
duration of, 180, 196, 201 
early eruptions in, 183 
etiology of, 184 
relation of Lustgarten’s bacillus to 
smegma bacillus, 184 
eruptions in, 197 
diagnosis of, 198 
experimental inoculation in, 186, 187 
gumma in, 183, 202, 203, 205 
histology of, 205 
in bones, 203 
in skin, 202, 203 
hereditary, 207 
infection from blood, 186 
ovum, 186, 207 
secretions, 186 
initial lesion of, 187 
inoculation in, 183 
insontium, 187 
iodide of potassium in, 210 
lymph-vessels and nodes in, 191, 194 
mediate contact in, 187 
mercury in, 210, 211 
mixed sore in, 190 
mode of infection, 187 
mucous patches in, 206 
of muscles, 496 
pathological anatomy of syphilitic in- 
flammation, 204 
primary syphilis, 183 
predisposing causes of, 186 
Profeta’s law in, 207 
secondary, 183, 194 
skin, 196, 202 
stages of, 183 
suppuration in, 185 
tertiary, 201 
gummatous syphilide in, 202 
syphilides in, 196 
tongue affections in, 206, 207 
transmission of, 207 
treatment of, 209 
by baths, 212, 213 
bv hypodermic administration, 212 
by inunction, 212 
711-BANDAGE, 283 
; 1 Tailor’s ankle, 513 
| Taenia echinococcus, 397 
! Teeth, extraction of, 278 
accidents from, 278, 279 
conditions demanding, 278 
instruments required, 278 
method of, 278 796 
INDEX. 
Teeth, wiring of, in fractures of jaw, 709 
Telangeiectasis of skin, 454 
treatment, 455 
by chemicals, 455 
by electricity, 456 
by knife, 456 
Tendon-sheath, regeneration of, 356 
tuberculosis of, 173 
Tendon-sheaths, anatomical arrangement in 
hand, 508 
Tendons, 487 
and tendon-sheaths, 502 
contraction of, in finger, 502 
contraction of, in toe, 502 
inflammation of, 502 
injuries of, 326 
lengthening of, 516 
regeneration of, 356 
symptoms and treatment, 326 
teno-synovitis, 503 
chronic, 503 
treatment, 504 
transplantation of, 516 
Tenotomes, 515 
Tenotomy, 514 
methods of performing it, 515 
Teratomata, 402 
Tertiary syphilis, 201 
Testes, gunshot wounds of, 349 
Testicle, suppuration in, 224 
tuberculosis of, 174 
Tetanella, 145 
Tetanus, 138 
cephalicus, 140 
chronic, 142 
death in, 142 
definition of, 138 
diagnosis of, 142 
from hydrophobia, 143 
from hysteria, 143 
from strychnine-poisoning, 143 
etiology of, 139 
incubation in, 140 
of new-born, 138, 140 
organism, 139 
parasitic nature of, 139 
post-mortem appearances in, 142 
prognosis in, 142 
in races, 138 
symptoms, 140 
toxalbumens of, 140 
toy-pistol tetanus, 139 
treatment, 143 
antitoxine, 144 
constitutional, 143 
local, 143 
specific, 144 
Tetany, causes of, 145 
differential diagnosis from tetanus, 145 
symptoms of, 145 
treatment of, 145 
Thecitis, 503 
The Rose, 130 
Thiersch’s method of skin-grafting, 277 
solution, 378 
Thigh, fracture of, 729 
Thoma’s lisemocytometer, 47 
| Thorax, gunshot wounds of, 344 
Thrombi, metamorphosis of, 35 
Thrombo-arteritis, 126 
Thrombo-phlebitis, 37 
treatment of, 37 
Thrombosis, 34 
of arteries, 549 
Thumb, excision of, 636 
Thyroid duct, 401 
Thyro-hyoid duct, 401 
Thyro-lingual duct, 401 
Thyroids, accessory, 400 
Tibia, fracture of, 742 
of lower end, 745 
of shaft, 743 
treatment, 744 
of upper end, 742 
Tissues, effect of modern bullets on, 327 
regeneration of, 356 
Toe-nail, ingrown, 276 
causes of, 276 
treatment, 276 
Tongue, gumma of, 207 
rhythmical traction of, 302 
Torsion for hemorrhage, 259 
Tourniquets, 258 
Toxalbumen of snakes, 247 
Toxalbumens, 115 
preparation of, 115 
tuberculin, 115 
Toxic antiseptics, 253 
erythemas, 119 
Toxicity of urine, 110, 112 
in Bright’s disease, 112 
Tracheal tugging in aneurism, 577 
Traction in reducing dislocations of shoul- 
der, 760 
Trauma as a cause for tumors, 387 
Traumatic fever, 118 
j mania, 252 
symptoms of, 253 
Transfusion of blood, 270 
normal salt solution, 271 
j Ti’ichina spiralis, 514 
I Trigger-finger, 502 
Trinchinosis, 514 
Trismus, 138 
Trophoneurotic diseases of bones, 673 
Trousseau’s sign, 145 
Tubercular arthritis, 612 
arthropathic, 613 
constitutional complications of, 620 
diagnosis of, 620 
etiology of, 612 
osteopathic, 613 
pathological anatomy of, 613 
prognosis in, 621 
repair in, 618 
symptoms of, 618 
treatment of, 671 
Tuberculin, 178 
dose, 178 
manner of preparation of, 178 
in skin diseases, 473 
Tuberculosis, 160 
bacillus of, 160 
of bones, 170, 171 Tuberculosis of bones, 658 
abscess of, 664 
acute miliary, 660 
chronic, 660 
pathology, 660 
pathology, 659 
symptoms, 661 
treatment, 662 
non-operative, 662 
operative, 663 
varieties, 660 
and joints, ultimate results of excis- 
ions, 632, 634, 636, 639, 642, 644, 
646 
Tuberculosis, bursae, 173 
cold abscesses in, 166 
diagnosis of, 166 
lumbar, 166 
psoas, 166 
retropharyngeal abscess, 166 
treatment of, 166 
cutis, 471 
degenerative changes in, 162 
diagnosis of, 176 
differential diagnosis of, 176 
constitutional, 177 
tuberculin in, 178 
diagnostic value of tuberculin, 178 
local, 177 
treatment, 177 
amputation in, 178 
Bier’s permanent hyperaemia, 177 
excision in, 178 
ignipuncture in, 178 
iodoform injections in, 177 
sclerogenic treatment of Lanne- 
longue, 177 
differential diagnosis from epithelioma, 
441 
followed by mixed infection, 241 
fungous granulation in, 167 
giant cells in, 161 
gummata in, 167, 168 
kidneys, ureter, and bladder, 174 
lupus, 168 
symptoms, 169 
of lymph-nodes, 530 
treatment of, 531 
of lymphatic structures, 169 
method of healing, 162 
absorption, 162 
calcification, 163 
caseation, 163 
incapsulation, 163 
suppuration, 163 
archepvon in, 165 
cold abscesses in, 163 
danger of pyophylactic membrane, 
165 
treatment of pyophylactic membrane, 
165 
miliary tubercle in, 161 
of mucous membranes, 168 
of muscles, 497 
ovary, 174 
paths of infection in, 175 
respiratory tract, 175 
INDEX. 
797 
Tuberculosis of skin, 168, 470 
diagnosis, 473 
etiology of, 471 
lupus vulgaris, 471 
scrofuloderma, 472 
treatment, 474 
tuberculosis cutis, 491 
verrucosa, 472 
of tendon-sheath, 173 
of testicle, 174 
verrucosa, 472 
Tuberosities of humerus, fracture of, 
715 
Tuffnel’s treatment for aneurism, 569 
Typhoid, secondary infection in, 242 
Tumors, 683 
adenoma, 429 
carcinoma, 431 
seats, 430-432 
of sebaceous glands, 430, 431 
angeioma, 418 
arterial, 419 
treatment, 419 
cavernous, 418 
nsevus, 418 
of bone, 683 
classification, 390 
definition of, 385 
nature and origin, 386-388 
nomenclature, 390 
theories as to origin, 386-389 
treatment, 391 
carcinoma, 433 
acinous, 435 
characteristics of, 433 
classification of, 434 
colloid, 434 
duct, 435 
lymph-node, infection in, 435 
metastasis in, 433, 435 
microscopical appearance, 433 
pain in, 435 
seats of, 436, 437 
treatment, general, 441 
aniline preparations, 443 
inoculation methods, 442 
non-operative, 442 
serum-therapy, 443 
chondroma, 412 
treatment, 414 
of complex mesoblastic type, 418 
dermoids, 398 
classification, 399 
implantation, 400 
ovarian, 402 
sequestration, 399 
tubulo-dermoids, 400 
endothelioma, 438 
clinical characteristics, 440 
microscopical appearance, 434 
of epiblastic origin, 421 
classification, 421 
epithelioma, 428 
lymph-nodes in, 427 
microscopical appearance, 426 
seats, 427, 428 
synonyms, 428 798 
Tumors, epithelioma, treatment, 428 
epulis, 412 
fibroma, 411 
of glandular-tissue type, 429 
glioma, 409 
of immature connective-tissue type, 403 
keloid, 412 
lipoma, 410 
lymphangeioma, 419 
cavernous, 420 
cysts, 420 
treatment, 421 
naevus, 419 
myxoma, 416, 417 
classification, 416, 417 
neuroma, 421 
classification, 423 
odontoma, 415 
classification, 415 
osteoma, 414 
classification of, 415 
exostoses, 415 
papilioma, 423 
classification, 423 
cutaneous horns, 425 
treatment, 426 
intracystic villous growths, 424 
psammomata, 425 
villous, 424 
warts. 423 
sarcoma, 403 
classification, 403 
alveolar, 406 
lympho-, 405 
melano-, 406, 409 
myeloid or giant-celled, 405 
round-celled sarcoma, 404 
spindle-celled sarcoma, 405 
general characteristics of, 406 
metastasis in, 407 
secondary changes in, 407 
seats of, 408 
treatment, inoculation method, 442 
of simple mesoblastic-tissue type, 410 
teratomata, 402 
ITLCER and ulceration, 89 
J atheromatous, 554 
callous, 92 
discharge from, 93 
causes of, 89 
constitution, 91 
local, 90 
traumatic, 89 
definition, 89 
erethistic, 91 
fungous, 91 
healthy, 91 
hemorrhagic, 91 
indolent, 91 
perforating, 477 
of foot, 91 
phagedenic, 91 
sloughing, 9l 
treatment for, 97, 99 
by continuous immersion, 99 
specific, 100 
INDEX. 
j Ulcer, varicose, treatment, 543 
Ulna, fracture of, 720 
coronoid process, 721 
dislocation of, 763 
olecranon, 720 
treatment, 721 
shaft, 721 
treatment, 721 
Unna’s paste, 451 
Unreduced dislocations, pathology of, 751 
Urea in auto-intoxication, 111 
medicinal use of, 113 
Ureter, tuberculosis of, 174 
Ureteritis, due to gonorrhoeal infection, 220 
Urethral fever, 273 
synovitis, 598 
Urethritis, deep gonorrhoeal, 219 
treatment of, 224 
non-specific, 216, 217 
Urethrometer, 226 
Urethroscope, 226 
Urethrotome, 227 
Urethrotomy, 629 
Urinary infiltration, following fracture of 
pelvis, 728 
Urine, toxicity of, 112 
VARICES, 538 
j V Varicose veins, 538 
Variola, 244 
secondary infection in, 244 
Varix, lymph, 521 
aneurismal, 566 
arterial, 566 
Veins, 536 
anatomy and physiology of, 536 
excision of, 541 
hypersemia of, 536 
inflammation of, 537 
injury to, 323 
rupture of, 544 
sudden occlusion of, 544 
surgical injuries and diseases of, 536 
varicose, of lower extremity, 153, 539 
causes, 153, 539 
symptoms, 540 
treatment, 541 
upper extremity, 540 
Velpeau’s bandage, 281 
Venesection, 260 
Venous nsevus, 544 
cause, 544 
seats, 544 
treatment, 545 
Verruca, 451 
acuminata, 451 
digitata, 451 
seborrhcea, 451 
vulgaris, 451 
Vertebral artery, aneurism of, 581 
Vesicants, 265 
Vesiculitis, treatment of, 224 
Vessels, injuries of, 321 
arteries, 321 
diagnosis, 321 
symptoms, 321 
treatment, 321 INDEX. 
799 
Vessels, lymphatics, 323 
lymph-, injuries and diseases of, 518 
veins, 323 
Virchow’s theory of inflammation, 54 
Viscera, gunshot wounds of, 345 
Volkmann’s method of opening abdominal 
abscesses, 84 
Von Mosetig-Moorhof’s method of excision 
of elbow, 633 
TITARDROP’S operation for treatment of 
T V aneurism, 572 
Warts, 423, 451 
Wax, in treatment of bone disease, 671 
Webbed fingers, 487 
Weeping sinew, 509 
Wen, 430 
Whitlow, 506 
Wiring bone fragments in fracture of jaw, 
707, 709, 710 
fragments in compound fractures, 702 
Wladirnirov and Mikulicz’s osteoplastic ex- 
cision of foot, 644 
Wolflian body, cysts of, 392, 393 
Wool-sorter’s disease, 151 
Wound infection in joints, 588 
Wounds of bladder, 348 
prognosis, symptoms, 348 
treatment, 348 
changes of dressing in, 381 
classification, 379 
conditions furthering infection, 363 
treatment of, 378 
constitutional effect of, 381 
incised, 379 
lacerated and contused, 381 
treatment, 382 
of penis, 348 
prognosis and treatment, 348 
punctured, 382 
symptoms, 382 
treatment, 383 
treatment of, 378 
union of, 379 
treatment, 379 
Wounds, gunshot, 327 
of abdomen, solid and hollow viscera, 345 
non-penetrating, treatment, 345 
penetrating and perforating, 346 
prognosis, diagnosis, 346, 347 
Wounds, penetrating and perforating, treat- 
ment, 346 
by operation, 347 
after-, 348 
of cranial bones, 339 
diagnosis, 339, 341 
penetrating, 340 
prognosis, 340 
treatment, 339, 341 
determination of location of balls, 331 
diagnosis, prognosis, and treatment, 
345 
effects on tissue, 327 
of face, 341 
treatment, 342 
fate of bullets in body, 330 
of heart, 345 
missiles, 327 
of neck, 342 
prognosis, 342 
treatment, 342, 343 
prognosis in, 333 
small-shot wounds, 333 
of spinal column, 343 
symptoms, 343 
prognosis, 343 
treatment, 344 
symptoms of, 332 
of thorax, 344 
diagnosis, 344 
prognosis, 344 
treatment, 344 
treatment, general considerations, 334 
of bones and joints, 335 
of soft parts, 334 
wound of exit and entrance in, 330 
Wrist, dislocation of, 764 
excision of, 634 
fracture of, 726 
Writer’s cramp, 493 
XIPHOID CARTILAGE, fracture of, 
712 
X-rays in gunshot wounds, 331 
Y-LIGAMENT, its influence on dislo- 
cations and their reduction, 769 
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